ACUTE VIRAL HEPATITIS

CLINICAL PRESENTATION.DIGNOSIS.EPEDEMOLOGY OF VIRAL

HEPATITIS INFECTION A,B,C IN KSA.

MANAGEMENT.

Viral Hepatitis - OverviewViral Hepatitis - Overview

AA BB CC DD EESource ofvirus

feces blood/blood-derived

body fluids

blood/blood-derived

body fluids

blood/blood-derived

body fluids

feces

Route oftransmission

fecal-oral percutaneouspermucosal

percutaneouspermucosal

percutaneouspermucosal

fecal-oral

Chronicinfection

no yes yes yes no

Prevention pre/post-exposure

immunization

pre/post-exposure

immunization

blood donorscreening;

risk behaviormodification

pre/post-exposure

immunization;risk behaviormodification

ensure safedrinkingwater

Type of HepatitisType of Hepatitis

Diagnosis of hepatitis

Patient historyPhysical examinationLiver function testsSerologic tests

Symptoms and Signs Pre-icteric phase

1. Anorexia2. Fatigue3. Nausea4. Vomiting5. Arthralgia6. Myalgia7. Headache8. Photophobia9. Pharangitis10. 11.

Icteric phase::1. Enlarged liver2. Tender upper quadrant3. Discomfort4. Splenomegaly (10-20%)5. General adenopathy

Post-icteric phase

Lab Findings

1. L FT increase >5-10 times of normal2. Markers of hepatitis B or C or A might be

positive

Case report.

30/9/13Ahamed ,50y.teacher,living in jazan. abdominal discomfort, nausea, lose of appetit,coloration of urine.Exam. Marked jaundice.

Lab. result

30/9/13 :ALT 1745 U/L(40) AST 990 U/L (17-59)BIL.9.5MG/DL (0.0-1.4)PLT:267000(150000-400000)

Lab. result

28/10/113 :ALT 185U/L(21-72) AST 41 U/L (17-59)ALKALINE PHOSPHATASE 247.0 U/L.YGT 97,0U/LBIL.1.4MG/DL (0.0-1.4)ALB.3.6 g/l(3.5-5.0)PT 14,8.6 (10-14)

PLT:88000(150000-400000)

Lab. result

22/2/12 :ALT 176 U/L(21-72) AST 61 U/L (17-59)ALKALINE PHOSPHATASE 47 U/L.YGT 64U/L(15.0-73)BIL.2.4MG/DL (0.0-1.4)ALB.3.7 g/l(3.5-5.0)PT

DD:

1. Infectious Mononucleosis2. Drug Induced Hepatitis3. Chronic Hepatitis.4. Alcohol Hepatitis5. Cholecystitis, Cholelithiasis6-Auto-immun hepatitis

MARKERS OF VIRAL HEPATITIS

HBV MARKERSHCV MARKERSHAV MARKERS

Hepatitis B Markers

anti-HBc exposure (IgM = acute) HBsAg infection (carrier)anti-HBs immunityHBeAg viral replication anti-HBe seroconversionHBV-DNA viral replication

Hepatitis C Markers

ANTI -HCVPCR-RNA HCV

Hepatitis A Markers

HAV igMHAV igG

Hepatitis E Markers

HEV igMHEV igGHEV RNA PCR

AUTOIMMUN HEPATITIS MARKERS

ANAANTI MITOCHONDRIAL ABANTI SMOOTH MUSCLES ABS.

AUTOIMMUN HEPATITIS MARKERS

ANA (1:1280)ANTI MITOCHONDRIAL AB(1:400)ANTI SMOOTH MUSCLES ABS.(1:400)

FINAL DIAGNOSIS

ACUTE AI HEPATITIS

MANAGMENT

INCIDENCE OF ACUTE HEPATITIS IN 5 HEPATOLOGY CLINICS IN KSA 2013

Causes of Hepatitis

HAV HBV HCV AIH DILI

KKUH 7 3 1 11 ?

NGH 10 5 2 8 8

AMC 1 0 0 3 3

KFH 1 2 0 3 ?

DAMMAM UN.

