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Viral hepatitis
Hepatitis A, B, and C are caused by different viruses that infect the liver. Hepatitis A is transmitted through the fecal-oral route and causes an acute infection but does not result in chronic liver disease. Hepatitis B can be transmitted through blood or bodily fluids and may result in either an acute or chronic infection. Hepatitis C is transmitted through blood and causes a chronic infection that can lead to cirrhosis or liver cancer.
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Viral hepatitis
- 1. Hepatitis A,B &CHepatitis A,B & C VirusesViruses
- 2. IntroductionIntroduction Hepatitis is adisease of the liver that causes inflammation and swelling, potentially resulting in permanent damage. It can be quite painful and its effects can make its victims feel weak. Hepatitis infections can be acute or chronic, and people can die from them. The disease can be caused by many different factors, including infectious organisms, chemical toxins, poisons, drugs, and alcohol. Unlike non viral hepatitis, which can be caused by any number of noninfectious means, viral hepatitis is caused by one of six different viruses: hepatitis A, hepatitis B, hepatitis C, hepatitis D, hepatitis E, or hepatitis G.
- 3. Differential Diagnosis ofAcute HepatitisDifferential Diagnosis of Acute Hepatitis Autoimmune diseases Viral infections Bacterial infections Parasitic infections Drugs Toxins hepatitis A, B, C, D, and E, CMV, EBV, HSV, VZV, yellow fever typhoid fever, Q fever, leptospirosis, secondary syphillis, sepsis toxocariasis, liver flukes ASA (Aspirin ), acetaminophen,rifampin, oral contraceptives, sulfonamides, etc Alcohol, carbon tetrachloride Autoimmune hepatitis, SLE
- 4. Classification of HepatitisVirusesClassification of Hepatitis Viruses *linear, single strand; ** circular, double strand; Virus HAV HBV HCV DNA or RNA RNA* DNA** RNA* Family Picornaviridae Hepadnaviridae Flaviviridae Envelope no yes yes
- 5. Clinical Manifestations ofClinicalManifestations of Acute Viral HepatitisAcute Viral Hepatitis Asymptomatic Symptomatic Fulminant liver failure and death • Jaundice • Scleral icterus • Abdominal/RUQ pain • Hepatomegaly • Arthritis Typical Signs and Symptoms • FeverFever • MalaiseMalaise • AnorexiaAnorexia • NauseaNausea • VomitingVomiting
- 6. Laboratory Findings inAcute ViralLaboratory Findings in Acute Viral HepatitisHepatitis • Elevated ALT (SGPT) and AST (SGOT). • Elevated bilirubin. • Elevated alkaline phosphates. Laboratory indicators of liver pathologyLaboratory indicators of liver pathology Laboratory indicators of infectionLaboratory indicators of infection • Increased WBC.
- 7. Immunologic Markers UsedforImmunologic Markers Used for Serologic DiagnosisSerologic Diagnosis Immune globulin of the G subclass (IgG): • Produced in later infection Total immune globulin (Total Ig): • Combination of IgM and IgG Immune globulin of the M sublcass (IgM): • Produced in early infection
- 8. Source of virus feces blood/ blood-derived bodyfluids blood/ blood-derived body fluids Route of transmission fecal-oral percutaneous permucosal percutaneous permucosal Chronic infection no yes yes Prevention pre/post- exposure immunization pre/post- exposure immunization blood donor screening; risk behavior modification Type of Hepatitis A B C
- 9. Hepatitis A VirusHepatitisA Virus Hepatitis A is a very infectious viral cause of acute hepatitis. It is an acute illness, which means that the symptoms can come on suddenly and sharply, causing a range of clinical problems from mild illness with no symptoms to more severe illness and even, on rare occasion, acute liver failure and death. Hepatitis A eventually goes away and does not cause chronic problems . At one time, hepatitis A was referred to as "infectious hepatitis" because it could be spread from person to person like other viral infections.
