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PDAT2 > 20/21 - Hep A & B > Flashcards

20/21 - Hep A & B Flashcards

1
Q

Pathophysiology of HAV

A

Mainly from Fecal-Oral Route > serum > saliva
could live in dried feces >4 weeks

from RAW seafood

does NOT cause CHRONIC DISEASE

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2
Q

HAV deographic distribution

A

HIGHEST in Africa / India
Mexico = south america = asia

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3
Q

anti-HAV IgM

Determines what?

A

Antibodies to Hep A IgM

Diagnoses ACUTE** **HAV

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4
Q

anti-HAV IgG

Determines what?

A

Past HAV Infection

or

  • *Lifelong IMMUNITY** to HAV Vaccine
  • may not need another dose*
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5
Q

Total anti-HAV

determines what?

A

Past HAV Infection

or

  • *Lifelong IMMUNITY** to HAV Vaccine
  • ​may not need another dose*
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6
Q

HBV Demographic Distriution

A

2 billion infected –> 257mil chronic

1 in 10 are ASIANS & PACIFIC ISLANDERS

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7
Q

HBV concentrations in Body fluids

A

HIGH:
BLOOD / SERUM / WOUND EXUDATES

Moderate:
semen / vaginal fluid / saliva

low / not detected:
urine / feces / sweat / tears / breast milk

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8
Q

HBV Transmission + Risk Factors

A

Blood + Infected Bodily fluids:
Percutaneous / SEXUAL / PERINATAL

Risk factors:
Vertical = perinatal/infants

Horizontal:
Children in day care , Sex > MM-Sex > Healthcare workers > travel

  • *Parenteral**:
  • *DIABETES** ( due to using the same meter / pen needles)
  • *IV drug users** / Blood transfusion / tatoos / acupuncture
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9
Q

HBV GEOGRAPHIC Distribution

A

HIGHEST in AFRICA

> Asia/Northern china

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10
Q

Effect of AGE OF ACQUISITION of HBV

A

Getting ACUTE HBV when you are YOUNG

= GREATER RISK to develop into CHRONIC HBV

Adults have a LARGER chance to
eliminate the infection / less chance to develop CHRONICITIY

(perinatal / as a child)

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11
Q

Hepatitis B Development into Chronicity

A

Adult Acquired = 10-15% -> Chronic

  • *Infant Acquired = 80-90% –> Chronic**
  • Inactive carrier* = 50%

Mild/Moderate Hepatitis = 20-30%

Cirrhosis = 8-20%

EVEN WITHOUT CIRRHOSIS –> CAN DEVELOP TO LIVER CANCER
(HCC = hepatocellular carcinoma)

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12
Q

Which Hepatitis can develop into HCC

even WITHOUT symptoms or Cirrhosis?

A

HBV

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13
Q

HBsAg

HEP B surface antigen

What does this help diagnose?

A

GOLD STANDARD = Marker of INFECTION
1st serologic marker to appear

Shows in serum 1-9 weeks post exposure
>6 mos = chronic infection​

Just tells if you if you have the infection,
does NOT tell if Chronic / Acute

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14
Q

anti-HBs

antibodies to HEP B surface antigens

What does this help diagnose?

A

If Positive & NO other markers = IMMUNITY/VACCINATED

Documents RECOVERY +/- IMMUNITY to HBV
Detectable after immunity conferred by HBV Vaccine

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15
Q

HBcAg

Hepatitis B CORE antigen

What does this help diagnose?

A

not useful in diagnosing active or chronic HBV

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16
Q

anti-HBc ( IgM )

antibody to hep B CORE IgM

What does this help diagnose?

A

ACUTE
HEPATITIS B INFECTION

IgM = ACUTE

M = making still

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17
Q

anti-HBc ( IgG )
Antibody to HEP B CORE IgG

What does this help diagnose?

