Viral Hepatitis and HIV based on Centers for Disease Control information

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Viral Hepatitis and HIVbased on Centers for
Disease Control information

• IPPF Competencies Workshop, Mexico City,
• 28 July - 1 August 2008
• Lynn Collins, Technical Advisor, HIV/AIDS, UNFPA

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What is hepatitis?

• Definition inflammation of the liver
• Causes
• toxins
• certain drugs
• some diseases
• heavy alcohol use
• bacterial and viral infections
• Also the name of a family of viral infections
  that affect the liver A,B,C,D, and E

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Hepatitis A Virus (HAV)

• Hepatitis A an acute liver disease caused by the
  hepatitis A virus (HAV), lasting from a few weeks
  to several months. It does not lead to chronic
  infection.
• Transmission Ingestion of fecal matter, even in
  microscopic amounts, from close person-to-person
  contact or ingestion of contaminated food or
  drinks.
• Vaccination Hepatitis A vaccination is
  recommended for all children starting at age 1
  year, travelers to certain countries, and others
  at risk.

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Hepatitis A

• Signs/symptoms (usually lt2 mo.)
• Fever
• Fatigue
• Loss of appetite
• Nausea
• Vomiting
• Abdominal pain
• Dark urine
• Clay-colored bowel movements
• Joint pain
• Jaundice
• jaundice or elevated serum aminotransferase
  levels.
• Confirmation
• a positive serologic test for IgM antibody to
  hepatitis A virus, or
• clinical case definition

• Person-to-person transmission through the
  fecal-oral route
• ingestion of something that has been contaminated
  with the feces of an infected person
• Most infections result from close personal
  contact with an infected household member or sex
  partner.
• Common-source outbreaks and sporadic cases also
  can occur from exposure to fecally contaminated
  food or water.

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Who is at increased risk for HAV?

• Travelers to countries with high or intermediate
  endemicity of HAV
• Men who have sex with men
• Users of injection and non-injection illegal
  drugs
• Persons with clotting factor disorders
• Persons working with nonhuman primates
  susceptible to HAV infection

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HAV

• Incubation period 28 days (range 1550 days).
• Survival outside the body for months, depending
  on the environmental conditions. The virus is
  killed by heating to 185 degrees F (85 degrees C)
  for one minute. Adequate chlorination of water
  kills HAV that enters the water supply.
• Hepatitis A does not become chronic.
• Reinfection not possible IgG antibodies to HAV,
  which appear early in the course of infection,
  provide lifelong protection against the disease.
• Prevention
• by vaccination with the full, two-dose series
  lasts 25 years in adults and at least 1420 years
  in children
• The safety of hepatitis A vaccination during
  pregnancy has not been determined however,
  because the vaccine is produced from inactivated
  HAV, the theoretical risk to the developing fetus
  is expected to be low.
• Because hepatitis A vaccine is inactivated, no
  special precautions need to be taken when
  vaccinating immunocompromised persons
• Immune globulin is available for short-term
  protection (approximately 3 months) both pre- and
  post-exposure. Immune globulin must be
  administered within 2 weeks after exposure for
  maximum protection.
• Good hygiene.

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Vaccination candidates HAV

• All children at age 1 year (i.e., 1223 months).
   
• Children and adolescents ages 218 who live in
  states or communities where routine hepatitis A
  vaccination has been implemented because of high
  disease incidence..
• Persons traveling to or working in countries that
  have high or intermediate rates of hepatitis A.
• Men who have sex with men. Sexually active men
  (both adolescents and adults) who have sex with
  men should be vaccinated. Hepatitis A outbreaks
  among men who have sex with men have been
  reported frequently.
• Users of illegal injection and noninjection
  drugs. During the past two decades, outbreaks of
  hepatitis A have been reported with increasing
  frequency among users of both injection and
  noninjection drugs (e.g., methamphetamine) in
  North America, Europe, and Australia.
• Persons who have occupational risk for infection.
  Persons who work with HAV-infected primates or
  with HAV in a research laboratory setting should
  be vaccinated. No other groups have been shown to
  be at increased risk for HAV infection because of
  occupational exposure.
• Persons who have chronic liver disease. Persons
  with chronic liver disease who have never had
  hepatitis A should be vaccinated, as they have a
  higher rate of fulminant hepatitis A (i.e., rapid
  onset of liver failure, often leading to death).
  Persons who are either awaiting or have received
  liver transplants also should be vaccinated.
• Persons who have clotting-factor disorders.
  Persons who have never had hepatitis A and who
  are administered clotting-factor concentrates,
  especially solvent detergent-treated
  preparations, should be vaccinated.

