1. Viral hepatitis overview Itodo Ewaoche 27/02/2015

2. Normal liver

3. Functions of the liver

4. Hepatitis General term meaning liver injury (inflammation) Causes are many –Viruses –Alcohol –Toxins including drugs –Fats

5. Viral hepatitis Viruses that affect the liver Commonly hepatitis A, B, C, D and E Rarely other viruses

6. Hepatitis A Transmitted through eating or drinking food contaminated by stool. Hepatitis A common in developing countries 2/3 of children infected by 5 years of age Mainly does not make them ill They become protected for life

7. Hepatitis A In developed countries, HAV occurs in outbreaks –Contaminated salads, raw seafoods – Travels to developing countries Causes sickness like sore throat, fever, fatigue Rarely may cause severe liver disease (liver failure) Prevention –Good hygiene and sanitation practices –vaccine

8. Hepatitis E Acquired through contaminated food & drinks In developing countries it occurs in outbreaks –e.g Kitgum (2007), outbreak in Napak 2013-2014 Mainly causes mild disease More deaths among pregnant women Prevention –Hygiene –No readily available vaccine

9. Hepatitis C Transmitted through –IV drug use, –Sexual transmission –Tattooing and body piercing –blood transfusion before 1990 In Nigeria – at 2.6% across studies Causes liver scarring and its complications No vaccine

10. Hepatitis D Only occurs together with hepatitis B. The two viruses together cause more severe disease

11. Hepatitis B Transmitted through –Contact with infected blood –Sexual contact with an infected person –Sharing sharps –Mother to child

12. Hepatitis B NOT TRANSMITTED THROUGH: –Hugging –Sharing clothes, cups, plates, basins, or toilets –Sitting close to an infected person Therefore NO NEED FOR ISOLATION of infected persons

13. Distribution of hepatitis B in Nigeria 16.0% 13.09% 13.04% 12.08% 3.0% 7.04%

14. Proportion of adults who are exposed to HBsAg and HCV by age (Nigeria,2013)

15. Chronic HBV Nigeria Female sex workers (Forbic et al., 2008), Chronic Infection 17.1% Surgeons (Bello, 2000), Chronic Infection 25.7% Healthy Blood Donors, (Ejele et al., 2004), 14.9%

16. Chronic HBV in across some states 11.6% Maiduguri (Harry et al., 1994) 13.8% Lagos (Nasidi et al., 1985) 4.3% Portharcourt (Akani et al., 2005) 5.7% Illorin (Agbede et al., 2007)

17. Age at HBV infection % of patients who become chronic carriers 0 20 40 60 80 100 Birth1- 6 Months 7- 12 Months 1- 4 Years Adults Age-dependent risk of becoming a carrier of HBV

18. Natural Progression of CHB Adapted from: Fattovich, et al. Gastroenterology. 2004;127:S35-S50. Torresi, et al. Gastroenterology. 2000;118:S83- S103. Fattovich, et al. Hepatology. 1995;21:77-82. Perrillo, et al. Hepatology. 2001;33:424-432. Chronic Infection Cirrhosis Liver Failure Liver Cancer (HCC) Death 30% 23% in 5 yr Liver Transplantation Acute flare 10%–15% in 5 yr 5%– 10% 15%–40% of CHB patients may experience disease progression

19. Symptoms Like common illnesses e.g fatigue, joint pains, e.t.c If complications occur –Body swelling –Abdominal swelling/pain –Vomiting blood

20. Who should be tested for HBV? Blood and organs donors Pregnant women Infants of HBsAg + mothers Behavioural contacts: o Household and sexual contacts o HIV+, MSM, IDU Individuals from countries where prevalence is ≥2% Patients receiving cancer treatment Hemodialysis patients

21. How is HBV diagnosed? May be suspected from complaints Blood tests –Tests for HBV DNA –Virus particles –Tests of liver function –Liver scan Also screen for other viruses

22. Summary of required tests Viral load requirement- expensive HBeAg test- expensive Fibrosis –APRI –Fibroscan- not available in most SSA –Ultrasound –Biopsy not really done More available- LFTs, CBC

23. How is it treated? Supportive treatment for symptoms and complications Anti-viral drugs Diet restriction? –Depends on stage of disease

24. Approved HBV treatments Interferon alfa-2b – 1991 Lamivudine – 1998 Adefovir – 2002 Entecavir – 2005 Peginterferon alfa-2a – 2005 Telbivudine – 2006 Tenofovir - 2008

25. Prevention Safe sex practices Safe injection practices Void sharing sharps even within households Vaccine

26. Childhood vaccination All children in areas of high endemicity In Nigeria vaccine introduced in 2002 Pentavalent with DPT –Schedule 6 weeks, 10 weeks, 14 weeks

27. In high endemicity Birth dose vaccine recommended Not currently in Nigeria due to combination vaccine

28. Dose schedules Generally, 3 doses recommended –First Injection - At any given time Time 0 –Second Injection - At least one month after the first dose 4 weeks –Third Injection - Six months after the first dose 6 months

29. 29 Effectiveness of Hepatitis B Vaccination Programs  Incidence of acute hepatitis B  Prevalence of chronic HBV infection  Incidence of hepatocellular carcinoma Routine infant hepatitis B immunization programs decrease:

30. Summary of HBV infection Hepatitis B common in Nigeria It is preventable Need to test to know infection status Treatment for Hepatitis B available and may prevent complications