A

can also be Total anti-HBc

  • *PREVIOUS_ or _CHRONIC**
  • *HBV**
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18
Q

HBeAg

Hep B ENVELOPE antigen

What does this help diagnose?

A

Indicates ACTIVE REPLICATION of HBV

is ABSENT in Pre-Core MUTANT HBV

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19
Q

anti-HBe

antibody to hep B envelope antigen

What does this help diagnose?

A

Indicates that:
Viral Replication has STOPPED or is DECREASING

patient can STILL be positive for HBsAg

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20
Q

HBV DNA

What does this help diagnose?

A

Use to ASSESS** & **QUANTIFY

HBV replication

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21
Q

HBV Genotyping

What does this help diagnose?

A

Helps determine the SEVERITY of the liver disease

&

Helps determine RESPONSE to IFN Therapy

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22
Q

HBV Genotypes, comparison of B vs C

A-J

A

A B C = Most Common
vary by location, B&C mainly in ASIA

B > C
in terms of IFN RESPONSE
&
BETTER in other ways
remission / preogression to cirrhosis / chronicity

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23
Q

Serological Test Chart for HBV

A
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24
Q

HDV Transmission

A

NEED TO HAVE HBV before you can get HDV
transmission is the same as HBV

Percutaneous = Injecting drug use

Permucosal = Sex

but RARE in vertical transmision

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25
**HDV CO-infection**
You can be infected with **HBV & HDV _AT THE SAME TIME_** **most will recover,** \<5% develop chronicity *may develop _fulminant liver failure --\> DEATH_*
26
**HDV SUPERINFECTION**
Already infected w/ HBV --\> **Acquire HDV LATER IN LIFE** **more common than Co-infection:** Usually leads to **_MORE SEVERE LIVER DISEASE_** / **70-90% Develop _CIRRHOSIS_**
27
**HEV Distribution / Pathophysiology**
Also found in the **_FECES**_ / _**STOOL_** Usually a **SELF-LIMITING ACUTE Illness** HIGH mortality in **pregnant** women & seen in **Immunocompromised patients** **4 genotypes**, mainly in **ASIA & AFRICA** **_CHINA_** has a **HEV Vaccine**
28
**HGV** Information
Transmission through **_BLOOD_ & _SEXUAL CONTACT_** found from **blood donors** Liver is NOT a significant site of replication **_May PREVENT cirrhosis in HIV patients_** **being researched**
29
**Agents for PREVENTION of HAV**
**HAND WASHING!** **_Immune Globulin = IG_** gives passive **_TEMPORARY_** immunity, for **post/pre-exposure** * *_Hep A VACCINE_** * *active & _LONG-TERM_** immunity, also for post/pre-exposure * some may have **HYPERSENSITIVITY to vaccine components = NEOMYCIN***
30
**Immune Globulin = IG** **for HAV**
_for **PRE-Exposure** = TRAVEL_ for up to **\<1 Month of Travel**, 1 dose or **2+ months of Travel**, greater dose / can REPEAT for **_POST-exposure_** **1 dose** weight based 0.1mL/kg
31
**HAV Vaccines** Dose / Names
**_HAVRIX_** 2 Doses, 2nd dose between **month 6 - 12** _INTERCHANGABLE_ **_VAQTA_** 2 doses, 2nd dose between **month 6 - 18** _think 18 is greater & V\>H_
32
