window period

surface antigen the one that binds to receptor in hepatocytes

anti hbc not enough to clear infection
HBeAg= soluble antigen

e= early antigen

1= acute hep b
note: if only HBsAg +ve also is acute infection. but very acute, early in incubation
period, <3 weeks after vaccination, before IgM antiHBc forms
2= chronic infection replicating
3= previous immunisation vaccine
4= past infection, recovered, immune
5= acute infection, window period resolving- hbsag disappeard, anti-hbs not come
yet

to rule out other causes of hepatitis

because most adults 90-95% clear the infection spontaneously within 6 months.
They may live many years without symptoms. However a proportion takes 20-30
years to develop cirrhosis
Remaining 5-10% develop chronic infection.
Infection passing from mother to child at birth lead to chronic infection in the child
in 90% of cases and recovery is rare.
Chronic infection is also more common in immunodeficient individuals such as
Downs syindrome and HIV.

immunotolerance is common in children and can go on longterm. No point treating

here. wont achieve anything
immunoreactive= immune clearance- immune system recognises and starts t clear
the virus. ALT levels rise or flucturate and there is higher risk of liver fibrosis. this
is the initial phase in most adults. can last weeks to years, and usually ends in
HBeAg seroconversion. treat
immune surveillance = immune control phase- very low or undetectable HBV DNA
levels, normal ALT and minimal fibrosis progression.
Immune escape: however some people may experience rising HBV DNA levels

eAg negative- if normal liver functions, nothing to do, if high liver function u must
treat

There is a lot of overlap between HIV and Hep B treatment

intron A has a 30-40% response rate
Q. Where is interferon beta used dr?
-multiple sclerosis
Interferon gamma?
- chronic granulomatous disease
Antiviral therapy suppresses HBV replication and decreases hepatic inflammation
and fibrosis, thereby reducing the likelihood of serious clinical disease.
if patient is on zidovudine, interferon may raise the levels of zidovudine

Immune active phase and immune escape phase.

Q. What is so special about pegylated interferon?

Longer acting can be given once weekly
Once a week injection- cost is 4 times higher.
Telbivudine is still in clinical trial so it is not used routinely. has a lot of probs with
myopathy with increased creatine kinase levels

Surrogate markers

The diagnosis of acute hepatitis C virus (HCV) infection is infrequently made,

primarily because more than 70% of patients do not have symptoms associated
with the acute infection
Most often, patients diagosed by chance.
Sultan Abdullah Muhammad Shah II- of Perak
Exiled to Seychelles after attempting assassination of JWW Birch in 1877

anti-HCV are not protective antibodies, thus does not produce immunity to the
patients against the virus.
if a patient comes with increased ALT but is Hep negative--- test for Hep C

HCV antibody- generally used to diagnose Hep C infection. It is not useful in the
acute phase as it takes at least 4 weeks to appear
HCV RNA- various techniques are available- PCR and branched DNA, It may be
used to diagnose HCv infection in the acute phase. However its mian use is in
monitoring the response to antiviral therapy
HCV antigen- an EIA for HCV antigen is available. It is used in the same capacity
as HCV RNA tests but is much easier to carry out

1. Never dx on basis of elisa. Anti-HCV can remain in the circulation even years
after infection has gone.
Can be false negative in immunosuppressed patients, those with renal failure.
And antibody testing cannot distinguish between acute, chronic and resolved
infections.
Dx: HCV RNA PCR
If PCR positive, that tells me that there is infection in the body

unlike hep b, all pt are liable for treatment. even in acute stage

F0= no fibrosis
F1= portal tract fibbrosis
F2- few septa
F3- numerous septa
F 4 = cirrhosis

Aim of treatment: to eradicate the infection in patients with chronic.

Indications: All patients are potential candidates for treatment. can defer if only
mild disease.
Persistently,Elevated liver enzymes/ in acute infection, if HCV RNA remains
positive 12 months after jaundice resolves
Liver biopsy consistent with chronic hepatitis
You have to give them together. Alone they do not work
WHy i ask side effects? because it can affect the patients quality of life.
*boceprovir, telaprevir

There are 6 common viral genotypes whose distribution varies worldwide. In

malaysia- 4 types are found--- 1(39%), 2(4%), 3(56%), 4 (!%)
Genotype has no effect on progression of liver disease but it does affect the
response to treatment. Length of treatment and efficacy
Type 1 is worldwide. it is more common in northern europe and is easy to
eradicate with current treatments
type 2 and 3, response to therapy is excellent. type 1- response is quite poor.
Type 1- 12 months of treatment results in 40% SVR
Type 2, 3- 6 months treatment results in SVR >70%
Response to treatment is better in patients who ave an early virological response
as defined by negativity of HCVRNA in seum 1 month after starting therapy, and it

Despite undetectable viruses in peripheral blood.

reservoir in mononuclear cells, spleen and other organs.

vaccine and HepB immune globulin within 12 hours of birth, 1-2 months, 6months

The annual campaign, marked on 28 July, aims not only to raise awareness
among the general public and infected patients, but also to urgently promote
improved access to hepatitis services, particularly prevention interventions, by
policymakers.
Very quickly...
1. What is role of HbeAg?
2. What is window period?
3. How will you know its a chronic infection?
4. Do we need to treat acute infection? y?
5. Name 4 phases of chronic infection