Hepatitis

Hepatitis

§"Inflammation of liver" qViral, OR autoimmune §Hepatitis A, B, C, D, E §"Hepatitis" also caused by: qCytomegalovirus (CMV), Epstein-Barr Virus (EBV), Herpes Simplex Virus (HSV), & some medications.

Hepatitis: A, B, C

"Hepatitis" refers to an inflammatory condition of the liver. It's commonly caused by a viral infection, but there are other possible causes of hepatitis. These include autoimmune hepatitis and hepatitis that occurs as a secondary result of medications, drugs, toxins, and alcohol (WHO, 2020) Important to know when getting disease and when it shows sytmpoms A: Makes it hard for contact tracing - like at a restaurant Nasty stomach flu - not causing chronic disease Hep C - more likely to have chronic Hep B - easier to have a vaccine since DNA

Question: *A member of the clinic housekeeping staff experiences a needlestick by a contaminated needle. Which of the following should be administered by the healthcare personnel? Choose 1 answer: ■A: Antiviral medication ■B: Hepatitis B immune globulin (HBIG) ■C: Hepatitis B vaccine ■D: Interferon

*Hepatitis B vaccine •Want to try and make the puncture bleed and wash with soap and water • Is the vaccine active or passive immunity? "Active" •When exposure to organism triggers immune response to produce antibodies to the disease. • C - actual vaccine because looking at incubation period, not getting acute symptoms for 90 days. If worried for hep b , can give them the vaccine and it'd kick in within two weeks. Theyd be protected! B - if acute hepatitis or corona - like on death bed.... For corona. Help in acute fight

Prevention Hep C

- No Vaccine - but several new drugs approved by FDA for treatment of HCV: §Boceprevir §Telaprevir §Harvoni. §Mavyret. §Peginterferon. §Olysio (with interferon and ribavirin). vSide effects common: Flu-like (headache, fatigue, fever, chills, muscle ache), fatigue, and rash

Healthcare Personnel - Potential Exposure to Hepatitis C (link to CDC)

After a needlestick or sharps exposure to anti-HCV positive blood, a recent report of data from more than 1,300 potentially exposed HCP estimated the risk of HCV infection as approximately 0.2% for percutaneous injuries and 0% for mucocutaneous exposures (CDC, 2019) Tell charge nurse, correct intervention Higher than hiv spread, milk out of finger, bleed as mch as you can, soap and water, reducs your converson . Take care of yourself

Overview Hep ABC

Again, you do not need to memorize vaccination names, meds. The FDA approved Mavyret in 2017 for use in the treatment of any HCV genotype. It contains glecaprevir and pibrentasvir. Mavyret is the first treatment that can be administered for only 8 weeks in people without cirrhosis. Most of the other combination drugs must be administered for a minimum of 12 weeks. These drugs are notoriously expensive. Gilead priced its first new hepatitis C drug, sofosbuvir, at $1,000 per pill, or $84,000 for a three-month course of treatment. Its first combination pill, Harvoni, cost $94,500. Not all health insurance plans cover all prescribed medications for HCV treatment with few exceptions. Most insurers cover Sovaldi. It has an estimated copay of $75 to $175 per month. Hep C treatment side effects •Harvoni. • Fatigue. • Headache. ... •Mavyret. • Headache. ... •Olysio with interferon and ribavirin. • Rash (sensitivity to sunlight) ... •Peginterferon. • Flu-like (headache, fatigue, fever, chills, muscle ache) These drugs are notoriously expensive. Gilead priced its first new hepatitis C drug, sofosbuvir, at $1,000 per pill, or $84,000 for a three-month course of treatment. Its first combination pill, Harvoni, cost $94,500. If treatment is available, insurance and medicare aid have to pay it Hep c - makes expsneive meds a reality Give hep b vax as a baby because mom might have hep b Hep c - side effects for some of the drugs. Anything the screening task force recommends, payed for. So option is available.