2 1 0 1 5

TOTAL 21 11 4 26 16

Complications

1.Chronic hepatitis cirrhosis- HCC

2.Fulmnant hepatitis

FULMINANT HEPATITIS

Definition: Hepatic Failure Within 8 Weeks Of Onset Of Illness.Manifestation: Encephalopathy and Prolonged PTHistopathology: Massive Hepatic Necrosis.

Hepatitis B - Clinical FeaturesHepatitis B - Clinical Features• Incubation period: Average 60-90 days

Range 45-180 days• Clinical illness (jaundice): <5 yrs, <10%

5 yrs, 30%-50%• Acute case-fatality rate: 0.5%-1%• Chronic infection: <5 yrs, 30%-90%

5 yrs, 2%-10% • Premature mortality from

chronic liver disease: 15%-25%

Natural History

Gow, BMJ 2001

• Sexual

• Parenteral

• Perinatal

Hepatitis B Virus Modes of Transmission

Hepatitis B Virus Modes of Transmission

Concentration of Hepatitis B Virus in Various Body Fluids

Concentration of Hepatitis B Virus in Various Body Fluids

High ModerateLow/Not

Detectable

blood semen urineserum vaginal fluid feces

wound exudates saliva sweattears

breastmilk

Possible transmission route of HBV in KSA

1-Horisontal transmission (person to person) is the main transmission route 2-Perintal transmission (positive HBSAG mothers) especially if they are HBEAG positive3- Heterosexual transmission 4-Illegal injection drug use 5- Contaminated equipment used for therapeutic injections and other health care related procedures6- Folk medicine practice 7-Blood and blood products transfusion without prior screening

HBV INFECTIONbefore and after

vaccination program

OVERALL PREVALENCE OF HBsAg AMONG SAUDIS IN THE 80’S ACCORDING TO REGIONS

5.5

8.99.6

8.3

0

2

4

6

8

10

Central (n=6649) South-western(n=7235)

Eastern(n=8300)

Total (n=32183)

Posi

tivity

(%)

Al-Faleh. Annals of Saudi Medicine, 1988

PREVALENCE OF HBeAg AMONG HBsAg POSITIVE SAUDIS PREGNANT WOMEN (n = 20920)

3.7

5.4

0

1

2

3

4

5

6

% of HBsAg pos. % of HBeAg Pos.

Al-Faleh, Annals of Saudi Medicine, 1988

FREQUENCY OF HBeAg AMONG HBsAg POSITIVE SAUDI CHILDREN (n=307)

17.2

19.4

17.1

17.9

15.5

16

16.5

17

17.5

18

18.5

19

19.5

Perc

ent

1-3 years(93/16)

4-6 years(103/20)

7-10 years(111/19)

Total(307/55)

Al-Faleh et al. Journal of Infection, 1992

PREVENTION STRATEGIES OF MINISTRY OF HEALTH IN KSA

Introducing HBV vaccine in EPI program; and

Mandatory screening of blood donors and expatriates.

Vaccination of risk groups.

Health education especially among medical personnel.

History of HBV infection control in KSA

Vaccination of All infants

At birth

Vaccination of all children

at school entry

vaccination of All risk groups

mandatory

Screening of all Expatriates coming

To work in KSA

1989 1990 - until now

1990 - until now1990

THE CURRENT EPI IN THE KINGDOM OF SAUDI ARABIA

1. At birth BCG + HB12. At 6 weeks DPT1 + OPV1 Hb23. At 3 months DPT2 + OPV24. At 5 months DPT3 + OPV35. At 5months Measles HB36. At 12 monthsMMR7. At 18 months(DPT + OPV) Booster 18. At 4-6 years (DPT + OPV) Booster 2

COMPARISON OF PREVALENCE OF HBsAg AMONG SAUDI CHILDREN IN 1989 (n=4575) AND 1997 (n=5355) – ACCORDING TO AGE

9.68

0 0

6.54

0.16

7.24

0.3

5.06

0

6.35

0

7.57

0.2

6.51

0.82

7.2

0.93

5.81

2.31

0

66.71

0.310

2

4

6

8

10

Perc

enta

ge

1 2 3 4 5 6 7 8 9 10 11 12

Tota

l

(Age in years)

