1. Four inmates have presented with upper abdominal pain and diarrhea, symptoms consistent with hepatitis A.
2. The latest patient reports eating raw seashells from home, indicating potential fecal-oral transmission of hepatitis A through contaminated food.
3. Outbreaks of hepatitis A can occur in closed settings like prisons where hygiene and sanitation may be challenges, allowing the virus to spread among susceptible individuals. Testing is needed to confirm hepatitis A as the cause.
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Viral hepatitis in human
1.
2.
3. Brief History of Hepatitis
• A breakthrough of understanding Hepatitis came
in 1963 by Dr. Baruch Blumberg.
• He discovered an antigen that detected the
presence of Hepatitis B (HBV) in blood samples.
• Later discovered an unusual antigen from a blood
sample of an Australian Aborigine, which they
called the Australian antigen.
• After further research, it was recognised to be the
antigen that caused Hepatitis B - 1967
4. Cont.
• Hepatitis A- Early 1970s
• In 1989 Hepatitis C virus (HCV) was isolated,
unfortunately there is no vaccine for Hepatitis
C.
• Hepatitis E (HEV) – Identified in 1990
• Hepatitis G(HGV) - Identified in 1995
8. Cont.
• Hepatitis A is a viral liver disease that can cause
mild to severe illness.
• Is caused by the hepatitis A viruses(HAV).
• Almost everyone recovers fully from hepatitis A
with lifelong immunity. However, a very small
proportion of people infected with hepatitis A
could die from fulminant hepatitis.
• A safe and effective vaccine is available to
prevent Hepatitis A.
• The incubation period of Hepatitis A is usually an
average of 10-50 days.
9.
10. How Is It Spread?
• HAV is found in the feces of people(fecal-oral
route) with hepatitis A and is usually spread by
close personal contact. (including sexual
intercourse or living in the same household)
• It can also be spread by eating food or drinking
water contaminated with HAV and by travelling
internationally where HAV infection is occurring.
• Waterborne outbreaks, though infrequent, are
usually associated with sewage-contaminated or
inadequately treated water.
11. Symptoms
• Symptoms of hepatitis A range from mild to
severe, and can include:
Fever
Malaise
Loss of appetite
Diarrhoea
Nausea
Jaundice
Dark coloured urine
Abdominal discomfort
12.
13. Cont.
• Hepatitis B is a viral infection that attacks the
liver and can cause both acute and chronic
disease.
• Is caused by the Hepatitis B virus (HBV)
• According WHO, an estimated of 240 million
people are chronically infected with hepatitis B
and more than 686 000 people die every year due
to complications including cirrhosis and liver
cancer.
• Hepatitis B can be prevented currently by a
vaccine.
14. Pathogenesis of Hepatitis B
• Proliferative Phase: Episomal form produces
complete viral particles (infectivity)
• Target viral antigens (HBsAg,HBcAg)expressed on the
surface in association whith HLA class 1.
• Cytotoxic T lymphocytes directed against multiple
HBV epitopes kill infected hepatocytes.
• Antiviral antibodies apperar- infectivity ends, hepatitis
ends.
• Replication continues- carier with chronic hepatitis
• Intergrative Phase: Intergrated into DNA(chronic
hepatitis)
15. How Is It Spread?
• The Hepatitis B virus can survive outside the body for
at least 7 days.
• The incubation period is 75 days on average, but can
vary from 30 to 180 days.
• In highly endemic areas, hepatitis B is most commonly
spread from mother to child(perinatal transmission) or
through horizontal transmission (exposure to infected
blood).
• Hepatitis B is also spread by percutaneous or mucosal
exposure to infected blood and various body fluid, as
well as through saliva, menstrual, vaginal and seminal
fluids.
16. Cont.
• Sexual transmission of hepatitis B may occur,
particularly in unvaccinated men who have sex
with men and heterosexual persons with multiple
sex partners or contact with sex workers.
• Transmission of the virus may also occur through
the reuse of needles and syringes either in health-
care settings or among persons who inject drugs.
• In addition, infection can occur during medical,
surgical and dental procedures, through tattooing,
or through the use of razors and similar objects
that are contaminated with infected blood.
