VIRAL HEPATITIS

DR.BHAKTRAJ SINGH
Clinical pharmacist resident & Assistant Professor
Introduction
• Hepatitis means inflammation of the liver. The liver is a vital organ
that processes nutrients, filters the blood, and fights infections. When
the liver is inflamed or damaged, its function can be affected.
• Hepatitis, a general term referring to inflammation of the liver, may
result from various causes, both infectious (ie, viral, bacterial, fungal,
and parasitic organisms) and noninfectious (eg, alcohol, drugs,
autoimmune diseases, and metabolic diseases).
• viral hepatitis is most commonly caused by hepatitis A virus (HAV),
hepatitis B virus (HBV), and hepatitis C virus (HCV).
EPIDEMIOLOGY
• Hepatitis A: According to the Centers for Disease Control and Prevention, there were about
2,007 instances of acute hepatitis A infections in the U.S. in 2016. This form of hepatitis does not
lead to a chronic infection and usually has no complications.
• Hepatitis B: Around 22,000 new cases of hepatitis B occurred in 2017, and around 900,000
people are living with the disease in the US. Approximately 95% of adults recover from hepatitis
B and do not become chronically infected.
• Hepatitis C: Hepatitis C is one of the most common causes of liver disease in the U.S., and used
to be the number one reason for liver transplant. About 75% to 85% of patients with hepatitis C
develop a chronic liver infection. Roughly 2.4 million people in the U.S. are estimated to have
chronic hepatitis C infection.
• Hepatitis D: Hepatitis D only happens to people who are infected by the hepatitis B virus. If you
are vaccinated against hepatitis B, you will be protected against hepatitis D virus.
• Hepatitis E: This type of hepatitis is spread by ingesting contaminated food or water. Hepatitis
E is common throughout the world. Even though vaccines exist, they are not available
everywhere.
INDIAN
• Viral hepatitis, caused by hepatitis viruses A through E, still remains a major public health
problem in India. India has “intermediate to high endemicity” for Hepatitis B surface antigen and
an estimated 40 million chronic HBV infected people, constituting approximately 11% of the
estimated global burden. Population prevalence of chronic HBV infection in India is around 3-4 %.
• In a recent study conducted in Punjab, with 5.2% prevalence of HCV infection, the risk factors for
acquiring HCV infection identified were history of surgery, dental treatment and unprotected sex.
• HAV is responsible for 10-30% of acute hepatitis and 5-15% of acute liver failure cases in India.
HEV is responsible for 10-40% of acute hepatitis and 15-45% of acute liver failure in India.
PATHOLOGY
• Please refer class notes
 Sign & Symptoms
• Hepatitis A Virus Infection: patients present with the abrupt onset of
prodromal symptoms including, fatigue, malaise, nausea, vomiting,
anorexia, fever, and right upper quadrant pain.
• Hepatitis E Virus Infection: Jaundice is usually accompanied by malaise,
anorexia, nausea, vomiting, abdominal pain, fever, and hepatomegaly.
Other less common features include diarrhea, arthralgia, pruritus, and
urticarial rash. Some patients have asymptomatic infection.
• Acute liver failure occurs more frequently during pregnancy, resulting in an
inordinately high mortality rate of 15 to 25 percent, primarily in women in
the third trimester.
• HEPATITIS C INFECTION:
More than two-thirds of patients with acute HCV are asymptomatic during the acute
episode. In patients who experience symptoms, the acute illness usually lasts for 2 to 12
weeks. Symptoms may include jaundice, nausea, dark urine, and right upper quadrant
pain. Patients with acute HCV typically have moderate transaminase elevations, though
they may go undetected in asymptomatic patients.

• ACUTE HEPATITIS B INFECTION:

I. If HBsAg remains positive for more than 6 months it is called chronic hepatitis B virus
infection. Individuals with chronic hepatitis B should undergo a complete history and physical
exam with a focus on assessing the extent of underlying liver disease and evaluating
candidacy for treatment.
II. A history should emphasize use of alcohol, and family history of HBV infection and liver
disease and liver cancer , history of complications that would suggest underlying cirrhosis
(e.g., ascites, hematemesis, and mental status changes), and other factors including
underlying cardiopulmonary disease, past or present psychiatric problems, autoimmune
diseases, and other co-morbid conditions.
III. Laboratory tests should include complete blood count with platelets, liver biochemical tests
(AST, ALT, total bilirubin, alkaline phosphates, albumin), prothrombin time, and tests for HBV
replication (HBeAg, anti-HBe, HBV DNA). Evaluation for other causes of liver disease should
also be done. An abdominal ultrasound or other cross sectional imaging is needed.
IV. Screening for hepatocellular carcinoma if indicated. Physical examination should include
evaluation for stigmata of advanced liver disease such as spider angiomata, palmar erythema,
splenomegaly, jaundice, or caput medusa. However, clinicians should be aware that absence
of any of these findings does not rule out the possibility of underlying cirrhosis.
DIAGNOSIS
• SEROLOGICAL TESTS
• ALT
• AST
• ALP
• TOTAL BILLIRUBIN
• PROTHROMBIN TIME/INR
• APTT
• LACTATE DEHYDROGENASE
DIAGNOSIS OF Hep B
TREATMENT
• Prevention and prophylaxis are keys to managing this vaccine
preventable virus. No specific treatment options exist for HAV
infections. Instead, patients should receive general supportive care.
The importance of good hand hygiene cannot be overemphasized in
preventing disease transmission. Passive immunity with Ig is used for
preexposure and postexposure prophylaxis.
 Immunoglobulin
• Ig is used when preexposure or postexposure prophylaxis against HAV infection is needed in persons for
whom vaccination is not an option. Vaccination is preferred for multiple reasons, including that it induces
active immunity and therefore a longer time of protection against HAV than IgSerious adverse events from Ig
are rare.
• Anaphylaxis has been reported in patients with IgA deficiency. Patients who had an anaphylaxis reaction to Ig
should not receive it. There is no contraindication for use in pregnancy or lactation.
• Dosing of Ig is the same for adults and children. For postexposure prophylaxis and for short-term preexposure
coverage of less than 3 months, a single dose of 0.02 mL/kg IM is given. For long-term preexposure
prophylaxis of less than or equal to 5 months, a single dose of 0.06 mL/kg is used. Either the deltoid or gluteal
muscle may be used. In children younger than 24 months, Ig can be given in the anterolateral thigh muscle.
• In most patients who were recently exposed to HAV and who had not been previously vaccinated,
postexposure prophylaxis with vaccination is preferred. Ig prophylaxis is preferred in the following situations:
patients are younger than 12 months or older than 40 years, are immunocompromised, have chronic liver
disease or have underlying medical conditions, or for whom vaccine is contraindicated. Ig can be given
concomitantly with the HAV vaccine. However, Ig can interfere with the response of other live, attenuated
vaccines and should be delayed.
• In HIV-infected patients, greater immunogenic response may correlate with higher baseline CD4 cell counts.
Patients with CD4 counts less than 200 cells/mm3 (
Hep B Treatment Algorithm