Overview Hepatitis ABCD

An Overview of Hepatitis: Each week, health departments report cases of hepatitis A, hepatitis B, and hepatitis C to the Centers for Disease Control and Prevention (CDC) through the National Notifiable Diseases Surveillance System (NNDSS). Hepatitis A is an acute infection that can result in mild illness or be severe enough to result in hospitalization or, in rare cases, death. Hepatitis A has been a vaccine preventable disease since 1995. Incidence rates decreased more than 95% from 1995 to 2011, however, increased by 140% from 2011 to 2017. Until 2017, US incidence rates were influenced by occasional outbreaks, often linked to imported food, and from time-to-time among non-immune persons. In 2017, large person-to-person outbreaks began occurring among persons who use drugs and persons experiencing homelessness (CDC, 2020) oral fecal Hepatitis B often occurs as an acute infection that may or may not be identified or reported. Later, a chronic infection may develop. Hepatitis B is also a vaccine preventable disease and reported cases of acute hepatitis B declined from 1990-2014 after routine vaccination of children was recommended. Injection drug use is a major risk factor associated with acute hepatitis B cases in the US. Chronic hepatitis B infections primarily occur among persons born outside the US in countries with intermediate or high rates of hepatitis B prevalence. Chronic hepatitis B infection can be treated and managed clinically but cannot be cured (CDC, 2020) blood body fluids Hepatitis C occurs as an acute infection that is most often asymptomatic and frequently develops into a chronic infection. New cases of acute hepatitis C have increased rapidly in the US since 2010 and most often been associated with injection drug use. There is no vaccine against hepatitis C, but short-term treatment for chronic hepatitis C can clear the virus and cure the infection (CDC, 2020). Blood body fluids E - more so in asia - similar to hep a

Hepatitis C

Before widespread screening of the blood supply began in 1992, Hepatitis C was spread through blood transfusions and organ transplants. People with clotting problems who took blood products prior to 1987 could have been exposed to Hepatitis C. Hepatitis C is a liver infection caused by the hepatitis C virus (HCV). Hepatitis C is a blood-borne virus. Today, most people become infected with the hepatitis C virus by sharing needles or other equipment to inject drugs. For some people, hepatitis C is a short-term illness but for 70%-85% of people who become infected with the hepatitis C virus, it becomes a long-term, chronic infection. Chronic hepatitis C is a serious disease than can result in long-term health problems, even death. Many people might not be aware of their infection because they are not clinically ill. There is no vaccine for hepatitis C. The best way to prevent hepatitis C is by avoiding behaviors that can spread the disease, especially injecting drugs. NEEDLES. Most common. Blood transfusion

Question *A patient is diagnosed with an infection caused by the hepatitis A virus. Which statement, if made by the patient, would indicate the patient needs further teaching about the infection? Choose 1 answer: ■A: "I will wash raw fruits and vegetables thoroughly before I eat them." ■B: "Before I take any over-the-counter medicines, I should call the clinic." ■C: "I might get liver cancer someday because I have this infection." ■D: "It's important for me to remember to wash my hands after I use the bathroom."

C: "I might get liver cancer someday because I have this infection." Chronic liver- getting confused with cancer. Look at chart

Hepatitis B

Hepatitis B is a liver infection caused by the hepatitis B virus (HBV). HBV is transmitted when blood, semen, or another body fluid from a person infected with virus enters the body of someone who is not infected. Among adults in the United States, HBV is spread mainly through sexual contact. According to the Centers for Disease Control and Prevention (CDC), approximately 10% of people with HIV in the United States also have HBV. Infection with both HIV and HBV is called HIV/HBV coinfection (CDC, 19) 90 day incubation , severe symptoms Feeling lousy Sexual contact sti Can get it other ways Sexual contact number one

Active Immunity

Exposed to trigger, body agnre , causes a response. Can come from active infection or vaccine. Mild to sig reaction. Active immunity for some time. Getting sick from covid = active response

Tests for Hepatitis B

FYI do not need to memorize HBV specific antigens and antibodies: Hepatitis B serologic testing involves measurement of several hepatitis B virus (HBV)-specific antigens and antibodies. Different serologic "markers" or combinations of markers are used to identify different phases of HBV infection and to determine whether a patient has acute or chronic HBV infection, is immune to HBV as a result of prior infection or vaccination or is susceptible to infection. •Hepatitis B surface antigen (HBsAg): A protein on the surface of hepatitis B virus; it can be detected in high levels in serum during acute or chronic hepatitis B virus infection. The presence of HBsAg indicates that the person is infectious. The body normally produces antibodies to HBsAg as part of the normal immune response to infection. HBsAg is the antigen used to make hepatitis B vaccine •Hepatitis B surface antibody (anti-HBs): The presence of anti-HBs is generally interpreted as indicating recovery and immunity from hepatitis B virus infection. Anti-HBs also develops in a person who has been successfully vaccinated against hepatitis B. •Total hepatitis B core antibody (anti-HBc): Appears at the onset of symptoms in acute hepatitis B and persists for life. The presence of anti-HBc indicates previous or ongoing infection with hepatitis B virus in an undefined time frame. •IgM antibody to hepatitis B core antigen (IgM anti-HBc): Positivity indicates recent infection with hepatitis B virus (>6mos). Its presence indicates acute infection. The hepatitis B blood panel requires only one blood sample but includes three tests: HBsAg (hepatitis B surface antigen) Anti-HBs or HBsAb (hepatitis B surface antibody) anti-HBc or HBcAb (hepatitis B core antibody) HBsAg is the antigen used to make hepatitis B vaccine. Hepatitis B surface antibody (anti-HBs): The presence of anti-HBs is generally interpreted as indicating recovery and immunity from hepatitis B virus infection. Anti-HBs also develops in a person who has been successfully vaccinated against hepatitis B. What lab says, requires nurse to interpret it Lok for several antigens and antibodies Tells where you are Checked to make sure you are immune for vaccine Not tested, just be aware this si what youd look like with the combo of antibodeis