17. Symptoms
• Most people do not experience any symptoms
during the acute infection phase. However, some
people have acute illness with symptoms that last
several weeks, including:
• Jaundice
• Dark urine
• Extreme fatigue
• Nausea
• Vomiting
18.
19. Cont.
• Hepatitis C is a liver disease caused by the hepatitis C virus.
The virus can cause both acute and chronic hepatitis
infection, ranging in severity from a mild illness lasting a
few weeks to a serious, lifelong illness.
• Globally, between 130–150 million people globally have
chronic hepatitis C infection.
• Approximately, 700 000 people die each year from hepatitis
C-related liver diseases.
• Antiviral medicines can cure approximately 90% of persons
with hepatitis C infection, thereby reducing the risk of death
from liver cancer and cirrhosis, but access to diagnosis and
treatment is low.
• There is currently no vaccine for hepatitis C; however
research in this area is ongoing.
20. Pathogenesis of Hepatitis C
• Inoculation of the pathogen.
• Viremia
• Viral integration and replication in hepatocytes,
also maybe in blood cells, bone marrow, lymph
nodes and spleen.
• Activation of immune system with low immune
response.
• Mutation changeability of the virus.
• Persistence of the virus.
21. How Is It Spread?
• The hepatitis C virus is a bloodborne virus. It is
most commonly transmitted through:
injecting drug use through the sharing of
injection equipment;
the reuse or inadequate sterilization of medical
equipment, especially syringes and needles in
healthcare settings; and
the transfusion of unscreened blood and blood
products.
The incubation period for hepatitis C is 2 weeks
to 6 months.
22. Symptoms
• Following initial infection, approximately 80% of
people do not exhibit any symptoms. Those who
are acutely symptomatic may exhibit:
Fever
Fatigue
Decreased appetite
Nausea
Vomiting
Dark urine
jaundice
23.
24. Cont.
• Also referred to as hepatitis D virus (HDV) and
classified as hepatitis delta virus, is a disease caused by
a small circular enveloped RNA virus.
• It is considered to be a sub-viral satellite because it can
only propagate in the presence of the hepatitis B viruses
(HBV).
• Hepatitis D virus (HDV) is a virus-like particle
consisting of a coat of hepatitis B viruses (HBV)
surface antigen and a unique internal antigen, the delta
antigen.
• Reservoirs- humans
• Hosts- humans
25. Cont.
• Vertical transmission from mother to child is
rare.
• Approximately 15 million people across the
world are chronically coinfected with HDV
and HBV.
• Currently there is no effective antiviral
treatment for hepatitis D.
• Hepatitis D infection can be prevented by
hepatitis B immunization.
26. Pathogenesis of Hepatitis D
• Sexual, parenteral, and perinatal transmission.
• Replication by RNA-directed RNAPol(Host
RNA Pol II)
• Requires concurrent HBV infection (needs it
for HBsAg)
• HDV greatly exacerbates liver damage caused
by HDV
• Chronic infections are a major cause of PHC
27. How Is It Spread?
• The routes of HDV transmission are the same as for
HBV: percutaneously or sexually through contact with
infected blood or blood products.
• Vertical transmission is possible but rare.
• Vaccination against HBV prevents HDV coinfection,
and hence expansion of childhood HBV immunization
programmes has resulted in a decline in hepatitis D
incidence worldwide.
• However, in some settings, the increase of hepatitis D
prevalence has been observed in people who inject
drugs, or as a result of migration from areas where
HDV is endemic.
28. Symptoms
• The symptoms for hepatitis D are similar to
hepatitis B, such as:
Fatigue
Abdominal pain
Nausea and vomiting
Jaundice
Fever
29.
30. Cont.
• Hepatitis E is a liver disease caused by infection with a
virus known as hepatitis E virus (HEV).
• Every year, there are an estimated 20 million HEV
infections worldwide, leading to an estimated 3.3
million symptomatic cases of hepatitis E, and 56 600
hepatitis E-related deaths.
• Hepatitis E is usually self-limiting but some cases may
develop into fulminant hepatitis (acute liver failure).
