ACUTE VIRAL HEPATITIS

CLINICAL PRESENTATION.

DIGNOSIS.

EPEDEMOLOGY OF VIRAL HEPATITIS INFECTION A,B,C IN KSA.

MANAGEMENT.

INCIDENCE OF ACUTE HEPATITIS IN 5

HEPATOLOGY CLINICS IN KSA 2013

Causes of

Hepatitis

HAV HBV HCV AIH DILI

KKUH 7 3 1 11 ?

NGH 10 5 2 8 8

AMC 1 0 0 3 3

KFH 1 2 0 3 ?

DAMMAM

UN.

2 1 0 1 5

TOTAL 21 11 4 26 16

Viral Hepatitis - OverviewViral Hepatitis - Overview

AA BB CC DD EESource ofvirus

feces blood/blood-derived

body fluids

blood/blood-derived

body fluids

blood/blood-derived

body fluids

feces

Route oftransmission

fecal-oral percutaneouspermucosal

percutaneouspermucosal

percutaneouspermucosal

fecal-oral

Chronicinfection

no yes yes yes no

Prevention pre/post-exposure

immunization

pre/post-exposure

immunization

blood donorscreening;

risk behaviormodification

pre/post-exposure

immunization;risk behaviormodification

ensure safedrinking

water

Type of HepatitisType of Hepatitis

Diagnosis of hepatitis

Patient history

Physical examination

Liver function tests

Serologic tests

Symptoms and SignsPre-icteric phase

1. Anorexia

2. Fatigue

3. Nausea

4. Vomiting

5. Arthralgia

6. Myalgia

7. Headache

8. Photophobia

9. Pharangitis

10.

11.

Icteric phase::

1. Enlarged liver

2. Tender upper quadrant

3. Discomfort

4. Splenomegaly (10-20%)

5. General adenopathy

Post-icteric phase

Lab Findings

1. L FT increase >5-10 times of normal

2. Markers of hepatitis B or C or A might be

positive

DD:

1. Infectious Mononucleosis

2. Drug Induced Hepatitis

3. Chronic Hepatitis.

4. Alcohol Hepatitis

5. Cholecystitis, Cholelithiasis

6-Auto-immun hepatitis

MARKERS OF VIRAL

HEPATITISHBV MARKERS

HCV MARKERS

HAV MARKERS

Hepatitis B Markers

anti-HBc exposure (IgM = acute)

HBsAg infection (carrier)

anti-HBs immunity

HBeAg viral replication

anti-HBe seroconversion

HBV-DNA viral replication:

Hepatitis C Markers

ANTI -HCV

PCR-RNA HCV

Hepatitis A Markers

HAV igM

HAV igG

Hepatitis E Markers

HEV igM

HEV igG

HEV RNA PCR

AUTOIMMUN HEPATITIS

MARKERSANF

ANTI MITOCHONDRIAL AB

ANTI SMOOTH MUSCLES ABS.

AUTOIMMUN HEPATITIS

MARKERSANA)

ANTI MITOCHONDRIAL

ANTI SMOOTH MUSCLES ABS

Complications

1.Chronic hepatitis cirrhosis- HCC

2.Fulmnant hepatitis

FULMINANT HEPATITIS

Definition: Hepatic Failure Within 8 Weeks

Of Onset Of Illness.

Manifestation: Encephalopathy and

Prolonged PT

Histopathology: Massive Hepatic Necrosis.

Natural History

Gow, BMJ 2001

• Sexual

• Parenteral

• Perinatal

Hepatitis B Virus

Modes of Transmission

Hepatitis B Virus

Modes of Transmission

Concentration of Hepatitis B Virus

in Various Body Fluids

Concentration of Hepatitis B Virus

in Various Body Fluids

High ModerateLow/Not

Detectable

blood semen urine

serum vaginal fluid feces

wound exudates saliva sweat

tears

breastmilk

Possible transmission route of HBV

in KSA1-Horisontal transmission (person to person) is the main transmission route

2-Perintal transmission (positive HBSAG mothers) especially if they are HBEAG positive

3- Heterosexual transmission

4-Illegal injection drug use

5- Contaminated equipment used for therapeutic injections and other health care related procedures

6- Folk medicine practice

7-Blood and blood products transfusion without prior screening

HBV INFECTION

before and after

vaccination program

OVERALL PREVALENCE OF HBsAg AMONG

SAUDIS IN THE 80’S ACCORDING TO REGIONS

5.5

8.99.6

8.3

0

2

4

6

8

10

Central (n=6649) South-western

(n=7235)

Eastern

(n=8300)

Total (n=32183)

Posi

tivit

y (

%)

Al-Faleh. Annals of Saudi Medicine, 1988

PREVALENCE OF HBeAg AMONG HBsAg POSITIVE

SAUDIS PREGNANT WOMEN (n = 20920)

3.7

5.4

0

1

2

3

4

5

6

% of HBsAg pos. % of HBeAg Pos.

