Pediatric viral Hepatitis

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Slide 1 : Viral Hepatitis A,B & C in children Prof. Dr. Saad S Al Ani Senior Pediatric Consultant Head of Pediatric Department Khorfakkan Hospital Sharjah ,UAE saadsalani@aol.com
Slide 2 : “Life is not way it’s supposed to be .. It’s the way it is.. The way we cope with it , is what makes the difference” 11/9/2011 2 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 3 : Hepatotropic viruses Are designated hepatitis A, B, C, D, E, and G viruses 11/9/2011 3 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 4 : Can cause hepatitis as one component of a multisystem disease including: 1.HSV 2.CMV 3.EBV 4.VZV 5.HIV 6.Rubella 7. Adenoviruses 8 .Enteroviruses 9. parvovirus B19 10.arboviruses Other viruses 11/9/2011 4 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 5 : Why are the hepatitis viruses considered together? 11/9/2011 5 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 6 : Remember Hepatotropic viruses have little in common from a virology standpoint other than that they infect the same organ. In general, the symptoms result from the body's immune response, not infection itself. 11/9/2011 6 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 7 : The key differences are: Transmission route Incubation period Clinical manifestations Availability of a vaccine. Re-Remember 11/9/2011 7 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 8 : Hepatitis A in Children * Small RNA virus. * Picorna virus family, * Spread by infected human excrement 11/9/2011 8 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 9 : The Most Common and Silent Viral Hepatitis in Children HEPATITIS A (HAV) 11/9/2011 9 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 10 : Children play an important role in spreading HAV ? Why? 11/9/2011 10 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 11 : Because They are the ones most likely to become infected As They rarely have symptoms, they are a silent source of infection for others. 11/9/2011 11 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 12 :
Slide 13 : Remember Children are frequently asymptomatic Diarrhea is more common in children than in adults, Children may also report nausea and vomiting. 11/9/2011 13 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 14 : Re-Remember Other nonspecific symptoms include : * Anorexia * Fatigue * Low-grade fever. 11/9/2011 14 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 15 : Re-Remember Jaundice can occur, and dark urine and pale stools may be reported. On examination, children may complain of pain with palpation in the upper right quadrant. 11/9/2011 15 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 16 : Risk factors Living or traveling in an endemic area Contact with an infected individual Working in a daycare or healthcare facility Anal intercourse. 11/9/2011 16 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 17 : The majority of individuals who are exposed to the virus, approximately 70%, will become infected Incubation period in the liver is approximately 2-3 weeks Facts 11/9/2011 17 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 18 : During that time there is a large amount of excretion of the virus in the stool. This is really the infectious period just before the onset of symptoms. The virus can be excreted up to 7 days after the onset of illness. Cont. 11/9/2011 18 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 19 : Symptoms of acute hepatitis A *Fever *Malaise *Jaundice *Abdominal pain. Young children have symptoms much less frequently than teens or adults and may often be asymptomatic. 11/9/2011 19 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 20 : Of infected children younger than 6 years of age 30% will be symptomatic whereas jaundice will occur in almost 70% of older kids and adults. Cont. 11/9/2011 20 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 21 : Diagnosis of Hepatitis A 11/9/2011 21 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 22 : Diagnosis HAV-specific immunoglobulin M (IgM), an acute response. The antibody should be present by the time symptoms develop and may persist for several months. An IgG response is usually detectable by 10-12 weeks after exposure. 11/9/2011 22 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 23 : HAV Prevention Wash hands Use gloves when appropriate Risk reduction if involved in oral/anal sexual practices Risk reduction if involved in intravenous drug use Vaccination 11/9/2011 23 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 24 : Hepatitis A Vaccines There are no live viruses in hepatitis A vaccines The virus is inactivated or killed the vaccines will protect 94 to 100 percent of those vaccinated against HAV infection 11/9/2011 24 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 25 : In children Hepatitis A vaccines are recommended for: All children 1 year of age. Persons 1 year of age and older traveling to countries with high or intermediate prevalence of hepatitis A Persons who are treated with clotting factor concentrates 11/9/2011 25 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 26 : Treating Hepatitis A No specific treatment for people with hepatitis A When a person has been exposed to HAV, immune globulin must be administered within two weeks after exposure to the virus for maximum protection. The hepatitis A vaccine is not approved for use in a postexposure situation 11/9/2011 26 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 27 : Hepatitis A Vaccine Side Effects Among children, the most frequently reported side effects were: • Pain or tenderness at the site of injection • Headache • Feeding problems 11/9/2011 27 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 28 : Hepatitis B DNA virus Hepadnaviridae class Hepatitis B virus is 100 times more infectious than the HIV virus. 11/9/2011 28 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 29 :
