Hepatitis in healthcare workers (HCWs)

Transcription

1 Hepatitis in healthcare workers (HCWs) Mongolia 2012, September Walter Popp 1 Hepatitis A Hepatitis B + D Hepatitis C Data from Mongolia and worldwide Vaccination Hand hygiene 2 1

2 Liver disease differential diagnosis Viral infections (hepatitis A, B, C, CMV, EBV) bacteria (Brucella, Leptospira) Parasites (malaria, amebiasis) Toxic Alcohol Drugs Aflatoxin Autoimmun Autoimmune hepatitis (AIH) Primary biliary Cirrhosis (PBC) Primary sclerosing Cholangitis (PSC) genetic Wilsons disease Hдmochromatosis Alpha-1 Antitrypsin deficiency Non alcoholic steato hepatitis (NASH) Diabetes High body weight others z.b. Budd-Chiari 3 Hepatitis A Hepatitis A is caused by hepatitis A virus transmission fecal oral strongly associated with poor sanitation and lack of personal hygiene (hand washing) does not cause chronic liver disease (like hepatitis B and C) 4 2

3 Hepatitis A In developing countries the lifetime risk of infection is > 90 % (most infections in early childhood very faint disease) In developed countries infection rates are low. Disease occurs in high risk groups and travellers. 5 HBV/HCV/HIV Infection prevalence in 2008 Infections worldwide 1 HBV HCV HIV

4 Hepatitis B -Viral infection that attacks the liver and can cause acute and chronic disease -Transmitted by blood and other body fluids -About 350 million people worldwide live with a chronic infection -About people die each year due to hepatitis

5 9 10 5

6 Hepatitis B Transmission - Contact with blood (of an infected person) - Contact with other body fluids (semen, vaginal fluid,..) - HBV can survive outside the body for seven days 11 Hepatitis B Mode of transmission in low resource countries - perinatal - early childhood infections - unsafe injections practice - blood transfusions - sexual contacts - health care workers

7 Markers of Hepatitis B HBs AG Anti Hbs Anti Hbc Anti Hbc IgM HBV PCR Result pos neg neg pos pos Acute Infection pos neg neg neg pos Chronic Infection neg pos neg neg neg Vaccination neg pos pos neg neg Condition after Hepatitis B 13 Hepatitis B Symptoms - 50 % without symptoms - Acute illness (about 50 %) with - weakness - extreme fatigue - jaundice - nausea, vomiting - abdominal pain 14 7

8 Hepatitis B Hepatitis B is endemic in Asia 8 10 % of the adult population is chronically infected Liver cancer caused by HBV is among the first three causes of death Also high rates of chronic infections in the Amazon, eastern and central Europe 15 Hepatitis B risk of chronic infection About 90 % of children infected during first year of life develop chronicinfection infection 30 to 50 % of children infected between one to four years of age develop chronic infection 10 % of adults develop chronic infection 25 % of adults who become chronically infected during childhood develop cirrhosis or liver cancer

9 17 Health Indicators 2009 (Mongolia) Incidence: 26 per 10,000 population for hepatitis A, B, C ( 260 per 100,000 ) 18 9

10 Hepatitis D Hepatitis D delta hepatitis Serious liver disease, can be acute or chronic Occurs only among HBV infected patients (Co-infection or superinfection) Prevention: Vaccination against hepatitis B Highest prevalence in Middle East and Central Asia, less common in East Asia, China and India 19 Hepatitis C About 170 mio cases of Hepatitis C worldwide About 30 % acute illness about 80 % chronic hepatitis without specific symptoms % of these will develop chronic liver disease, 1-5 % will develop liver cancer 20 10

11 Development of hepatocellular carcinoma (HCC) 1. Normal liver 2. Acute infection 3. Chronic infection (fibrosis I-IV) 4. cirrhosis 5. Cirrhosis with cancer (hepatocellular carcinoma) 21 Consequences of liver cirrhosis ascites Esophageal varices Hepatocellular carcinoma 22 11

12 Risk for the development of liver cancer Cumulative incid dence for prim liver canc [%] HCV + Alkohol Alkohol HCV HBV Jahre Greten, Wedemeyer, Manns Deutsches Дrzteblatt Dominant HCV genotypes - worldwide 1a, 1b (2,3) 1a, 1b (2,3) 4 3 1a,1b (2,3) Genotypes 1 3 are worldwide distributed Genotypes 1a und 1b are most common and represent 60 % of all infections worldwide

13 Prognostic factors in relationship to the HCV Genotype Genotyp 1,4: slow progression to cirrhosis, but success of therapy is low Genotyp 2,3: fast progression to cirrhosis, good effect of Interferon/Ribaverin Risc factors to progression: Gender (male) Alcohol (use) Diabetes mellitus BMI > 25 Smoking, esp. Cannabis, intravenous drug abuse

