• Fecal-Oral mainly
• Rarely sexual or parenteral (IVDU)

• Fecal-Oral mainly
• Rarely sexual or parenteral (IVDU)

Blood and bodily fluids

• Parenteral, both IVDU and healthcare workers
• Perinatal, mother to child = high risk
• Sexual contact and mucous membranes less common

Blood and bodily fluids

• Parenteral, both IVDU and healthcare workers
• Perinatal, mother to child = high risk
• Sexual contact and mucous membranes less common

• Acute only
• No chance of cirrhosis or hepatocellular carcinoma
• You get sick and it goes away

• Acute only
• No chance of cirrhosis or hepatocellular carcinoma
• You get sick and it goes away

• Chronic disease and hepatocellular carcinoma possible, but uncommon in adults (body develops antibodies against it)
• Most likely to become chronic when acquired as newborn --> if mother develops Hep B, that means she hasn't developed antibodies against, which means the baby doesn't have antibodies against it either

• Very likely to become chronic in adults
• Takes many years (~20) for cirrhosis to develop --> that is when symptoms start to appear
• Hepatocellular carcinoma possible

• Person to person contact, fecal contamination and oral ingestion
• Contaminated water and food: raw, unwashed fruits, vegetables, or inadequately cooked shellfish
• Associated with unsanitary conditions and hygiene practices

• International Travelers
• Associated with food-borne outbreaks
• Homosexual men
• IV drug abusers (rare)

• Mild, self-limiting disease -- lasts only a few weeks, but can take up to 6 months to fully resolve
• Children

 Mild flu-like symptoms

No jaundice

• Adults

 Mild flu-like symptoms (malaise, fever, headache, RUQ pain)

Abrupt onset of anorexia, N/V/D
Jaundice from increased total bilirubin -> scleral icterus

Elevated LFTs = hepatic transaminase, GGTP, Alkaline Phosphatase

• Fulminant hepatitis or death (from dehydration usually) can occur rarely
• No cases of chronic hepatitis or carrier state

• Prevention: Hep A vaccine -- good handwashing and hygiene will help
• Post-exposure prophylaxis: vaccine or IV immunoglobulin
• Avoid alcohol and hepatoxic drugs
• Eat a healthy diet and rest

Blood and bodily fluid

• saliva, vaginal fluids, or semen
• post-transfusion infection now rare

• IV Drug Abusers
• Multi-transfused patients
• Health care workers through needlesticks, etc.
• Male homosexuals
• Heterosexual partners of HBV infected persons and partners of HIV infected patients

• First, an asymptomatic incubation period

THEN

• Symptomatic Prodromal Phase: 

Malaise, fatigue, weakness, anorexia, myalgias, and arthralgias

Jaundice occurs in 1/3 of patients and may persist for several weeks

• Symptoms are age dependent (range from no signs to developing liver failure)
• Newborns: generally asymptomatic, but can't clear the virus and can develop a chronic or persistent infection --> vaccination critical at birth
• Adults: most adults develop antibodies against virus and have a subclinical infection -- the others have symptomatic illness with jaundice and can develop:

 fulminant hepatic failure

chronic or persistent infection

chronic aggressive hepatitis

cirrhosis, ascites

• Chronic infection can lead to cirrhosis or Hepatocellular Carcinoma

FIRST LINE ORAL NRTIs

1. Entecavir (HepB only)
2. Tenofovir (HepB and HIV)

OTHER ORAL NRTIs

1. Telbivudine (resistance developed quickly)
2. Lamivudine (resistance developed quickly)
3. Adefovir (no cross resistance with the above two)

ALT.

• Interferon α-2 SQ injection

Disease:

• Loss of antigen and viral DNA
• Decrease symptoms (flu-like, etc.)
• Normalize LFTs
• Reduce rate of cirrhosis, liver failure, and death

Treatment Side Effects:

• NRTIs: Lactic Acidosis, peripheral neuropathy/paresthias
• Tenofovir and Adefovir: Renal function/SCr
• Telbivudine: Myopathies
• Interferon: bone marrow suppression, etc.

• Lactic Acidosis
• Peripheral neuropathy/paresthias
• Pancreatitis
• Myopathy
• Bone Marrow Toxicity
• Hepatic Toxicity

Blood and Bodily Fluids

• IV drug users
• Sexual contact with infected persons
• Persons with multiple sex partners
• Recipient of transfusion before July 1992
• Recipient of clotting factors made before 1987
• Infants born to infected women
• Intranasal cocaine use
• Tattooing/body piercing
• Shared razors
• Hemodialysis patients
• Health care workers

• Physical symptoms do not correlate well with severity of liver injury
• Little evidence that disease is progressing in patient
• Serum enzymes can be normal or elevated
• Symptoms: fatigue, malaise, anorexia, weight loss -- NO N/V/D
• Some patients develop jaundice
• Mild but persistent elevations of LFTs
• Ongoing viral replication is the most important factor in evaluating disease progression
• Can progress to cirrhosis, then liver failure, and/or HCC

ALWAYS USE COMBINATION IF POSSIBLE

Interferon-α 2a or 2b SQ infection -- once weekly pegylated formulation

+

Ribavirin PO BID with food for GI upset

Vaccinate against Hep A and B

Viral Load: by halfway point of therapy, it must decrease by 2 log or else therapy is very unlikely to work

Drug Side Effects

• Injection site reactions plus rash and dry skin
• Flu-like symptoms and fatigue
• Psychiatric events: depression and suicidal ideation
• CBC: hemoglobin, neutrophils, platelets and TSH
• Birth defects with ribavirin, pregnancy test monthly

• Virus is similar to Hep B
• It can only be acquired in presence of HBV
• Therefore, vaccinate against Hep B to prevent it!