Viral Hepatitis Andy King Consultant Gastroenterologist/Hepatologist Birmingham Heartlands Hospital

HEPATITIS A Faeco-oral transmission Contaminated Food/Water ALT often >1000 LFTs peak at one month after exposure Self limiting Fulminant in <1%, older, CLD 70% symptomatic Nausea, vomiting, anorexia, fever, malaise Jaundice in 40% Jaundice resolves by 2 weeks Complete recovery usual by 2-3 months HEPATITIS A Diagnosis : IgM HAV positive (3-6 months) IgG positive lifelong after exposure Treatment Supportive Care with Hepatotoxics

HAV Vaccination Pre exposure Travellers to areas of high/intermediate prevalence CLD Haemophilia MSM IVDU Post exposure Contact of HAV infection Outbreaks (local health protection team)

HEPATITIS E ALT +++, usually back to normal 1-6 weeks Occasional prolonged cholestasis Asia/Africa – contmainated water Europe/America –porcine zoonosis Diagnosis: IgM HEV positive, (5 months) HEV RNA PCR but short viraemia Self limiting Most cases Asymptomatic HEPATITIS E Immunosuppressed/ CLD High Risk Pregnancy / CLD – 25-75% Mortality 0.5-4% Liver Failure Supportive Treatment Possible role for Ribavirin

Hepatitis B Largely imported – Asia, Africa, E. Europe Most infectious BBV (x100 more than HIV)

Hepatitis B Transmission Endemic Countries Vertical transmission (in utero, birth, breast feeding) Early childood, close interpersonal contact Unsterilised medical equipment UK Unprotected penetrative sex Sharing any drug equipment (not just needles) Unsterilised tattoos/piercings Needlestick Rarely – toothbrush/razor NOT contaminated food/water or casually in home/workplace

Serology OPD^22021466 ---------------------------------------- Hepatitis B HBsAg POSITIVE by EIA Hepatitis B HBsAg. Confirmed by Neutralisation Hepatitis B anti HBc POSITIVE by EIA Hepatitis B anti HBc IgM Negative by EIA Hepatitis B HBeAg Negative by EIA Hepatitis B anti HBe POSITIVE by EIA Hepatitis B Anti HBs Negative Hepatitis C Antibody Negative by EIA (Abbott) These results confirm previous findings. Please retest at 2-12 weeks after last exposure, for Hepatitis C if clinically indicated

+ - Meaning Acute Infection Chronic Infection Cleared infection Immunised Healthy Carrier HB core Antibody Exposure + - HB surface Antigen Infection HB surface Antibody Immunity

c Ab s Ag s Ab + -

c Ab s Ag s Ab + - c Ab s Ag s Ab + -

c Ab s Ag s Ab + -

c Ab s Ag s Ab + - > 6 months

c Ab s Ag s Ab + - c Ab s Ag s Ab + - > 6 months

c Ab s Ag s Ab + - c Ab s Ag s Ab + - > 6 months

Immunised c Ab s Ag s Ab - +

c Ab s Ag s Ab + - c Ab s Ag s Ab + - c Ab s Ag s Ab + - c Ab s Ag Immunised c Ab s Ag s Ab + - c Ab s Ag s Ab - + > 6 months

HBV Treatment Liver Events HCCa Liver Mortality Mortality

Reduced Risk Cirrhosis HCCa Mortality Prevent Transmission

HBV Vaccination Pre exposure Drug Users (partners and children) Sex workers Close family contact esp sexual Family adopting children from high prevalence area Regular blood products (eg haemophilia) CRF, CLD Travelling to areas of high prevalence Occupational risk Immediate post exposure Neonatal Needlestick (+/- Immunoglobulin)

Hepatitis C 200 million worldwide 3% worlds population 1.5 million deaths per year from HCV related liver disease 80% Acute HCV asymptomatic 80% become Chronic Most common symptom = Fatigue

HCV Transmission Drug Users - ANY drug equipment 27% users had shared in last 6 months, lack of disclosure Don’t forget anabolics, novel psychoactives, historical drug use even if only once Piercings/tattoos/shaving – rarely from razors, nail clippers, toothbrushes Vey low risk to household contacts Vertical: approx 5%, breast feeding NOT contraindicated

HCV Transmission Needlestick 1:50 risk from known HCV Sexual : uncommon but possible (0-2 per 1000 yrs) increased if coinfected HIV/STI or traumatic sex Transfusion :clotting factor<1987, blood <1991, transplant <1992 Medical/dental treatment in areas where HCV common and infection control poor - Pakistan, India, Africa, E Europe

- + Never Exposed Current Infection Spontaneous Clearance Successful Treatment Antibody - + RNA ‘viral load’ Not needed 12 – 100000+ <12 Genotype 1-6

HCV Ab + HCV RNA Detectable

HCV Treatment Mortality Liver Mortality HCCa Liver Failure

Interferon 6 mo

Genotype 3, no cirrhosis, 8 weeks Genotype 3, cirrhosis, 12 weeks 2016… 100 % 97 100 100 75 50 25 144 ABT-493 + ABT-530 ABT-493 + ABT-530 ABT-493 + ABT-530 + RBV Genotype 3, no cirrhosis, 8 weeks Genotype 3, cirrhosis, 12 weeks

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Primary Care: Adults and children at increased risk of infection Migrants from medium or high prevalence countries Current or Past Drug Use Newly registered – ever used drugs? Hep B Testing AND Vaccination to those at Increased risk of infection Annual Hep C testing to those at Ongoing risk of infection

Public Health: Overall responsibility for Contact Tracing Advise and oversee other organisations to ensure surveillance and follow up of Hepatitis B and C eg GPs providing HBV vaccination and specialist referral

Questions? andrew.king@heartofengland.nhs.uk