2. Sr: Lecturer Dept of Com: Medicine Hepatitis A, B C & E
By Dr Noreen Shah
Sr: Lecturer
Dept of Com: Medicine

3. Objectives: At the end of this lecture the students will be able to;
Define hepatitis and its types
Describe their epidemiology
Describe their prevention and control measurements

4. Definition Hepatitis is an inflammation of the liver.
The condition can be self-limiting or can progress to fibrosis (scarring), cirrhosis or liver cancer.
5 main hepatitis types A, B, C, D and E.
There is potential for outbreaks and epidemic spread.
Types B and C lead to chronic disease, most common cause of liver cirrhosis and cancer.

5. Hepatitis A & E

6. Definition
Hepatitis A is one of the oldest diseases, causing inflammation of the liver.
Causative agent: Hepatitis A virus.
Route of infection: is fecal – oral route.
The disease is associated with unsafe water or food, inadequate sanitation and poor personal hygiene.
Infection does not cause chronic liver disease and is rarely fatal, but it can cause and fulminant hepatitis (acute liver failure)

7. Hepatitis A occurs sporadically and in epidemics worldwide, with a tendency for cyclic recurrences.
Epidemics are related to contaminated food or water.
The disease can lead to significant economic and social consequences in communities.
It can take weeks or months for recovery to return to work, school, or daily life.

8. Geographical distribution;
Areas with high levels of infection are,
Developing countries with very poor sanitation & hygiene (parts of Africa, Asia, Central and South America)
About 90% children are infected before 10 years, but do not experience any noticeable symptoms
Epidemics are uncommon as older children & adults are usually immune

9. 2. Areas with intermediate levels of infection are,
Developing countries like Southern & Eastern Europe, some parts of Middle East and in regions where sanitary conditions are variable.
Children often escape infection in early childhood.
The improved economic and sanitary conditions may lead to a higher susceptibility in older age groups.
As infections occur mostly in adolescents and adults, large outbreaks may occur.

10. 3. Areas with low levels of infection
Infection rates are low in developed countries due to good sanitary and hygienic conditions, (Northern & Western Europe, Japan, Australia, New Zealand, USA, Canada) 
Disease may occur in adults in high-risk groups, such as,
Injecting-drug users
Homosexual men
In people travelling to areas of high endemicity
Isolated populations such as closed religious communities

11. Hepatitis A distribution 2015

12. Case Definition Suspected case: Confirmed case:
An acute illness with discrete onset of symptoms of jaundice, dark urine, anorexia, malaise, extreme fatigue, and right upper quadrant tenderness /OR elevated serum alanine aminotransferase level >2.5 times the upper limit.
Confirmed case:
A suspected case that meets the clinical case definition AND is laboratory confirmed for Anti‐HAV IgM a antibodies

14. Symptoms
Incubation period: 15–50 days, virus excretes in stools wks before illness & continue for several weeks.
Fever, malaise, abdominal symptoms, dark-colored urine & jaundice.
Diagnosis:
IgG anti-HAV. IgM anti – HAV for chronic hepatitis A
Reverse transcriptase polymerase chain reaction (RT-PCR) to detect the hepatitis A virus RNA.

15. Treatment Recovery may be slow and take several weeks or months.
Complete bed rest
Avoid unnecessary medications like paracetmol
Maintenance of adequate nutritional balance and fluid replacement.
Hospitalization is only required for IV fluid replacement and acute liver failure.

16. Hepatitis E Definition: Hepatitis E is an inflammatory liver disease
Causative agent: Hepatitis E virus.
Transmission: Fecal – oral route.
Host: Human beings.
It is usually a self-limiting and resolves within 4–6 weeks.
Occasionally, a fulminant form of hepatitis develops (acute liver failure), which can lead to death.

17. Geographical distribution
Sporadic cases occur around the world.
Outbreaks occurs in countries with limited access to clean water, sanitation, hygiene and health services.
World wide an estimated 20 million infections, 3.3 million acute cases & deaths occur annually.
Over 60% of all infections & 65% of all deaths occur in East and South Asia.

18. Hepatitis E distribution 2015- 2017

19. Transmission
Hepatitis E virus is transmitted mainly by contaminated drinking water.
Other transmission routes include:
Food borne transmission
Transfusion of infected blood products
Vertical transmission from a pregnant woman to her fetus.

