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Prevention & control of

Hepatitis B&C

Dr Huma Qureshi (TI)


Executive Director
Pakistan Medical Research Council,
Islamabad
Hepatitis

Two types of hepatitis:


Waterborne (Hepatitis A & E)
Blood borne (Hepatitis B, D & C)

Acute illness: Irrespective of the virus type:


clinical and other manifestations are
identical.
Water borne Hepatitis A &E
Both are transmitted by consuming sewage
contaminated water/food
Hepatitis A is a disease of children in
Pakistan, over 90% have been exposed and
recovered by the age of 12 years
Produces flu like symptoms in over 50%
without jaundice, rest have jaundice
Recovery is 100% in 2-3months
Hepatitis E
It is seen all the year the round but more so
after rains and in summer
It is a disease of children and adults both
Mostly presents with jaundice and itching
Takes 2-3 months to recover with 100%
recovery in all cases except 6% mortality
in pregnant cases
Treatment of A & E Viruses
Vaccine is available for hepatitis A but not
recommended as routine in Pakistan
No vaccine for hepatitis E is available
Both recover fully
Give normal diet with full fats, proteins
and CHO, allow normal work and avoid
drips,glucose and liver supporting drugs
Prevalence data of B&C(2007-8)
50,000 subjects selected from 7000 houses
all over Pakistan by FBS sampling unit
Rapid test used (ELISA verified)
2.5% were HBsAg positive (4 million)
5% were HCV positive (8 million)
Total positive 7.5% (12 million)
Major risk factors for spread of
hepatitis B & C
Therapeutic injections for various reasons
with reused syringe (14/person/year)
Improperly sterilized medical devices
Blood transfusion
Shaving by barbers, body piercing
Rituals
Who need screening for B&C
Operated
Blood transfused/thalessemia etc
Frequent therapeutic injections
Dental treatment
Dialysis
Health care providers
HBV/HCV cases
Others
How do u diagnose hepatitis C
Anti HCV is a permanent stamp that identifies
exposure
Whether virus is there or not is based on LFTs
(ALT)
Raised ALT means virus is there and patient may
need treatment
Normal ALT means virus is expelled out, no
treatment is required
PCR (HCV RNA) indicates viral presence
What is chronic hepatitis B&C
Any hepatitis infection that lasts over 6
months is chronic hepatitis
Most of the times it is difficult to tell how
old is the exposure
Need 2 reports of HBsAg and ALT 6
months apart
For HCV 2 raised ALTs and 1 ELISA
Inclusion criteria for HCV for the
program
Nave patient (non responders have poor response)
No co-infection with HBV
Age 10-60 years
Non pregnant
No cirrhosis (albumin, spleen. PV)
No decompensation
HCV reactive by ELISA
ALT raised by 1.5 to 2 times the upper limit on 2
occasions 6 months apart
Baseline tests for HCV after
induction
CP
ALT
Serum albumin
Ultrasound abdomen (PV,spleen, ascites)
Sugar
Creatinine
Optional- Thyroid functions
- liver biopsy in normal ALT
When to do PCR
Patient is HCV+ve
ALT is raised at 2 occasions 6 months apart
Patient fulfills inclusion criteria
Willing to take treatment
Can afford PCR
No need to do qualitiative PCR or
genotyping
HCV treatment plan
HCV +ve ELISA

ALT raised> 2 times at 2


Occasions 6 months apart

Inclusion criteria

HCV RNA+ve

Start 6 months
IFN therapy

CP,ALT every month


HCV RNA at 3 or 6 months
What treatment
IFN 3 Miu 3 times/wk for 6 months
Patient should take injection
subcutaneously himself, those who inject
get infected
Take ribavarin daily
Normal diet, normal activity
Check PCR at end of treatment
Side effects of IFN
Fever
Bodyaches
Temporary hair fall
Anorexia
Fatigue

Panadol, B complex and good food will


reduce these effects
Side effects of Ribavarin
Produces hemolysis
In most cases Hb will drop by 3 grams
Always start therapy when Hb is over 11 grams, else
give iron and folate to bring Hb up
With ribazole, anemia is macrocytic as heme goes
back in circulation
Add folic acid when ever more drastic Hb drop is
seen
Reduce ribazole dose or stop if Hb <6 gms
How to follow
CP, ALT every month (Hb, TLC, platelets)
ALT should reach baseline in a month (if no
check, site of injection/compliance)
HCV RNA at 3 or 6 months (should become
non detected by 3 months)
HCVRNA at 12 months (sustained response)
Tailor drugs when CP shows side effects
Response/ relapse
About 60-70% will recover completely
30% will relapse
Disease shall not aggravate in relapsers, so
dont panic yourself and the patient
Do not give Peg.IFN as chances are only
10% response
Wait as new drugs are in pipeline
Interventions during therapy

Ribazole: Hemolysis-add folic acid


Add iron if microcytosis
Acetaminophen oral for pains and fever
Vitamin B complex to keep going
Fever to be appreciated as a response and
not reaction
Good food intake
When to reduce therapy
Hb drops around 8 grams
Reduce Ribazole
TLC /platelets are around 2500 and 40,000
Reduce IFN
When to stop treatment in between
therapy
Stop treatment if ALT does not touch
baseline by 3 months
HCV RNA is still positive at 3 or 6 months
Hb drops below 6 gms
Platelets go below 30,000
TLC goes below 1200-1500
Treatment urgency
No urgency, virus takes 15-20 years to go into
cirrhosis- a stage where only supportive treatment
is done
Wait for 4-6 months to follow the disease
Avoid treatment in aged, non responders,
relapsers,non affording cases
Virus is not passed from mother to child during
pregnancy or feeding
Breast feeding should be continued for at least a
year before starting mothers treatment
Whom to observe but not treat
Pregnant and lactating cases
Low Hemoglobin
Uncontrolled diabetes

All above cases can be treated once they are fit


HCV is a chronic slow growing disease so no harm
in waiting and observing.
If someone goes in decompensation in 1-2 years then
it is already an advanced disease
Do not treat
Relapsed cases
Non responders
Non compliant
Low platelets (< 70.000)
Advanced cirrhosis
Decompensated liver disease
Dialysis (CRF), cardiac cases
Pregnant
Prevention of HCV
No vaccine available globally
Avoid un necessary injections
Always destroy a syringe after use
Always sterilize invasive medical devices
Rationalize blood transfusion
Avoid shaving outside
Public awareness to demand good clinical
practices
Our duty!
We all have a role in health sector
Follow SOPs in our fields, make SOPs where
required
At least adhere to minimum standards
Justify all transfusions, injections and
practices/treatments that we prescribe
Should feel proud in avoiding transfusion,
injection and reuse of devices- would mean
saving at least 1life/ procedure