Objectives. Hepatitis: A-E. Hepatitis. Viral Hepatitis - Overview HEPATITIS A VIRUS (HAV) Classification & Pathophysiological Principles of Hepatitis

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1 Objectives Hepatitis: A-E Donna Scemons PhD, MSN, RN, FNP-C, CNS, CWOCN Discuss the pathophysiological principles of hepatitis A-E Analyze various methods of transmission of Hepatitis A-E Consider the clinical signs & symptoms of Hepatitis A-E Determine methods of prevention in the management of Hepatitis A-E 1/26/ D.Scemons 1 1/26/ D.Scemons 2 Hepatitis Inflammatory disease of the liver that may affect: Parenchyma (key elements essential to liver functioning) Kupffer s cells (aka Browicz-Kupffer cells, specialized macrophages in the liver that form part of the reticuloendothelial system (RES) (aka: mononuclear phagocyte system) Bile ducts (the excretory passages in the liver that carry bile to the hepatic duct, which joins with the cystic duct to form the common bile duct opening into the duodenum) Blood vessels Severe disease may lead to liver failure Hepatitis Cirrhotic liver disease Liver cancer Immune system will remove damaged liver cells & over time these are replaced by healthy liver cells Most patients with hepatitis recover some liver function Classification & Pathophysiological Principles of Hepatitis Classification of hepatitis according to specific infecting agent & serology markers: Hepatitis A (HAV: formerly infectious hepatitis ) Hepatitis B (HBV: formerly serum hepatitis ) Hepatitis C (HCV: has been known as transfusion hepatitis ) Hepatitis D (HDV: delta hepatitis) Hepatitis E (HEV: epidemic non-a, non-b hepatitis ) Alcoholic Hepatitis: (inflammation of the liver caused by alcohol) Drug and Toxin induced Hepatitis: (Inflammation of the liver due to an adverse reaction with a drug; aka toxic hepatitis ) 1/26/ D.Scemons 3 1/26/ D.Scemons 4 Viral Hepatitis - Overview Type of Hepatitis A B C D E HEPATITIS A VIRUS (HAV) Source of virus Route of Fecal-oral transmission Blood/ blood-derived body fluids Percutaneous permucosal Blood/ Blood/ Feces blood-derived blood-derived body fluids body fluids Percutaneous permucosal Percutaneous permucosal Fecaloral Chronic infection no yes yes yes no Prevention Pre/post Pre/post Blood donor Pre/post Ensure exposure exposure screening exposure safe immunization immunization Risk behavior immunization drinking modification Risk behavior water 1/26/ D.Scemons modification 5 1/26/ D.Scemons 6 1

2 CDC HAV Pathophysiological Principles of Hepatitis A (HAV) Fecal-oral transmission Food-borne & water-borne; shellfish have transmitted May be epidemic in nature Clinical course usually 1-3 months Recovery usually complete, does not lead to chronic hepatitis Rare: fulminating liver failure 1/26/ D.Scemons 7 1/26/ D.Scemons 8 FEATURES Jaundice by <6 yrs <10% age group: 6-14 yrs 40%-50% >14 yrs 70%-80% Rare complications: Incubation period: Chronic sequelae: Fulminant hepatitis Cholestatic hepatitis Relapsing hepatitis Average 30 days Range days None HEPATITIS A (HAV), UNITED STATES Most disease occurs in the context of communitywide outbreaks Infection transmitted from person to person in households and extended family settings - facilitated by asymptomatic infection among children No risk factor identified for 40%-50% of cases 1/26/ D.Scemons 9 1/26/ D.Scemons 10 HEPATITIS A VIRUS (HAV) TRANSMISSION Close personal contact: household contact, changing contaminated diapers, sexual contact child day-care centers toys, non-vaccinated troops, living in heavily populated, crowded & squalid conditions, refugees, prisoners of war Contaminated food, water infected food handlers Blood exposure (rare) (injection drug use, rarely by transfusion) 1/26/ D.Scemons 11 RISK FACTORS ASSOCIATED WITH REPORTED HEPATITIS A, , UNITED STATES Unknown 46% Other Contact 8% Source: NNDSS/VHSP Contact of daycare child/employee 6% Sexual or Household Contact 14% Food- or waterborne outbreak 4% International travel 5% Men who have sex with men 10% Injection drug use 6% Child/employee in day-care 2% 1/26/ D.Scemons 12 2