Slide 30 : Symptoms HBeAg anti-HBe Total anti-HBc IgM anti-HBc anti-HBs HBsAg 0 4 8 12 16 20 24 28 32 36 52 100 Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Weeks after Exposure Titre 11/9/2011 30 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 31 : Concentration of the Hepatitis B virus High concentration of the Hepatitis B virus is present in: Blood Serum Wound secretions (exudates) N.B.: The higher the concentration = the easier to get infected 11/9/2011 31 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 32 : Cont. Moderate concentration of Hepatitis B virus is present in Semen vaginal fluid saliva 11/9/2011 32 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 33 : Cont. Low or Absent concentration of Hepatitis B virus is present in: urine feces sweat tears breast milk 11/9/2011 33 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 34 : Clinical presentation Jaundice fatigue/abdominal pain appetite loss nausea/vomiting mild fever dark urine 11/9/2011 34 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 35 : Cont. One third of adults & 90% of children have no symptoms Symptoms last 1-4 weeks up to 6 months 90-95% recover within 6 months with lifelong immunity 50% develop acute liver disease 11/9/2011 35 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 36 : Transmission Percutaneous = virus enters through the skin Contaminated needle stick [injection drug use/occupational exposure] Hemodialysis Human bite Transplantation/transfusion Acupuncture, tattooing, body piercing 11/9/2011 36 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 37 : Cont. Mucosal = through the mucous membranes (mouth, vagina, etc) Sex – oral, anal, vaginal Perinatal – mother to child Infected household items, [i.e., toothbrush w/blood, razors] Intranasal drug use, sharing straws for snorting 11/9/2011 37 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 38 : Hepatitis B: Diagnosis Symptoms Elevated LFTs Confirmed by serology 11/9/2011 38 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 39 : Cont. IgM anti-HBc (core antibody) Appears early Persists for 6 months HBsAg (surface antigen) Detectable 30-60 days after exposure May indicate chronic carrier status HBsAb (antibody to surface antigen) Develops after resolved infection Indicates long term immunity 11/9/2011 39 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 40 : Cont. Anti-HBc/HBcAb (antibody to core antigen) Develops in all HBV infections HBeAg (E antigen) Indicates HBV replication Correlates with high infectivity Present in acute or chronic infection Anti-HBe (antibody to E antigen) Develops in most HBV infections Correlates with lower infectivity 11/9/2011 40 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 41 : Treatment for Hepatitis B Alpha-interferons were the first drugs approved in the United States for the treatment of chronic hepatitis B. 11/9/2011 41 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 42 : Prevention Screen pregnant women and vaccinate all exposed infants Routine early childhood vaccination – 1991 Vaccinate active IDU’s, non-monogamous adults, healthcare workers, & household contacts Standard precautions used to prevent exposure to blood – healthcare workers, tattoo artists, body piercing. Wear protective gear such as gloves, goggles, etc Don’t use an infected person’s toothbrush, razor, or anything else that could have blood on it 11/9/2011 42 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 43 : Hepatitis C in Children (HCV) * Single–stranded, plus-sense RNA virus. * Flavivirus * Spread through contamination by infected human excrement 11/9/2011 43 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 44 : 11/9/2011 44 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 45 : Hepatitis C: Typical Serologic Course Time after Exposure Symptoms Titer HCV antibody ALT (liver function test) Normal 0 1 2 3 4 5 6 1 2 3 4 Years Months Person is sick, but test for Hep C is negative 11/9/2011 45 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 46 : Transmission Contaminated blood or blood-containing body fluids with intravenous drug use representing a major mode of transmission. Blood transfusions prior to 1992 11/9/2011 46 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 47 : Cont. Most children are infected is as a result of mother-to-child vertical transmission, which occurs in approximately 5%-10% of pregnancies in women infected with HCV. 11/9/2011 47 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 48 : Cont. Fortunately, children usually resolve high levels of viremia at a much higher rate than adults for reasons that are incompletely understood. 11/9/2011 48 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 49 : Clinical Manifestations of Hepatitis C Acute subclinical hepatitis is most common after bloodborne exposure and symptoms, if they occur, are indolent and may not occur until months or years after infection. 11/9/2011 49 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 50 : Cont. While fever, fatigue, and jaundice can occur, patients may not have any symptoms until they present with signs of end-stage liver disease. Most children with HCV will be asymptomatic. 11/9/2011 50 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 51 : Why there is a major obstacle to the development of a vaccine ? 11/9/2011 51 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 52 : Because Every time the body creates antibodies, the virus mutates to escape those antibodies 11/9/2011 52 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 53 : Treatment FDA approved the use of Interferon –a 2b and Ribuvirin for HCV in children> 3 years old 11/9/2011 53 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 54 : Viral Hepatitis and Pregnancy and Newborn 11/9/2011 54 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 55 : Hepatitis A and Pregnancy Oral-fecal route 1 in every thousand pregnant women worldwide Diagnosed by checking the levels of IgM anti-HAV antibodies (which can persist for months after the infection). 11/9/2011 55 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 56 : (cont. ) If a newborn is exposed, the infection is usually mild and they will have a lifelong immunity to the disease. 