- 10. Incubation period:Average 30 days Range 15-50 days Jaundice by <6 yrs, <10% age group: 6-14 yrs, 40%-50% >14 yrs, 70%-80% Complications: Fulminant hepatitis Cholestatic hepatitis Relapsing hepatitis Chronic sequelae: None Hepatitis A - Clinical Features
- 11. Fecal HAV Symptoms 0 1 23 4 5 6 1 2 2 4 Hepatitis A Infection Total anti- HAV Titre ALT IgM anti-HAV Months after exposureMonths after exposure Typical Serological Course
- 12. NauseaNausea Loss of appetiteLossof appetite VomitingVomiting FatigueFatigue FeverFever Dark urineDark urine Pale stoolPale stool JaundiceJaundice Stomach painStomach pain Side painSide pain A person may have all, some or none of these Hepatitis AHepatitis A SymptomsSymptoms
- 13. Close personal contact (e.g.,household contact, sex contact, child day care centers) Contaminated food, water (e.g., infected food handlers, raw shellfish) Blood exposure (rare) (e.g., injecting drug use, transfusion) Hepatitis A Virus Transmission
- 14. Laboratory DiagnosisLaboratory Diagnosis Acuteinfection is diagnosed by the detection ofAcute infection is diagnosed by the detection of HAV-IgM in serum by EIAHAV-IgM in serum by EIA.. Past Infection i.e. immunity is determined by thePast Infection i.e. immunity is determined by the detection of HAV-IgG by EIAdetection of HAV-IgG by EIA..
- 15. Many cases occurin community-wideMany cases occur in community-wide outbreaksoutbreaks no risk factor identified for most casesno risk factor identified for most cases highest attack rates in 5-14 year oldshighest attack rates in 5-14 year olds children serve as reservoir of infectionchildren serve as reservoir of infection Persons at increased risk of infectionPersons at increased risk of infection Travelers to endemic countriesTravelers to endemic countries homosexual menhomosexual men injecting drug usersinjecting drug users Hepatitis A Vaccination Strategies Epidemiologic Considerations
- 16. -Pre-exposure-Pre-exposure travelers to intermediateand hightravelers to intermediate and high HAV-endemic regionsHAV-endemic regions -Post-exposure (within 14 days)-Post-exposure (within 14 days) RoutineRoutine household and other intimate contactshousehold and other intimate contacts Selected situationsSelected situations institutions (e.g., day care centers)institutions (e.g., day care centers) common source exposure (e.g., food prepared bycommon source exposure (e.g., food prepared by infected food handler)infected food handler) Hepatitis A Prevention - Immune Globulin
- 17. Hepatitis B VirusHepatitisB Virus Type B hepatitis was at one time referred to as "serum hepatitis," because it was thought that the only way hepatitis B virus (HBV) could spread was through blood or serum ) the liquid portion of blood) containing the virus. The course of hepatitis B may be extremely variable. Hepatitis B virus infection has different clinical manifestations depending on the patient’s age at infection and immune status, and the stage at which the disease is recognized.
- 18. Incubation period:Average 60-90 days Range 45-180 days Clinical illness (jaundice): <5 yrs, <10% 5 yrs, 30%-50% Acute case-fatality rate: 0.5%-1% Chronic infection: <5 yrs, 30%-90% 5 yrs, 2%-10% Premature mortality from chronic liver disease: 15%-25% Hepatitis B - Clinical Features
- 19. Spectrum of ClinicalManifestations ofSpectrum of Clinical Manifestations of Hepatitis B DiseasesHepatitis B Diseases The spectrum of clinical manifestations of hepatitis B virus (HBV) infection varies in both acute and chronic disease. During the acute phase, manifestations range from subclinical or anicteric hepatitis to icteric hepatitis and, in some cases, fulminant hepatitis; during the chronic phase, manifestations range from an asymptomatic carrier state to chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Extrahepatic manifestations can also occur with both acute and chronic infection
- 20.