3 Clinical Signs & Symptoms: Hepatitis A (HAV) Incubation period (2-7 weeks average 1 month) Patient may be asymptomatic but highly contagious (1 week before symptoms until jaundice appears) Acute onset Flu-like (therefore may be misdiagnosed) Loss of appetite Nausea & vomiting Fever (rarely 101 F 38.3 C) Weakness, fatigue Chills Right upper quadrant pain Headache Clinical Signs & Symptoms:Hepatitis A (HAV)(continued) Irritability Brown urine Clay-colored feces Depression Some patients do not seek treatment until they become jaundiced Acute symptoms may progress or disappear Hepatitis A virus (HAV) Diagnosed by presence of Hepatitis A antibodies (and-hav) in blood 1/26/ D.Scemons 13 1/26/ D.Scemons 14 Prognosis/Prophylaxis: Hepatitis A (HAV) The antibodies occur 2 to 5 weeks and remain in the serum indefinitely The antibodies are IgM class immunoglobulins = current, active infection Later these antibodies are replaced by IgG class Indicates immunity to HAV Prognosis usually very good Prophylaxis adults Hep A vaccine = 2 doses 6 months apart --? Use of Immune globulin for short term only Carrier - NO Hepatitis A (HAV) : Prevention Hygiene hand washing Not sharing items with those infected, use care in sexual contact Sanitation clean water sources Travelers avoid water & ice or boil for 1 minute before use if uncertain of purity Packaged or cooked food Wash & peel fresh food Avoid shellfish especially clams & oysters Hepatitis A vaccine (pre-exposure) Immune globulin (pre- and post-exposure; immune serum globulin (ISG) 90% if given within 2 weeks of exposure; anyone living w infected person) 1/26/ D.Scemons 15 1/26/ D.Scemons 16 HEPATITIS A (HAV) VACCINE Who should receive it? Children months Persons traveling or working in countries with high or intermediate prevalence Those who use street drugs Men who have sex with men Persons with chronic liver disease Persons treated with clotting factor concentrates Work with HAV-infected primates or in HAV research facilities Possibly persons in areas of current outbreaks 1/26/ D.Scemons 17 HEPATITIS A (HAV) VACCINE Most common side effects - usually 1-2 days Soreness/tenderness at injection site 1 in 2 adults, 1 in 6 children Headache 1 in 6 adults, 1 in 25 children Malaise, tiredness 1 in 14 adults Appetite loss 1 in 12 children No severe adverse reactions attributed to vaccine 2 doses required for lasting protection 6 months apart If traveling & receiving vaccine < 1 month before may also receive IG for immediate & temporary protection 1/26/ D.Scemons 18 3

4 HEPATITIS A VACCINE SAFETY Safety in pregnancy not determined risk likely low Contraindications - severe adverse reaction to previous dose or allergy to any vaccine component Moderately or severely ill when vaccine is scheduled should wait No special precautions for immunocompromised persons COMBINED HEPATITIS A HEPATITIS B VACCINE Approved by the FDA in United States for persons >18 years old Contains 720 EL.U. hepatitis A antigen & 20 µg. HBsAg Vaccination schedule: 0,1,6 months Immunogenicity similar to single-antigen vaccines given separately Can be used in persons > 18 years old who need vaccination against both hepatitis A and B Formulation for children available in many other countries 1/26/ D.Scemons 19 1/26/ D.Scemons 20 Hepatitis B Virus (HBV) CDC Statistics HBV 1/26/ D.Scemons 21 1/26/ D.Scemons 22 Pathophysiological Principles of Hepatitis B (HBV) Blood or blood product transmission Parenteral route more common e.g. blood transfusions, needlestick injuries, use of contaminated needles Significant number of individuals contract through non-parenteral route Antigen identified in body secretions Semen Mucus Saliva Pathophysiological Principles of Hepatitis B (HBV) Sexual exposure to person with Hepatitis B can result in infection: especially anal sex Maternal perinatal exposure occurs Contact with mucous membrane or break in skin necessary for transmission Chronic hepatitis seen in 10% of patients with Hepatitis B 1/26/ D.Scemons 23 1/26/ D.Scemons 24 4

