Hundreds of millions of individuals worldwide suffer from a class of infectious disorders known as viral hepatitis. There are now five recognized viruses: A, B, C, D, and E.
In the context of SRH, this chapter will examine hepatitis A, B, and C.
Since acute viral hepatitis infection frequently shows no symptoms, it is underdiagnosed. It is a major public health problem in the UK. In England and Wales, acute viral hepatitis is a notifiable illness; in Scotland, hepatitis A, B, and C are notifiable diseases.
Hepatitis A
Poor sanitation in poorer nations makes the Hepatitis A virus (HAV) prevalent. Expelled in the stools, it is typically contracted via direct contact with an ill person or by consuming tainted food or drink. Children are mostly affected in endemic areas. Though HPV can infect people of any age, it is less frequent in industrialized nations. Sexual transmission can occur via digital-rectal or oro-anal contact. Although there have been outbreaks in MSM in the UK, seroprevalence investigations have revealed comparable frequencies of HAV antibodies in men who identify as either heterosexual or homosexual.
Symptoms and signs
- Most children and up to 50% of adults will either have moderate non-specific symptoms with little or no jaundice.
- Symptoms include an icteric illness with jaundice, nausea, and exhaustion lasting one to three weeks after a prodromal illness with flu-like symptoms, pyrexia, and right upper abdomen pain lasting three to ten days.
- Hepatatomegaly, dehydration, jaundice, pale stools and black urine
Complications - Acute liver failure (ALF) may complicate around 0.4% of cases and 15% will need hospitalisation. Death from HAV is quite rare (<0.1%).
- General management: condition information and recommendations. Up till it is not infectious, advise against handling food or UPSI.
- Investigations include HIV and syphilis, serology for additional hepatitis viruses, LFTs and coagulation factors. If you have sexually contracted hepatitis, check for other STIs.
- Most cases are treated supportively as outpatients; nevertheless, if the Prothrombin time (PT) is longer than five seconds, there is significant dehydration, or there are indications of hepatic decompensation, then hospital admission is necessary.
Follow-up until LFTs are normal at two weekly intervals
Hepatitis B
Globally endemic, the hepatitis B virus (HBV) affects 240 million people with chronic infection. The seroprevalence in the UK is 0.01–0.04% for blood donors but >1% for MSM and drug injectors. It can spread sexually, vertically, or parenterally (via sharing contaminated needles or “works,” needle-stick injuries, and tattoos). In unvaccinated MSM, sexual transmission is associated with many partners, unprotected anal intercourse, and oro-anal sex, or “rimming.” Later on, after heterosexual interaction, transmission also occurs. The infection is more likely to strike sex workers. A >6-month HBsAg positive is considered a chronic infection.
Symptoms and signs - Acute phase: almost all babies and children, and 10–50% of adults (particularly if HIV co-infection) are asymptomatic.
- Prodromal and icteric symptoms may be more severe than those of HAV. Usually asymptomatic, chronic carriers only experience exhaustion and appetite loss.
- Acute HBV symptoms are comparable to those of HAV. Signs of chronic liver disease, such as finger clubbing, jaundice, and ascites, may become apparent in chronic infection after many years.
Complications - In less than one percent of acute cases, fulminant hepatitis results.
- The immune-compromised are more likely to contract chronic infections, such as HIV, of which 10–50% will go on to develop liver cirrhosis and ≥10% will go on to liver cancer.
- Concurrent HCV infection can cause liver disease to proceed more quickly.
Management - General advice: stay away from UPSI until they are no longer contagious, or their partners have had a valid vaccination.
- Treatment and investigations of acute infections: same as for HAV. Imaging and a liver biopsy could be recommended.
- A hepatologist should be in charge of patients with persistent infections.
- Following up as per acute HAV, but to rule out persistent infection, repeat serology after six months.
- Licenced for use in chronic infections are interferon and antiviral medications.
Screening - Screening commonly uses anti-HBc and/or HBsAg. Should both test negative, there is no proof of an infection, either past or present, and if necessary, a vaccination should be administered. Should Anti-HBc test positive but HBsAg test negative, the patient is considered naturally immune and no further treatment is needed. The patient is currently infected, either acutely or chronically, if HBsAg is also positive.
Hepatitis C
Worldwide endemic, hepatitis C virus (HCV) is the most prevalent BBV in the UK. Adult prevalence in the UK is about 0.5%, but in PWIDs it rises to over 40% (and in Scotland to over 60%). Sharing of drug injecting equipment by PWIDs and transfusion of contaminated blood or blood products have been the two main ways that HCV has been transmitted in the UK (before 1990s). Although it happens seldom, if the index patient also has HIV, sexual transmission increases.
Symptoms and signs
Most people (between 70 and 80%) get an acute infection without any symptoms.
Similar symptoms and signs are seen in acute icteric hepatitis. Acute
Similar symptoms and signs to HAV are seen in acute icteric hepatitis. Usually without symptoms, chronic carriers may have generalized health problems. Signs of a persistent infection resemble those of HBV.
Complications
- Out of acute instances, less than 1% progress to fulminant hepatitis.
- After 14 to 30 years, up to one third of chronic carriers will develop serious liver disease.
- After 20 years, 20% to 30% of people acquire cirrhosis, and the risk of liver cancer increases.
Management - Inform the patient against donating organs, semen, or blood.
- Alcohol should be stayed away from and toothbrushes, razors, and needles should not be shared.
- More research in accordance with HAV.
- Pegylated or high-dose α-interferon lowers the rate of chronicity to less than 10%. Imaging and a liver biopsy could be recommended. A specialized center should receive referrals for all patients with active infections.
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