1. Hepatitis B Virus

2. *-در آزمايشلت دوران حاملگي خانمي30 ساله HbsAg مثبت و Anti Hbc IgMمنفی گزارش مي شود اين بيمار سراسيمه به شما مراجعه مي نمايد. به سوالات مطرح شده در ارتباط با اين بيمار پاسخ دهيد؟

3. 1 - خطر ابتلاء به بيماريهاي مزمن كبدي و عواقب ناشي از آن براي اين بيمار حدوداً چقدر مي باشد الف ـ 15-5% ب ـ 25-15% ج ـ 65-35% د ـ 80-60%

5. Hepatitis B - Clinical Features Incubation period:Average 60-90 days Range 45-180 days Acute case-fatality rate:0.5%-1% Premature mortality from chronic liver disease:15%-25%

6. 2- خطر مزمن شدن هپاتيت در اين فرد در صورتيكه در زمان نوزادي يا بلوغ مبتلا به هپاتيت B شود به ترتيب چقدر مي باشد ؟ الف ) 5-10 % ـ 90 % ب ) 25-30 % ـ 75 % ج ) 90-95 % ـ 5-10 % د ) 75 % ـ 25 %

7. Outcome of Hepatitis B Virus Infection by Age at Infection Outcome of Hepatitis B Virus Infection by Age at Infection Symptomatic Infection Chronic Infection Age at Infection Chronic Infection (%) Symptomatic Infection (%) Birth 1-6 months7-12 months 1-4 years Older Children and Adults 0 20 40 60 80 100 80 60 40 20 0

8. Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Weeks after Exposure Titer Symptoms HBeAg anti-HBe Total anti-HBc IgM anti-HBc anti-HBs HBsAg 0481216 20 242832 36 52100

9. Progression to Chronic Hepatitis B Virus Infection Typical Serologic Course Weeks after Exposure Titer IgM anti-HBc Total anti-HBc HBsAg Acute (6 months) HBeAg Chronic (Years) anti-HBe 048 12 16202428 32 36 52 Years

10. 3-ميزان آلودگي به هپاتيت Bدر كشور ما چقدرمي باشد ؟ الف ) 3-1.7% ب ) 1-0.5 % ج ) 8-5 % د ) 10 %

11. An estimated 350 million persons worldwide are chronically infected with HBV

12. The HBsAg carriers rate varies from 0.1 to 20 percent in different population in the world

13. High (  8%): 45% of global population –lifetime risk of infection >60% –early childhood infections common Intermediate (2%-7%): 43% of global population –lifetime risk of infection 20%-60% –infections occur in all age groups Low (<2%): 12% of global population –lifetime risk of infection <20% –most infections occur in adult risk groups Global Patterns of Chronic HBV Infection

14. Geographic Distribution of Chronic HBV Infection HBsAg Prevalence ³ 8% - High 2-7% - Intermediate <2% - Low

15. 4- كداميك از موارد زير جزء معيارهاي ناقلين سالم هپاتيت Bمي باشد؟ الف ـ ALTنرمال ب ـ HBV DNA < 105 copy/ml ج ـ HBe Ab (+) د ـ هر سه

16. Diagnostic Criteria:

17. Resolved Hepatitis B: 1- Previous known history of hepatitis or anti-HBC ± anti HBs 2- HBsAg - 3- Undetectable HBV DNA 4- Normal ALT

18. Inactive HBsAg Carrier State: - HBeAb+ - Normal ALT - Minimal or No Necroinflammation - Outcome is Benign - Serial tests should be performed before determined - 20% can have exacerbations: - ALT > 5 – 10 times - HBeAg± - Repeat can lead to progressive Fibrosis

19. Chronic Hepatitis B: 1- HBsAg+ > 6 m 2- HBV DNA > 10 5 3- Persistent or Intermittent  ALT/AST 4- Liver Biopsy Score ≥ 4

20. 5 - كداميك از حالات هاي زيرممکن است براي بيمار اتفاق افتد؟ الف ـ بهبود خود به خودي ب ـ سيروز ج ـ HCC د ـ هر سه

21. Outcome of Inactive HBsAg Carriers: -Generally Benign Exacerbation of hepatitis to 20% (as evidenced by  Alt ) Seroconversion of HBsAg to Anti HBs (0.5-1%per year) Progression to cirrhosis or HCC

22. Liver Cirrhosis The most common aetiology of liver cirrhosis in Iran is HBV,the second problem is higher chronically rate in those who acquired HBV in Perinatal period or early childhood and unfortunately screening of HBsAg in all of pregnant is not an obligatory.