5 Pathophysiological Principles of Hepatitis B (HBV) Degree of liver impairment = variable Mild to serious Can progress to cirrhosis Individuals with Hepatitis B continue to have high levels of surface antigen & can be infective **Leading cause of fulminant liver failure Liver cancer risk increased 1/26/ D.Scemons 25 Incubation period: Hepatitis B Clinical Features Average days Range days Clinical illness <5 yrs, <10% (jaundice): >5 yrs, 30%-50% Acute case-fatality rate: 0.5%-1% Chronic infection: <5 yrs, 30%-90% >5 yrs, 2%-10% Premature mortality from chronic liver disease: 15%-25% 1/26/ D.Scemons 26 Signs & Symptoms:Hepatitis (HBV) Insidious onset Flu-like symptoms Loss of appetite Nausea & vomiting Fever Weakness Arthralgia Hallmark sign High fever Hallmark sign Rash Hallmark sign Greater risk for fulminant hepatic failure Sudden liver degeneration Loss of all liver functions liver size Signs & Symptoms:Hepatitis (HBV) (continued) 3 antigens Hepatitis surface antigen (HBsAg) First to rise Usually present when aspartate transaminase (AST) and alanine transaminase (ALT) Patient improves HBsAg, AST, ALT Surface antibody anti-hbs as patient improves Core antigen & core antigen titers: used to determine previous infection after surface antigen is negative 1/26/ D.Scemons 27 1/26/ D.Scemons 28 Signs & Symptoms:Hepatitis (HBV) (continued) 3 antigens (continued) E antigen HBeAg: used to determine when patient is most infectious Usually very active liver disease acute or chronic Tendency to be carriers for a long time Prognosis: worse with age, debility Prophylaxis: Hep B vaccine, Immune globulin Carrier: YES HBV Modes of Transmission Sexual Parenteral Perinatal 1/26/ D.Scemons 29 1/26/ D.Scemons 30 5

6 Low/Not High Moderate Detectable blood serum wound exudates Concentration of HBV in Various Body Fluids semen vaginal fluid saliva urine feces sweat tears breast milk 1/26/ D.Scemons 31 Risk Factors Associated with Reported Hepatitis B, , United States Other* 15% Unknown 32% Blood transfusion 0% Injection drug use 14% Sexual contact with hepatitis B patient 13% Household contact of hepatitis B patient 2% Men who have sex with men 6% Medical Employee 1% Multiple sex partners 17% Hemodialysis 0% *Other: Surgery, dental surgery, acupuncture, tattoo, other percutaneous 1/26/2010 injury 2010 D.Scemons 32 Source: NNDSS/VHSP Elimination of HBV Transmission, United States Prevent perinatal HBV transmission Routine vaccination of all infants Vaccinate children in high-risk groups Vaccinate adolescents - all children up through age 18 Vaccinate adults in high-risk groups Hepatitis B Vaccine 3 dose series, typical schedule 0, 1-2, 4-6 months - no maximum time between doses (no need to repeat missed doses or restart) 2 dose series (adult dose) licensed by FDA for year olds Protection ~30-50% dose 1; 75% - 2; 96% - 3; lower in older, immunosuppressive illnesses (e.g., HIV, chronic liver diseases, diabetes), obese, smokers 1/26/ D.Scemons 33 1/26/ D.Scemons 34 Hepatitis B Vaccine Safety Administered to over 12 million infants and children in the United States side effects rare Anaphylaxis estimated to occur in 1/600,000 doses given No scientific data to link hepatitis B vaccine with multiple sclerosis (MS), other autoimmune diseases, autism 1/26/ D.Scemons 35 Hepatitis B Vaccination Routine at birth completed series by 6-18 months of age Ages catch up, and through age 18(VFC eligible) Over 18 high risk Occupational risk (HCWs; exposure to human blood) Hemodyalisis patients, chronic liver or kidney disease Sexual partners of +HBV individuals All STD clinic clients Multiple sex partners or prior STD Inmates in Correctional settings Men who have sex with men Those who inject street drugs Residents & staff of institution for developmental disability Household contacts of infected HBV individuals Travelers to countries where HBV is common + HIV 1/26/ D.Scemons 36 6

