ACUTE VIRAL HEPATITIS

It is one of the most common health problems in the world, especially in third world countries.

It is caused by any one of several viruses.

1. Hepatitis A

2. Hepatitis B

3. Hepatitis C

4. Non-A, non-B, non-C Hepatitis

5. Delta Hepatitis (hepatitis D)

6. Hepatitis E

7. Hepatitis G

8. Other viruses that can cause acute hepatitis include the Epstein-Barr virus, CMV, HSV, and those causing yellow fever and rubella.

  The viruses which are most common cause of hepatitis are the first 3 viruses, the other viruses are rare causes but may results in fatal deaths. As example Hepatitis E which is water born meaning it spreads through poor sanitary control .It effects pregnant women. The mortality rate in pregnant women may be 10%-20%.

VIRAL HEPATITIS "A"

One of the most common cause of epidemic jaundice in the third world countries. Let us talk in detail about this virus step by step.

Infectious agent:-

This kind of hepatitis is caused by a virus called hepatitis A virus (HAV),a 27-nm picoranavirus ie, a positive strand RNA virus.

The infectious agent is fount in feaces, reaching  peak levels the week or two before onset of symptoms appear, and diminishing rapidly after liver dysfunction or symptoms appear, which is concurrent with the appearance of circulating antibodies to HAV.

Mode of transmission:-

There are several ways this virus can spread in a community which are,

1. Person to person by the fecal-oral route.

2. Direct transmission occurs among male homosexual.

3. Contaminated water

4. Food contaminated by infected food handlers, including sandwiches and salads which are no cooked or are handled after cooking.

5. Raw or undercooked mollusks harvested from contaminated waters.

6. Persons in daycare centers.

7. Persons in in situations.

8. Military personals

9. Intravenous drug users.

10. Transmission by transfusion of blood from a donor during the incubation period.

Clinical features:-

Onset is usually abrupt with fever, malaise, anorexia, nausea and abdominal pain, follows within a few days by jaundice.

The disease varies in clinical severity from mild illness lasting 1--2 weeks, to a severely diabling disease lasting several months which is rare.

Severity of disease also depend on age as age increases the severity of the disease increases. Many person infected with the virus could be without symptoms, many are mild jaundice and without jaundice especially childrens, and recognizable only by liver function tests.

Case fatality:-

The case fatality is rate is low about0.6% , the rate of death usually occurs in an older patient in whom the disease has a fulminant course.

Diagnosis:-

Diagnosis is established by the demonstration of IgM antibodies against hepatitis A virus in the serum of acutely or recently ill patients, IgM may remain detectable for 4-6 months after onset. Diagnosis may also be made by a fourfold or greater rise in specific antibodies in paired sera. Virus  and antibodies can be detected by RIA or ELISA tests.

  If lab tests are not available , epidemiologic evidence can provide support for diagnosis. Sometimes it is difficult to distinguish it from hepatitis E in areas in which this virus is endemic.

Therapy:-

Therapy is supportive and includes intravenous fluids to provide hydration, correct electrocyte abnormalities, and provide caloric intake if nausea and vomiting is present.

Vitamin K should be given if the prothombin time is elevated.

            METHODS OF CONTROL

  A---Vaccination:-

  Dose and adminstration of Inactivated Hepatitis A vaccine

 Age/status                     Recommendation

< 2 years                        no available data, immune serum globulin can be given.

2-18 years                      HARVIX
                                      0.5 ml IM at 0, 1 and booster at 6 to 12 months
                                      VAQTA
                                      0.5 ml IM at 0 and booster at 6 to 18 months

>18years                        HARVIX
                                      1.0  ml IM at 0 and booster at 6 to 12 months
                                      VAQTA
                                      1.0 ml IM at 0 and booster at 6 to 12 months

Pregnancy                     no available data, immune serum globulin can be given

Allergic to vaccine         Immune serum globulin

Immunodeficiency         vaccination in these patients may not induce expected
Syndromes                     response.
                                     

 B---Preventive measures:-

1. Educate the public about good sanitation and personal hygiene, with special emphasis on careful hand washing and sanitary disposal of feces.

2. Provide proper water treatment and distribution systems, and sewage disposal.

3. Management of day-care centers should stress measures to minimize the possibility of fecal-oral transmission, including through hand washing after every diaper change and before eating. If one or more HA cases are associated with a center, IG should be administered to the staff and attendance.

4. Travelers to high endemic areas should be given prophylactic dose of IG.

5. Use disposable units and properly sterilize syringes, needles and other equipments used for parenteral injections.

6. Sea food from contaminated areas should be properly cooked and heated to a temperature of 85-90 C(185-194F) for 4 minutes before eating; steaming for 90 seconds will achieve this.

 
C---Control of patient, contacts and the immediate environment:-

1. Report to local health authority.

2. Isolation: For proven hepatitis A, enteric precautions during the first 2 weeks of illness, but no more than week after onset of jaundice.

3. Concurrent disinfection: Sanitary disposal of feaces , urine, and blood.

4. Immunization of contacts. Passive immunization should be given as soon as possible after exposure.

5. Investigation of contacts and source of infections: Search for missed cases and maintain surveillance of contacts in the patient’s household or , in a common-source outbreak, persons exposed to the same risk.

D--- Epidemic measures

1. Determine mode of transmission by epidemiologic investigation, weather person to person or by common vehicle, and identify the population exposed to increased risk of infection. Eliminate any common source of infection. If HA occurs in food handler, vaccination should be given to other food handlers in the establishment.

2. Make special efforts to improve sanitary and hygienic practices to eliminate fecal contamination of foods and water.

3. Focal outbreaks in institutions may need vaccination and prophylaxis with IG.
   
   By: Dr. Nusrat Shafiq
   email: dr_n@pakistanreview.com