23. Outcome of Cirrhosis - Compensated – 84% at 5y - 68% at 10 y - HBeAg+ 72% - HBeAg- 97% - De-Compensated – 14% at 10y Risk Factors for De-compensation: - HBeAg+ - Failure to Respond to Interferon

24. HCC HBV is the most common aetiology of hepatocellular carcinoma (72% of HCC patients have HBcAb, 46% of them are HBsAg positive).

25. 6 - براي تشخيص هپاتوسلولاركارسينوما (HCC) در فرد مبتلا به هپاتيت B كداميك از متدهاي زير مناسب است ؟ الف )  FP ب )  GT ج ) U.S (سونوگرافي) د ) الف و ج

26. Periodil: Screening for HCC

27. AFPr Testing

28. Normal is Less than 8-12 ng/ml - Sensitivity for Small HCC, 50-75% - Specificity is Above 90% - Negative Predictive Value > 99% - Positive Predictive Value is: 9-30%

29. US is the only radiographic test that has been prospectively studied as an imaging tool for HCC surveillance. the sensitivity for small HCC ranged from 68% to 87% and false- positive rate from 28% to 82%. Regenerating nodules, seen In patients with cirrhosis, are the most common reason for false-positive results. US is considerably more expensive than AFP.

30. Carriers of any age, even Asymptotic Persons with Normal ALT and Minimal or Absent Liver Disease, Can Develop HCC

31. Evaluation of patients with chronic HBV infection

32. Initial evaluation  History and physical examination  Laboratory tests to assess liver disease -complete blood counts with platelets, hepatic panel, and prothrombin time  Tests for HBV replication-HBeAg/anti-HBe, HBV DNA  Tests to rule out other causes of liver disease -anti-HCV,anti - HDV  Tests to screen for HCC-AFP and, in high risk patients, ultrasound  Liver biopsy to grade and stage liver disease-for patients who meet criteria for chronic hepatitis

33. Laboratory Tests CBC,Plt Liver function tests : Ast Alt,Alkp,GGt Bili(T,D)PT,PTT Total protein Albumin Globulin       FBS-chol-TG HBsAg,HBsAb,HBeA g,HBeAb,HBcAb

34. In High Risk Patients HIV Ab HCV Ab HDV Ab

35. 1-Hepatits B panel HBsAg-HBeAg-HBeAb - HBcAb- HBsAb  Confirmation of HBsAg(+)  Filing

36. Abdominal Sonography Liver-Spleen-Diameter of Portal vein Liver Biopsy Grading Staging

37. Follow-up for Patients Not Considered for Treatment

38. 1-InActive HBsAg Carrier State - ALT Every 6-12 months - If ALT > 1-2 x U.L.N, Check HBV DNA and Exclude Other Causes of Liver Disease - Screening for HCC

39. 2- HBeAg+, HBV DNA>10 5, Normal ALT - ALT Every 3-6 months - If ALT > 1-2 uln, Every 1-3 m. - If ALT>2, for 3-6 m., Consider Liver Biopsy and Treatment - Screening for HCC

40. Counseling and Prevention of Hepatitis B

41. HBV is transmitted by Perinatal, Percutaneous, Sexual Exposure, and Close person-to-person contact (presumably by open cuts and sores, especially among children in hyperendemic areas)

42. 7 - كداميك از موارد زير بيماري را بيشتر منتقل مي نمايد؟ الف ـ ترشحات زخم ب ـ بزاق ج ـ شير مادر د ـ ترشحات واژينال

43. Concentration of Hepatitis B Virus in Various Body Fluids Concentration of Hepatitis B Virus in Various Body Fluids HighModerate Low/Not Detectable bloodsemenurine serumvaginal fluidfeces wound exudatessalivasweat tears breastmilk

44. 8 - كداميك از توصيه هاي زير براي پيشگيري از انتقال بيماري به اطرافيان مورد قبول شماست؟ الف ـ جدا كردن ظرف غذا خوري و قاشق و چنگال ب ـ عدم دست دادن و بوسيدن فرد بيمار ج ـ عدم شنا در استخر يااستفاده از وان حمامي كه بيمار قبلا از آن استفاده كرده است. دـ هيچكدام

45. Prevent perinatal HBV transmission Routine vaccination of all infants Vaccination of children in high-risk groups Vaccination of adolescents – all unvaccinated children at 11-12 years of age –“ high-risk ” adolescents at all ages Vaccination of adults in high-risk groups Elimination of Hepatitis B Virus Transmission United States Strategy

46. Steady sexual partners should be tested and vaccinated against hepatitis B if found to be seronegative. For casual sex partners or steady partners who have not been tested or have not completed the full immuniza­ tion series, barrier protection methods should be employed.