7 Hepatitis B Vaccination (continued) Pre-vaccination testing if cost effective Post-vaccination testing 1-2 months after last shot, if establishing response critical (HCW) Should NOT receive HBV vaccine Life threatening allergy to baker s yeast or other vaccine component Previous allergic response to HBV vaccine Moderately or severely ill at time vaccine is due Mild side effects Soreness in injection site I in 4 people Temperature 99.9 F or - 1 in 15 people 1/26/ D.Scemons 37 Barriers (Real & Perceived) to Hepatitis B Vaccination of Adolescents & Adults in High Risk Groups Lack of funding for adult hepatitis B vaccine Lack of integrated services at sites where persons at risk are seen: leadership & staff commitment ( buy-in ); resources Sites not enrolled in Vaccine for Children Lack of resources for: prevaccination counseling, vaccine administration, tracking series completion Compliance with 3-dose vaccine series ONE DOSE better than NONE! 2 better than 1, 3 better than 2; flexible schedule; 2-dose formulation (11-15 years old) 1/26/ D.Scemons 38 HCV CDC HCV Source: Stanford Report, September 10, /26/ D.Scemons 39 1/26/ D.Scemons 40 Pathophysiological Principles of Hepatitis C (HCV) Blood borne > 90% of transfusion related non-a, non-b are caused by Hepatitis C Transmission usually: Blood Blood products Shared needles Transplanted organs from infected donors Evidence of Transmission: Perinatal Sexual Household Occupational exposures Hepatitis C does not confer immunity & patients may progress to chronic infection 1/26/ D.Scemons 41 Pathophysiological Principles of Hepatitis C (HCV) (continued) Presence of HCV RNA in serum for 6 months or more ~ 2/3 infected asymptomatic Inflammation NOT reversed = becomes chronic ~ 75% infected develop chronic hepatitis C End stage treatment = liver transplant Symptoms may not appear for years post exposure 1/26/ D.Scemons 42 7

8 HCV Prevalence by Selected Groups United States Hemophilia Injecting drug users Hemodialysis STD clients Gen population adults Surgeons, other HCWs Pregnant women Military personnel Average Percent Anti-HCV Positive 1/26/ D.Scemons 43 Hepatitis C HCV Clinical Features Incubation period: Average weeks Range weeks Acute illness (jaundice) Mild (<20%( Case fatality rate Low w Chronic infection 60%-85% 20%ld ( 20%) Symptoms can occur years after initial infection & significant liver damage has occurred. 1/26/ D.Scemons 44 Hepatitis C HCV Clinical Features (continued) 60%-85% Chronic hepatitis 10%-70% (most asx) Cirrhosis <5%-20% 5%-20% Mortality from CLD : 1%-5% expected to triple in next year ~ $600 million in US costs per year currently 1/26/ D.Scemons 45 3% Signs & Symptoms:Hepatitis C HCV (continued) Insidious onset Fatigue Anorexia Loss of appetite Abdominal pain Hepatitis C antibodies, rise in liver enzymes confirm diagnosis Prognosis: moderate Prophylaxis:? Immune globulin Carrier:?? 1/26/ D.Scemons 46 Chronic Hepatitis C HCV Factors Promoting Progression or Severity Increased alcohol intake Age > 40 years at time of infection HIV co-infection Other Male gender Chronic HBV co-infection 1/26/ D.Scemons 47 Risk Factors Associated with Transmission of HCV Illegal injection drug use Transfusion or transplant from infected donor Clotting factor before 1987, transplant before 1992 Occupational exposure to blood Mostly needle sticks Iatrogenic (unsafe injections), tattoos, body piercing Birth to HCV-infected mother Sexual/household exposure to anti-hcv positive contact Multiple sex partners, partner w HCV 1/26/ D.Scemons 48 8

