viral hepatitis - historical perspective a “infectious” “serum” viral hepatitis...
TRANSCRIPT
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Viral Hepatitis - Historical Perspective
Viral Hepatitis - Historical Perspective
AA““Infectious”Infectious”
““Serum”Serum”
Viral Viral hepatitishepatitis
EntericallyEntericallytransmittedtransmitted
ParenterallyParenterallytransmittedtransmitted
F, G,F, G,? other? other
EE
NANBNANB
BB DD CC
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EnsureDrertyu
Viral Hepatitis -
OverviewViral Hepatitis -
Overview
AA BB CC DD EESource ofvirus
feces blood/
body fluids
blood/
body fluids
blood/
body fluids
feces
Route oftransmission
fecal-oral Skin, mucosa fecal-oral
Chronicinfection
no yes yes yes no
Prevention
Blood Donor Screening
High Risk behavior Modification
Ensure Safe Drinking Water
Type of HepatitisType of Hepatitis
Skin, mucosa Skin, mucosa
Vaccine +No Vaccine Vaccine +Vaccine + No Vaccine
Ensure Safe Drinking Water
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47%
34%
16%
3%
Hepatitis AHepatitis BHepatitis CHepatitis Non-ABC
Source: CDC Sentinel Counties Study on Viral Hepatitis
Acute Viral Hepatitis by Type, United States, 1982-1993
Acute Viral Hepatitis by Type, United States, 1982-1993
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HEPATITIS A VIRUS
RNA Picornavirus Single serotype worldwide Acute disease and asymptomatic infection
No chronic infection Protective antibodies develop in response
to infection - confers lifelong immunity
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HEPATITIS A - CLINICAL FEATURES
Jaundice by <6 yrs <10% age group: 6-14 yrs 40%-50% >14 yrs 70%-80%
Rare complications: Fulminant hepatitis Cholestatic hepatitis
Relapsing hepatitis
Incubation period: Average 30 days Range 15-50 days
Chronic sequelae: None
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0 1 2 3 4 5 6 7 8 9 10 11 12 13Week
Re
sp
on
se
Clinical illness
ALT
IgM IgG
HAV in stool
Infection
Viremia
EVENTS IN HEPATITIS A VIRUS INFECTION
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CONCENTRATION OF HEPATITIS A VIRUSIN VARIOUS BODY FLUIDS
Source: Viral Hepatitis and Liver Disease 1984;9-22J Infect Dis 1989;160:887-890
Feces
Serum
Saliva
Urine
100 102 104 106 108 1010
Bo
dy
Flu
ids
Infectious Doses per mL
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GEOGRAPHIC DISTRIBUTION OF HEPATITIS A VIRUS INFECTION
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0
5
10
15
20
25
30
35
40
45
52 56 60 64 68 72 76 80 84 88 92 96 2002
Year
Rate
per
100,0
00
Source: NNDSS, CDC
REPORTED CASES OF HEPATITIS- A, 1952-2002
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• Close personal contact
(e.g., household contact, sex contact, child day-care centers)
• Contaminated food, water(e.g., infected food handlers)
• Blood exposure (very rare)(e.g., injection drug use, rarely by transfusion)
HEPATITIS A VIRUS TRANSMISSION
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PREVENTING HEPATITIS A
• Hygiene (e.g., hand washing)
• Sanitation (e.g., clean water sources)
• Hepatitis A vaccine (pre-exposure)• Immune globulin (pre- and post-
exposure)
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• Highly immunogenic• 97%-100% of children, adolescents, and adults have protective levels of antibody within 1 month of receiving first dose; essentially 100% have protective levels after second dose
• Highly efficacious• In published studies, 94%-100% of children protected against clinical hepatitis A after equivalent of one dose
HEPATITIS A VACCINES
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HEPATITIS A VACCINES
Age Volume 2-Dose ScheduleVaccine (yrs) Dose (mL) (mos)
HAVRIX ® # 1-18 720 (EL.U.*) 0.5 0, 6-12
>18 1,440 1.0 0, 6-12
VAQTA ® ## 1-18 25 (U**) 0.5 0, 6-18
>18 50 1.0 0, 6-18
* EL.U. – Enzyme-linked immunosorbent assay (ELISA) units
** Units
# has 2-phenoxyethanol as a preservative
## has no preservative
Recommended Dosages of Hepatitis A Vaccines
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Most common side effects Soreness/tenderness at injection site - 50% Headache - 15% Malaise - 7%
No severe adverse reactions attributed to vaccine Safety in pregnancy not determined – risk likely low Contraindications - severe adverse reaction to previous dose or allergy to a vaccine component No special precautions for
immunocompromised persons
SAFETY OF HEPATITIS A VACCINE
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DURATION OF PROTECTION AFTER
HEPATITIS A VACCINATION Persistence of antibody
• At least 5-8 years among adults and children• Efficacy
No cases in vaccinated children at 5-6 years of follow-up
Mathematical models of antibody decline suggest protective antibody levels persist for at least 20 years
Other mechanisms, such as cellular memory, may contribute
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Approved by the FDA in United States for persons >18 years old
Contains 720 EL.U. hepatitis A antigen and
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
COMBINED HEPATITIS A HEPATITIS B VACCINE
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• High response rate among vaccinees
• Commercially available assay not sensitive enough to detect lower (protective) levels of vaccine-induced antibody
POST-VACCINATION TESTING
Not recommended:
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Reported Hepatitis- A cases by year 1968-2002
0
50100
150
200250
300
350
400450
500
1968 1972 1976 1980 1984 1988 1992 1996 2000
Year
Nu
mb
er o
f C
ases
* Estimated first dose coverage (children 2-12 years) = 71%** 2002 Preliminary data† Counties: Bennett, Corson, Dewey, Jackson, Roberts, Shannon, Todd, Ziebach
* † Source: South Dakota Department of Health
Vaccination program*
**