When to give **PRE-Exposure HAV IG or HAV Vaccine** **_Healthy Traveler 1-40 years old_**
International Travel - Africa / Asia Based on: **AGE & TRAVEL TIME** _**HAV** **VACCINE ONLY**_ given ANYTIME prior to travel
33
When to give **PRE-exposure HAV IG or HAV Vaccine** For **traveler LEAVING _\<_ 2 WEEKS**
International Travel - Africa / Asia Based on: AGE & TRAVEL TIME **\> 40 Years Old** or **Immunocompromised** or **Chronic Disease** (+liver) **_BOTH IG & HAV VACCINE_**
34
When to give **PRE-exposure HAV IG or HAV Vaccine?** ## Footnote **Traveler can NOT recieve HAV vaccine**
International Travel - Africa / Asia Based on: AGE & TRAVEL TIME **\< 12 months old** (NOT approved for this age group) **ALLERGIC to vaccine** / **Choose NOT to** **_IG ONLY_**
35
When to give **POST-exposure HAV** **IG / HAV Vaccine**
Persons **recently exposed to HAV &** **_have NOT been VACCINATED_** **Give _WITHIN 2 WEEKS AFTER_ exposure** **_HAV Vaccine_** ONLY for **Healthy 12mo - 40y/o** **_IG_ \<12 mo & \>40 y/o Immunocompromised & Chronic Liver Disease** *can give HAV vaccine INSTEAD, if they can NOT obtain IG*
36
**HAV Vaccine FACTS**
* *_VERY GOOD RESPONSE_** * *97-100%** 1st dose --\> **100%** after 2nd dose **_do NOT need routine vaccination_** Recommended in specific circumstances: **Injection Drug Users High Prevelance of HAV**
37
**PREVENTION of HBV**
Mainly from **SEX / BLOOD / Vertical Transmission** **_HBV IG = HBIG_** Immunoglobulin = PASSIVE immunity * *_HBV Vaccine_** * *Engerix-B / Recombivax HB**
38
**HBV Vaccine Dosing Schedule**
**Recombivax HB** or **Engerix B** both have same schedule **_3 DOSE REGIMEN_** **0 / 1 / 6-12** **months**
39
**Limitations of HBV Vaccines** **Recombivax HB / Engerix-B**
**_requires 3 DOSES over 6 Months_** *_REDUCED EFFICACY_* in some patient populations **_Diabetes:_** \<40 y/o = \>90% effective \>70 y/o \<40% effective , **worse when OLDER** **_OBESE**_ / _**ELDERLY**_ / _**SMOKERS**_ / _**Immunocompromised_**
40
* *HEPLISAV-B** * *new HBV Vaccine** ## Footnote **Advantages / Disadvantages**
**_ONLY 2 DOSES_** = **0 / 1** month Contains a **ADJUVANT** **_BETTER EFFICACY_** especially for **diabetics / 40-70 / obesity / smokers** ***BUT it showed an:* INCREASED RISK IN _ACUTE MI_**
41
**Recommendations for HBV POST-exposure what do we need to know?**
we have to know **_THE SOURCE_** of the HBV * *_HBsAg POS_** * *HBIG & Vaccine Series** **HBsAg neg / Unknown** just the **HBV Vaccine series**
42
**HBV Vaccine Dosing Schedule for INFANTS** **based on what?**
Based on Two factors: **_MOTHER's HBsAg STATUS_** **_BIRTH WEIGHT_**
43
**HBV Vaccine Dosing for infants** **Mother's HBsAg is POSITIVE**
**_REGARDLESS of WEIGHT_** **HBV Vaccine + _HBIG_** within **12 hours of birth** **Test for anti-HBs @ 9-12 months**
44
**HBV Vaccine Dosing for infants** **Mother's HBsAg is _negative_**
**\>2kg** = vaccine within **24 hours of birth** **\< 2kg** = vaccine @**day 30** or @**hospital discharge** **No need to Test for anti-HBs** if **immunocompetent**
45
**WHO to test PRIOR to HBV Vaccination?**
Household, **sexual, or needle contacts** of **HBsAg + Persons** **HIV Positive** Elevated **LFT** **M-M Sex** / **Inject Drugs** **Immunosupressive therapy** **DONORS** blood / plasma / organs / tissue /semen