11/9/2011 56 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 57 : (cont. ) If a pregnant woman is exposed (such as when traveling or by contact with known carriers) she will be given immune gamma globulin (IG) to help protect her from getting the disease. 11/9/2011 57 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 58 : Hepatitis B and Pregnancy One of the most highly transmitted forms of hepatitis from mother to child around the world, especially in developing countries. In the United States, 15,000 women a year who are positive for the hepatitis B surface antigen 11/9/2011 58 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 59 : (cont. ) Mother will usually become jaundiced during the acute stage, some women have no symptoms of hepatitis . Usually, the disease is passed on during delivery with exposure to the blood and fluids during the birth process. 11/9/2011 59 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 60 : (cont. ) If a pregnant woman tests positive during her prenatal visits for hepatitis B, she will receive hepatitis B immune globulin 11/9/2011 60 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 61 : (cont. ) When her infant is born, the newborn : Will receive Hepatitis B immune globulin at birth Should be vaccinated with a hepatitis B vaccine at: * One week * One month * Six months after birth. 11/9/2011 61 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 62 : CDC guidelines include mandatory screening of all women for hepatitis B during the first prenatal visit ? Why 11/9/2011 62 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 63 : This virus is highly contagious, and the risk that the newborn infant will develop hepatitis B: - 10 to 20% if the mother is positive for the hepatitis B surface antigen ( HBsAg ) - as high as 90 percent if she is also positive for the HbeAg. Because 11/9/2011 63 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 64 : The Center for Disease Control and Prevention (CDC) has recommended that all newborn infants be vaccinated for hepatitis B? Why 11/9/2011 64 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 65 : Because This reduces the risk that the infant will become infected with hepatitis B to a range of zero to three percent 11/9/2011 65 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 66 : Hepatitis C and Pregnancy Most women become pregnant during the years between 20 and 40, which is also the age group in which the incidence of hepatitis C infection is rising most quickly. 11/9/2011 66 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 67 : Any woman with risk factors for hepatitis C such as : * Exposure to transfusions * Contaminated needles * Injected drug use Should be screened for hepatitis C before and during pregnancy. Cont. 11/9/2011 67 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 68 : (Cont.) The risk of a pregnant woman passing the hepatitis C virus to her unborn child has been related to: * Levels of quantitative RNA levels in her blood * HIV positive. 11/9/2011 68 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 69 : (Cont.) The risk of transmission to the infant is less (0 to 18% ) if: * The mother is HIV negative * She has no history of: - I.v. drug use - Blood transfusions. 11/9/2011 69 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 70 : (Cont.) Transmission of the virus to the fetus is highest in women with hepatitis C RNA titer greater than 1 million copies/mL . Mothers without hepatitis C RNA levels detected did not transmit hepatitis C infection to their infants. 11/9/2011 70 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 71 : (Cont.) There is no preventive treatment at this time that can influence the rate of transmission of the virus from mother to infant. A pregnant woman with hepatitis C will need to be followed by a specialist who can check their liver function tests on a regular basis. 11/9/2011 71 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 72 : (Cont.) There is no preventive treatment at this time that can influence the rate of transmission of the virus from mother to infant. 11/9/2011 72 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 73 : Summary Pregnancy will not change the course of most forms of hepatitis. 11/9/2011 73 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 74 : Cont. 2. With hepatitis A and B, although there is a risk of transmission to the fetus, immunoglobulin therapy and vaccination can decrease it. 11/9/2011 74 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 75 : Cont. 3. The risk of transmission of hepatitis C to the infant seems related to the mother's level of viral RNA and other factors. 11/9/2011 75 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 76 : References Armstrong G, Alter MJ, McQuillan GM, et al: The past incidence of hepatitis C virus infection: Implications for the future burden of chronic liver disease in the United States. Hepatology 2000;31:777-82. Francavilla R, Mieli-Vergani G: Treatment of hepatitis C virus infection in children. an J Gastroenterol 2000;14:41B-4B. Jacobs RJ, Margolis HS, Coleman PJ: The cost-effectiveness of adolescent hepatitis A vaccination in states with the highest disease rates. Arch Pediatr Adolesc Med 2000;154:763-70. Rosenberg, PM. Hepatitis C: Hepatologist's approach to an infectious disease. Clin Infect Dis 2001;33:1728-32. Shamoun DK, Anania FA: Which patients with hepatitis C virus should be treated? Semin Gastrointest Dis 2000;11:84-95. Thomas DL, Astemborski J, Rai RM, et al: The natural history of hepatitis C virus infection: Host, viral, and environmental factors. JAMA 2000;284:450-6. Tung J, Hadzic N, Layton M, et al: Bone marrow failure in children with acute liver failure. J Pediatr Gastroenterol Nutr 2000;31:557-61. Wilson ME: Travel-related vaccines. Infect Dis Clin North Am 2001;15:231-51. 11/9/2011 76 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE
Slide 77 : The way we cope with life, is what makes the difference” Thank you 11/9/2011 77 Viral Hepatitis A ,B & C in children Prof. Dr. Saad S Al Ani Khorfakkan ,Sharjah ,UAE

 


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