1. Viral Hepatitis

2. Viral hepatitis is a major public health problem, occurring endemically in all areas of the world

3. TYPES OF VIRAL HEPATITIS
TYPE A (HAV)
TYPE B (HBV)
TYPE C (HCV)
TYPE DELTA (HDV)
TYPE E (HEV) 2

4. THREE PHASES OF “CLASSIC” HEPATITIS
PRODROMAL PHASE
Flu-like symptoms
ICTERIC PHASE
Jaundice
CONVALESCENT PHASE
Recovery 6

5. LAB TESTS Liver enzymes:
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
10 TO 100 FOLD INCREASE CAN BE EXPECTED 10

6. LAB TESTS SERUM BILIRUBIN: hyperbilirubinemia
LEVELS MUST APPROACH 3mg/100ml TO
MANIFEST AS JAUNDICE
JAUNDICE OFTEN FIRST MANIFESTS IN SCLERA 12

7. LAB TESTS Prothrombin time: HIGHER THE PROTHROMBIN TIME (PT), THE
MORE SEVERE THE HEPATIC DAMAGE 14

8. HEPATITIS TYPE A (HAV) SINGLE-STRANDED RNA VIRUs
SPREAD MAINLY BY ORAL-FECAL
ROUTE
INCUBATION PERIOD DAYS 16

9. HAV Usually disease of young but can affect adult. OFTEN ASYMPTOMATIC
ILLNESS USUALLY SELF-LIMITING RECOVERY IS COMPLETE and does not need any specific treatment
NO EVIDENCE OF CHRONIC FORM OR CARRIER STATE OF HAV 21

10. Prevention TWO-DOSE VACCINE HEALTH CARE PROVIDERS -RECOMMENDED
6 MONTHS APART
AVAILABLE SINCE 1994
HEALTH CARE PROVIDERS -RECOMMENDED 22

11. Hepatitis B virus Hepadnaviridae member
100 times more infectious than HIV
10 times more infectious than HCV
The most common carcinogen after tobacco in man
Hepatitis B virus
Hepatitis B is a small enveloped virus within the Hepadnaviridae family of viruses.1 The photo shows an electron micrograph of hepatitis B virions.
Despite having a relatively low public profile compared with hepatitis C virus (HCV) or human immunodeficiency virus (HIV), hepatitis B is in fact 100 times more infectious than HIV and 10 times more infective than HCV.2
The National Institute of Health in the USA has designated hepatitis B as a known human carcinogen based on evidence from studies in humans.3
1. Schaefer S. World J Gastroenterol. 2007;13:14–21.
2. Hepatitis B: Revealing a Silent Killer. Workshop at the European Parliament, < [Accessed ].
3. NIH 11th report on carcinogens <ntp.niehs.nih.gov/ntp/roc/eleventh/profiles/s092thpb.pdf> [Accessed ].
Schaefer S. World J Gastroenterol. 2007;13:14–21. European Parliament. Hepatitis B: Revealing a Silent Killer. Workshop at the European Parliament, Available at: NIH 11th report on carcinogens Available at: ntp.niehs.nih.gov/ntp/roc/eleventh/profiles/s092thpb.pdf.

12. HEPATITIS B (HBV) CAN CAUSE ACUTE / AND A CHRONIC HEPATITIS
Can also cause CARRIER STATE
DAY INCUBATION PERIOD
MANY CASES ARE SUBCLINICAL AND MOST ARE ANICTERIC 23

13. Concentration of Hepatitis B Virus in Various Body Fluids
High concentration blood serum wound exudates
Moderate concentration semen vaginal fluid saliva
Low/Not Detectable urine feces sweat tears breast milk

14. Mode of spread Mainly by parenteral route
DIRECT PERCUTANEOUS INOCULATION OF INFECTED SERUM OR PLASMA
INDIRECTLY THROUGH CUTS OR ABRASIONS
ABSORPTION THROUGH MUCOSAL SURFACES
ABSORPTION OF OTHER INFECTIOUS SECRETIONS (SALIVA OR SEMEN) 28

15. WHO IS AT GREATEST RISK FOR HBV INFECTION?
LAB PERSONNEL WORKING WITH BLOOD PRODUCTS
MEDICAL/DENTAL PERSONNEL
IV DRUG ABUSERS
BLOOD PRODUCT RECIPIENTS 31

16. Clinical Features Can be asymptomatic (subclinical)
Symptomatic case pass through 3 phases:
Prodromal phase
Icteric phase
Recovery phase
Persistence of infection beyond 6 months indicate progression to chronic phase