46
**_WHO & WHEN_** **to test AFTER HBV vaccination**
**anti-HBs** @ **_1-2 Months AFTER_** the **last dose** of the vaccine series **INFANTS** born to **HBsAg POSitive** / **Unknown** mother status **Health care** professionals **HIV** infected persons **Immunocompromised** persons **Sex partners** of HBsAg Positive
47
**TWINRIX** for what & Indication?
**BOTH** **A & B** Hepatitis Vaccines **_\>_** **18 years old** **_PRE-exposure Prophylaxis_**
48
**Difference between** **ACUTE & CHRONIC viral hepatitis**
**CHRONIC = \> 6 MONTHS** same for all
49
**Recommendations for HAV** **PRE-exposure**
**_GIVE THESE PEOPLE HAV VACCINE!_** **Children @ 1 y/o** Occupational risk / **M-M Sex** / **Inj Drug User** * *_CHRONIC LIVER DISEASE_** * *HBV / HCV / CIRRHOTIC** Persons w/ **clotting factor disorders** Work / living / traveling to **high HAV rates**
50
**WHY do we treat HBV?**
to **_REDUCE CHANCE of Developing CIRRHOSIS_** & **HCC** Only HEP that does NOT need to develop into cirrhotic state to develop CANCER
51
**WHEN to treat HBV?** What **Serological tests / Other levels**
HB**_e_**Ag = **"ENVELOPE"** Antigen **Positive** indicates **ACTIVE replication** of HBV virus Treat patients based on **HIGH** **LEVELS of:** **_ALT / HBV DNA_** + Moderate to severe inflammation / fibrosis If **HBV DNA** is HIGH \>20k & **ALT** is HIGH \> **2 ULN** (35 for men / 25 for women) --\> **body is trying to fight it off = TREAT IT** *if levels are norma = not trying to fight it = _we do not treat_*
52
**WHEN to treat HBV**? If **patient does NOT meet HBsAg Pos/Neg** definition of treatment
**HBsAg** +POS / **HBeAg -Neg** ***age \>40 y/o*** **Family History of HCC** **CO-Inefected** w/ **_HIV**_ or _**HCV_** _Moderate to severe_ **fibrosis** ~1mil VL **Cirrhosis** *w/ low VL*
53
**Therapies for CHRONIC HBV**
**_TDF**_ / _**TAF_** / **Entecavir** **NRTI**'s TAF has less liver disease issues **_pegINTERFERON_**
54
**PegINF** **Positives & Negatives**
Pegylated Interferon = **HBV Treatment** positive is **_NO CHANCE OF RESISTANCE_** Negatives = ***_SIDE EFFECTS_*** **PSYCHIATRIC complaints** / **Depression** CI **+ many more & also many contraindications**
55
How **LONG** do we take **HBV Treatment?**
**LIFELONG**
56
**WHEN do we** **MONITOR anti-HBV Agents?** ## Footnote **PEG-IFN**
**Liver Chemistry + CBC + HBV DNA + TSH + HBesAG/Anti-HBe** during treatment= various **Post**treatment = **12 & 24 weeks** * *HBsAg** * *every 5 months**
57
**CONTRAIndications** for **IFN / PegIFN**
**Autoimmune** disease Uncontrolled **Psychiatric** disease **Cytopenias / Seizures** **_DE-COMPENSATED Cirrhosis_**
58
**Resistance in HBV Treatments**
**LONGER you treat ==\> HIGHER RESISTANCE** Even **HIGHER if taken ANOTHER medication in the past** *INTERFERON HAS NO RESISTANCE*
59
**Warnings for Anti-HBV Agents**
**_FIRST RULE OUT HIV_** before treating HBV Ensure **_PATIENT COMPLIANCE_** important due to --\> **hepatitis flare** **Lactic Acidosis** * *Bone Density / Nephrotoxicity** * LOWER RISK WITH TAF vs TDF* **Lamivudine** has a risk for **Pancreatitis**
60
