1. Infectious Disease in the Elderly and Long-Term Care Facilities module 2 Viral Hepatitis
Welcome to module two on Viral Hepatitis in the Older Patient, I am Claudia Chaperon an Assistant Professor with the University of Nebraska College of Nursing and faculty of the Nebraska Geriatric Education Center. I will be your host and moderator for the infectious disease modules. We feel these modules bring new insights and ideas into the care of the infections in the elderly. If you have not completed module one of this unit, please close out of this module, do unit one on gastroenteritis, and then return here.
UNMC
Section of Infectious Diseases
Brandi L. Lesiak, PA-C, MPAS
Kim Meyer, PA-C, MPAS
Claudia Chaperon APRN, Phd
Ed Vandenberg, M.D., CMD
Updated

2. PROCESS A series of modules and questions
Step #1: Power point module with voice overlay
Step #2: Case-based question and answer
Step # 3: Proceed to additional modules or take a break
Our process will be to review Viral Hepatitis in the Older Patient with the PowerPoint module with voice overlay. This will be followed by case based questions with answers to explain the right and wrong answers. Then you will have the option to continue with the next module or take a break at that time. The learner is recommended to complete a module before disengaging. When the module and questions are completed click on “Mark Reviewed” on the main page of the minifellowship to indicate your completion.

3. Objectives for module two
Upon completion, the learner will be able to:
List the causes of viral hepatitis
List the at-risk populations in the elderly
Describe the evaluation for viral hepatitis
List the prevention and basic treatment of viral hepatitis in the elderly
Listed here are the objectives for this module. Upon completion we hope you will be able to: list the causes of viral hepatitis and the at-risk populations in the elderly. Also we hope you will be able to describe the evaluation for viral hepatitis. And lastly, be able to list the prevention and basic treatment of viral hepatitis in the elderly

4. Viral Hepatitis Definition = inflammation of the liver
Almost all cases caused by:
Hepatitis A virus
Hepatitis B virus
Hepatitis C virus
Hepatitis D virus
Hepatitis E virus
The simple definition of viral hepatitis is inflammation of the liver. Almost all cases are caused by 5 different viruses: A, B, C, D and E.

5. Viral Hepatitis Symptoms: Prodromal symptoms are systemic:
Anorexia, athralgias, coryza, cough, fatigue, fever, headache, malaise, myalgias, nausea, vomiting
Constitutional symptoms may precede onset of jaundice by 1 to 2 weeks
Symptoms usually diminish with onset of jaundice
A large number of patients with viral hepatitis never become icteric
The prodromal symptoms are systemic: anorexia, athralgias, coryza, cough, fatigue, fever, headache, malaise, myalgia, nausea and vomiting. Certainly these symptoms are nonspecific. These constitutional symptoms may precede the onset of jaundice by 1-2 weeks. Symptoms usually diminish with the onset of jaundice. A large number of patients with viral hepatitis never become icteric ( jaundiced), which means they’ll escape detection of the initial infection.

6. Viral Hepatitis Signs Laboratory Liver; enlarged and tender
Right upper quadrant pain and discomfort
Laboratory
Elevation of aminotransferases (ALT, AST)
Elevation of bilirubin
Elevation of prothrombin time (PT)
Signs of viral hepatitis: The liver does become enlarged and tender. Patients usually describe right upper quadrant pain and discomfort.
Laboratory: you will have an elevation in liver enzymes, mainly ALT and AST. You will also have an elevation of bilirubin and you’ll have elevation of prothrombin time as disease progresses. But all these tests tell you is that you have inflammation of the liver but not why. We will discuss the specific viral tests on future slides

7. Viral Hepatitis Incubation periods HAV: 15 to 45 days
HBV: 1 to 6 months
HCV: 15 to 160 days
HDV: 1 to 6 months
HEV: 15 to 60 days
This shows typical incubation periods. Hepatitis A is relatively quick: days. Hepatitis B: 1-6 months. Hepatitis C: days, etc.

8. Hepatitis A
Transmission is fecal-oral (infected food handlers, fecal contaminated fruit, shellfish, childcare centers)
Incubation is days
Symptoms < 2 months
Mortality is 0.1%
No chronic disease
Hepatitis A: Transmission is fecal-oral. Typically, infected food handlers pass this on through fecal contaminated fruit and shellfish. Also childcare center and changing diapers, etc can transmit. The picture shows an area that is not very modern or clean with dirty polluted water; a breeding ground for this disease. Incubation period is days. Symptoms typically last less than 2 months and are nonspecific. Mortality is extremely low at 0.1%. There is no chronic disease with Hepatitis A. Once you get it, you cannot get it again. About one-third of Americans will show evidence of past infection, which means they have immunity.

9. Hepatitis A Prevention
Inactivated vaccine: 1 dose offers protection at 4 weeks, 2-3 doses effective for at least 1 year
Indications specific to the elderly
travelers to endemic areas
men who have sex with men
hepatitis B with chronic liver disease
illegal drug users
persons with clotting factor disorders
chronic liver disease
Don’t forget!!
Proper hand washing important
Prevention: There is an inactivated vaccine that is offered. One dose offers protection at 4 weeks. Two to three doses are effective for at least 1 year. Doses are given at 0 and 6 months. Typically the vaccine is given to travelers to endemic areas, men who have sex with men, hepatitis B with chronic liver disease, illegal drug users, persons with clotting factor disorders, chronic liver disease, and children in areas with increased Hepatitis A rates. As always, wash the hands!!

