VIRAL HEPATITIS (an overview) ;presentation by Dr. Urooj Arshad.

An overview of Hep A-E .

1. VIRAL HEPATITIS An overview PRESENTATION BY: DR. UROOJ ARSHAD

2. Around 12 million people are suffering from hepatitis B or C in Pakistan. Each year brings about 150 000 new cases. The Department of Health also states that among children who are infected with Hepatitis-B , more than 90% will most likely suffer from life-long infection.

3. What is Viral Hepatitis? Viral hepatitis is a systemic disease with primary inflammation of the liver by any one of a heterogeneous group of hepatotropic viruses. The most common causes of viral hepatitis are the five unrelated hepatotropic viruses Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D, and Hepatitis E.

4. Hepatitis A Hepatitis A is an inflammation of the liver that can cause mild to severe illness. The hepatitis A virus (HAV) is transmitted through ingestion of contaminated food and water or through direct contact with an infectious person. Almost everyone recovers fully from hepatitis A with a lifelong immunity. However, a very small proportion of people infected with hepatitis A could die from fulminant hepatitis. The risk of hepatitis A infection is associated with a lack of safe water and poor sanitation and hygiene (such as contaminated and dirty hands). A safe and effective vaccine is available to prevent hepatitis A . There is no specific treatment for hepatitis A. Recovery from symptoms following infection may be slow and can take several weeks or months.

5. Hepatitis B Hepatitis B is an infection of the liver caused by the hepatitis B virus. The infection can be acute (short and severe) or chronic (long term). If the virus remains in the blood for more than six months, then it is considered a chronic infection. Hepatitis B can cause a chronic infection and puts people at high risk of death from cirrhosis and liver cancer. While most adults do not develop chronic hepatitis B, infants and young children are less able to rid their bodies of the virus and may develop chronic hepatitis B as a result.

6. Mode of Transmission Hepatitis B virus can be transmitted through: Blood transfusions Sexual contact IV needle sharing From mother to child during pregnancy and birth

7. CLINICAL MANIFESTATIONS Incubation period is 30-180 days. There are three phases of  acute  hepatitis B infection, and symptoms may differ depending on the stage. Early in the disease, called the prodromal phase , symptoms may include: Fever Joint pain or arthritis Rash Edema (swelling) Symptoms of the next phase, the preicteric phase , include: Fatigue Myalgia (muscle pain) Anorexia Nausea and/or vomiting Fever Cough Abdominal pain and/or diarrhea Dark urine and light stool color During the icteric phase : Jaundice (yellowing of the skin and whites of the eyes) develops Anorexia, nausea and vomiting may worsen Irritated skin lesions may develop Other symptoms may subside

8. DIAGNOSIS Blood Tests: Liver Function Test H epatitis B surface antigen ( HBsAg ) Antibody to hepatitis B surface antigen ( anti-HBs) T otal antibody to hepatitis B core antigen (total anti- HBc ). Liver Biopsy

9. INTERPRETATION OF TEST RESULTS

10. MANAGEMENT APPROACH For Acute Hepatitis B infection: More than 95% of immunocompetent individuals with acute infection will achieve seroconversion with appearance of antibody to hepatitis B surface antigen in the absence of treatment. Therefore, supportive care is usually all that is needed in most patients . However, Initiate antiviral therapy in patients with acute liver failure or in those who have a severe, protracted course (i.e., total bilirubin level (> 3 mg/ dL ), INR >1.5 , encephalopathy, or ascites). Entecavir , tenofovir alafenamide , and tenofovir disoproxil are the drugs of choice. Simultaneously, assess the patient for the need for liver transplantation, as there is a high risk of mortality in patients with liver failure who do not undergo a transplant.

11. For Chronic hepatitis B infection without complications (cirrhosis): Initiate antiviral therapy in patients with immune-active chronic hepatitis B virus (HBV) infection (i.e., elevated alanine aminotransferase [ALT] levels ≥2 the upper limit of normal [ULN] or evidence of histological disease with elevated HBV DNA levels >2000 IU/mL if hepatitis B e antigen [ HBeAg ] negative, or >20,000 IU/mL if HBeAg positive ) Entecavir , tenofovir disoproxil or tenofovir alafenamide , or peginterferon alfa 2a are the recommended first-line drugs.

