ACUTE VIRAL HEPATITIS CLINICAL PRESENTATION. DIGNOSIS. EPEDEMOLOGY OF VIRAL HEPATITIS INFECTION A,B,C IN KSA. MANAGEMENT .
ACUTE VIRAL HEPATITIS
CLINICAL PRESENTATION.
DIGNOSIS.
EPEDEMOLOGY OF VIRAL HEPATITIS INFECTION A,B,C IN KSA.
MANAGEMENT.
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
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 safedrinking
water
Type of HepatitisType of Hepatitis
Diagnosis of hepatitis
Patient history
Physical examination
Liver function tests
Serologic tests
Symptoms and SignsPre-icteric phase
1. Anorexia
2. Fatigue
3. Nausea
4. Vomiting
5. Arthralgia
6. Myalgia
7. Headache
8. Photophobia
9. Pharangitis
10.
11.
Icteric phase::
1. Enlarged liver
2. Tender upper quadrant
3. Discomfort
4. Splenomegaly (10-20%)
5. General adenopathy
Post-icteric phase
Lab Findings
1. L FT increase >5-10 times of normal
2. Markers of hepatitis B or C or A might be
positive
DD:
1. Infectious Mononucleosis
2. Drug Induced Hepatitis
3. Chronic Hepatitis.
4. Alcohol Hepatitis
5. Cholecystitis, Cholelithiasis
6-Auto-immun hepatitis
MARKERS OF VIRAL
HEPATITISHBV MARKERS
HCV MARKERS
HAV MARKERS
Hepatitis B Markers
anti-HBc exposure (IgM = acute)
HBsAg infection (carrier)
anti-HBs immunity
HBeAg viral replication
anti-HBe seroconversion
HBV-DNA viral replication:
Hepatitis C Markers
ANTI -HCV
PCR-RNA HCV
Hepatitis A Markers
HAV igM
HAV igG
Hepatitis E Markers
HEV igM
HEV igG
HEV RNA PCR
AUTOIMMUN HEPATITIS
MARKERSANF
ANTI MITOCHONDRIAL AB
ANTI SMOOTH MUSCLES ABS.
AUTOIMMUN HEPATITIS
MARKERSANA)
ANTI MITOCHONDRIAL
ANTI SMOOTH MUSCLES ABS
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 PT
Histopathology: Massive Hepatic Necrosis.
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 urine
serum vaginal fluid feces
wound exudates saliva sweat
tears
breastmilk
Possible transmission route of HBV
in KSA1-Horisontal transmission (person to person) is the main transmission route
2-Perintal transmission (positive HBSAG mothers) especially if they are HBEAG positive
3- Heterosexual transmission
4-Illegal injection drug use
5- Contaminated equipment used for therapeutic injections and other health care related procedures
6- Folk medicine practice
7-Blood and blood products transfusion without prior screening
HBV INFECTION
before 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
tivit
y (
%)
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
Per
cen
t
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
19891990-
until now
1990-
until now1990
THE CURRENT EPI IN THE
KINGDOM OF SAUDI ARABIA
1. At birth BCG + HB1
2. At 6 weeks DPT1 + OPV1 Hb2
3. At 3 months DPT2 + OPV2
4. At 5 months DPT3 + OPV3
5. At 5months Measles HB3
6. At 12 months MMR
7. At 18 months (DPT + OPV) Booster 1
8. 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 AGE9.68
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
Percen
tage
1 2 3 4 5 6 7 8 9
10
11
12
To
tal
(Age in years)
1989 1997
Al 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
Percen
tage
Riy
adh
Qas
sim
Hai
l
Mak
kah
Med
ina
Ase
er
Al-
Bah
a
Giz
an
Naj
ran
Al-
Jou
f
Tab
ouk
Dam
mam
Jed
dah
Tai
f
To
tal
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
1-10yr
4575
1-2yr637
1-12yr3666
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
1-2yr
637
1-12yr3666
16-18yr1365
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 2007/8
1-2yr
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 1994-2005
4.4
3.25
1.5
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
1994
n=9690
2000
n=91695
2005
n=177037
4.7
3
1.4
1.971.7
22.2
1 10.8 0.780.65
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Po
sit
ivit
y %
1987(n= 3
565)
1991 (n=1991)
1996 (n=6885)
1997 (n=6285)
1998 (n=6031)
2002 (n=4793)
2003 (n=5472)
2004(n=9146)
2005(n=8361)
2006(n=9156)
2007 (n=8664)
2008(n=9667)
PREVALENCE OF HBsAg POSITIVITY AMONG
BLOOD DONORS IN KKUH FROM 1987 TO
2008
PRI-MARITALSCREENINGبرنامج الزواج الصحي
هـ1435-1429التهاب الكبد ب وج
HBV,HCV INFECTION FROM2009-2014
عدد المتقدمي
NR.OF
SCREENDS
HIV الكبد ج
HCV
الكبد ب
HBV
2.131.018
512538824103
0.02 %0.3%1%
هـ1435-1429عدد حاالت التهاب الكبد ب وج
NR.OF POSITIVE HBV&HCV CASES(2009-2014)
HCV=RED
0
500
1000
1500
2000
2500
3000
3500
4000
4500
1429h1430h1431h1432h1433h1434h1435h
40304174
3735
2926309730493092
921921842706704678616
الكبد ب
الكبدج
HCV INFECTION
Natural history
Marcellin, J Hepat 1999
1989 1997 2008
No. of
childrenPositive (%)
No. of
children
Positive
(%)
No. of
studentsPositive (%)
449639*
(0.87%)5350
2**
(0.04%) 1357
(5)3
0.22%
Diagnostic test
only by
1st-generation EIA
kit.
Diagnostic test by
3rd-generation EIA
kit and confirmatory
test by RIBA kit.
Diagnostic test by
PCR 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
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
Percen
tage
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
45.6
38.4
18.2
51.1
17.5 19
9.6
50.5
24.9
1
11
21
31
41
51
61
71
81
91
Percen
tage
Riy
ad
h
Qa
ssim
Ha
il
Ma
kka
h
Me
din
a
Ase
er
Al-
Ba
ha
Giz
an
Na
jra
n
Al-
Jo
uf
Ta
bo
uk
Da
mm
am
Je
dd
ah
Ta
if
To
tal
1989 1997
Changing pattern of Hepatitis A prevalence
within the Saudi population over 18 yrs
53
24.3
18.1
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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