1989 1997Al Faleh, J Infect 1999

COMPARISON OF PREVALENCE OF HBsAg AMONG SAUDI CHILDREN IN 1989 (n=4575)

AND 1997 (n=5355) – ACCORDING TO REGION

8.63

0

3.48

0.52

2.87

0

5.83

0.83

5.71

0

10.29

1.52

7.59

0

8.83

0.77

5.22

0

9.04

0

12.67

0.47

3.14

0

3.73

0.3

7.53

0

6.71

0.31

-1

1

3

5

7

9

11

13

Perc

enta

ge

Riy

adh

Qas

sim Hai

l

Mak

kah

Med

ina

Ase

er

Al-B

aha

Giz

an

Naj

ran

Al-J

ouf

Tabo

uk

Dam

mam

Jedd

ah Taif

Tota

l

1989 1997

Al Faleh, J Infect 1999

Prevalence Of HBsAg Among Saudi Population Before & After Vaccination over 18 y

6.70%

0%0.16%

0%0%

2%

4%

6%

8%

10%

1989 1992 1997 2007/8

After

Before

1-10yr4575

1-2yr637

1-12yr 3666

Agenumbers

16-18yr1365

Long Term Seroconversion Rate Over 18 Years (Anti-HBS)

95%

77%

60%

0%

20%

40%

60%

80%

100%

1992 1997 2007/8

*Al Faleh et al Annals of Saudi meds 1993 **Al Faleh et al Journal of infection 1999

***AlFaleh et al journal of infection2008

1-2yr637

1-12yr3666

16-18yr 1365

AgeN

*

***

**

Long-Term protection of HB- vaccine over 18 years ( anti-HBS>10IU/L)(n=1355)

93%(637)

65%(3666)

38%(1365)

0%

20%

40%

60%

80%

100%

1992 1997 2007/81-2yr

5 1-8yr

13 16-18yr

3 Age

Region

AL Faleh et al, J Infection 2008

CHANGING PATTERNS OF HBsAg POSITIVITY AMONG BLOOD DONORS IN MOH,CENTRAL

BLOOD BANK 1994-20054.4

3.25

1.5

00.5

11.5

22.5

33.5

44.5

1994n=9690

2000n=91695

2005n=177037

4.7

3

1.41.97 1.7

2 2.2

1 1 0.8 0.780.65

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Posi

tivity

%

PREVALENCE OF HBsAg POSITIVITY AMONG BLOOD DONORS IN KKUH FROM 1987 TO 2008

HCV INFECTION

Transmission of HCV Percutaneous

– Injecting drug use– Clotting factors before viral inactivation– Transfusion, transplant from infected donor – Therapeutic (contaminated equipment, unsafe

injection practices)– Occupational (needlestick)

Permucosal– Perinatal– Sexual

Features of Hepatitis C Virus InfectionFeatures of Hepatitis C Virus Infection

Incubation periodIncubation period Average 6Average 6--7 weeks7 weeksRange 2Range 2--26 weeks26 weeks

Acute illness (jaundice)Acute illness (jaundice) Mild (Mild (<<20%)20%)Case fatality rateCase fatality rate LowLowChronic infectionChronic infection 75%75%--85%85%Chronic hepatitisChronic hepatitis 70% (most asx)70% (most asx)CirrhosisCirrhosis 10%10%--20%20%Mortality from CLDMortality from CLD 1%1%--5%5%

*Reported in U.S.

Household Transmission of HCV

Rare but not absent Could occur through percutaneous/mucosal

exposures to blood– Theoretically through sharing of contaminated

personal articles (razors, toothbrushes)– Contaminated equipment used for home therapies

• Injections*• Folk remedies

Sexual Transmission of HCV

Occurs, but efficiency is low– Rare between long-term steady partners– Factors that facilitate transmission between

partners unknown (e.g., viral titer) Accounts for 15-20% of acute and chronic

infections in the United States– Sex is a common behavior – Large chronic reservoir provides multiple

opportunities for exposure to potentially infectious partners

* Reported in U.S.