Al-Faleh, Annals of Saudi Medicine, 1988

FREQUENCY OF HBeAg AMONG HBsAg

POSITIVE SAUDI CHILDREN (n=307)

17.2

19.4

17.1

17.9

15.5

16

16.5

17

17.5

18

18.5

19

19.5

Per

cen

t

1-3 years

(93/16)

4-6 years

(103/20)

7-10 years

(111/19)

Total

(307/55)

Al-Faleh et al. Journal of Infection, 1992

PREVENTION STRATEGIES OF

MINISTRY OF HEALTH IN KSA

Introducing HBV vaccine in EPI program; and

Mandatory screening of blood donors

and expatriates.

Vaccination of risk groups.

Health education especially among

medical personnel.

History of HBV infection control

in KSA

Vaccination of

All infants

At birth

Vaccination of

all children

at school entry

vaccination of

All risk groups

mandatory

Screening of all

Expatriates coming

To work in KSA

19891990-

until now

1990-

until now1990

THE CURRENT EPI IN THE

KINGDOM OF SAUDI ARABIA

1. At birth BCG + HB1

2. At 6 weeks DPT1 + OPV1 Hb2

3. At 3 months DPT2 + OPV2

4. At 5 months DPT3 + OPV3

5. At 5months Measles HB3

6. At 12 months MMR

7. At 18 months (DPT + OPV) Booster 1

8. At 4-6 years (DPT + OPV) Booster 2

COMPARISON OF PREVALENCE OF HBsAg

AMONG SAUDI CHILDREN IN 1989 (n=4575)

AND 1997 (n=5355) – ACCORDING TO AGE9.68

0 0

6.54

0.16

7.24

0.3

5.06

0

6.35

0

7.57

0.2

6.51

0.82

7.2

0.93

5.81

2.31

0

66.71

0.310

2

4

6

8

10

Percen

tage

1 2 3 4 5 6 7 8 9

10

11

12

To

tal

(Age in years)

1989 1997

Al Faleh, J Infect 1999

COMPARISON OF PREVALENCE OF HBsAg

AMONG SAUDI CHILDREN IN 1989 (n=4575)

AND 1997 (n=5355) – ACCORDING TO REGION

8.63

0

3.48

0.52

2.87

0

5.83

0.83

5.71

0

10.29

1.52

7.59

0

8.83

0.77

5.22

0

9.04

0

12.67

0.47

3.14

0

3.73

0.3

7.53

0

6.71

0.31

-1

1

3

5

7

9

11

13

Percen

tage

Riy

adh

Qas

sim

Hai

l

Mak

kah

Med

ina

Ase

er

Al-

Bah

a

Giz

an

Naj

ran

Al-

Jou

f

Tab

ouk

Dam

mam

Jed

dah

Tai

f

To

tal

1989 1997

Al Faleh, J Infect 1999

Prevalence Of HBsAg Among Saudi Population

Before & After Vaccination over 18 y

6.70%

0%0.16%

0%0%

2%

4%

6%

8%

10%

1989 1992 1997 2007/8

After

Before

1-10yr

4575

1-2yr637

1-12yr3666

Agenumbers

16-18yr1365

Long Term Seroconversion Rate Over 18

Years (Anti-HBS)

95%

77%

60%

0%

20%

40%

60%

80%

100%

1992 1997 2007/8

* Al Faleh et al Annals of Saudi meds 1993** Al Faleh et al Journal of infection 1999

*** AlFaleh et al journal of infection2008

1-2yr

637

1-12yr3666

16-18yr1365

AgeN

*

***

**

Long-Term protection of HB- vaccine over

18 years ( anti-HBS>10IU/L)(n=1355)93%

(637)

65%

(3666)

38%

(1365)