12. For Chronic Hepatitis B infection with cirrhosis: (a) With compensated Cirrhosis: Initiate anti- virals in such patients. Monitor patients (at least every 3 months for 1 year) after stopping therapy to check for viral rebound that could lead to decompensation . (b) With decompensated Cirrhosis: Initiate antiviral therapy as soon as possible. In patients with chronic HBV and decompensated cirrhosis, referral to a liver transplantation centre is necessary.

13. COMPLICATIONS Fulminant hepatic failure: Heightened immune response to hepatitis B virus (HBV) resulting in massive immune-mediated lysis of infected hepatocytes is thought to be the cause of fulminant hepatitis associated with acute hepatitis B infection . Cirrhosis: It occurs in about 20% of patients with chronic hepatitis B virus (HBV) and is thought to be due to ongoing immune attack of infected cells in the liver, resulting in development of fibrosis and regenerative nodules . Hepatocellular Carcinoma

14. Hepatitis C Hepatitis C is an inflammation of the liver caused by the hepatitis C virus. The virus can cause both acute and chronic hepatitis, ranging in severity from a mild illness to a serious, lifelong illness including liver cirrhosis and cancer.

15. Mode of Transmission Hepatitis C virus can be transmitted through: Blood transfusions Sexual contact IV needle sharing From mother to child during pregnancy and birth

16. CLINICAL MANIFESTATIONS For people who develop symptoms, they usually happen 2–12 weeks after exposure to the hepatitis C virus and can include: yellow skin or eyes (icterus) Anorexia upset stomach nausea and vomiting Abdominal pain fever dark urine light-colored stool joint pain (arthralgia) fatigue

17. DIAGNOSIS

18. MANAGEMENT APPROACH Treatment should be initiated in all patients with acute hepatitis C virus (HCV) infection with viremia without awaiting spontaneous resolution. The same regimens that are used for chronic infection are recommended for acute infection Direct-acting oral agents are recommended by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA). The specific regimen depends on the genotype and the presence or absence of cirrhosis . Ribavirin and alpha pegylated interferon is also used in combination for the treatment of patients 5 years of age and older with chronic hepatitis C (CHCV) virus infection who have compensated liver disease and have not been previously treated with interferon alpha. Treatment duration is of 24 – 48 weeks. Liver transplantation is the definite treatment of decompensated Liver Cirrhosis.

19. Direct Acting Oral Antiviral Agents

20. Hepatitis D Hepatitis D, also known as “delta hepatitis,” is a liver infection caused by the hepatitis D virus (HDV). Hepatitis D only occurs in people who are also infected with the hepatitis B virus. Hepatitis D is spread when blood or other body fluids from a person infected with the virus enters the body of someone who is not infected. Hepatitis D can be an acute, short-term infection or become a long-term, chronic infection. Hepatitis D can cause severe symptoms and serious illness that can lead to life-long liver damage and even death. People can become infected with both hepatitis B and hepatitis D viruses at the same time (known as “coinfection”) or get hepatitis D after first being infected with the hepatitis B virus (known as “superinfection”). There is no vaccine to prevent hepatitis D. However , prevention of hepatitis B with hepatitis B vaccine also protects against future hepatitis D infection.

21. Hepatitis E Hepatitis E is a liver infection caused by the hepatitis E virus (HEV). HEV is found in the stool of an infected person. It is spread when someone unknowingly ingests the virus – even in microscopic amounts. P eople most often get hepatitis E from drinking water contaminated by feces from people who are infected with the virus. In the past, most cases in developed countries involved people who have recently traveled to countries where hepatitis E is common. Symptoms of hepatitis E can include fatigue, poor appetite, stomach pain, nausea, and jaundice. However, many people with hepatitis E, especially young children, have no symptoms. Except for the rare occurrence of chronic hepatitis E in people with compromised immune systems, most people recover fully from the disease without any complications.