**When do we monitor NRTI's**?
* *_DURING TREATMENT_** * likely on the medication FOR LIFE* **_Liver chemistry / serum creatinine_** every **12** weeks **_HBV DNA / HBeAg / Anti-HBe_** every **24** weeks **_HBsAg_** q **6 - 12 months**
61
**AASLD Guideline for DURATION / Monitoring of NRTI Treatment** **_HBeAg_** **+POS+** with **NO Cirrhosis**
_treatment should be continued until:_ **undetectable HBV DNA** & persistantly **normal ALT levels** **at LEAST \> 12 months** of **additional treatment** after the **appearance** of **anti-HBe** * if we DC the therapy we need CLOSE monitoring for RELAPSE:* * *every 3 MONTHS for \>1 YEAR**
62
**AASLD Guideline for DURATION / Monitoring ​of NRTI Treatment** * *HBeAg +POS+ chronic HBV** * *_WITH CIRRHOSIS_**
Patient has achieved **undetectable HBV DNA level** + **Normal ALTs & Anti-HBe** **_STILL TREAT INDEFINITELY_**
63
**AASLD Guideline for DURATION / Monitoring ​of NRTI Treatment** **ALL HBeAg -NEG-** & **Chronic HBV**
**NEGATIVE HBeAg** but **CHRONIC HEP B** **_TREATMENT IS STILL INDEFINITE_**
64
**Recommendations for managing HBV RESISTANCE** **PREVENTION**
**AVOID *unnecessary treatment*** Initiate **POTENT antiviral tx** w/ ***low rate resistance*** **Switch therapy** w/ **1\* non-response** **ADHERENCE**
65
**Resistance to Adefovir** Recommendations for managing HBV RESISTANCE
Switch Strategy: **ENTECAVIR** Add Strategy: *typically add 2 drugs w/o cross resistance* Continue **Adefovir +** ADD **_Entacavir_**
66
**MULTI-Drug Resistance** Recommendations for managing HBV RESISTANCE
Switch Strategy: **TENOFOVIR** Add Strategy: Combo of **Tenofovir + Entecavir**
67
**Resistance to: Lamivudine / Telbivudine / Entecavir** Recommendations for managing HBV RESISTANCE
Switch Strategy: **All switch to _TENOFOVIR_** Add Strategy: Continue the **Original drug** + **ADD _TENOFOVIR_**
68
**Renal Adjustment for TAF / TDF?**
**Dose adjustments for everything else!** **still 300mg but every 24 - 48 - 72 -96 hours** **CrCl \<15** = **Do NOT recommend TAF**
69
**NRTI's & Pregnancy**
* *TDF =** Pregnancy class **B** * TAF = no human data yet* **Lamivudine / Entecavir** = Pregnancy class **C** Initiate **TX** if 3rd trimester w/ **HBV DNA \> 200k** **DC DRUG @ BIRTH or \<1mo post partum**
70
**WHEN to treat CHILDREN for HBV?**
**_for 2-18 y/o_** **ALT \> 1.3x ULN** + **HBV DNA \> 104 IU/mL** *do not treat if normal ALT*
71
**WHAT Agents to treat CHILDREN** **with HBV?**
High ALT + HBV DNA **_Interferon_ \>1y/o for 24 weeks** Peg-IFN for \>5y/o for HCV * *_Lamivudine + Entacavir_** * *\>2 y/o** - same adult rec **_TDF_** for **\>12y/o** for same adult rec
72
**Pro / Con** **of NUCLEOSIDE THERAPY for HBV**
* *_PRO_** * *Oral / High activity** * low resistance w/ newer drugs* * *Minimal ADR** * *_Negatives_** * *LONG TERM** / indefinite * *renal toxicity rare** * *slower action than IFN** * may induce HIV*
73
**PRO / CON** **of INTERFERON-BASED THERAPY** **for HBV**
**_PRO_** **finite duration = 48-96 weeks** **NO RESISTANCE** HIGH rate of viral loss / clearance * *_Negative_** * *SUBQ** * *LOT OF ADR = PSYCHOLOGICAL**

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