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Hepatitis B

• Hepatitis B a liver disease caused by the
  hepatitis B virus (HBV). It ranges in severity
  from a mild illness, lasting a few weeks (acute),
  to a serious long-term (chronic) illness that can
  lead to liver disease or liver cancer.
• Transmission Contact with infectious blood,
  semen, and other body fluids from having sex with
  an infected person, sharing contaminated needles
  to inject drugs, orfrom an infected mother to her
  newborn.
• Vaccination Hepatitis B vaccination is
  recommended for all infants, older children and
  adolescents who were not vaccinated previously,
  and adults at risk for HBV infection

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Hepatitis B

• Signs/symptoms (acute several weeks to 6
  months)
• Fever
• Fatigue
• Loss of appetite
• Nausea
• Vomiting
• Abdominal pain
• Dark urine
• Clay-colored bowel movements
• Joint pain
• Jaundice
• Persons with chronic HBV infection might be
  asymptomatic, have no evidence of liver disease,
  or have a spectrum of disease ranging from
  chronic hepatitis to cirrhosis or hepatocellular
  carcinoma (a type of liver cancer).
• Confirmation
• a serologic testing

• HBV is transmitted through activities that
  involve percutaneous (i.e., puncture through the
  skin) or mucosal contact with infectious blood or
  body fluids (e.g., semen, saliva), including
• Sex with an infected partner
• Injection drug use that involves sharing needles,
  syringes, or drug-preparation equipment
• Birth to an infected mother
• Contact with blood or open sores of an infected
  person
• Needle sticks or sharp instrument exposures
• Sharing items such as razors or toothbrushes with
  an infected person
• HBV is not spread through food or water, sharing
  eating utensils, breastfeeding, hugging, kissing,
  hand holding, coughing, or sneezing.

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Who is at increased risk for HBV?

• Infants born to infected mothers
• Sex partners of infected persons
• Sexually active persons who are not in a
  long-term, mutually monogamous relationship
  (e.g., gt1 sex partner during the previous 6
  months)
• Men who have sex with men
• Injection drug users
• Household contacts of persons with chronic HBV
  infection
• Healthcare and public safety workers at risk for
  occupational exposure to blood or
  blood-contaminated body fluids
• Hemodialysis patients
• Residents and staff of facilities for
  developmentally disabled persons
• Travelers to countries with intermediate or high
  prevalence of HBV

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HBV

• Incubation period 90 days (range 60150 days)
• Survival outside the body for 7 days
• Acute infection ranges from asymptomatic or mild
  disease to rarely fulminant hepatitis.
• Chronic HBV infection
• Approximately 25 of those who become chronically
  infected during childhood and 15 of those who
  become chronically infected after childhood die
  prematurely from cirrhosis or liver cancer, and
  the majority remain asymptomatic until onset of
  cirrhosis or end-stage liver disease.
• The risk for chronic infection varies according
  to the age at infection and is greatest among
  young children. Approximately 90 of infants and
  2550 of children aged 15 years will remain
  chronically infected with HBV. By contrast,
  approximately 95 of adults recover completely
  from HBV infection and do not become chronically
  infected.

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HBV

• Prevention
• Vaccination with the full, two-dose series
  lasts 23 years
• Hepatitis B vaccine contains no live virus, so
  neither pregnancy nor lactation should be
  considered a contraindication to vaccination of
  women. On the basis of limited experience, there
  is no apparent risk of adverse effects to
  developing fetuses when hepatitis B vaccine is
  administered to pregnant women.
• Larger doses or additional doses might also be
  necessary hemodialysis and immunocompromised
  persons and serologic testing is recommended 12
  months after administration of the final dose of
  the primary vaccine series to determine the need
  for revaccination. Also for sex partners of
  persons with chronic HBV infection, and exposed
  infants
• Need for booster doses not known for PLHIV
• After a person has been exposed to HBV,
  appropriate prophylaxis, given as soon as
  possible but preferably within 24 hours, can
  effectively prevent infection. The mainstay of
  postexposure immunoprophylaxis is hepatitis B
  vaccine, but in certain circumstances the
  addition of HBIG will provide increased
  protection.
• Treatment
• For acute infection, no medication is available
  treatment is supportive.
• For chronic infection, several antiviral drugs
  (adefovir dipivoxil, interferon alfa-2b,
  pegylated interferon alfa-2a, lamivudine,
  entecavir, and telbivudine) are available.
  Persons with chronic HBV infection require
  medical evaluation and regular monitoring to
  determine whether disease is progressing and to
  identify liver damage or hepatocellular
  carcinoma.

