ACUTE VIRAL HEPATITIS

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ACUTE VIRAL HEPATITIS Powered By Docstoc
					ACUTE VIRAL HEPATITIS

  CLINICAL PRESENTATION.
  DIGNOSIS.
  EPEDEMOLOGY OF VIRAL
 HEPATITIS INFECTION A,B,C IN
 KSA.
  MANAGEMENT.
                Viral Hepatitis - Overview
                                     Type of Hepatitis
                   A               B             C             D              E
Source of         feces           blood/        blood/        blood/         feces
virus                         blood-derived blood-derived blood-derived
                               body fluids   body fluids   body fluids
Route of        fecal-oral    percutaneous percutaneous percutaneous       fecal-oral
transmission                   permucosal   permucosal   permucosal

Chronic            no             yes           yes            yes            no
infection

Prevention       pre/post-      pre/post-   blood donor     pre/post-     ensure safe
                 exposure       exposure     screening;    exposure         drinking
               immunization   immunization risk behavior immunization;       water
                                            modification risk behavior
                                                           modification
     Diagnosis of hepatitis
Patient history
Physical examination
Liver function tests
Serologic tests
         Symptoms and Signs
      Pre-icteric phase
1.    Anorexia
2.    Fatigue
3.    Nausea
4.    Vomiting
5.    Arthralgia
6.    Myalgia
7.    Headache
8.    Photophobia
9.    Pharangitis
10.
11.
     Icteric phase::
1.   Enlarged liver
2.   Tender upper quadrant
3.   Discomfort
4.   Splenomegaly (10-20%)
5.   General adenopathy

     Post-icteric phase
             Lab Findings
1. L FT increase >5-10 times of normal
2. Markers of hepatitis B or C or A might be
   positive
        Pathological findings
1. Pan lobular infiltration with mononuclear
   cells
2. Hepatic cell necrosis
3. Reticulum framework are intact
                     DD:
1.   Infectious Mononucleosis
2.   Drug Induced Hepatitis
3.   Chronic Hepatitis.
4.   Alcohol Hepatitis
5.   Cholecystitis, Cholelithiasis
            Complications
1.Chronic hepatitis    cirrhosis- HCC

2.Fulmnant hepatitis
FULMINANT HEPATITIS
 Definition: Hepatic Failure Within 8 Weeks
 Of Onset Of Illness.
 Manifestation: Encephalopathy and
 Prolonged PT
 Histopathology: Massive Hepatic Necrosis.
         Hepatitis B - Clinical Features
• Incubation period:             Average 60-90 days
                                 Range 45-180 days
• Clinical illness (jaundice):   <5 yrs, <10%
                                 5 yrs, 30%-50%
• Acute case-fatality rate:      0.5%-1%
• Chronic infection:             <5 yrs, 30%-90%
                                 5 yrs, 2%-10%
• Premature mortality from
  chronic liver disease:         15%-25%
                 HBV infection
   Factors affecting transmission ability

1.Replicative status
   - HBeAg
   - high HBVDNA

2.Route of infection
   - percutanouse
   - Transmucosal

3. Exposure frequency : Single vs. Multiple

4. Inoculums size : transfusion vs. needle stick
Hepatitis B
   Hepatitis B serology

anti-HBc exposure (IgM = acute)
HBsAg  infection (carrier)
anti-HBs  immunity
HBeAg  viral replication
anti-HBe  seroconversion
HBV-DNA  viral replication
Natural History




                  Gow, BMJ 2001
  Hepatitis B Virus
Modes of Transmission


    • Sexual
    • Parenteral
    • Perinatal
   Concentration of Hepatitis B Virus
        in Various Body Fluids

                                  Low/Not
     High         Moderate       Detectable

    blood          semen            urine
    serum        vaginal fluid     feces
wound exudates      saliva         sweat
                                    tears
                                 breastmilk
Possible transmission route of HBV
              in KSA
 1-Horisontal transmission (person to person) is the main
 transmission route
 2-Perintal transmission (positive HBSAG mothers)
 especially if they are HBEAG positive
 3- Heterosexual transmission
 4-Illegal injection drug use
 5- Contaminated equipment used for therapeutic
 injections and other health care related procedures
 6- Folk medicine practice
 7-Blood and blood products transfusion without prior
 screening
  HBV INFECTION
  before and after
vaccination program
         OVERALL PREVALENCE OF HBsAg AMONG
        SAUDIS IN THE 80’S ACCORDING TO REGIONS

     10                                                     9.6
                                           8.9
                                                                              8.3
                 8
Positivity (%)




                 6          5.5

                 4

                 2

                 0
                     Central (n=6649) South-western      Eastern      Total (n=32183)
                                        (n=7235)        (n=8300)

                                   Al-Faleh. Annals of Saudi Medicine, 1988
PREVALENCE OF HBeAg AMONG HBsAg POSITIVE
    SAUDIS PREGNANT WOMEN (n = 20920)


 6                                           5.4

 5
             3.7
 4
 3
 2
 1
 0
      % of HBsAg pos.              % of HBeAg Pos.