• A vaccine to prevent hepatitis E virus infection has
been developed and is licensed in China, but is not yet
available elsewhere.
31. Cont.
• The virus has at least 4 different types:
genotypes 1, 2, 3 and 4. Genotypes 1 and 2
have been found only in humans. Genotype 3
and 4 viruses circulate in several animals
(including pigs, wild boars, and deer) without
causing any disease, and occasionally infect
humans.
• Usually the infection is self-limiting and
resolves within 2–6 weeks.
32. Pathogenesis of Hepatitis E
• Similar to Hepatitis A.
• Virus replicates in the gut initially, before
invading the liver, and virus is shed in the stool
prior to the onset of symptoms.
• Viremia is transient
33. How Is It Spread?
• The hepatitis E virus is transmitted mainly
through the faecal-oral route due to faecal
contamination of drinking water.
• Ingestion of undercooked meat or meat products
derived from infected animals.
• transfusion of infected blood products.
• Vertical transmission from a pregnant woman to
her fetus.
• Incubation period following exposure to the
hepatitis E virus ranges from 2 to 10 weeks, with
an average of 5–6 weeks.
34. Symptoms
• An initial phase of mild fever, reduced appetite
(anorexia), nausea and vomiting, lasting for a
few days; some persons may also have
abdominal pain, itching (without skin lesions),
skin rash, or joint pain.
• Jaundice (yellow discolouration of the skin and
sclera of the eyes), with dark urine and pale
stools.
35.
36.
37. Hepatitis In Fiji
• The common one in Fiji is Hepatitis A- spread
through contaminated food or water.
• Hepatitis A outbreak in ____ during 20_?
• There were 160 clinical cases of hepatitis A
from which 15 were laboratory confirmed. The
attack rate as 349 per 10000 amongst the
population in the Nukuloa nursing zone.
• There was no reported deaths.
39. Hepatitis A
• Hepatitis A- There is no specific treatment for
hepatitis A. Recovery from symptoms
following infection may be slow and may take
several weeks or months.
• Therapy is aimed at maintaining comfort and
adequate nutritional balance, including
replacement of fluids that are lost from
vomiting and diarrhoea.
40. Hepatitis B
• Management-prevent progression of the disease
Pharmacotherapy
• Nucleos(t)ide reverse transcriptase inhibitors (eg, tenofovir disoproxil
fumarate, lamivudine)
• Hepatitis B/hepatitis C agents (eg, adefovir dipivoxil, entecavir, telbivudine,
PEG-IFN-a 2a, interferon alfa-2b)
Dietary changes
-For individuals with decompensated cirrhosis (prominent signs of portal
hypertension or encephalopathy
• A low-sodium diet (1.5 g/day)
• High-protein diet (ie, white-meat protein [eg, chicken, turkey, fish])
• Fluid restriction (1.5 L/day) in cases of hyponatremia
Liver transplantation
• Orthotopic liver transplantation
- fulminant hepatic failure
- end-stage liver disease
41. Hepatitis C
• ACUTE HEPATITIS C
-Acute hepatitis C is detected infrequently.
-When it is identified, early IFN therapy should be considered.
• CHRONIC HEPATITIS C
- Combinations of antiviral medications can help fight viral infections and
prevent serious liver problems such as cirrhosis and liver cancer.
Treatment for chronic hepatitis :
• pegylated interferon
• Ribavirin
newer medicines
• simeprevir
• sofosbuvir
• Aclatasvir
• a combination of ledipasvir and sofosbuvir
• a combination of ombitasvir, paritaprevir and ritonavir, taken with or without
dasabuvir
• Note: Ribavirin is contraindicated in pregnancy.
42. Hepatitis D
• There are no known treatments for acute or
chronic hepatitis D.
• You may be given large doses of a medication
called interferon for up to 12 months.
43. Hepatitis E
• Acute Hepatitis E
patient with severe acute hepatitis E can be
treated with ribavirin for 21 days.
ribavirin therapy is contraindicated in
pregnancy.
44. Tests
1.Hepatitis A
-blood test - proteins (antibodies) made by the body in response
to the virus.
