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Prevention & control of
Hepatitis B&C
Dr Huma Qureshi (TI)
Executive Director
Pakistan Medical Research Council,
Islamabad
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Hepatitis
Two types of hepatitis:
Waterborne (Hepatitis A & E)
Blood borne (Hepatitis B, D & C)
Acute illness: Irrespective of the virus type:clinical and other manifestations areidentical.
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Water borne Hepatitis A &E Both are transmitted by consuming sewage
contaminated water/food
Hepatitis A is a disease of children inPakistan, over 90% have been exposed andrecovered by the age of 12 years
Produces flu like symptoms in over 50%without jaundice, rest have jaundice
Recovery is 100% in 2-3months
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Hepatitis E It is seen all the year the round but more so
after rains and in summer
It is a disease of children and adults both
Mostly presents with jaundice and itching
Takes 2-3 months to recover with 100%recovery in all cases except 6% mortality in
pregnant cases
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Treatment of A & E Viruses Vaccine is available for hepatitis A but not
recommended as routine in Pakistan
No vaccine for hepatitis E is available
Both recover fully
Give normal diet with full fats, proteinsand CHO, allow normal work and avoid
drips,glucose and liver supporting drugs
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Prevalence data of B&C(2007-8) 50,000 subjects selected from 7000 houses
all over Pakistan by FBS sampling unit
Rapid test used (ELISA verified)
2.5% were HBsAg positive (4 million)
5% were HCV positive (8 million) Total positive 7.5% (12 million)
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Major risk factors for spread of
hepatitis B & C Therapeutic injections for various reasons
with reused syringe (14/person/year)
Improperly sterilized medical devices
Blood transfusion
Shaving by barbers, body piercing Rituals
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Who need screening for B&C Operated
Blood transfused/thalessemia etc
Frequent therapeutic injections
Dental treatment
Dialysis
Health care providers
HBV/HCV cases
Others
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How do u diagnose hepatitis C Anti HCV is a permanent stamp that identifies
exposure
Whether virus is there or not is based on LFTs(ALT)
Raised ALT means virus is there and patient mayneed treatment
Normal ALT means virus is expelled out, notreatment is required
PCR (HCV RNA) indicates viral presence
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What is chronic hepatitis B&C Any hepatitis infection that lasts over 6
months is chronic hepatitis
Most of the times it is difficult to tell how
old is the exposure
Need 2 reports of HBsAg and ALT 6
months apart
For HCV 2 raised ALTs and 1 ELISA
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Inclusion criteria for HCV for the
program Nave patient (non responders have poor
response)
No co-infection with HBV Age 10-60 years
Non pregnant
No cirrhosis (albumin, spleen. PV)
No decompensation HCV reactive by ELISA
ALT raised by 1.5 to 2 times the upper limit on 2occasions 6 months apart
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Baseline tests for HCV after
induction CP
ALT
Serum albumin
Ultrasound abdomen (PV,spleen, ascites)
Sugar
Creatinine
Optional- Thyroid functions
- liver biopsy in normal ALT
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When to do PCR Patient is HCV+ve
ALT is raised at 2 occasions 6 months
apart
Patient fulfills inclusion criteria
Willing to take treatment Can afford PCR
No need to do qualitiative PCR or
genotyping
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HCV treatment planHCV +ve ELISA
ALT raised> 2 times at 2
Occasions 6 months apart
HCV RNA+ve
Start 6 months
IFN therapy
CP,ALT every month
HCV RNA at 3 or 6 months
Inclusion criteria
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What treatment IFN 3 Miu 3 times/wk for 6 months
Patient should take injection
subcutaneously himself, those who inject
get infected
Take ribavarin daily
Normal diet, normal activity
Check PCR at end of treatment
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Side effects of IFN Fever
Bodyaches
Temporary hair fall
Anorexia
FatiguePanadol, B complex and good food will
reduce these effects
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Side effects of Ribavarin Produces hemolysis
In most cases Hb will drop by 3 grams
Always start therapy when Hb is over 11 grams,
else give iron and folate to bring Hb up
With ribazole, anemia is macrocytic as heme goes
back in circulation Add folic acid when ever more drastic Hb drop is
seen
Reduce ribazole dose or stop if Hb
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How to follow CP, ALT every month (Hb, TLC, platelets)
ALT should reach baseline in a month (if
no check, site of injection/compliance)
HCV RNA at 3 or 6 months (should
become non detected by 3 months)
HCVRNA at 12 months (sustained
response)
Tailor drugs when CP shows side effects
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Response/ relapse About 60-70% will recover completely
30% will relapse
Disease shall not aggravate in relapsers, so
dont panic yourself and the patient
Do not give Peg.IFN as chances are only10% response
Wait as new drugs are in pipeline
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Interventions during therapy
Ribazole: Hemolysis-add folic acid
Add iron if microcytosis
Acetaminophen oral for pains and fever
Vitamin B complex to keep going
Fever to be appreciated as a response andnot reaction
Good food intake
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When to reduce therapy Hb drops around 8 grams
Reduce Ribazole
TLC /platelets are around 2500 and 40,000
Reduce IFN
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When to stop treatment in between
therapy Stop treatment if ALT does not touch
baseline by 3 months
HCV RNA is still positive at 3 or 6 months
Hb drops below 6 gms
Platelets go below 30,000 TLC goes below 1200-1500
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Treatment urgency No urgency, virus takes 15-20 years to go into
cirrhosis- a stage where only supportive treatmentis done
Wait for 4-6 months to follow the disease
Avoid treatment in aged, non responders,relapsers,non affording cases
Virus is not passed from mother to child duringpregnancy or feeding
Breast feeding should be continued for at least ayear before starting mothers treatment
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Whom to observe but not treat Pregnant and lactating cases
Low Hemoglobin
Uncontrolled diabetes
All above cases can be treated once they are fit
HCV is a chronic slow growing disease so no harm
in waiting and observing.If someone goes in decompensation in 1-2 years then
it is already an advanced disease
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Do not treat Relapsed cases
Non responders
Non compliant
Low platelets (< 70.000)
Advanced cirrhosis
Decompensated liver disease
Dialysis (CRF), cardiac cases
Pregnant
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Prevention of HCV No vaccine available globally
Avoid un necessary injections
Always destroy a syringe after use
Always sterilize invasive medical devices
Rationalize blood transfusion
Avoid shaving outside
Public awareness to demand good clinical
practices
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Our duty! We all have a role in health sector
Follow SOPs in our fields, make SOPs where
required At least adhere to minimum standards
Justify all transfusions, injections andpractices/treatments that we prescribe
Should feel proud in avoiding transfusion,injection and reuse of devices- would meansaving at least 1life/ procedure