- 21. Patient with LivercirrhosisPatient with Liver cirrhosis
- 22. Symptoms HBeAg anti-HBe Total anti-HBc IgManti-HBc anti-HBsHBsAg 0 4 8 12 16 20 24 28 32 36 52 100 Acute Hepatitis B Virus Infection withAcute Hepatitis B Virus Infection with RecoveryRecovery Typical Serologic CourseTypical Serologic Course Weeks after Exposure Titre
- 23. IgM anti-HBc Total anti-HBc HBsAg Acute (6months) HBeAg Chronic (Years) anti-HBe 0 4 8 12 16 20 24 28 32 36 52 Years Weeks after Exposure Titr e Progression to Chronic Hepatitis B Virus InfectionProgression to Chronic Hepatitis B Virus Infection Typical Serologic CourseTypical Serologic Course
- 24. NauseaNausea Loss of appetiteLossof appetite VomitingVomiting FatigueFatigue FeverFever Dark urineDark urine Pale stoolPale stool JaundiceJaundice Stomach painStomach pain Side painSide pain A person may have all, some or none of these Hepatitis BHepatitis B SymptomsSymptoms
- 25. High Moderate Low/Not Detectable blood semenurine serum vaginal fluid feces wound exudates saliva sweat tears breastmilk Concentration of Hepatitis B Virus in Various Body Fluids
- 26. Sexual -sex workers and homosexuals are particular at risk. Parenteral - IVDA, Health Workers are at increased risk. Perinatal - Mothers who are HBeAg positive are much more likely to transmit to their offspring than those who are not. Perinatal transmission is the main means of transmission in high prevalence populations. Hepatitis B Virus Modes of Transmission
- 27. Who is atRisk for HBV InfectionWho is at Risk for HBV Infection?? High-risk heterosexual men and women Sexually active homosexual men Injection drug users Health care workers Household and sex partners of persons with chronic infection Hemodialysis patients Recipients of blood products Clients and employees of institution for developmentally disabled Families of adoptees from HBV endemic countries Inmates of correctional facilities
- 28. DiagnosisDiagnosis --A battery ofserological tests are used for the diagnosis ofA battery of serological tests are used for the diagnosis of acute and chronic hepatitis B infectionacute and chronic hepatitis B infection.. HBsAgHBsAg - used as a general marker of infection- used as a general marker of infection.. HBsAbHBsAb - used to document recovery and/or immunity to- used to document recovery and/or immunity to HBV infectionHBV infection.. anti-HBc IgManti-HBc IgM - marker of acute infection- marker of acute infection.. anti-HBcIgGanti-HBcIgG - past or chronic infection- past or chronic infection.. HBeAgHBeAg - indicates active replication of virus and therefore- indicates active replication of virus and therefore infectivenessinfectiveness.. Anti-HbeAnti-Hbe - virus no longer replicating. However, the patient- virus no longer replicating. However, the patient can still be positive for HBsAg which is made bycan still be positive for HBsAg which is made by integrated HBVintegrated HBV.. HBV-DNAHBV-DNA - indicates active replication of virus, more- indicates active replication of virus, more accurate than HBeAg especially in cases of escapeaccurate than HBeAg especially in cases of escape mutants. Used mainly for monitoring response tomutants. Used mainly for monitoring response to
- 29. TreatmentTreatment InterferonInterferon - forHBeAg +ve carriers with chronic- for HBeAg +ve carriers with chronic active hepatitis. Response rate is 30 to 40%active hepatitis. Response rate is 30 to 40%.. LamivudineLamivudine - a nucleoside analogue reverse- a nucleoside analogue reverse transcriptase inhibitor. Well tolerated, most patientstranscriptase inhibitor. Well tolerated, most patients will respond favorably. However, tendency towill respond favorably. However, tendency to relapse on cessation of treatment. Another problemrelapse on cessation of treatment. Another problem is the rapid emergence of drug resistanceis the rapid emergence of drug resistance.. Successful response to treatment will result in theSuccessful response to treatment will result in the disappearance of HBsAg, HBV-DNA, anddisappearance of HBsAg, HBV-DNA, and seroconversion to HBeAgseroconversion to HBeAg..
