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home - Liver - Various Viruses - Hepatitis A Written by Dr Sebastian Zeki
Knowledge


Understands the serological interpretation categorisation and
investigation of patients with chronic hepatitis B and/or C with
particular emphasis on the need for treatment and surveillance

Recognises the particular populations at risk
Aware of national and international agreed guidelines on viral
hepatitis management and use of interferon and antiviral drugs

Aware of hepatitis B reactivation in the context of immunosuppression
Skills
Uses appropriate diagnostic modalities including serology
genotyping viral load measurements liver biopsy and related
investigations

Monitors anti-viral and immunomodulatory therapies with appropriate
investigations

Behaviours
Communicates effectively with patients and relatives in the context of
viral liver disease and underlying social and psychological risk factors

Marshals multi-disciplinary support networks and in particular
recognise the crucial role of nurse practitioners in disease
management

Hepatitis A

12 14 2 4 6 8 10 IgM IgG Immunity Incubation period Symptoms/ Jaundice Elevated transaminases Virus in faeces Viraemia Weeks after infection 0 Hepatitis A: Time course of infection Atypical manifestations of hepatitis A virus infection Cholestatic HepatitisOccasional get prolonged cholestasis.Get raised bili (<170)- peaks at 8 wks, ALP, cholesterol and small ALT riseJaundice can last >12 weeks but completely resolvesTreatment is usually supportive. Relapsing Hepatitis10 % Occurs 1-4 m post full recovery. Usually milder. Can get multiple relapsesPatients remain infectiousALT can be >1000 IU/L during relapse;IgM anti-HAV typically persist throughout the course of the disease.A cholestatic form can also be seen. Extrahepatic MnifestationsRash 11%; Arthralgia14 % Immune complex disease and vasculitis assoc. diseases eg:Leukocytoclastic vasculitis ( legs and buttocks; IgM anti-HAV and complement in blood vessel walls)Glomerulonephritis; Arthritis; Cryoglobulinemia;Toxic epidermal necrolysis;Myocarditis;Optic neuritis; Transverse myelitis; Thrombocy-topenia; Aplastic anemia; Red cell aplasia; Autoimmune hepatitisMore common in protracted disease,eg relapsing or cholestatic hepatitis Live attenuated vaccinesWell tolerated and highly immunogenic but use is limitedInactivated HAV vaccinesHAVRIX-inactivated- need booster 6m after 1st doseVAQTA inactivated- poor- need booster 12m after 1st doseImmunogenicityAntibody titres peak at 7m then decline slowlyLasts 20-30 yrs so no boosters may be unnecessary.Child-Pugh class B or C predictive of a lower vaccination response rate.Simultaneous administration with other vaccinesCan be given with most other vaccines Indications for Vaccination:-Clotting-factor disorders.-Chronic liver disease- esp in Hep C (high mortality with Hep A superinfection) but response will be less.-Homosexual men or users of illegal drugs.-Hep A researchers.-Travellers to countries with high or intermediate endemicity.-Children.-HIV infection-recommended but decreased efficacy. Give single antigen vaccine or IG ASAP post-exposureClose personal contactPrev. unvaccinated household +sexual contacts Hep A contact get IG.Shared drugs, get IG and vaccineChild care centersVaccine or IG to all staff and attendees if:1) 1+ hepatitis A in kids/ employees or 2)in 2+ households of center attendees.If centre has children without any nappie wearers,Hep A vaccine or IG should be given to classroom contacts of an index patient only, rather than to all staff and attendees.IF outbreak happens, give vaccination or IG to household contacts of nappie wearing kidsCommon-source exposureVaccine or IG to all food handlers at index establishmentNo vaccination for patrons unless1)Whilst in infectious period, food handler directly handled uncooked foods or foods after cooking and had diarrhea or poor hygienic practices and 2) patrons can be identified and treated >2 weeks after exposure.If exposure occurred over time, more reason to use of hepatitis A vaccine or IG is warranted.Schools, hospitals and work settingsHepatitis A PEP not needed for a single case in adult environment and source is outside of workDo vaccinate if transmission documented between close contacts Treatment and PrognosisTreatment is supportive.Mortality is 0.1 % in infants and children, 0.4% in15-39 yrs.Handwashing is v. effective- HAV can survive for 4 hrs on fingertips.Chlorination and disinfectants (household bleach 1:100 dilution) can inactivate virus. EpidemiologySpread is by the faeco-oral route.10% is from sexual/ household contact with hep A case.9% is from homosexual activity in men.7% is from food or waterborne outbreaks.4% is from child or employee in a daycare centre.3% is from IVDU.Community outbreaks from water/food (often shellfish or green onions) (can survive up to 6 months in well water) can occur.Hepatitis A can occur sporadically or in an epidemic form. Remains detectable for decades Gold standard for acute illness= Serum IgM anti-HAV But raised IgM can be due to prolonged presence of IgM anti-HAV, a false-positive result, or asymptomatic infection (which is much more common in children < six)Remains positive for 4-6m Incubation average 30 days Prodrome (1-2 weeks)Fatigue, malaise,N+V, anorexia, fever, +RUQ pain. Dark urine, acholic stool, jaundice (70%), and pruritus and hepatomegaly (80%).Prodrome disappears at jaundice onset Rarely: splenomegaly, cervical LN, evanescent rash, arthritis, and, rarely, a leukocytoclastic vasculitis.High ALT (>1000), ALP, Bilirubin (can be>170)Can also get raised ESR, CRP and IG’s Usually acute, self-limited; Fulminant hepatic failure v rare.Kids: Usually silent or subclinical.Adults: Mild flu-like illness to fulminant hepatitis (more likely if liver disease esp Hep C) NK cells CD8+ T lymphocytes Destroy infected cells- example excessive host response causing the hepatitisHep A itself is non cytopathic Assembled virus particles are shed into the biliary tree and excreted in the feces 85 % make full recovery by 3m, and 99% by 6mRecovery in ALT faster than bilirubin. Hepatitis A Genomic Organiza-tionIt is a heparnavirus genus of the Picornaviridae.It is a nonenveloped, icosahedral,+ve-stranded RNA virus.There are 4 distinct genotypes. Complications Pathogenesis Vaccination Types Postvaccination testingPostvaccination testing is not required because of the high rate of vaccine response among adults and children. Postexposure Prophylaxis: 1.1% if >40 (especially in chronic hep C)Prevention Written by Dr Sebastian Zeki

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