9 Injecting Drug Use & HCV Transmission Sexual Transmission of HCV Highly efficient Contamination of drug paraphernalia, not just needles and syringes Rapidly acquired after initiation 30% prevalence after 3 years >50% after 5 years Four times more common than HIV Occurs, but efficiency is low Rare between long-term steady partners (1.5-3%) MSM 3% (1-18% in selected STD clinic settings) same as heterosexuals Factors that facilitate transmission between partners unknown (e.g., viral titer) Accounts for 15-20% of acute and chronic infections in the United States Sex is a common behavior Large chronic reservoir provides multiple opportunities for exposure to potentially infectious partners 1/26/ D.Scemons 49 1/26/ D.Scemons 50 Sexual Transmission of HCV Persons with High-Risk Sexual Behaviors At risk for sexually transmitted diseases, e.g., HIV, HBV, gonorrhea, chlamydia, etc. Reduce risk Limit number of partners Use latex condoms Get vaccinated against hepatitis B MSMs also get vaccinated against hepatitis A Perinatal, Mother-Infant Transmission HCV Transmission only from women HCV+ RNA positive at delivery Average rate of infection 6% Higher (17%) if woman co-infected with HIV Role of viral titer unclear No association with delivery method Infected infants do well Severe hepatitis is rare No need to avoid pregnancy or breastfeeding Consider bottle feeding if nipples cracked/bleeding Test infants born to HCV+ positive women Consider testing any children born since woman became infected 1/26/ D.Scemons 51 1/26/ D.Scemons 52 Household Transmission of HCV Rare but not absent Could occur through percutaneous/mucosal exposures to blood Theoretically through sharing of contaminated personal articles (razors, toothbrushes) Contaminated equipment used for home therapies IV therapy Injections Transmission -Health Care Procedures Recognized primarily in context of outbreaks Chronic hemodialysis Hospital inpatient setting Private practice setting Home Therapy Unsafe injection practices Reuse of syringes and needles Contaminated multiple does medication vials Case reports of transmission from blood splash to eye. Prevalence among health care workers 1-2% Lower than adults in the general population 10 times lower than for HBV infection Inefficient by occupational exposures Average incidence 1.8% following needlesticks from HCV-infected source Associated with hollow-bore needles 1/26/ D.Scemons 53 1/26/ D.Scemons 54 9

10 Reduce or Eliminate Risks for Acquiring HCV Infection Screening & testing donors of blood, organs, & tissues Virus inactivation of plasma-derived products Risk-reduction counseling & services Obtain history of high-risk drug & sex behaviors Provide information on minimizing risky behavior, including referral to other services Vaccinate against hepatitis A and/or hepatitis B Infection control practices Blood & body fluid precautions Preventing HCV Transmission to Others Avoid Direct Exposure to Blood Anti-HCV positive individuals should not donate blood, body organs, other tissue or semen Do not share items that might have blood on them personal care (e.g., razor, toothbrush) home therapy (e.g., needles) Cover cuts and sores on the skin Studies suggest that HCV can survive on environmental surfaces at room temperature for at least 16 hours but not longer than 4 days 1/26/ D.Scemons 55 1/26/ D.Scemons 56 HCV Testing Routinely Recommended (Based on Risk for Infection) Persons who ever injected illegal drugs Persons with selected medical conditions received clotting factor concentrates produced before 1987 ever on chronic hemodialysis evidence of liver disease Prior recipients of transfusion/organs before July 1992 notified that donor later tested positive Healthcare, emergency medical, and public safety workers after needle sticks, sharps, or mucosal exposures to HCV- positive blood Children born to HCV-positive women 1/26/ D.Scemons 57 Post-exposure Prophylaxis: Hepatitis C Issues & Considerations for Recommendations nig, antivirals not recommended for prophylaxis nfollow-up No protective after needlesticks, antibody response sharps, identified or mucosal exposures to HCV-positive blood Test source for anti-hcv Prior studies of IG use to prevent posttransfusion worker if hepatitis source anti-hcv may not positive be relevant Test Anti-HCV & d ALT at baseline & 4-6 months later For earlier diagnosis, HCV RNA at 4-6 weeks IG prepared from high anti-hcv titer plasma Confirm all anti-hcv results did not prevent infection in chimpanzees Refer infected worker to specialist for medical evaluation & management 1/26/ D.Scemons 58 Medical Evaluation and Management for Chronic HCV Infection HCV Counseling Assess for biochemical evidence of CLD Assess for severity of disease and possible treatment, according to current practice guidelines 40-50% sustained response to antiviral combination therapy (peg interferon, ribavirin) Vaccinate against hepatitis A Counsel to reduce further harm to liver Limit or abstain from alcohol Prevent transmission to others Direct exposure to blood Perinatal exposure Sexual exposure Refer to support group Do not donate blood, body organs, other tissue or semen Do not share items that might have blood on them personal care (e.g., razor, toothbrush) home therapy (e.g., needles) Cover cuts & sores on the skin Using illegal/street drugs Provide risk reduction counseling, education Stop using & injecting Refer to substance abuse treatment program If continuing to inject Never reuse or share syringes, needles, or drug preparation equipment Vaccinate against hepatitis B & hepatitis A Refer to communitybased risk reduction programs 1/26/ D.Scemons 59 1/26/ D.Scemons 60 10