Tests for Hepatitis C

FYI do not need to memorize test outcomes: Diagnostic tests for hepatitis C include serologic assays that measure human antibodies generated in response to HCV infection and molecular virologic assays that directly detect HCV RNA. The third-generation HCV EIA test is the most frequently used antibody test to initially screen for HCV infection (USSTF, 2020) Like hep b needs knowledge to interpret results Interptreations are based on what outcome would be What further action should happen

Hepatitis (0.59)

HEPAR= Liver (Latin) ITIS= Inflammation (suffix) Anything that causes infterm-10lammation and effects the liver is by nature a form of hepatitis. Hepattiis - is not the disease, it's a result of a symptom from disease or virus From lupus or autoimmune Inflammation of liver ABCDE = from virus Reducing immune system - may manifest to inflammation of liver Similar presentations

Hepatitis A

Hand to mouth contact Has vaccine Immunize children for it - wekare immune system - prevents secondary cost though of nation"??? Payed time off

Prevention: Hepatitis A

Hepatitis A - Vaccination or immune globulin (IG): §Hepatitis A vaccine: Havrix, Vaqta §Combined Hepatis A & B: Twinrix

Hepatitis C Treatment

Hepatitis C infection is treated with antiviral medications intended to clear the virus from the body. The provider may recommend one medication or a combination of two to three medications to be taken for 12 - 24 weeks or longer. Hep C treatment side effects •Harvoni. • Fatigue. • Headache. ... •Mavyret. • Headache. ... •Olysio with interferon and ribavirin. • Rash (sensitivity to sunlight) ... •Peginterferon. • Flu-like (headache, fatigue, fever, chills, muscle ache) These drugs are notoriously expensive. Gilead priced its first new hepatitis C drug, sofosbuvir, at $1,000 per pill, or $84,000 for a three-month course of treatment. Its first combination pill, Harvoni, cost $94,500. No vaccine. Meant to cler your body. Expensive

Other significant history includes JB was immunized against hepatitis B at 12 years of age, and she recently participated in a two-week mission trip to Central America. Although she was very cautious about the foods ingested during the mission trip, the patient indicated that a primary recreational activity after the day's work was to swim in the lagoon near the village. The lagoon was fed both by the stream in which the natives washed their clothes and the adjacent bay. Rainfall averaged 2-3 inches per day. JB returned to the United States five weeks ago. ■*What is on your differential Dx list now?

Most likely diagnosis is acute hepatitis A infection Case Study Discussion JB has presented with classic signs and symptoms of acute hepatitis. Based on her past history, travel, and exposure history, the most likely diagnosis is acute hepatitis A infection. The hepatic chemistry profile and serologic studies confirm this diagnosis. Exposure probably resulted from accidental ingestion of contaminated water while swimming in the lagoon. Because acute viral hepatitis is usually a self-limited disease and Patient A is alert with no evidence of coagulopathy, she can be managed as an outpatient with close follow-up. Liver enzymes and PT should be monitored every 5 to 7 days for the first two weeks, then, if convalescence is satisfactory, at 14-day intervals until function test results have returned to normal. Bed rest is not indicated, but the patient should avoid strenuous activity. She should eat a well-balanced diet and abstain from alcohol for the duration of the illness. Because acetaminophen can be toxic to the liver, ibuprofen would be a better alternative for controlling fever. No other alterations in the patient's medications are necessary at this point. If nausea precludes the patient from ingesting food and fluids, IV replacement of fluids and electrolytes may be necessary. In the event the patient develops bleeding tendencies or signs of encephalopathy, she should immediately be taken to the hospital or her physician's office. Hepatitis A virus is a reportable disease. The health department should be informed of the case immediately. Because the exposure probably occurred outside the geographical area, follow-up will be limited to those with similar exposure (i.e., persons who were also on the mission trip) and to her intimate and/or household contacts. A single dose of HAV immunoglobulin is recommended for close contacts. If immunoglobulin is not available, administration of hepatitis A vaccine may prevent illness or lessen the severity of the contact's symptoms if infection does occur. Immunoglobulin is not recommended for those who may have been exposed on the mission trip, as those exposures occurred more than two weeks prior to the diagnosis. Follow-up with these persons is primarily to determine if they too are experiencing symptoms and are possible sources of spreading the disease.