10. Hepatitis B
Incubation 1 – 6 months
Transmission is parenteral, sexual, from infected mother to baby during birth
~30% asymptomatic
~10% of infected people will develop chronic active hepatitis
Highest rate of disease in y.o.
Elderly at risk: hemodialysis patients, recipients of blood products, men who have sex with men and institutionalized developmentally disabled
Hepatitis B. Incubation is longer: 1-6 months. Transmission is parenteral; sexual or with needle stick ( risk is about 15-30%.) Also transmitted from infected mother to baby during birth. About 30% of people have no signs or symptoms. About 10% of infected people will develop chronic active hepatitis. The highest rates of disease are in the year olds, mostly people who use i.v. drugs. For the elderly the high risk include: hemodialysis patients, recipients of blood products (ie those with clotting disorders), men who have sex with men and institutionalized developmentally disabled

11. + - +/- Interpretation of Hepatitis B Serology
HBsAg
HBsAb
HBc Ab IgM
Total HbcAb
Interpretation + -
Early HBV infection before HBc response
Early HBV infection
+/-
Recent (4-6 months) acute HBV infection
Chronic HBV infection
HBV vaccine
Recovered HBV
This shows an interpretation of Hepatitis B serology. It’s a pretty busy slide that basically shows that with all of these tests you can determine where a person is at in the duration of their infection: whether they have an early infection, whether it’s chronic, whether they’ve been vaccinated, recovered from their disease, etc. I suggest you pause a moment and explore this slide.
HB=hepatitis B, s=surface, Ag=antigen, Ab=antibody

12. Hepatitis B Vaccination: All health care workers should be vaccinated
Elderly: hemodialysis, blood products, men who have sex with men and institutionalized developmentally disabled.
Schedule: 0, 1, and 4-6 months
75% decline in incidence of acute HBV due to immunization
Treatment for chronic active Hepatitis B
Adefovir dipivoxil, alpha interferon, lamivudine
Most health care workers certainly should have had Hepatitis B vaccine. For the elderly patient this includes: hemodialysis patients, recipients of blood products ( other than RBC transfusions), men who have sex with men and institutionalized developmentally disabled.
The schedule for the vaccine is at 0, 1 and 4-6 months, so 3 shots. There’s been a 75% decline in incidence of acute Hepatitis B from due to immunization so it’s very effective. In the 10% of people who develop chronic Hepatitis B, there is treatment available. Some of the drugs are outlined and should be managed by an infectious disease expert or gastroenterologist.

13. Hepatitis C Incubation 15 to 160 days
Mode of transmission is parenteral;(needle stick, tatoos), sexual, from infected mother to baby during birth
Risk of transmission with needlestick; ~ 3%
80 % ; no signs or symptoms
Most infections due to illegal injection drug use
Transfusion-associated cases now occur in less than one per million transfused unit of blood
No vaccine available
Incubation period of Hepatitis C is days. Mode of transmission is parenteral (needle stick, tattoos), sexual is less common, also from infected mother to baby during birth. Risk of transmission with needle stick is about 3%. About 80% of people will have no signs or symptoms. Most infections are due to illegal injection drug use. Transfusion-associated cases now occur in less than one per million due to the extensive testing. Unfortunately, there is no vaccine available.

14. Self-resolves (25 people) Chronic Infection (75 people)
Exposure
(100 people)
Self-resolves (25 people)
Chronic Infection (75 people)
Stable
(60 people)
Cirrhosis
(15 people)
This slide shows the epidemiology of a typical exposure. Say you expose 100 people to Hepatitis C. Twenty-five persons will self-resolve, and 75 people will have chronic infection. Of those 75,sixty will remain stable and 15% will develop cirrhosis. Of those that develop cirrhosis, 11 will become slowly progressive and 4 of those will go on to either require liver transplant, develop cancer or die.
Slowly progressive
(11 people)
Liver transplant,
Cancer, Death,
(4 people)

15. Hepatitis C Treatment: Pegylated interferon Ribavirin
Combination therapy best
There is treatment for Hepatitis C, usually interferon, ribavirin, and combination therapy is best. There are certain genotypes, particularly 2 and 3, that respond better to treatment than genotype 1. But if you are like me, I would like treatment to be managed by an infectious disease expert or gastroenterologist.

16. Infectious Gastrointestinal diseases in the elderly
The End of Module Two on
Infectious
Gastrointestinal diseases
in the elderly
This completes our second module on Infectious Gastrointestinal diseases in the elderly. To complete the question for credit for this module, please close out this module, and advance to the question in 2 in Blackboard, then answer the question and review the answer. Then, when ready proceed to module #3 where we will continue our discussion on the next topic: Genitourinary infections.
( see next two slides for the question and answer for this module)

17. Question
You chair the infection-control committee at a 120-bed nursing home. In reviewing the facility’s immunization program, due to budget restrictions, you must decide which immunization is top priority for the employees, Which of the following would you recommend?
Diphtheria tetanus
Varicella zoster
Hepatitis B
Hepatitis A

18. Answer Answer C; Hepatitis B: Why:
OSHA requires all health care employees to be offered Hepatitis B immunization.
All people should receive a dT every 10 years but health care staff are not at increased risk for tetanus.
Varicella zoster can be considered for health care staff. It is not OSHA required. It adds no protection to residents but does improves health of work force. It is recommended for those susceptible. Who are Susceptible? Those without reliable history (self or parent) of Chicken Pox.
Hepatitis A is not indicated for health staff outside those at risk: such as travelers to endemic areas, men who have sex with men, hepatitis B with chronic liver disease, illegal drug users, persons with clotting factor disorders and chronic liver disease.