IgM anti-HAV antibodies are found if you have an active or a
recent infection
IgG anti-HAV antibodies are found if you have had an infection
in the past or when you have had the hepatitis A vaccine.
2. Hepatitis B
-blood test-
• Hepatitis B antigens and antibodies
• Test to see whether HCV ,HAV, Epstein Bar virus are causing
the infection
• Test to see if infected with hepatitis D along with HBV.
45. Cont.
3.Hepatitis C
- BLOOD TEST
• looks for antibodies against HCV
• looks for the genetic material (RNA) of the hepatitis C virus
• find out the kind of hepatitis C virus (genotype) you have.
4. HEPATITIS D
-blood test- that can detect anti-hepatitis D antibodies in
your blood
5.HEPATITIS E
-BLOOD TEST -detection of IgM and IgG anti-HEV
antibodies and detection of HEV RNA.
-presence of HEV RNA indicates current infection
46. Cont.
Blood tests to check for liver damage
• Bilirubin, albumin, prothrombin time –to test how
well the liver is working
• ALT , AST, Alkaline phosphatase, lactic
dehydrogenase (LDH)- to test whether the liver is
damaged or inflamed.
47. Prevention
• Hepatitis A
Hepatitis A vaccine- offers immunity to adults &
children older that 1 yr of age.
Practicing good hygiene and sanitation
Avoid unclean food and water.
• Hepatitis B
Hepatitis B vaccine offers the best protection. All
infants and unvaccinated children, adolescents
and adults are at risk.
48. Cont.
• Those not vaccinated can prevent hepatitis B
by reducing exposure to virus by:
Using protection e.g. condoms
Not sharing needles
Not sharing personal items e.g. toothbrush,
razors, with an infected person
49. Cont.
• Hepatitis C
There is no vaccine.
Hand hygiene: including surgical hand preparation, hand
washing and use of gloves;
Safe handling and disposal of sharps and waste;
Provision of comprehensive harm-reduction services to
people who inject drugs including sterile injecting
equipment;
Testing of donated blood for hepatitis B and C (as well as
HIV and syphilis);
Training of health personnel; and
Promotion of correct and consistent use of condoms.
50. Cont.
• Hepatitis D
Prevention and control of HDV infection requires
prevention of HBV transmission through hepatitis B
immunization, blood safety, injection safety, and
harm reduction services. Hepatitis B immunization
does not provide protection against HDV for those
already HBV infected.
51. Cont.
• Hepatitis E
Prevention is the most effective approach against the
disease. At the population level, transmission of HEV
and hepatitis E disease can be reduced by:
maintaining quality standards for public water supplies;
establishing proper disposal systems for human feces.
• On an individual level, infection risk can be reduced by:
maintaining hygienic practices such as hand-washing
with safe water, particularly before handling food;
avoiding consumption of water and/or ice of unknown
purity.
52.
53. Case Study
• A 37 yr old male Itaukei, from prison,
presented pain in the upper quadrant.
• He has been having diarrhoea for 5 days.
• He is now the 4th inmate to have been
presenting such problems.
• Upon further investigation, the patient gives
history of eating seashells brought from home
which he had shared with others.
54. Cont.
Upon examination:
Patient was found to have Jaundice
His vitals were normal
Mild tenderness on RUQ
His chest was clear
Jaundice: sclera and palms
Pathogenesis
Shortly after the viruses eneters a new host, its initial response is to infect liver cells, called hepatocytes.
The viruses main target is the liver because the virus possesses surface antigens specific for resceptos found in the liver cells only
The binding of these viral antigens to hepatocyte receptos induces viral entry by receptor-mediated endocytosis and uncoats in the cytoplasm.
Generally, the liver is responsible for purifying blood and processing nutrients. A healthy liver is essential to the functioning of blood, lymph, and bile production. If the liver fails, all the other organs in the body will soon start to fail.
HCV can also be transmitted sexually and can be passed from an infected mother to her baby; however these modes of transmission are much less common.
Hepatitis C is not spread through breast milk, food, water or by casual contact such as hugging, kissing and sharing food or drinks with an infected person.
HDV- incomplete virus, so it needs help from HBV to replicate.