2Hepatitis is inflammation of the liver which can be caused by viruses, medications, or toxic agents. Non viral : miliary TB, staphylococcal bacteriemia, salmonelloses, amebiasis, drugs, etc.Viral hepatitis :, Hepatitis A,B,C,D,ECMV, Herpes, Epstein Barr virus, Rubella
3Viral Hepatitis 5 1 6 2 7 3 8 4 Hepatitis E Hepatitis A Click to add Title6Hepatitis GClick to add TitleHepatitis B7Hepatitis TTHepatitis C8Hepatitis DHepatitis Sen
4A Major Public Health Problems VIRAL HEPATITISA Major Public Health ProblemsCause Morbidity & MortalityChronic Hepatitis B & CHCCLiverCirrhosis
5SYMPTOMS a short, mild, flu-like illness nausea, vomiting and diarrhoealoss of appetiteweight lossjaundice (yellow skin and white of eyes, darker yellow urine and pale faeces)itchy skinabdominal pain
6Type of Hepatitis A B C D E Source of feces blood/ blood/ blood/ feces virusblood-derivedblood-derivedblood-derivedbody fluidsbody fluidsbody fluidsRoute offecal-oralpercutaneouspercutaneouspercutaneousfecal-oraltransmissionpermucosalpermucosalpermucosalChronicnoyesyesyesnoinfectionPreventionpre/post-pre/post-blood donorpre/post-ensure safeexposureexposurescreening;exposuredrinkingimmunizationimmunizationrisk behaviorimmunization;watermodificationrisk behaviormodification3
7Hepatitis A (HAV)Due to non enveloped, single stranded RNA picornavirusSerum AST and ALT increased to hundreds for 1 to 3 weeksRelative lymphocytosis is frequent
8Serologic test for HAV Ig M anti HAV : Anti HAV total: appears at the same time as syptoms in > 99% of casespeaks within first month, becomes nondetectable in 12 (usually 6)Presence confirms diagnosis of recent acute infectionAnti HAV total:Predominantly IgGAlmost always positive at onset of acute hepatitis and is usually detectable for lifeFound in ± 50% of population, indicaes previous exposure to HAV
9Hepatitis A Infection Typical Serological Course Total anti-HAV Titre SymptomsTitreALTFecalHAVIgM anti-HAV1234561224Months after exposure9
10Hepatitis B (HBV) Due to enveloped, double stranded DNA hepadna virus Divided into 3 stages:Acute hepatitis: lasts 1-6 months, mild/ no symptomsAST & ALT increased > tenfoldsSerum bilirubin is usually normal or slightly increasedHBsAg gradually arises to high titer and persist, HBeAg also appears
112. Chronic hepatitis: transaminase increased > 50% for > 6 months, most cases resolve but some develop cirrhosis and liver failureAST & ALT fall to 2-10x normal rangeHBsAg usually remains high and HBeAg remains present3. Chronic carrier: are usually but not always healthy and asymptomaticAST and ALT fall to normal or < 2x normalHBsAg positive > 6 months, HBc IgM negative, but anti HBc positive
12Hepatitis B Virus Modes of Transmission 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.222
13Concentration of Hepatitis B Virus in Various Body Fluids Low/NotHighModerateDetectablebloodsemenurineserumvaginal fluidfeceswound exudatessalivasweattearsbreastmilk111
15SEROLOGICAL TEST OF HBV A battery of serological tests are used for the diagnosis of acute and chronic hepatitis B infection.HBsAg - used as a general marker of infection.HBsAb - used to document recovery and/or immunity to HBV infection.anti-HBc IgM - marker of acute infection.anti-HBcIgG - past or chronic infection.HBeAg - indicates active replication of virus and therefore infectiveness.Anti-Hbe - virus no longer replicating. However, the patient can still be positive for HBsAg which is made by integrated HBV.HBV-DNA - indicates active replication of virus, more accurate than HBeAg especially in cases of escape mutants. Used mainly for monitoring response to therapy.
19Possible Outcomes of HBV Infection Acute hepatitis B infection3-5% of adult-acquired infections95% of infant-acquired infectionsChronic HBV infectionChronic hepatitis12-25% in 5 yearsCirrhosis6-15% in 5 years20-23% in 5 yearsHepatocellular carcinomaLiver failureDeathLiver transplantDeath
20PreventionVaccination - highly effective 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.
23Risk Factors Associated with Transmission of HCV Transfusion or transplant from infected donorInjecting drug useHemodialysis (yrs on treatment)Accidental injuries with needles/sharpsSexual/household exposure to anti-HCV-positive contactMultiple sex partnersBirth to HCV-infected mother111111
25Hepatitis C Virus Infection Typical Serologic Courseanti-HCVSymptomsTitreALTNormal1234561234MonthsYearsTime after Exposure101010
26PROGRESSION ACUTE HEPATITIS C CHRONIC 15-40% will spontaneously resolve, generally within the first 6-18 months after acute onset.60-85% will progress to chronic infectionCHRONIC85-90% stable10-15% progress to cirrhosis
27PROGRESSION CIRRHOSIS HCC 75% slowly progressive 25% progress to HCC 2-4% liver failureHCCRisk increases for every year for a patient with chronic hepatitis C.Patients without signs of cirrhosis can develop HCCFactors of poor prognosis:-Age >40 years-Alcohol > 50g/Hour-Male gender-Duration of infection-Co-infection HBV/HIV-Tobacco consumption
28Direct tests : components of the HCV particle Diagnosisof HCV InfectionDirect tests : components of the HCV particle1.HCV RNA(PCR)QualitativeQuantitative2. HCV Core antigenUsefull in detecting window peroidIndirect tests: detect antibody against HCVAnti HCVRIBA (recombinant immunoblot assay)
29Prevention of Hepatitis C Screening of blood, organ, tissue donorsHigh-risk behavior modificationBlood and body fluid precautions151515
30HEPATITIS D Double stranded enveloped RNA virus Depends upon HBV for expression and replicationOften severe with relatively high mortality in acute disease and frequent development of cirrhosis in chronic diseaseChronic HDV inf. Is more severe and higher mortality rate than other types of viral hepatitisSerologic test :Anti HDV in px with HBsAg positive hepatitis
31HEPATITIS E Unveloped, single stranded enveloped RNA virus Endemic area: Mexico, India, Africa, Burma, RussiaSerologic test:Antibody to hepatitis E establish dx.IgM antibodies indicate recent infectionSerologic markers for HVA, HBV, HCV and other cause of acute hepatiti are absent
32Soal KasusLaki2 datang dengan keluhan demam 14 hari, sklera tampak ikterus, nyeri tekan abdomen kanan atasPemeriksaan Lab apa yg anda usulkan?HBsAg (-)HBsAb (+)IgM anti HAV (+)anti HBc (-)Apa diagnosis pasien ini?