0%

20%

40%

60%

80%

100%

1992 1997 2007/8

1-2yr

5

1-8yr

13

16-18yr

3

Age

Region

AL Faleh et al, J

Infection 2008

CHANGING PATTERNS OF HBsAg POSITIVITY

AMONG BLOOD DONORS IN MOH,CENTRAL

BLOOD BANK 1994-2005

4.4

3.25

1.5

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

1994

n=9690

2000

n=91695

2005

n=177037

4.7

3

1.4

1.971.7

22.2

1 10.8 0.780.65

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Po

sit

ivit

y %

1987(n= 3

565)

1991 (n=1991)

1996 (n=6885)

1997 (n=6285)

1998 (n=6031)

2002 (n=4793)

2003 (n=5472)

2004(n=9146)

2005(n=8361)

2006(n=9156)

2007 (n=8664)

2008(n=9667)

PREVALENCE OF HBsAg POSITIVITY AMONG

BLOOD DONORS IN KKUH FROM 1987 TO

2008

PRI-MARITALSCREENINGبرنامج الزواج الصحي

هـ1435-1429التهاب الكبد ب وج

HBV,HCV INFECTION FROM2009-2014

عدد المتقدمي

NR.OF

SCREENDS

HIV الكبد ج

HCV

الكبد ب

HBV

2.131.018

512538824103

0.02 %0.3%1%

هـ1435-1429عدد حاالت التهاب الكبد ب وج

NR.OF POSITIVE HBV&HCV CASES(2009-2014)

HCV=RED

0

500

1000

1500

2000

2500

3000

3500

4000

4500

1429h1430h1431h1432h1433h1434h1435h

40304174

3735

2926309730493092

921921842706704678616

الكبد ب

الكبدج

HCV INFECTION

Natural history

Marcellin, J Hepat 1999

1989 1997 2008

No. of

childrenPositive (%)

No. of

children

Positive

(%)

No. of

studentsPositive (%)

449639*

(0.87%)5350

2**

(0.04%) 1357

(5)3

0.22%

Diagnostic test

only by

1st-generation EIA

kit.

Diagnostic test by

3rd-generation EIA

kit and confirmatory

test by RIBA kit.

Diagnostic test by

PCR for anti- HCV

Positive cases.

Overall prevalence rate of HCV infection in

KSA among children and adolescent during the

last 18 yrs.

* ALFaleh et al. Hepatology 1991

** ALFaleh Ann Saudi Med. 2003

Prevention Of HCV Transmission

Avoiding shared use of Razors or brushes

and any item that pierces the skin.

Strict adherence of the universal

precautions in health facilities.

Educating and training of HCW’s to the

proper use of standard precautions

Folk medicine?!

HAV INFECTION

COMPARISON OF PREVALENCE OF ANTI-HAV AMONG

SAUDI CHILDREN IN 1989 (n=4375) AND 1997 (n=5255) –

ACCORDING TO AGE

23.7

13.4

34.8

17.6

41.6

20.3

43.9

23.4

48.5

24

54.1

26.7

59.8

28

59.7

30.6

63.5

33.1

72.6

34.5

26.4

48.850.5

24.9

0

10

20

30

40

50

60

70

80

Percen

tage

1 3 5 7 9 11 Total

(Age in years)

1989 1997

Al-Faleh et al. Saudi Med. J, 1999

COMPARISON OF PREVALENCE OF ANTI-HAV

AMONG SAUDI CHILDREN IN 1989 (n=4375) AND

1997 (n=5255) – ACCORDING TO REGION

39

16.1

62.7

31.6

56

20.4

55

20.1

59.5

28.2

44.5

19

43.6

25.4

81.682.279.1

51.3

64.4

47.9

76

45.6

38.4

18.2

51.1

17.5 19

9.6

50.5

24.9

1

11

21

31

41

51

61

71

81

91

Percen

tage

Riy

ad

h

Qa

ssim

Ha

il

Ma

kka

h

Me

din

a

Ase

er

Al-

Ba

ha

Giz

an

Na

jra

n

Al-

Jo

uf

Ta

bo

uk

Da

mm

am

Je

dd

ah

Ta

if

To

tal

1989 1997

Changing pattern of Hepatitis A prevalence

within the Saudi population over 18 yrs

53

24.3

18.1

0

10

20

30

40

50

60

1989 1999 2008

Age

Region

1-10 YRS

13

1-12 yrs

13

16-18 yrs

3

*

*****

*AlRashed R. Ann SM 1997

** AlFaleh et al SMJ 1999

*** AlFaleh et al WJG 2008

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