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Vaccination candidates HBV

• All infants, beginning at birth
• All children aged lt19 years who have not been
  vaccinated previously
• Susceptible sex partners of hepatitis B surface
  antigen (HBsAg)-positive persons
• Sexually active persons who are not in a
  long-term, mutually monogamous relationship
  (e.g., gt1 sex partner during the previous 6
  months)
• Persons seeking evaluation or treatment for a
  sexually transmitted disease
• Men who have sex with men
• Injection drug users
• Susceptible household contacts of HBsAg-positive
  persons
• Healthcare and public safety workers at risk for
  exposure to blood or blood-contaminated body
  fluids
• Persons with end-stage renal disease, including
  predialysis, hemodialysis, peritoneal dialysis,
  and home dialysis patients
• Residents and staff of facilities for
  developmentally disabled persons
• Travelers to regions with intermediate or high
  rates of endemic HBV
• Persons with chronic liver disease
• Persons with HIV infection
• All other persons seeking protection from HBV
  infection acknowledgment of a specific risk
  factor is not a requirement for vaccination

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Hepatitis C

• Hepatitis C a liver disease caused by the
  hepatitis C virus (HCV). HCV infection sometimes
  results in an acute illness, but most often
  becomes a chronic condition that can lead to
  cirrhosis of the liver and liver cancer.
• Transmission Contact with the blood of an
  infected person, primarily through sharing
  contaminated needles to inject drugs.
• Vaccination There is no vaccine for hepatitis C.

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Hepatitis C

• HCV is transmitted by
• Sharing needles, syringes, or other equipment to
  inject drugs
• Needlestick injuries
• Being born to a HepC mother
• Less commonly, a person can also get hepatitis C
  virus infection through
• Sharing personal care items that may have come in
  contact with another persons blood (razors or
  toothbrushes)
• Having sexual contact with a HepC person
• the risk of transmission from sexual contact is
  believed to be low.
• Risk increases for those who have multiple sex
  partners, have a sexually transmitted disease,
  engage in rough sex, or are living with HIV. More
  research is needed to better understand how and
  when hepatitis C can be spread through sexual
  contact.
• Hepatitis C virus is not spread by sharing eating
  utensils, breastfeeding, hugging, kissing,
  holding hands, coughing, or sneezing. It is also
  not spread through food or water.

• Signs/symptoms 7080 of people with acute
  hepatitis C do not have any symptoms. For those
  who do, they appear 6-7 weeks after exposure.
• Fever
• Fatigue
• Loss of appetite
• Nausea
• Vomiting
• Abdominal pain
• Dark urine
• Clay-colored bowel movements
• Joint pain
• Jaundice (yellow color in the skin or eyes)

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Who is at increased risk for HCV?

• Current injection drug users
• Past injection drug users, including those who
  injected only one time or many years ago
• Recipients of donated blood, blood products, and
  organs
• People who received a blood product for clotting
  problems made before 1987
• Hemodialysis patients or persons who spent many
  years on dialysis for kidney failure
• People who received body piercing or tattoos done
  with non-sterile instruments
• People with known exposures to the hepatitis C
  virus, such as
• Healthcare workers injured by needlesticks
• Recipients of blood or organs from a donor who
  tested positive for the hepatitis C virus
• People living with HIV
• Children born to mothers infected with the
  hepatitis C virus

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HCV

• Incubation period 412 weeks (range 224 weeks).
  
• Of every 100 people infected with the hepatitis C
  virus, about
• 7585 people will develop chronic hepatitis C
  virus infection of those,
• 6070 people will go on to develop chronic liver
  disease
• 520 people will go on to develop cirrhosis over
  a period of 2030 years
• 15 people will die from cirrhosis or liver
  cancer
• Approximately 1525 of people who get hepatitis
  C will clear the virus from their bodies without
  treatment and will not develop chronic infection.
  Experts do not fully understand why this happens
  for some people. 