              Al-Faleh, Annals of Saudi Medicine, 1988
FREQUENCY OF HBeAg AMONG HBsAg
  POSITIVE SAUDI CHILDREN (n=307)

          19.5                       19.4
           19
          18.5
           18                                                           17.9
Percent




          17.5      17.2                              17.1
           17
          16.5
           16
          15.5
                 1-3 years       4-6 years       7-10 years          Total
                  (93/16)         (103/20)        (111/19)         (307/55)

                           Al-Faleh et al. Journal of Infection, 1992
  PREVENTION STRATEGIES OF
  MINISTRY OF HEALTH IN KSA

Introducing HBV vaccine in EPI program; and

   Mandatory screening of blood donors
   and expatriates.

   Vaccination of risk groups.

   Health education especially among
   medical personnel.
      THE CURRENT EPI IN THE
     KINGDOM OF SAUDI ARABIA


1.   At birth       BCG +         HB1
2.   At 6 weeks     DPT1 + OPV1   Hb2
3.   At 3 months    DPT2 + OPV2
4.   At 5 months    DPT3 + OPV3
5.   At 5months     Measles       HB3
6.   At 12 months   MMR
7.   At 18 months   (DPT + OPV)   Booster 1
8.   At 4-6 years   (DPT + OPV)   Booster 2
COMPARISON OF PREVALENCE OF HBsAg
AMONG SAUDI CHILDREN IN 1989 (n=4575)
AND 1997 (n=5355) – ACCORDING TO AGE
               10 9.68

                8                                         7.57
                                    7.24                                 7.2
  Percentage




                             6.54                                 6.51                           6.71
                                                   6.35
                6                                                              5.81          6
                                           5.06
                4

                                                                                2.31
                2
                                                                   0.82 0.93
                0    0   0    0.16 0.3       0        0     0.2                         0         0.31




                                                                                                  Total
                    1
                         2
                              3

                                     4
                                            5
                                                    6
                                                           7
                                                                   8
                                                                         9
                                                                                10

                                                                                       11
                                                                                            12
                                                  (Age in years)
                                                                                       Al Faleh, J Infect 1999
                                            1989           1997
 COMPARISON OF PREVALENCE OF HBsAg
 AMONG SAUDI CHILDREN IN 1989 (n=4575)
AND 1997 (n=5355) – ACCORDING TO REGION
                13                                                                                                    12.67

                11
                                                                   10.29
                9 8.63                                                                  8.83               9.04
   Percentage




                                                                             7.59                                                                     7.53
                7                                                                                                                                             6.71
                                                5.83 5.71
                5                                                                                5.22

                              3.48                                                                                                         3.73
                3                       2.87                                                                                     3.14

                                                                     1.52
                1              0.52              0.83                                    0.77                           0.47
                        0                  0                 0                    0                  0         0                     0        0.3        0     0.31
                -1




                                                                                                                                  Dammam
                     Riyadh




                                                                                         Gizan
                                         Hail




                                                                                                                                                       Taif
                                                                                                            Al-Jouf
                                                                              Al-Baha




                                                                                                                                                               Total
                               Qassim




                                                          Medina




                                                                                                                        Tabouk
                                                                     Aseer
                                                 Makkah




                                                                                                                                             Jeddah
                                                                                                  Najran


                                                                       1989             1997
                                                                                                                                           Al Faleh, J Infect 1999
Prevalence Of HBsAg Among Saudi Population
     Before & After Vaccination over 18 y
10%
        Before

 8%
        6.70%

 6%                        After


 4%


 2%
                          0.16%
                  0%                  0%
 0%
        1989     1992     1997      2007/8
  Age 1-10yr     1-2yr   1-12yr    16-18yr
numbers 4575     637     3666       1365
CHANGING PATTERNS OF HBsAg POSITIVITY
 AMONG BLOOD DONORS IN MOH,CENTRAL
        BLOOD BANK 1994-2005
   4.5     4.4
     4
   3.5              3.25
     3
   2.5
     2
                               1.5
   1.5
     1
   0.5
     0
          1994     2000       2005
         n=9690   n=91695   n=177037
PREVALENCE OF HBsAg POSITIVITY AMONG
 BLOOD DONORS IN KKUH FROM 1987 TO
                2005
                 5          4.7