CDC National Progress Report 2025 Goal: Reduce estimated* new hepatitis B virus infections by ≥20%

New cases of HBV infection in the United States had been decreasing until 2012. Since that time, reported cases of HBV have been fluctuating around 3,000 cases per year (HHS.gov) STIS are on the rise Esp chalymed, gornea, spyphs Hep b is on the decline though! Because of vaccination education.

Passive Immunity

Passive - given to us. Antibodies are acquired = mother to placenta For first couple life, fair amount of protection passivvly as baby but needs to build active immunity (that's why kids a lot of sick) Can also be reievedim glob

Case Study #3 ■PB is a paramedic, 48 years of age. Laboratory work obtained during his annual physical examination reveals hyperlipidemia; CBC, glucose, BUN, and electrolytes were within normal range. With the exception of his weight, (15 lbs. heavier than indicated for his height), his exam identifies no abnormalities. ■After two months of a diet and exercise program, his cholesterol level is 256. Therefore, his physician elects to begin a lipid-lowering agent. A baseline liver profile is drawn prior to initiation of the medication. The liver profile reveals an AST of 226 Units/L and an ALT of 282 Units/L (Elevated - typical ALT range 7 to 56 units per liter) ■To determine the cause of his elevated liver enzymes, you review his history and medications. He has been a paramedic for 25 years. He was immunized against HBV in 1988. During his career, he has experienced several exposures to blood (usually blood splashes, but also two needlesticks from IV needles), most before the advent of Standard Precautions. His most recent exposure was two years ago. An HIV test six months post-exposure was negative. ■The patient has never smoked. He drinks about six beers per week and rarely drinks hard liquor. He denies any history of illegal drug use. Although the patient has no current prescription medications, he uses several herbal preparations including garlic, ginkgo, and an antioxidant preparation. The patient takes ibuprofen for pain, consuming 6 to 10 tablets (200 mg each) per month. ■Although alcohol consumption and herbal antioxidants can both cause liver inflammation, the degree of his liver inflammation is much higher than would be expected from limited use of these two factors. Therefore, the provider orders a hepatitis profile. What would you expect to be next? (discussion notes below)

Suspect CHRONIC HEPATITIS C In order to evaluate the extent of liver damage and determine an appropriate treatment plan, the provider orders an HCV viral load and genotype as well as a PT. A gastroenterology specialist is consulted for liver biopsy and to co-manage the patient. The PT is within normal range. The liver biopsy reveals chronic inflammatory infiltration of the portal areas with minimal fibrosis. Genotype identifies the virus as type 3. HCV RNA viral load is 350,000 phages/cc. Treatment options appropriate for HCV genotype 3, and the timing of therapy in relation to biopsy findings and anticipated progression of disease are discussed with Patient B. He is advised to eat a nutritious, balanced diet and abstain completely from alcohol. Although he is not currently sexually active, the patient is educated about the low but present risk of sexual transmission of HCV and how to minimize the risk of transmission. Immunization against HAV is also recommended, as acquiring an acute case of HAV in a patient with pre-existing chronic hepatitis can be much more serious that either condition alone. Because of uncertainty as to how recently he acquired the infection, the decision is made to defer treatment for three to four months while monitoring the course of the infection. On treatment, the patient experiences transient nausea and persistent mild fatigue, but is compliant with the recommended duration of therapy. At 12 weeks, the ALT and AST are both within normal range and HCV RNA is undetectable. Treatment is discontinued and Patient B is asked to return in three months, six months, and one year after cessation of therapy to repeat HCV viral load and confirm a sustained virologic response.

■laboratory tests ordered include an HIV viral load, a CD4 count, a CBC, a chemistry panel, a liver profile and or a hepatitis profile were ordered. A tuberculin skin test (TST) is performed to determine the presence of a tuberculosis infection, and the patient is instructed to return in 72 hours to have the TST read, review lab results, and formulate a treatment plan. ■Upon his return, all results except the HIV viral load and Hepatis profile are available. His CD4 count is 246 (low). Hematocrit is 44% (WNL), hemoglobin 15 gm/dL (WNL), and WBC is 3,800 (low-less than 4,000 can't fight infection). The liver profile reveals AST 358 Units/L (high), ALT 383 Units/L (high), total bilirubin 1.2 mg/dL, and albumin 3.6 gm/dL. PT/PTT (WNL). The PPD is negative. The remainder of the chemistry panel is unremarkable. *What is on your differential diagnosis list?

