Executive Director Pakistan Medical Research Council, Islamabad 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 are identical. Water borne Hepatitis A &E Both are transmitted by consuming sewage contaminated water/food Hepatitis A is a disease of children in Pakistan, over 90% have been exposed and recovered by the age of 12 years Produces flu like symptoms in over 50% without jaundice, rest have jaundice Recovery is 100% in 2-3months 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 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, proteins and CHO, allow normal work and avoid drips,glucose and liver supporting drugs 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) 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 Who need screening for B&C Operated Blood transfused/thalessemia etc Frequent therapeutic injections Dental treatment Dialysis Health care providers HBV/HCV cases Others 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 may need treatment Normal ALT means virus is expelled out, no treatment is required PCR (HCV RNA) indicates viral presence 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 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 2 occasions 6 months apart 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 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 HCV treatment plan HCV +ve ELISA
ALT raised> 2 times at 2
Occasions 6 months apart
Inclusion criteria
HCV RNA+ve
Start 6 months IFN therapy
CP,ALT every month
HCV RNA at 3 or 6 months 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 Side effects of IFN Fever Bodyaches Temporary hair fall Anorexia Fatigue
Panadol, B complex and good food will
reduce these effects 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 <6 gms 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 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 only 10% response Wait as new drugs are in pipeline 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 and not reaction Good food intake When to reduce therapy Hb drops around 8 grams Reduce Ribazole TLC /platelets are around 2500 and 40,000 Reduce IFN 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 Treatment urgency No urgency, virus takes 15-20 years to go into cirrhosis- a stage where only supportive treatment is 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 during pregnancy or feeding Breast feeding should be continued for at least a year before starting mothers treatment 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 Do not treat Relapsed cases Non responders Non compliant Low platelets (< 70.000) Advanced cirrhosis Decompensated liver disease Dialysis (CRF), cardiac cases Pregnant 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 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 and practices/treatments that we prescribe Should feel proud in avoiding transfusion, injection and reuse of devices- would mean saving at least 1life/ procedure
Generation of Hepatocyte-Like Cells From Human Induced Pluripotent Stem (iPS) Cells by Co-Culturing Embryoid Body Cells With Liver Non-Parenchymal Cell Line TWNT-1