1. Why we are here? However, a general lack of understanding exists among health-care professionals regarding the interpretation of screening test results, when more specific testing should be performed, and which tests should be considered for this purpose.

2. Epidemiology and Prevention of Viral Hepatitis A to E: Hepatitis Branch Centers for Disease Control and Prevention An Overview

3. Viral Hepatitis - Historical Perspective A “Infectious” “Serum” Viral hepatitis Entericallytransmitted Parenterallytransmitted F, G, ? other E NANB BD C

4. Viral Hepatitis - Overview A A B B C C D D E E Source of virus fecesblood/ blood-derived body fluids blood/ blood-derived body fluids blood/ blood-derived body fluids feces Route of transmission fecal-oralpercutaneous permucosal percutaneous permucosal percutaneous permucosal fecal-oral Chronic infection noyes no Preventionpre/post- exposure immunization pre/post- exposure immunization blood donor screening; risk behavior modification pre/post- exposure immunization; risk behavior modification ensure safe drinking water Type of Hepatitis

5. 47% 34% 16% 3% Hepatitis A Hepatitis B Hepatitis C Hepatitis Non-ABC Source: CDC Sentinel Counties Study on Viral Hepatitis Acute Viral Hepatitis by Type, United States, 1982-1993

6. Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Weeks after Exposure Titer Symptoms HBeAg anti-HBe Total anti-HBc IgM anti-HBc anti-HBs HBsAg 0481216 20 242832 36 52100

7. Progression to Chronic Hepatitis B Virus Infection Typical Serologic Course Weeks after Exposure Titer IgM anti-HBc Total anti-HBc HBsAg Acute (6 months) HBeAg Chronic (Years) anti-HBe 048 12 16202428 32 36 52 Years

8. Outcome of Hepatitis B Virus Infection by Age at Infection Outcome of Hepatitis B Virus Infection by Age at Infection Symptomatic Infection Chronic Infection Age at Infection Chronic Infection (%) Symptomatic Infection (%) Birth 1-6 months7-12 months 1-4 years Older Children and Adults 0 20 40 60 80 100 80 60 40 20 0

9. 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

10. Geographic Distribution of Chronic HBV Infection HBsAg Prevalence ³ 8% - High 2-7% - Intermediate <2% - Low

11. Concentration of Hepatitis B Virus in Various Body Fluids Concentration of Hepatitis B Virus in Various Body Fluids HighModerate Low/Not Detectable bloodsemenurine serumvaginal fluidfeces wound exudatessalivasweat tears breastmilk

12. Prevent perinatal HBV transmission Routine vaccination of all infants Vaccination of children in high-risk groups Vaccination of adolescents – all unvaccinated children at 11-12 years of age –“ high-risk ” adolescents at all ages Vaccination of adults in high-risk groups Elimination of Hepatitis B Virus Transmission United States Strategy

13. Diagnosis: HBV/HDV Co-infection Anti-HDV positive Suspicion of HDV co-infection based on: Risk factors (e.g., IVDA) Risk factors (e.g., IVDA) Clinical signs of severe hepatities Clinical signs of severe hepatities Check anti-HDV Diagnosis: Chronic HBV infection HBsAg positive with or without Abnormal aminotransferase Check HBsAg and ALT/ AST in 6-9 months Re-check anti-HCV In 3-6 months Consider possibility of HEV Infection if recent foreign travel Diagnosis: Acute hepatitis A infection Diagnosis: Acute hepatitis B infection Diagnosis: Acute HCV infection or exacebation of infection or exacebation of chronic HCV infection Consider non-viral etiologies (e.g., Ischemia, toxins) or other infectious Etiologies (e.g., CMV, EBV) Anti-HAV IgM positive Anti-HBc IgM positive With or without HBsAg Anti-HCV positive Negative serologies Obtain viral serologies: Anti-HAV IgM Anti-HAV IgM HBsAg and Anti-HBc IgMHBsAg and Anti-HBc IgM Anti-HCV (EIA or RIBA)Anti-HCV (EIA or RIBA) Suspicion of acute viral hepatitis based upon: History, physical exam, epidemiologic situation History, physical exam, epidemiologic situation Elevated serum aminotransferase activity (ALT/AST)Elevated serum aminotransferase activity (ALT/AST) آزمايشات تكميلي براي تشخيص يا اثبات اتيولوژي هپاتيت اتيولوژي هپاتيت

15. Up to 9 out of 10 babies born to infected mothers will end up being hepatitis B carriers for the rest of their lives, if they do not get the shots. If you make sure your babies get all 3 shots, plus a shot called H-BIG, they have a 95% chance of being safe from hepatitis B for life. Can my baby die from hepatitis B? Most babies do not die from hepatitis B. carriers

16. 6 months old Hepatitis B Vaccine Baby Shots for Hepatitis B if the mother has Hepatitis B 1 - 2 months old Hepatitis B Vaccine + Birth H-BIG Hepatitis B Vaccine

17. If you have never had hepatitis B, you can get 3 shots...... and get long lasting protection. 321 Hepatitis B can be prevented!

18. Babies who end up as carriers have a 1 out of 4 chance of dying from liver problems. Up to 9 out of 10 babies born to infected mothers will end up being carriers for the rest of their lives, if they do not get the shots. 19 out of 20 babies who get the shots will be protected for life! What if my baby does not get these shots?

19. HBV-HDV Coinfection Pre or postexposure prophylaxis to prevent HBV infection HBV-HDV Superinfection Education to reduce risk behaviors among persons with chronic HBV infection Hepatitis D - Prevention

20. Estimated Incidence of Acute Hepatitis B United States, 1978-1995 Estimated Incidence of Acute Hepatitis B United States, 1978-1995 Vaccine licensed HBsAg screening of pregnant women recommended Infant immunization recommended OSHA Rule enacted Adolescent immunization recommended * Decline among homosexual men & HCWs Decline among injecting drug users 80 70 60 50 40 30 20 10 0 7879 80 8182838485 86 878889909192939495 Year Cases per 100,000 Population * Provisional date