- 30. PreventionPrevention Vaccination - highlyeffective recombinant vaccines are now available. Vaccine can be given to those who are at increased risk of HBV infection such as health care workers. It is also given routinely to neonates as universal vaccination in many countries. Hepatitis B Immunoglobulin - HBIG may be used to protect persons who are exposed to hepatitis B. It is particular efficacious within 48 hours of the incident. It may also be given to neonates who are at increased risk of contracting hepatitis B i.e. whose mothers are HBsAg and HBeAg positive. Other measures - screening of blood donors, blood and body fluid precautions.
- 31. Hepatitis C VirusHepatitisC Virus Type C hepatitis was previously referred to as "non-A, non-B hepatitis," because the causative virus had not been identified, but it was known to be neither hepatitis A nor hepatitis B. The hepatitis C virus (HCV) usually is spread by shared needles among drug abusers, blood transfusion, hemodialysis, and needle sticks. Approximately 90% of transfusion-associated hepatitis is caused by hepatitis C. Transmission of the virus by sexual contact has been reported, but is considered rare. An estimated 50-70% of patients with acute hepatitis C infection develop chronic HCV infection. Patients with chronic hepatitis C infection can continue to infect others. Patients with chronic hepatitis C infection are at risk for developing cirrhosis, liver failure, and liver cancer.
- 32. Features ofFeatures of HCVInfectionHCV Infection Incubation periodIncubation period Average, 6–7 wkAverage, 6–7 wk Range, 2–26 wkRange, 2–26 wk Acute illness (jaundice)Acute illness (jaundice) Mild (20%–30%)Mild (20%–30%) Persistent infectionPersistent infection 75%–85%75%–85% Chronic hepatitisChronic hepatitis 70%70% ImmunityImmunity No protective antibodyNo protective antibody response identifiedresponse identified
- 33. Cirrhosis 17 Chronic 85 Risk of FatalOutcome in Persons WhoRisk of Fatal Outcome in Persons Who Develop Hepatitis C InfectionDevelop Hepatitis C Infection Courtesy of Seeff, LB and Alter, HJ. 100 Resolve 15 Stable 68 Stable 13 Mortality 4 80% 20% 75% 25% 15% 85%
- 34. Chronic Hepatitis CInfectionChronic Hepatitis C Infection The spectrum of chronic hepatitis C infection isThe spectrum of chronic hepatitis C infection is essentially the same as chronic hepatitis Bessentially the same as chronic hepatitis B infectioninfection.. All the manifestations of chronic hepatitis BAll the manifestations of chronic hepatitis B infection may be seen, albeit with a lowerinfection may be seen, albeit with a lower frequency i.e. chronic persistent hepatitis, chronicfrequency i.e. chronic persistent hepatitis, chronic active hepatitis, cirrhosis, and hepatocellularactive hepatitis, cirrhosis, and hepatocellular carcinomacarcinoma..