14 New cases of hepatitis per year / 100,000 HBV HCV Mongolia Germany Reason: better hygiene and vaccination Reason: no testing, 27 no reporting Health Indicators 2009 (Mongolia) Leading causes of cancer in male, in order of importance: Liver, stomach, lung, esophagus, prostate Leading causes of cancer in female, in order of importance: Liver, cercix, uterus, stomach, esophagus, lung. Survival of liver cancer patients: 0 1 year: 44 % 1 2 years: 51 % 3 4 years: 3 % 28 14

15 29 Table 1: Hepatitis B and C carriers in Mongolia year group n Hep B Hep C Ref. < 1998 outpatients % 48.0 % Fujioka adults % 14 % Takahashi Blood donors 17, % 7.5 % Oyunbileg Blood donors % 5.2 % Tsatsralt-Od adults % Baatarkhuu 2008 nurses % Blood donors % 9.6 % Tserenpuntsag /19y males % 5.3 % 2009 Army soldiers > % 2.0 % Pers. Comm

16 Hepatitis B - Vaccine against hepatitis B is available since Vaccine is 95 % effective in preventing HBV Infection First vaccine against human cancer -chronic hepatitis/cirrhosis/hepatocellular carcinoma is avoided

17 The risk of transmission from an infected patient to a HCW by a needlestick injury is around 30 % for hepatitis B, 3 % for hepatitis C and 0.3 % for HIV. 33 After each needlestick or sharp injury: A co-worker should immediately be called to help. Ideally a skin wound should be disinfected using alcohol or alcohol hand rub (use of alcohol will cause pain). If alcohol is not available, wash extensively with soap and water. For mucous membrane, in most cases only water douching may be realistic (alternatives: iodine, chlorhexidine or octenidin preparations). After disinfection the risk of transmission should be assessed. The risk may be increased with deep wounds, visible blood on the device, a blood-filled needle and a high viral load status of the index patient (if available)

18 Hepatitis B: Risk of infection with hepatitis B can be avoided by vaccination. Postexposure prophylaxis (PEP) is dependant on vaccination and immunity status of HCW. The following recommendations can be used independent from the status of the source: Unvaccinated HCW should receive both HBIG (hepatitis B immune globulin) + HB vaccination; Previously vaccinated and known responders HCWs: no treatment; Previously vaccinated, known non-responders HCWs should receive both HBIG + HB vaccination (second vaccine series); HCWs whose antibody response is unknown: test and administer HBIG + HB vaccination if results are inadequate (<10mIU/ml). 35 Hepatitis C: There is currently no recommended PEP. Perform baseline and follow-up testing for anti-hcv and alanine aminotransferase (ALT) up to six months after exposure. Perform HCV RNA at four to six weeks if earlier diagnosis of HCV infection desired. Hepatitis C should be treated after seroconversion

19 Table 2: Results of hep B vaccination program for children in Mongolia since n 1, ,894 Age (years) HBsAg 5.2 % 0.5 % Anti-HBc 15.6 % Complete hep B vaccination Anti-HBs > 10IU/ml 17 % Anti-HCV 0.6 % 60 % 82 % Health Science University 2011, Davaalkham et al. 2006, 2007a, b 37 Possible reasons for high hepatitis prevalence in Mongolia Blood products are not consequently tested in countryside (Baatarkhuu et al. 2011). Traditional medicine, acupuncture, tattoing, especially in countryside. Baatarkhuu et al. (2011) hint to bloodletting kind of folk medicine in rural areas. It was reported (pers. communication) that in former decades one glas syringe was used for all family members which was only cooked in boiling water. Self injection practice in families and toothbrush sharing, especially in rural areas (Ochirbat et al. 2008, Togoobaatar et al. 2010). Insufficient reprocessing of medical devices. This is presumed especially for dentists in rural areas. Many iv applications of drugs in hospitals without real indications (eg vitamins) (Logez et al. 2004, Kakizaki et al. 2011, Togoobaatar et al. 2010; pers. Communication). This might easily be reduced, also oral drugs might be given more often easily. Pregnancy. It must be an open question whether hepatitis is transmitted sexually or by birth (eg not sterile instruments). Insufficient vaccination: very often rather old vaccines are used bought on the international market by some NGO shortly before storability is over. Another reason may be transport in winter with freezing and inactivation of vaccine, but only in coutryside. Sexual behaviour: little is known about that, but increasing number of STDs is hinting to this possible reason

20 High risk activities (US and German guidelines) for getting a hepatitis in healthcare Operations in a narrow operating field, with reduced view control, long durance, with fingers working very near to sharp instruments or needles, with manual feeling and groping of needles and closure of sterniotomia (RKI 1999, CDC 2012). Solution for hepatitis carriers: Forbid them to do their job any longer or treat them so that a big number of them will loose carrier status and infectiosity. 39 Lamivudin, perhaps life long Tenofovir, elimination possible 40 20

21 ADB Fifth health sector development project Safe blood transfusions Adequate medical waste management Hospital hygiene and infection prevention and control 41 Thank you for your attention! 42 21