11 HCV Counseling Sexual Transmission of HCV Persons with One Long-Term Steady Sex Partner Do not need to change their sexual practices Should discuss with their partner Risk (low but not absent) of sexual transmission Counseling & testing of partner should be individualized May provide couple with reassurance Some couples might decide to use barrier precautions to lower limited risk further 1/26/ D.Scemons 61 HCV Counseling Sexual Transmission of HCV Persons with High-Risk Sexual Behaviors At risk for sexually transmitted diseases, e.g., HIV, HBV, gonorrhea, chlamydia, etc. Reduce risk Limit number of partners Use latex condoms Get vaccinated against hepatitis B MSMs also get vaccinated against hepatitis A 1/26/ D.Scemons 62 HCV Counseling Other Transmission Issues HCV not spread by kissing, hugging, sneezing, coughing, food or water, sharing eating utensils or drinking glasses, or casual contact Do not exclude from work, school, play, child-care or other settings based on HCV infection status Hepatitis C HCV Staging: Liver biopsy bridging fibrosis, cirrhosis Blood viral load & genotype Treatment Interferon body makes this protein naturally in response to viral infections Ribavirin anti-viral pro-drug chemical precursor for pharmacologically active molecule Pegylated interferon = gold standard chemical process making interferon last longer in the body 1/26/ D.Scemons 63 1/26/ D.Scemons 64 Hepatitis C HCV Hepatitis D HDV (Delta) Virus Genotype 1 & 4 treatment for 48 weeks Genotype 2 treatment 24 weeks Success: RNA level remains near 0 for at least 6 months post treatment (about 55% in combination treatement, 15% in interferon alone) Pegylated interferon + ribovirin response rate: 40-45% in Genotype 1 80% in Genotype 2 & 3 δ antigen HBsAg RNA 1/26/ D.Scemons 65 1/26/ D.Scemons 66 11

12 Pathophysiological Principles of Delta Hepatitis (Hepatitis D) HDV Always occurs in presence of Hepatitis B transmitted primarily through serum Relies on this virus to spread May occur along with Hepatitis B infection Simple parasite Single stranded RNA virus, NO enzymes or protein coat Can progress to fulminant Hepatitis and chronic disease Endemic Middle East, Mediterranean, Italy, parts of South America In United States it occurs primarily: Multiple transfusion patients IV drug abusers Hepatitis D HDV - Clinical Features Coinfection severe acute disease low risk of chronic infection Superinfection usually develop chronic HDV infection high risk of severe chronic liver disease 1/26/ D.Scemons 67 1/26/ D.Scemons 68 Signs & Symptoms:Hepatitis D HDV Incubation period days Similar to acute/chronic Hep B but more pronounced Hepatitis D antigen- HDVAg present early in disease Hepatitis D antibodies (anti-hdv) present later in disease Prognosis: fair, worse with chronic disease Prophylaxis: NONE Treatment: NONE TX HBV Carrier: YES Hepatitis D (HDV) Transmission Percutaneous exposures Injecting drugs Permucosal exposures Sexual contact Prevention HBV-HDV coinfection Pre or post exposure prophylaxsis to prevent HBV infection HBV-HDV superinfection Education to reduce risk behaviors among persons w chronic HBV infection 1/26/ D.Scemons 69 1/26/ D.Scemons 70 Hepatitis E Virus (HEV) CDC: Statistics 1/26/ D.Scemons 71 1/26/ D.Scemons 72 12