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HCV

• Prevention
• Clients should be informed about the low but
  present risk for transmission with sex partners.
• Sharing personal items that might have blood on
  them, such as toothbrushes or razors, can pose a
  risk.
• Cuts and sores on the skin should be covered to
  keep from spreading infectious blood or
  secretions.
• Donating blood, organs, tissue, or semen can
  spread HCV to others.
• HCV is not spread by sneezing, hugging, holding
  hands, coughing, sharing eating utensils or
  drinking glasses, or through food or water.
• Patients may benefit from a joining support
  group.
• Treatment
• Combination therapy with pegylated interferon and
  ribavirin is the treatment of choice. Treatment
  success rates are now being improved with the
  addition of polymerase and protease inhibitors to
  standard pegylated interferon/ribavirin
  combination therapy.
• HCV-positive persons should be advised to avoid
  alcohol because it can accelerate cirrhosis and
  end-stage liver disease.
• Viral hepatitis patients should also check with a
  health professional before taking any new
  prescription pills, over-the counter drugs (such
  as non-aspirin pain relievers), or supplements,
  as these can potentially damage the liver.

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Who should be tested for HCV?

• Persons who have ever injected illegal drugs,
  including those who injected only once many years
  ago
• Recipients of clotting factor concentrates made
  before 1987
• Recipients of blood transfusions or solid organ
  transplants before July 1992
• Patients who have ever received long-term
  hemodialysis treatment
• Persons with known exposures to HCV, such as
• healthcare workers after needlesticks involving
  HCV-positive blood
• recipients of blood or organs from a donor who
  later tested HCV-positive
• All persons living with HIV
• Patients with signs or symptoms of liver disease
  (e.g., abnormal liver enzyme tests)
• Children born to HCV-positive mothers (to avoid
  detecting maternal antibody, these children
  should not be tested before age 18 months)

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HIV and Hepatitis

• Hepatitis B and HIV
• HBV) and HIV are bloodborne viruses transmitted
  primarily through sexual contact and injection
  drug use. Because of these shared modes of
  transmission, a high proportion of adults at risk
  for HIV infection are also at risk for HBV
  infection.
• HIV-positive persons who become infected with
  HBVare at increased risk for developing chronic
  HBV infection.
• Persons who are co-infected with HIV and HBV can
  have serious medical complications, including an
  increased risk for liver-related morbidity and
  mortality.
• To prevent HBV infection in people living with
  HIV, hepatitis B vaccination is recommended
• Hepatitis C and HIV
• HCV is a bloodborne virus transmitted through
  direct contact with the blood of an infected
  person. Thus, coinfection with HIV and HCV is
  common (5090) among HIV positive injection
  drug users.
• HCV infection progresses more rapidly to liver
  damage in people living with HIV.
• HCV infection may also impact the course and
  management of HIV infection.
• People living with HIV should be screened for HCV
  infection.
• Injection drug users (IDUs) are at risk for HBV
  and HCV sharing needles and drug-preparation
  equipment. HAV outbreaks are believed to occur
  through both percutaneous and fecal-oral routes.
  IDUs should get vaccinated against hepatitis A
  and hepatitis B.
• Hepatitis, HIV, and MSM
• Men who have sex with men (MSM) are at elevated
  risk for certain sexually transmitted diseases
  (STDs), including hepatitis A, hepatitis B,
  HIV/AIDS, syphilis, gonorrhea, and chlamydia.
  Despite the availability of safe and effective
  vaccines, many MSM have not been adequately
  vaccinated against viral hepatitis.

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Hepatitis D

• Hepatitis D a serious liver disease caused by
  the hepatitis D virus (HDV) and relies on HBV to
  replicate.
• Transmission Contact with infectious blood,
  similar to how HBV is spread.
• Vaccination There is no vaccine for hepatitis D.

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Hepatitis E

• Hepatitis E a serious liver disease caused by
  the hepatitis E virus (HEV) that usually results
  in an acute infection. It does not lead to a
  chronic infection.
• Transmission Ingestion of fecal matter, even in
  microscopic amounts outbreaks are usually
  associated with contaminated water supply in
  countries with poor sanitation.
• Vaccination There is currently no FDA-approved
  vaccine for hepatitis E.