- 35. Symptoms anti- HCV ALT Normal 0 1 23 4 5 6 1 2 3 4 Hepatitis C Virus Infection Typical Serologic Course Titr e Mont hs Years Time after Exposure
- 36. NauseaNausea Loss of appetiteLossof appetite VomitingVomiting FatigueFatigue FeverFever Dark urineDark urine Pale stoolPale stool JaundiceJaundice Stomach painStomach pain Side painSide pain Hepatitis CHepatitis C SymptomsSymptoms 3 out of 4 persons have no symptoms and can infect others without knowing it
- 37. Transfusion ortransplant from infected donor Injecting drug use Hemodialysis (yrs on treatment) Accidental injuries with needles/sharps Sexual/household exposure to anti-HCV-positive contact Multiple sex partners Birth to HCV-infected mother Risk Factors Associated with Transmission of HCV
- 38. Laboratory DiagnosisLaboratory Diagnosis HCVantibodyHCV antibody - generally used to diagnose hepatitis- generally used to diagnose hepatitis C infection. Not useful in the acute phase as itC infection. Not useful in the acute phase as it takes at least 4 weeks after infection beforetakes at least 4 weeks after infection before antibody appearsantibody appears.. HCV-RNAHCV-RNA - various techniques are available e.g.- various techniques are available e.g. PCR and branched DNA. May be used toPCR and branched DNA. May be used to diagnose HCV infection in the acute phase.diagnose HCV infection in the acute phase. However, its main use is in monitoring theHowever, its main use is in monitoring the response to antiviral therapyresponse to antiviral therapy.. HCV-antigenHCV-antigen - an EIA for HCV antigen is available.- an EIA for HCV antigen is available. It is used in the same capacity as HCV-RNAIt is used in the same capacity as HCV-RNA tests but is much easier to carry outtests but is much easier to carry out..
- 39. TreatmentTreatment InterferonInterferon - maybe considered for patients with- may be considered for patients with chronic active hepatitis. The response rate ischronic active hepatitis. The response rate is around 50% but 50% of responders will relapsearound 50% but 50% of responders will relapse upon withdrawal of treatmentupon withdrawal of treatment.. RibavirinRibavirin - there is less experience with ribavirin- there is less experience with ribavirin than interferon. However, recent studies suggestthan interferon. However, recent studies suggest that a combination of interferon and ribavirin isthat a combination of interferon and ribavirin is more effective than interferon alonemore effective than interferon alone..
- 40. • There isno vaccination to protect against hepatitis C, but there are ways to reduce your risk of becoming infected. • Injecting drug users are most at risk of contracting the infection. Never share any injecting equipment, such as needles, syringes and filters. • Also, do not share razors, toothbrushes or towels that might be contaminated with blood. Use a condom if you are having sex with a new partner. Screening of blood, organ, tissue donors Blood and body fluid precautions Be cautious about body piercing and tattooing Prevention of Hepatitis CPrevention of Hepatitis C
- 41. ElecsysElecsys The roche diagnosticElecsys immunoassay system is a fully automated system that we use for testing serological investigation (HIV,HBV,HCV) (for donors and patients who shows positive results by card) and Hormones Thyroid hormones FT3,FT4,TSH) Only HBsAg and anti Hepatitis C are screened by Elecsys for donors and not Hepatitis A because Hepatitis A transmitted by food and not blood and is an acute infection that eventually goes away and does not cause chronic problem, so we just ask the donors if they had jaundice before.
- 42. Every day beforewe start the Elecsys we have toEvery day before we start the Elecsys we have to check the followingcheck the following:: Water level.Water level. Check the clean cell & the pro cell level.Check the clean cell & the pro cell level. Empty the liquid waste.Empty the liquid waste. Empty the solid waste.Empty the solid waste. Then open the machine and make the dailyThen open the machine and make the daily maintenance.maintenance. Place the reagent bottles and make reagentPlace the reagent bottles and make reagent scan.scan.
- 43. Calibration & Q.CCalibration& Q.C Controls must be done every time we use theControls must be done every time we use the machine.machine. If the control is not within range we changeIf the control is not within range we change the control with a new one (possiblethe control with a new one (possible contamination).contamination). If it still not good we make calibration.If it still not good we make calibration. Calibration is also require when the reagent isCalibration is also require when the reagent is new and need calibration.new and need calibration.
- 44. When finish workingon the machine make finalization and take the reagent out of the machine but them on the fridge, and shut down the machine.