hepatitis%20-%20viral
HEPATITIS - VIRAL
The majority of acute viral hepatitis infections are asymptomatic or they can cause an anicteric illness that may not be diagnosed as hepatitis.
Hepatitis A generally causes minor illness in childhood with >80% of infections being asymptomatic but more likely to produce clinical symptoms in adults. 
Hepatitis B, C, and D may also be asymptomatic.
Hepatitis A is predominantly transmitted through oral-fecal route.
Hepatitis B is transmitted through perinatal, percutaneous, or sexual routes or close person-to-person contact via open cuts and sores.
Hepatitis C infections are transmitted through perinatal, percutaneous, or sexual routes, blood transfusions, or organ transplants.
Hepatitis D's route of transmission is sexual or percutaneous, especially IV drug use.
Hepatitis E is transmitted primarily through contaminated drinking water and oral-fecal transmission.

Follow Up

Hepatitis B
  • Monitor patient to ensure that fulminant liver failure does not develop
  • Monitor liver function tests (LFT) every 1-4 weeks until normal; ALT every 3-6 months if patient did not meet criteria for treatment
  • Repeat serologic testing 6 months after infection to rule out development of chronic hepatitis

Prevention

PREVENTION and POST-EXPOSURE PROPHYLAXIS OF VIRAL HEPATITIS
Patient Group for Whom Prevention or Post-exposure Prophylaxis is Recommended Recommended Prevention or Post-exposure Prophylaxis Regimen
Prevention
Hepatitis A
Susceptible persons traveling to HAV-endemic areas
Household contacts, daycare children and staff
Healthcare personnel and lab researchers potentially exposed to HAV
Patients who will undergo blood transfusion or will receive clotting factor concentrates
Immunocompromised children (suboptimal response)
Men who have sex with men (MSM)
Illegal drug users (both injection and non-injection drug users)
Persons with chronic liver disease, including persons with chronic HBV and HCV infection who have evidence of chronic liver disease
Hepatitis A Vaccine1
Hepatitis B
Unvaccinated children, adolescents and adults
Premature infants with immediate risk of HBV infection
Unvaccinated persons who attend STD clinics, including pregnant women
Persons with any of the following sexual risk factors: History of STD and HIV, multiple sex partners, sex with an injection drug user, MSM, victims of sexual assault
Illegal IV drug users
Household members, sex partners and drug-sharing partners of a person with chronic HBV infection2
Persons on hemodialysis, or are receiving clotting factor concentrates, or who have occupational exposure to blood
Healthcare personnel in treatment facilities
Patients with diabetes mellitus, chronic liver disease
Travelers to places with endemic HBV infection
Hepatitis B Vaccine
Post-exposure Prophylaxis
Hepatitis A
Unvaccinated or nonimmune persons exposed to hepatitis A virus (HAV) through household or sexual contact or by sharing illegal drugs with a person who has hepatitis A3
Administer a single IM dose of human immunoglobulin (Ig) as soon as possible but not >2 weeks after exposure
Hepatitis B
Unvaccinated or nonimmune sex partners of persons with acute hepatitis B
Administer Ig within 14 days after the most recent sexual contact
1Postvaccination serologic testing is not indicated because most persons respond to the vaccine
2Vaccination of household contacts (especially children and adolescents) of persons with acute HBV infection is also encouraged. Consider postvaccination testing (anti-HBs) for sex partners of persons with chronic HBV infection. Those found to be antibody negative should receive a second, complete, vaccination series
3A person who has had 1 dose of hepatitis A vaccine at least 1 month before exposure to HAV does not need Ig

Hepatitis C

Primary Prevention

  • At present, there is no available vaccine for HCV
  • The prevention of HCV would depend on the reduction of the risk of exposure especially in patients in healthcare setting and those who are in a high risk population (eg IV drug use and through sexual contact)
  • Recommended primary interventions:
    • Hand hygiene should include proper surgical hand preparation, hand washing and use of gloves
    • Appropriate and safe use of injection
    • Proper handling and disposal of sharp needles and other objects and waste
    • Comprehensive harm-reduction services should be provided to IV drug users including the use of sterile injecting equipments
    • Sterilization of equipments
    • All healthcare personnel should be trained
    • Donated blood should be tested for HBV, HCV, HIV and syphilis
    • Proper and consistent use of condoms should be promoted

Secondary and Tertiary Prevention

  • Recommendations for people who are infected with HCV: 
    • Conduct an education and counseling program for patient care and treatment
    • Immunization with hepatitis A and B vaccines are recommended to prevent coinfection and provide protection to the liver
    • Early and appropriate use of antiviral therapy
    • Regular monitoring is the key to early diagnosis of chronic liver disease

Monitoring

Chronic Hepatitis B

During Therapy

  • Monitor ALT, HBeAg, anti-HBe, and/or HBV DNA at least every 3-6 months; HBsAg every 6-12 months
  • Monitor renal function (eg creatinine, phosphate) if Tenofovir, Entecavir, or Adefovir are used 
  • Monitor for adverse effects (ie CBC, TSH) if Interferons are used

End of Therapy

  • Monitor ALT and HBV markers (including HBV DNA) to detect relapse every 3-6 months for the 1st year then every 6-12 months
  • Every 3 months in patients with cirrhosis or HBeAg/HBV DNA positive
  • May monitor every 6 months in patients who responded to therapy
  • Further monitoring of HBV DNA every 3-6 months in non-responders is recommended to recognize delayed response and to plan retreatment if required
  • Monitor for hepatocellular carcinoma (HCC) in high-risk patients every 6-12 months using ultrasound and alpha-fetoprotein  

Chronic hepatitis B patients who are not treated but need continuous monitoring:

  • Patients age <30 years without cirrhosis, with PNALT, HBV DNA >20,000 IU/mL
  • HBeAg-negative patients age <30 years without cirrhosis, ALT levels intermittently abnormal, HBV DNA between 2000 and 20,000 IU/mL
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