Nosocomial Transmission of HCV

Recognized primarily in context of outbreaks Contaminated equipment

– hemodialysis*– endoscopy

Unsafe injection practices– plasmapheresis,* phlebotomy– multiple dose medication vials– therapeutic injections

Natural history

Marcellin, J Hepat 1999

1989 1997 2008

No. of children Positive(%) No. of

childrenPositive

(%)No. of

students Positive(%)

4496 39*)0.87%( 5350 2**

)0.04%( 1357)5(3

0.22%

Diagnostic test only by

1st-generation EIA kit .

Diagnostic test by3rd-generation EIA

kit and confirmatory test by RIBA kit.

Diagnostic test byPCR for anti- HCV

Positive cases.

Overall prevalence rate of HCV infection in KSA among children and adolescent during the last

18 yrs.

* ALFaleh et al. Hepatology 1991** ALFaleh Ann Saudi Med. 2003

Prevalence of HCV Positivity Among Different Saudi population

Type of patient number Prevalence(%)

Children from 1-18y 3854 0.1

Pregnant women 3127 0.7

Hemodialysis patients 29054 55.8

Drug addicts 9137 14

Shobokshi et al , SMJ 2003

Prevention Of HCV Transmission

Avoiding shared use of Razors or brushes and any item that pierces the skin.Strict adherence of the universal precautions in health facilities.Educating and training of HCW’s to the proper use of standard precautions Folk medicine?!

HAV INFECTION

COMPARISON OF PREVALENCE OF ANTI-HAV AMONG SAUDI CHILDREN IN 1989 (n=4375) AND 1997 (n=5255) –

ACCORDING TO AGE

23.7

13.4

34.8

17.6

41.6

20.3

43.9

23.4

48.5

24

54.1

26.7

59.8

28

59.7

30.6

63.5

33.1

72.6

34.5

26.4

48.850.5

24.9

0

10

20

30

40

50

60

70

80

Perc

enta

ge

1 3 5 7 9 11 Total

(Age in years)

1989 1997

Al-Faleh et al. Saudi Med. J, 1999

COMPARISON OF PREVALENCE OF ANTI-HAV AMONG SAUDI CHILDREN IN 1989 (n=4375) AND

1997 (n=5255) – ACCORDING TO REGION

39

16.1

62.7

31.6

56

20.4

55

20.1

59.5

28.2

44.5

19

43.6

25.4

81.682.279.1

51.3

64.4

47.9

76

45.638.4

18.2

51.1

17.5 19

9.6

50.5

24.9

1112131415161718191

Perc

enta

ge

Riy

adh

Qas

sim

Hai

l

Mak

kah

Med

ina

Ase

er

Al-B

aha

Giz

an

Naj

ran

Al-J

ouf

Tabo

uk

Dam

mam

Jedd

ah Taif

Tota

l

1989 1997

PREVALENCE OF ANTI-HAV IN SAUDI CHILDREN IN 1997 ACCORDING TO SEX

25.7524

0

5

10

15

20

25

30

Perc

ent

Male (n=2642) Female (n=2713)No. of children = 5355

PREVALENCE OF ANTI-HAV IN SAUDI CHILDREN IN 1997 ACCORDING TO LOCATION

20.98

33.04

05

101520253035

Perc

ent

Urban (n=3635) Rural (n=1715)No. of children = 5255

AGE SPECIFIC PREVALENCE OF ANTI-HAV IN SAUDIS FROM RIYADH, CENTRAL REGION

Age(Years)

1986 1994P

No. Positive/ No. Tested % No. Positive/

No. Tested %

1 – 9 103/194 53.0 81/210 38.6 3.4 x 10.3

10 – 19 164/193 85.0 110/180 61.1 1 x 10.4

20 – 30 182/200 91.0 188/240 78.3 3 x 10.4

Total 449/587 76.5 379/630 60.2 1 x 10.4

Arif et al. Saudi J Gastroenterology, 1995

Changing pattern of Hepatitis A prevalence within the Saudi population over 18 yrs

53

24.318.1

0

10

20

30

40

50

60

1989 1999 2008

Age Region

1-10 YRS 13

1-12 yrs 13

16-18 yrs 3

*

** ***

*AlRashed R. Ann SM 1997** AlFaleh et al SMJ 1999*** AlFaleh et al WJG 2008

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