                4.5
                 4
Positivity %




                3.5
                                              3
                 3

                2.5                                                              1.9                                          2        2.2
                                                                                                   1.7
                 2
                                                               1.4
                1.5
                                                                                                                                                            1                   1
                 1
                0.5
                 0
                                )                 )                 )                 )                 )                 )                 )                   )                   )
                         56
                            5
                                           9 91              8 85              2 85              0 31              7 93              4 72                14
                                                                                                                                                            6
                                                                                                                                                                             36
                                                                                                                                                                                1
                     3                =1                =6                =6                =6                =4                =5                   9                   8
               (n
                 =                  (n                (n                (n                (n                (n                (n                ( n=                ( n=
                                                                                                                                         4                  5
    9 87                  9 91             9 96              9 97              9 98              0 02              0 03             00                 00
1                     1                1                 1                 1                 2                 2                  2                  2
HBSAg positively Among Blood donors
         in KKUH ( 18-21y)

                1.4        1.24

                1.2

                 1
 positivity %




                0.8                                  0.6
                                         0.6
                0.6
                0.4

                0.2
                 0
                      2000 n= 647   2004 n=1371 2005 n=1504
                        (18- 20)      (18-20)     (18-21)
HCV INFECTION
     Transmission of HCV
EGYPT, mass campaigns of parenteral
antischistosomal therapy(discontinued
only in the 1980 ) may represent the
WORLD, largest iatrogenic transmission of
BLOOD BORNN PATHOGENS
frank c,Moh m k et all lancet 2000
Natural history




              Marcellin, J Hepat 1999
COMPARISON OF PREVALENCE OF ANTI-HCV IN
 SAUDI CHILDREN IN 1989 AND 1997 STUDIES



              1989                                1997


No. of children      Positive (%)   No. of children      Positive (%)

                          39                                   2
    4496                                5350
                       (0.87%)                             (0.04%)

   Diagnostic test only by                 Diagnostic test by
   1st-generation EIA kit.          3rd-generation EIA kit and
                                    confirmatory test by RIBA
                                                            kit.
  Overall prevalence rate of HCV infection in
KSA among children and adolescent during the
                  last 18 yrs.
            1989                         1997                         2008

  No. of                       No. of           Positive    No. of
              Positive (%)                                              Positive (%)
 children                     children            (%)      students
                     39*                           2**                        (5)3
  4496                          5350
                   (0.87%)                      (0.04%)     1357             0.22%

 Diagnostic test                                  Diagnostic test by
                              Diagnostic test by
      only by                   rd-generation EIA PCR for anti- HCV
                              3
1st-generation EIA                                 Positive cases.
                             kit and confirmatory
       kit.
                               test by RIBA kit.

* ALFaleh et al. Hepatology 1991
** ALFaleh Ann Saudi Med. 2003
Prevalence of HCV Among Saudi
   Blood donors (1998- 2002)
             1.4                                 1.3
                        1.2                                   1.2
             1.2

              1                      0.9
Precentage




             0.8                                                           0.7

             0.6

             0.4

             0.2

              0
                      1998         1999         2000        2001         2002
                   (n=104003)   (n=110608)   (n=114122   (n=115090)   (n=113993)


                                                                 Shobokshi et al , SMJ 2003
 HCV positivity among blood donors in 2005 in
central blood bank of MOH in KSA according to
                    regions
                             0.6
        0.6
                       0.5
        0.5
                                   0.4
        0.4
                                               0.3         0.3   0.3
        0.3
              0.2                                    0.2
        0.2
                                         0.1
        0.1

         0
               R


                    M


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                             a
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                               (n




                               =1
                               (n
                                (n




                                 m
                                 Pr
                                 (n


                                 =2




                                 =5
                                  =3




                                  =1




                                  72
                                   =9
                                    =2




                                    (n
                                    ov
                                    08




                                    31
                                     12




                                     27




                                     65
                                      84




                                      =2
                                       33




                                       ie
                                       40




                                       4)
                                        68




                                        50




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                                          60
                                          48


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                                            )




                                             )




                                               e


                                               94
                                               )




                                                 (n


                                                  )
                                                    =2
                                                       96
                                                          74
                                                            )
HCV positivity among Saudi blood donors from
      1996 – 2005 in KKUH (n=58910)


                0.8
                       0.58 0.55
   Percentage




                0.6
                                     0.36
                0.4                              0.28 0.3         0.3
                                            0.22
                                                                                0.2
                0.2                                                     0.14

                 0
                      1996 1997 1998 1999 2000 2002 2003 2004 2005
                      (n=40) (n=35) (n=22) (n=13) (n=18) (n=15) (n=17) (n=11) (n=19)


                                                                     KKUH Blood bank
HCV POSITIVITY AMONG SAUDI BLOOD DONORS
        FROM 1996 TO 2000 IN KKUH
       ACCORDING TO AGE GROUPS

               5                                         4.4

               4
  Percentage




               3

               2

               1                0.53         0.69
                                                                  0.38
                    0.17