20. Case Definition Suspected case: As for hepatitis A.
Confirmed case: A suspected case that meets the clinical case definition AND is laboratory confirmed for Anti-HEV immunoglobulin M (IgM)
Alert Threshold: A cluster of 3-5 cases in one location is an alert and requires investigation
Outbreak threshold: A cluster of 8-10 cases in one location is an outbreak

21. Symptoms Incubation period: 15-64 days (May vary from 26-42 days)
Typical signs and symptoms of hepatitis include:
Fever , nausea, vomiting, anorexia, yellow coloration of skin & sclera, abdominal pain with enlarged tender liver dark urine and pale stools.
Symptoms last for 1 – 2 weeks.

22. Complications
Pregnancy and hepatitis E: Fulminant hepatitis occurs more frequently during pregnancy.
With greater risk of obstetrical complications and mortality (20% among pregnant women in 3rd trimester).
Chronic hepatitis and reactivation of infection have been reported in immuno - suppressed people.

23. Diagnosis Treatment By detection of specific IgG & IgM antibodies
Reverse transcriptase polymerase chain reaction (RT-PCR) to detect hepatitis E virus RNA in blood and/or stool.
Treatment
As hepatitis E is usually self-limiting, hospitalization is generally not required.
Hospitalization is required for symptomatic pregnant women with fulminant hepatitis.

24. Prevention of hepatitis A & E
Improved sanitation, safe food, water
Proper disposal of sewage
Personal hygiene practices (regular hand-washing)
Immunization against hepatitis A is most cost effective method, nearly 100% people develop protective levels of antibodies within 1 month after a single dose of vaccine.
2 doses of vaccine are recommended to ensure a longer- term protection of about 5 to 8 years after vaccination
In 2015 the WHO’s has cost-effectiveness of the licensed hepatitis E vaccine

25. In Pakistan:
Hepatitis A vaccines are given in 2 doses in the upper arm.
1st dose (given at 1 year of age in Pakistan) followed by a 2nd dose 6 months later.
Nearly 100% people develop protective levels of antibodies to virus within 1 month after a single dose.
Even after exposure to virus, a single dose within 2 weeks of contact has protective effects.
Protection lasts for at least 15 – 25 years.

27. Hepatitis B Hepatitis B
Definition: Hepatitis B is a life threatening liver infection causing damage to liver cells.
Major global health problem, result in chronic liver disease that can lead to cirrhosis, cancer and death
Causative agent: Hepatitis B virus

28. Transmission
The hepatitis B virus can survive outside the body for at least 7 days.
During this period the virus is infective and cause infection if it enters the body.
Mode of transmission: Hepatitis B virus passes from person to person through blood, semen or other body fluids.

29. High risk people are;
Infants of mothers who are infected at time of delivery
People living in close contact with infected persons
People having multiple sex partners
Men who have sex with men
Drug users (injecting, inhaling, snorting, popping pills)
Unscreened blood transfusion or organ transplant

30. Individuals with unclean tattoos or body piercing
Individuals undergoing kidney dialysis
Individuals who use blood or blood products for medical conditions (hemophilia, sickle cell disease, thalassemia)
Residents and staff of correctional facilities & group homes
Un clean surgery's, dental treatment and by barbers.

32. Epidemiology: About 2 billion people have been exposed to HBV
Every year about 4 million new HBV infection
400 million are chronic HBV infection
Mortality about 1 million/ year
Prevalent in sub-Saharan Africa & East Asia.
Most infections occur during childhood and 5–10% adults are chronically infected.

33. Prevalence of hepatitis B infection 2015

34. Symptoms Incubation period: About 75 days (30 - 180 days).
About 90% adults will recover completely within 6 months.
Symptoms ranges from mild to severe:
Mostly no symptoms, but some have jaundice, dark urine, nausea, vomiting & abdominal pain
Sometimes infection become chronic and can later develop into cirrhosis or liver cancer.

35. Acute vs. chronic hepatitis B1
Acute infection lasts less than 6 months. Immune system clear the virus from body, complete recovery occurs within a few months (mostly in adults).
Chronic infection lasts for more
than 6 months & may lead to
cirrhosis, liver cancer. 2
During this time, the virus is infective and cause infection to others.
It may go undetected for decades until a person becomes seriously ill. 3
The younger the person the higher risk.

36. Diagnosis
HBsAg,
Chronic HBV infection is characterized by the persistence (>6 months) of HBsAg and is the principal marker of risk for developing chronic liver disease.

37. Treatment
Treatment of acute infection is aimed at maintaining comfort, adequate nutritional balance and fluid replacements.
Treatment of chronic infection need drugs like,
oral antiviral agents
interferon injections
Cirrhosis liver may need transplant with varying degrees of success. There is no treatment of liver cancer.