47. 8) رژيم غذايي بيمار چگونه بايد باشد؟ الف ـ عدم مصرف تخم مرغ ب ـ عدم مصرف گوشت قرمز ج ـ عدم مصرف چربي د ـ هيچكدام

48. Non-Specific Dietary Unless Use of Alcohol > 40 g/d

49. Pregnant Women HBsAg+ should be Counseled:

50. 9- خطر انتقال بيماري به نوزادش در صورتيكه مادر HBe Ag+باشد چقدر است؟ الف ـ بيش از 90% ب ـ 80-60% ج ـ 55-35% د ـ 15-5%

51. Up to 9 out of 10 babies born to infected mothers will end up being hepatitis B carriers for the rest of their lives, if they do not get the shots. If you make sure your babies get all 3 shots, plus a shot called H-BIG, they have a 95% chance of being safe from hepatitis B for life. Can my baby die from hepatitis B? Most babies do not die from hepatitis B. carriers

52. 10-خطر مزمن شدن بيماري در نوزادان اين افراد چقدر مي باشد ؟ الف ) 10-5 % ب ) 30-25 % ج ) 80-70 % د ) 95-90 %

53. Outcome of Hepatitis B Virus Infection by Age at Infection Outcome of Hepatitis B Virus Infection by Age at Infection Symptomatic Infection Chronic Infection Age at Infection Chronic Infection (%) Symptomatic Infection (%) Birth 1-6 months7-12 months 1-4 years Older Children and Adults 0 20 40 60 80 100 80 60 40 20 0

54. The risk of developing chronic HBV infection after acute exposure 90% in newborns of HBeAg-positive mothers 25% to 30% in infants and children under 5 less than 10% in adults

55. 11- در صورت تزريق به موقع (HBIG)و واكسن هپاتيت Bبه نوزاد خطر انتقال بيماري چقدر خواهد بود؟ الف ـ حدود 90% ب ـ 70-50% ج ـ 25-15% د ـ حدود 5%

56. Babies who end up as carriers have a 1 out of 4 chance of dying from liver problems. Up to 9 out of 10 babies born to infected mothers will end up being carriers for the rest of their lives, if they do not get the shots. 19 out of 20 babies who get the shots will be protected for life! What if my baby does not get these shots?

57. 6 months old Hepatitis B Vaccine Baby Shots for Hepatitis B if the mother has Hepatitis B 1 - 2 months old Hepatitis B Vaccine + Birth H-BIG Hepatitis B Vaccine

58. If you have never had hepatitis B, you can get 3 shots...... and get long lasting protection. 321 Hepatitis B can be prevented!

59. 12- خطر انتقال بيماري به اعضاء خانواده حدوداً چقد ميباشد؟ الف ـ 90% ب ـ 70-50% ج ـ 35-25% د ـ 8-3%

60. - Screening of Family Members of the patient and Vaccination, if the Screening Tests (HBsAg, HBsAb) are Negative - Available Vaccines Against HBV: - Given 3 times: At Start, 1 & 6 Months Later Age Limited? None, Can Give in Newborns HBV Prevention

61. . Postvaccination testing should be performed 3-9 months after the last dose in infants of carrier mothers and 1-2 months after the last dose in other persons

62. Anti-HBs Seroconversion Rates after Hepatitis B Vaccination(%) Neonates>95 Age(YEARS) 2-19~99 20-29~95 30-39~90 40-49~85 50-59~70 >59~50 Renal failure, HIV infection,50-70 Other immunosupperession Liver disease60-70

63. Carriers should be advised to cover open cuts and scratches and clean up blood spills with bleach. because HBV can survive on environmental surfaces for at least 1 week.

64. For HBV carriers who are health care workers. the CDC recommends that those who are HBeAg-positive should not perform invasive procedures without prior counseling and advice from an expert review panel under what circumstances. if any. they should be allowed to perform these procedures. These circumstances would include notifying prospective patients of their HBV status prior to procedures.

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