17. Diagnosis
Serological:
Detection of HBV antigen and antibodies.

19. Serological markers for hepatitis B
Name
Abbreviation
Definition/Comment
Hepatitis B surface antigen
HBsAg
Antigen indicating infection
Hepatitis B e antigen
HBeAg
Antigen correlating with hepatitis B replication and infectivity
Hepatitis B surface antibody
Anti-HBs
Usually indicates immunity
Hepatitis B e antibody
Anti-HBe
Presence in serum of persons with chronic hepatitis B infection indicates low titre of hepatitis B
Hepatitis B core antibody
Anti-HBc
Indicates previous or ongoing infection with hepatitis B
Serological markers for hepatitis B
Assessment of viral antigens and antibodies in the serum indicates the type of hepatitis B infection (whether acute or chronic), and if an infected person has seroconverted.
These are the common serological markers for hepatitis B:
HBsAg: is the first virological marker to appear in acute hepatitis B infection.1 If the viral infection is successfully removed by the body, it will be replaced by anti-HBs. The presence of HBsAg for > 6 months indicates chronic hepatitis B.2
HBeAg: indicates replicating hepatitis B in acute or chronic infection.
Anti-HBc: indicates acute infection (IgM), or resolved or ongoing chronic infection (IgG).1
Anti-HBs: indicates disease remission and immunity; it is also present after immunisation with the hepatitis B vaccine.
Mahoney F. Clin Microbiol Rev. 1999; 12:351–366.
Lok ASF, McMahon BJ. Hepatology. 2007;45(2):
Mahoney .Clin Microbiol Rev. 1999;12:351–366. http//

20. Outcome of Infection COMPLETE RESOLUTION IN 6 MONTHS (95% of adults)
Chronic infection
5% ADULTS CHRONIC CARRIERS
20% CHILDREN CHRONIC CARRIERS
80-90% NEONATES AND INFANTS BECOME CHRONIC CARRIERS 37

21. PREVENTION 1. PASSIVE IMMUNITY: INJECTION OF IMMUNE GLOBULIN (HBIG)
TRANSFERRING PREFORMED ANTIBODIES FROM AN IMMUNIZED HOST TO A PERSON IN NEED OF IMMUNITY
PROTECTION IS TRANSITORY, BUT ONSET IS IMMEDIATE 67

22. 2. ACTIVE IMMUNITY Using HBV vaccine
Act BY STIMULATING OWN IMMUNE RESPONSE using HBV vaccine
PROTECTION AFTER LATENT PERIOD
LONG-TERM IMMUNITY IS PROVIDED 66

23. The Hepatitis C Virus Spherical, enveloped, single-stranded RNA virus
Family Flaviviridae
HCV may produce ~ 1 trillion new viral particles each day

24. Hepatitis C: Basic Facts
Hepatitis C is a global health problem affecting over 170 million people worldwide.
Hepatitis C is a leading cause of end-stage liver disease and hepatocellular carcinoma.

25. HEPATITIS C (HCV) SPREAD MAINLY BY PARENTAL ROUTE
ACCOUNTS FOR 90-95% OF POST TRANSFUSION HEPATITIS 38

26. Sources of Infection for Persons with Hepatitis C
Sexual 15%
Injecting drug use 60%
Transfusion 10%
(before screening)
Other* 5%
Unknown 10%
* Hemodialysis; health-care work; perinatal
Source: Centers for Disease Control and Prevention

27. WHO IS AT GREATEST RISK FOR HCV INFECTION?
LAB PERSONNEL WORKING WITH BLOOD PRODUCTS
MEDICAL/DENTAL PERSONNEL (3-10% VIA NEEDLESTICK FROM INFECTED PATIENT)
IV DRUG ABUSERS
BLOOD PRODUCT RECIPIENTS
HEMODIALYSIS PATIENTS 41

28. Clinical features 30-180 DAY INCUBATION PERIOD
Acute infection can be asymptomatic.
Symptomatic cases present through 3 clinical phases 43

29. Outcome
UP TO 90% = CHRONIC CARRIERS

30. Diagnosis HCV antibody HCV RNA (PCR)
A positive antibody test should be repeated for confirmation

31. TREATMENT of Viral Hepatitis
HAV and HEV- ACUTE: SYMPTOMATIC
HBV - ACUTE: SYMPTOMATIC
CHRONIC: Antiviral agents
HCV - ACUTE: SYMPTOMATIC
CHRONIC: COMBINATION INTERFERON ALPHA and RIBAVIRIN
 SOURCE: RN December 1997

32. COMPLICATIONS HAV - RELAPSE; IN RARE CASES - FULMINANT HEPATITIS
HBV - CHRONIC LIVER DISEASE INCLUDING CIRRHOSIS, PRIMARY HEPATOCELLULAR CARCINOMA AND FULMINANT HEPATITIS
HCV - CHRONIC LIVER DISEASE INCLUDING CIRRHOSIS, PRIMARY HEPATOCELLULAR CARCINOMA

33. Dental Management: Difficult to identify all patient through history
Many acute cases of Hep B and C are mild
MUST use universal precautions for all
Screening recommended for patients from
high risk groups

34. Viral Hepatitis: A,B,C,D,E
Guidelines for blood exposure
From patients with Hepatitis B:
1. Determine the titrer of anti-HBs in the health
care professional
If adequate: no treatment is needed
If inadequate give Hepatitis B Immunoglobulin

35. Viral Hepatitis: Guidelines for blood exposure
From patients with Hepatitis C
Exposed professional gets baseline and
follow up testing for anti-HCV and liver
enzymes

36. Viral Hepatitis: Guidelines for blood exposure
From patients with Unknown
Ask for serological testing of the patient
(this can be ordered by the Medical
Officer)

38. The presence of HCV-RNA in saliva provides a biological basis for saliva as
a possible source of HCV infection,
Dentists were in a high risk of contracting this disease due to the procedures and instruments of dental
treatment.