Suspect HIV with HBV CO-INFECTION, HCV is reasonable to add as well due to his past Hx of IV drug use. https://www.cdc.gov/hepatitis/hbv/pdfs/serologicchartv8.pdf Remember a normal range for CD4 cells is about 500-1,500. Usually, the CD4 cell count increases when the HIV virus is controlled with effective HIV treatment. The higher your CD4 count, the better. The same test that measures your CD4 count often includes a CD8 cell count, too. Normal range for hematocrit is different between the sexes and is approximately 45% to 52% for men and 37% to 48% for women. The normal range for hemoglobin is: For men, 13.5 to 17.5 grams per deciliter. For women, 12.0 to 15.5 grams per deciliter. How many white blood cells (WBCs) someone has varies, but the normal range is usually between 4,000 and 11,000 per microliter of blood. A blood test that shows a WBC count of less than 4,000 per microliter (some labs say less than 4,500) could mean your body may not be able to fight infection the way it should. Normal levels of AST and ALT may slightly vary depending on the individual laboratory's reference values. Typically the range for normal AST is reported between 10 to 40 units per liter and ALT between 7 to 56 units per liter. The normal range of values for AST (SGOT) is about 5 to 40 units per liter of serum (the liquid part of the blood). The normal range of values for ALT (SGPT) is about 7 to 56 units per liter of serum. It is normal to have some bilirubin in the blood. A normal level is: Direct (also called conjugated) bilirubin: less than 0.3 mg/dL (less than 5.1 µmol/L) Total bilirubin: 0.1 to 1.2 mg/dL (1.71 to 20.5 µmol/L) A normal albumin range is 3.4 to 5.4 g/dL. If you have a lower albumin level, you may have malnutrition. It can also mean that you have liver disease or an inflammatory disease. Higher albumin levels may be caused by acute infections, burns, and stress from surgery or a heart attack. PTT test results are measured in seconds. Normal results are typically 25 to 35 seconds. This means that it took your blood sample 25 to 35 seconds to clot after adding the chemicals PT is measured in seconds. Most of the time, results are given as what is called INR (international normalized ratio). If you are not taking blood thinning medicines, such as warfarin, the normal range for your PT results is: 11 to 13.5 seconds. INR of 0.8 to 1.1.

Overview

Trends who we worry about What causes itterm-10 What

Prevention Hepatitis B

Vaccination available: §Heplisav-B® (< 18yrs old) §Vaqta® or Engerix-B® (pediatric)

Prevention & Treatment (CDC link)

Visit the link to learn more about available vaccinations for Hep A

Who is at high risk for Hepatitis A?

When hearing about hepatitis A, many people think about contaminated food and water. However, in the United States, hepatitis A is more commonly spread from person to person. Since March 2017, CDC's Division of Viral Hepatitis (DVH) has been assisting multiple state and local health departments with hepatitis A outbreaks, spread through person-to-person contact. sharing needles

HEP E

§self-limited disease that does not usually result in chronic infection §rare in the United States (Asia) §transmitted from ingestion of microscopic fecal matter (mostly contaminated water) §Vaccine offered parts of Asia. Hepatitis E is a liver infection caused by the Hepatitis E virus (HEV). Hepatitis E is a self-limited disease that does not result in chronic infection. While rare in the United States, Hepatitis E is common in many parts of the world. It is transmitted from ingestion of fecal matter, even in microscopic amounts, and is usually associated with contaminated water supply in countries with poor sanitation. There is currently no FDA-approved vaccine for Hepatitis E. E - not chronic . Waters of asia . There is a vaccine.

HEP D

§uncommon in the United States §only occurs in people who are infected with the hepatitis B virus Hepatitis D, also known as "delta hepatitis," is a liver infection caused by the hepatitis D virus (HDV). Hepatitis D is uncommon in the United States. Hepatitis D only occurs in people who are infected with the hepatitis B virus because HDV is an incomplete virus that requires the helper function of HBV to replicate. D - cant cause disease - but if you have hep B , need hep b to live in bodies. Should be tested together. Makes it more severe disease. Maybe death

The USPSTF now recommends that all adults aged 18 to 79 years be screened.

•Previously, only recommended screening adults born between 1945 and 1965 and others at high risk. Everyone should be screened Blood supply wasn't clean in this time period

Cheat Sheet for Healthcare Workers

■The ABCs of Hepatitis - for Health Professionals (CDC, 2020) This is good resource for all the information How get hep a - how to treat it etc