38. Complications
Chronic HBV infection can lead to serious complications like,
Liver cirrhosis. Extensive scarring of liver impairing liver's ability to function.
Liver cancer. 
Liver failure. Acute liver failure in which vital functions of the liver shut down (liver transplant)
Other conditions. People with chronic hepatitis B may have kidney disease, inflammation of blood vessels or anemia.

39. Prevention

40. Vaccination: The hepatitis B vaccine is the mainstay for prevention.
WHO recommends all infants to receive hepatitis B vaccine soon after birth, preferably within 24 hours.
In Pakistan, DPT + Hepatitis B vaccine (Hib) = given in 3 doses
Pentavalent weeks
Pentavalent weeks
Pentavalent weeks

41. Hepatitis C

42. Definition Hepatitis C: is an acute or chronic liver infection.
Causative agent: Hepatitis C virus (HCV) have multiple strains and their distribution varies by region.
Acute HCV infection is usually asymptomatic, and is only very rarely associated with life-threatening disease.
In about 15–45% of infected persons the virus clears within 6 months of infection without any treatment.
About 55–85% of persons will develop chronic HCV infection. The risk of cirrhosis of the liver is 15–30% within 20 years.

43. Geographical distribution
Hepatitis C is found worldwide.
The most affected regions are Central and East Asia and North Africa.
The hepatitis C epidemic can be concentrated in certain high-risk populations (e.g. injecting drugs users)

45. Diagnoses: Screening is done for presence of; Anti HCV antibodies
Chronic HCV is confirmed by positive nucleic acid HCV /RNA
Liver biopsy to assess liver damage.
Genotype of hepatitis C strain (person may be infected with more than one genotype.
The degree of liver damage & virus genotype are used to guide treatment decisions and management of the disease.

47. Treatment
Usually HCV does not require treatment due to immune response.
Careful screening is necessary before starting the treatment to determine the most appropriate approach for the patient.
The current standard treatment for hepatitis C is
Combination antiviral therapy
Interferon Injections

48. Screening is done of people if,
Have come from places where infection is common
Live with someone who has hepatitis B
Have sex with infected persons.
Liver enzyme tests with unexplained abnormal results
Have HIV or hepatitis C
Inject illegal drugs
Are a man who has sex with men
Are on dialysis or take immuno suppressive medications
Are pregnant

49. Prevention of hepatitis B & C

50. Primary prevention
There is no vaccine for hepatitis C, therefore prevention of HCV infection depends upon reducing risk of exposure,
WHO recommendations for primary prevention are;
hand hygiene: including surgical hand preparation, hand washing and use of gloves
safe handling & disposal of sharps and waste
safe cleaning of equipment
testing of donated blood
training of health personnel

51. Secondary and tertiary prevention
For people infected with the hepatitis C virus, WHO recommends:
Education & counseling on care and treatment
Immunization with hepatitis A & B vaccines to prevent co – infection
Early and appropriate medical management
Regular monitoring for early diagnosis of chronic liver disease

52. Key facts
130–150 million people globally have chronic hepatitis C infection, a liver disease caused by hepatitis C virus
The most common mode of infection is unsafe injection
A significant number of chronically infected will develop liver cirrhosis or liver cancer.
people die each year from hepatitis C
Antiviral treatment is successful in 50–90% of persons treated, depending on the treatment used, and has also been shown to reduce the development of liver cancer and cirrhosis.
There is currently no vaccine for hepatitis C.

53. Hepatitis in Pakistan
All five hepatitis A,B,C,D,E viruses are present in Pakistan.
Hepatitis A & E infections are endemic due to poor water and sewage systems. 
Lack of vaccination
Outbreaks and mini – epidemics occur following monsoon rains, heavy flooding.
The diseases are mild, self‐limiting but severe in about 10%
Improved sanitation and the hepatitis A vaccine are the most effective ways to combat the disease.

54. WHO response in Pakistan,
WHO has strengthen the resources to control disease transmission in the general population by;
Formation of Technical Advisory Group on Hepatitis
Training of health care providers on treatment, prevention, infection control, hospital waste management and surveillance.
Increasing awareness on transmission and prevention.

55. Guidelines for epidemic measures
In epidemics, WHO recommends to:
Determine the exact mode of transmission
Identify the population specifically exposed
Eliminate the source of infection
Improving sanitary & hygienic practices to eliminate fecal contamination.

56. World Hepatitis Day
WHO organizes World Hepatitis Day every year on July 28 to increase awareness and understanding of viral hepatitis.