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Viral Hepatitis
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Viral hepatitis is a major public health problem, occurring endemically in all areas of the world
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TYPES OF VIRAL HEPATITIS
TYPE A (HAV) TYPE B (HBV) TYPE C (HCV) TYPE DELTA (HDV) TYPE E (HEV) 2
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THREE PHASES OF “CLASSIC” HEPATITIS
PRODROMAL PHASE Flu-like symptoms ICTERIC PHASE Jaundice CONVALESCENT PHASE Recovery 6
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LAB TESTS Liver enzymes:
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) 10 TO 100 FOLD INCREASE CAN BE EXPECTED 10
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LAB TESTS SERUM BILIRUBIN: hyperbilirubinemia
LEVELS MUST APPROACH 3mg/100ml TO MANIFEST AS JAUNDICE JAUNDICE OFTEN FIRST MANIFESTS IN SCLERA 12
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LAB TESTS Prothrombin time: HIGHER THE PROTHROMBIN TIME (PT), THE
MORE SEVERE THE HEPATIC DAMAGE 14
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HEPATITIS TYPE A (HAV) SINGLE-STRANDED RNA VIRUs
SPREAD MAINLY BY ORAL-FECAL ROUTE INCUBATION PERIOD DAYS 16
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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
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Prevention TWO-DOSE VACCINE HEALTH CARE PROVIDERS -RECOMMENDED
6 MONTHS APART AVAILABLE SINCE 1994 HEALTH CARE PROVIDERS -RECOMMENDED 22
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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.
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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
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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
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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
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WHO IS AT GREATEST RISK FOR HBV INFECTION?
LAB PERSONNEL WORKING WITH BLOOD PRODUCTS MEDICAL/DENTAL PERSONNEL IV DRUG ABUSERS BLOOD PRODUCT RECIPIENTS 31
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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
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Diagnosis Serological: Detection of HBV antigen and antibodies.
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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//
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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
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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
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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
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The Hepatitis C Virus Spherical, enveloped, single-stranded RNA virus
Family Flaviviridae HCV may produce ~ 1 trillion new viral particles each day
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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.
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HEPATITIS C (HCV) SPREAD MAINLY BY PARENTAL ROUTE
ACCOUNTS FOR 90-95% OF POST TRANSFUSION HEPATITIS 38
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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
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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
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Clinical features 30-180 DAY INCUBATION PERIOD
Acute infection can be asymptomatic. Symptomatic cases present through 3 clinical phases 43
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Outcome UP TO 90% = CHRONIC CARRIERS
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Diagnosis HCV antibody HCV RNA (PCR)
A positive antibody test should be repeated for confirmation
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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
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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
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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
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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
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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
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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)
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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.
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