               0
                   20-30      30-40        40-50        > 50    Total
                                       (Age in years)
                           No. of blood donors = 32793
                                                               KKUH Blood bank
 Prevalence of HCV Positivity
Among Different Saudi population
   Type of patient      number       Prevalence(%)



 Children from 1-18y     3854              0.1



  Pregnant women         3127              0.7

Hemodialysis patients   29054              55.8



    Drug addicts         9137               14


                                 Shobokshi et al , SMJ 2003
Prevention Of HCV Transmission
Avoiding shared use of Razors or brushes
and any item that pierces the skin.
Strict adherence of the universal
precautions in health facilities.
Educating and training of HCW’s to the
proper use of standard precautions
Folk medicine?!
HAV INFECTION
COMPARISON OF PREVALENCE OF ANTI-HAV AMONG
SAUDI CHILDREN IN 1989 (n=4375) AND 1997 (n=5255) –
              ACCORDING TO AGE


               80
                                                                                   72.6
               70
                                                                            63.5
               60                                             59.8 59.7
  Percentage




                                                  48.5 54.1
               50                         43.9                                                   48.850.5
                                  41.6
               40          34.8
                                                                             33.1 34.5
               30 23.7                                               30.6
                                                         26.7 28                          26.4        24.9
                                           23.4     24
               20                  20.3
                            17.6
                    13.4
               10
                0
                    1               3              5           7             9            11        Total
                                                       (Age in years)

                                                  1989        1997

                                        Al-Faleh et al. Saudi Med. J, 1999
 COMPARISON OF PREVALENCE OF ANTI-HAV
AMONG SAUDI CHILDREN IN 1989 (n=4375) AND
   1997 (n=5255) – ACCORDING TO REGION


               91
               81                                                                    82.2
                                                                                    81.6 79.1
                                                                                                                  76
               71
  Percentage




                             62.7                      59.5                                            64.4
               61                      56     55

               51                                                                             51.3
                                                                                                        47.9 45.6
                                                                                                                                    51.1             50.5
                    39                                           44.5 43.6
               41                                                                                                38.4
               31            31.6
                                                       28.2
                                                                          25.4                                                                        24.9
               21   16.1
                                       20.4 20.1                   19                                                      18.2 17.5 19
               11                                                                                                                             9.6
                1
                    Riyadh




                                                                                              Najran

                                                                                                        Al-Jouf

                                                                                                                  Tabouk
                                                                                      Gizan
                                                                          Al-Baha
                                       Hail




                                                                                                                                                      Total
                                                                                                                                              Taif
                                              Makkah

                                                        Medina




                                                                                                                                     Jeddah
                              Qassim




                                                                  Aseer




                                                                                                                           Dammam
                                                                  1989              1997
        COMPARISON OF PREVALENCE OF ANTI-HAV
        IN ASEER REGION AMONG SAUDI CHILDREN
             IN 1989 (n=476) AND 1997 (n=411)



             91
             81
             71
Percentage




             61    44.5
             51
             41
             31                  19
             21
             11
              1
                  1989         1997
 PREVALENCE OF ANTI-HAV IN SAUDI
CHILDREN IN 1997 ACCORDING TO SEX



          30
                     25.75
                                                 24
          25
          20
Percent




          15
          10
          5
          0
               Male (n=2642)          Female (n=2713)
                        No. of children = 5355
PREVALENCE OF ANTI-HAV IN SAUDI CHILDREN IN 1997
           ACCORDING TO LOCATION



                                                  33.04
           35
           30
           25         20.98
           20
 Percent




           15
           10
           5
           0
                Urban (n=3635)          Rural (n=1715)
                         No. of children = 5255
AGE SPECIFIC PREVALENCE OF ANTI-HAV IN SAUDIS
        FROM RIYADH, CENTRAL REGION



                   1986                   1994
   Age
                                                             P
 (Years)   No. Positive/          No. Positive/
                            %                      %
            No. Tested             No. Tested

   1–9       103/194       53.0      81/210       38.6   3.4 x 10.3

 10 – 19     164/193       85.0     110/180       61.1   1 x 10.4

 20 – 30     182/200       91.0     188/240       78.3   3 x 10.4

   Total     449/587       76.5     379/630       60.2   1 x 10.4

            Arif et al. Saudi J Gastroenterology, 1995
Changing pattern of Hepatitis A prevalence
 within the Saudi population over 18 yrs
    60
                53 *
    50

    40

    30
                           24.3 **
    20                                           ***
                                          18.1
    10

     0
             1989      1999           2008
   Age      1-10 YRS   1-12 yrs      16-18 yrs
   Region      13         13            3

                                             *AlRashed R. Ann SM 1997
                                             ** AlFaleh et al SMJ 1999
                                             *** AlFaleh et al WJG 2008
THANK
 YOU
Global Patterns of Chronic HBV Infection

• 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

• 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
Hepatitis C

				
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