13 Epidemiological & Pathophysiological Features HEV Most outbreaks associated: fecally contaminated drinking water Minimal person to person transmission US cases usually have history of travel to HEV endemic areas Oral-fecal transmission Contaminated water & food transmission Implicated in epidemics in Middle East India Southeast Asia Africa Central America Mexico High fatality rates among pregnant women Possible zoonotic spread of the virus, since pigs & nonhuman primates are susceptible to infection 1/26/ D.Scemons 73 Hepatitis E (HEV) Clinical Features Incubation period: Average 40 days Range days Case-fatality rate: Overall, 1%-3% Pregnant women, 15%-25% Illness severity: Chronic sequelae: Increased with age None identified 1/26/ D.Scemons 74 Prognosis/Prophylaxsis: Hepatitis E (HEV) No specific test, diagnosis = serological marking not Hep A Prognosis: generally good unless pregnant Prophylaxis: NONE Carrier: NO Prevention & Control Measures for Travelers to HEV Endemic Regions Avoid drinking water (& beverages with ice) of unknown purity, uncooked shellfish, & uncooked fruit/vegetables not peeled or prepared by traveler IG prepared from donors in Western countries does not prevent infection Unknown efficacy of IG prepared from donors in endemic areas Future vaccine (?) 1/26/ D.Scemons 75 1/26/ D.Scemons 76 General Management:Hepatitis New Tricks Vaccination as available Primarily supportive Rest, adequate nutrition Prevent further stress Avoid hepatotoxic medications, substances High CHO diet to spare protein Cholestyramine = for pruritis 1/26/ D.Scemons 77 1/26/ D.Scemons 78 13

14 THE CREATOR GAVE YOU TWO ENDS-- ONE FOR SITTING, ONE FOR THINKING. Thank YOU! YOUR SUCCESS DEPENDS ON WHICH YOU USE. HEADS YOU WIN TAILS YOU LOSE! 1/26/ D.Scemons 79 1/26/ D.Scemons 80 Information Free internet training for healthcare providers re: hepatitis Free educational information for patients & families (available in several languages) Free patient handouts for healthcare professionals World-wide prevalence & incidence information 1/26/ D.Scemons 81 CDC Educational and Training Resources Website: Toll-free information: 888-4HEPCDC ( ) Web-based HCV training for professionals ( ndex.htm) Brochures, posters, slide sets, videos ( /index.htm) 1/26/ D.Scemons 82 References accessed January 16, 2010 Hepatitis: current concepts. Patton F; CRIT CARE NURSE, 1981 Mar-Apr; 1: A survey and analysis on viral infections of renal transplantation donors and recipients [Chinese]. Ye G; CHINESE NURS RES, 2002 Jun; 16(6): Chronic hepatitis C: implications for health-related quality of life. Heitkemper M; GASTROENTEROL NURS, 2001 Jul-Aug; 24(4): An update on hepatitis. Holcomb SS; DCCN, 2002 Sep-Oct; 21(5): Hagan H, Thiede H, Des Jarlais DC. Hepatitis C virus infection among injection drug users: survival analysis of time to seroconversion. Epidemiology. 2004;15:543-9 Hepatitis, part 1: which types are trouble? Holcomb SS; NURSING, 2002 Jun; 32(6): Critical Care: 32cc1-2, 32cc4 Health problems of Asian and Latino immigrants. Flaskerud JH; NURS CLIN NORTH AM, 1999 Jun; 34(2): Infection control. Update on viral hepatitis. Narbey A; NURS TIMES, 2005 May 17-23; 101(20): 55-7 References Orton SL, Stramer SL, Dodd RY, Alter MJ. Risk factors for HCV infection among blood donors confirmed to be positive for the presence of HCV RNA and not reactive for the presence of anti-hcv. Transfusion. 2004;44: Continuing professional development: infection control. Prevention and control of viral hepatitis. Pratt R; NURS STAND, 2003 Apr 30-May 6; 17(33): 43-52, 54-5 Hepatitis B and D. Thomas HC; MEDICINE (UK), 2002; 30(11): 34-6, /26/ D.Scemons 83 1/26/ D.Scemons 84 14