HIV

PART 1: INTRODUCTION TO HEPATITIS

Section 1: Learning Outcomes (Page 2)

By the end of this lecture, students will be able to:

• Understand infectious and non-infectious agents that can cause hepatitis.

• Understand the risk factors and associated symptoms of hepatitis.

• Demonstrate an understanding of the availability of vaccination for certain hepatitis types.

• Demonstrate an understanding of prevention measures of hepatitis.

• Apply knowledge through a case study.

Section 2: What is Hepatitis? (Page 3)

2.1. Definition:

• Hepatitis is the term used to describe inflammation of the liver.

2.2. Causes:
Hepatitis can be caused by a variety of infectious viruses and non-infectious agents.

2.3. Key Differences Between Viral Hepatitis Strains:
Although each strain leads to liver disease, they vary significantly in terms of:

• Mode of transmission

• Severity of illness

• Geographic distribution

• Prevention strategies (e.g., vaccination availability)

Section 3: Symptoms of Hepatitis (Page 4)

3.1. Acute Hepatitis Presentation:

• Many cases are asymptomatic or present with non-specific symptoms.

• When symptoms do develop, they can include:

  • Abdominal pain

  • Fatigue

  • Muscle and joint pain

  • Nausea and vomiting

  • Fever

  • Dark urine (due to bilirubin excretion)

  • Jaundice (yellowing of skin and eyes – caused by elevated bilirubin)

  • Pruritus (itching)

Section 4: Blood Tests for Hepatitis (Page 5)

A "hepatic picture" on liver function tests typically shows:

PART 2: HEPATITIS A (HAV)

Section 5: Hepatitis A – Epidemiology and Transmission (Page 6)

5.1. Global Epidemiology:

• Most common viral hepatitis worldwide, but relatively rare in the UK.

• Infection is common in low- and middle-income countries with poor sanitary conditions and hygienic practices.

• In endemic areas, most children (90%) have been infected with HAV before the age of 10 years, most often without symptoms.

5.2. Mode of Transmission: Faecal-Oral Route:

• Lack of safe water and poor sanitation and hygiene (such as contaminated and dirty hands).

• Close contact with someone who has hepatitis A.

• Having sex with someone who has the infection (particularly men who have sex with men, MSM).

• Injecting drugs using contaminated equipment.

Section 6: Hepatitis A – Management, Vaccination, and Prevention (Page 7)

6.1. Management:

• Supportive care with basic analgesia.

• Infection typically clears within 3-6 months without specific antiviral treatment.

6.2. Vaccination:

• Vaccine available to prevent hepatitis A, but not routinely offered in the UK due to low risk.

• Indications for vaccination:

  • Household contacts of infected people to prevent transmission.

  • Travellers to countries where hepatitis A is common (e.g., parts of Africa, Asia, the Middle East, Central and South America).

• Dosing Schedule:

  • Dose 1: Provides short-term protection (lasting approximately 6 months).

  • Dose 2 (booster): Given 6 to 12 months after the first dose, provides long-term protection (lasting at least 25 years).

6.3. Prevention Measures:
The spread of hepatitis A can be reduced by:

• Adequate supplies of safe drinking water.

• Proper disposal of sewage within communities.

• Personal hygiene practices such as regular handwashing before meals and after going to the bathroom.

PART 3: HEPATITIS B (HBV)

Section 7: Hepatitis B – Transmission and Disease Course (Pages 8-9)

7.1. Mode of Transmission (Page 8):

• Transmitted by direct contact with blood or bodily fluids.

• Routes of Transmission:

  • Sexual intercourse or sharing needles (e.g., IV drug users or tattoos/piercings).

  • Exposure to contaminated sharp objects in healthcare settings (needlestick injuries).

  • Mother to child during pregnancy and delivery (vertical transmission) .

  • Blood transfusion in a country that does not screen blood for hepatitis B. (Blood transfusions in the UK are checked for hepatitis B).

7.2. Acute vs. Chronic Hepatitis B (Page 8):

• Most chronic cases are acquired overseas in endemic countries prior to arrival in the UK.

• Most acute cases in the UK are acquired through sexual transmission and injecting drug use.

7.3. Age-Dependent Risk of Chronicity (Page 9):
This is a critical concept in hepatitis B:

• Clinical Implication: This explains why infant and childhood vaccination is prioritised globally. Preventing infection in early life prevents the vast majority of chronic infections and their long-term consequences (cirrhosis, liver cancer).

Section 8: Hepatitis B – Vaccination and Prevention (Pages 9-10)

8.1. Hepatitis B Vaccine (Page 9):

• Standard Schedule: Dose 1, followed by Dose 2 after 1 month, then Dose 3 after 5 months (from dose 1).

• Accelerated Schedules: Available for specific situations (e.g., poor compliance risk, imminent travel).

• Post-Exposure Prophylaxis:

  • For individuals with unknown vaccine status after exposure (e.g., needlestick injury).

  • Hepatitis B Immunoglobulin (HBIG) is used to give rapid, immediate protection until the hepatitis B vaccine (which should be given at the same time at a different site) becomes effective.

8.2. Who Needs the Hepatitis B Vaccine? (Page 10):
Adults need the vaccine if they are at high risk:

• Travelling to a high-risk country.

• Medical Conditions: HIV, hepatic or renal disease (increased risk of complications).

• Occupational Risk:

  • Healthcare workers

  • Prison staff

  • Tattoo artists

• Duration of Protection: The vaccine protects against hepatitis B for at least 20 years.

8.3. Prevention Measures (Page 10):
To reduce the risk of getting or spreading hepatitis B:

• Practice safe sex by using condoms and reducing the number of sexual partners.

• Avoid sharing needles or any equipment used for injecting drugs, piercing, or tattooing.

• Wash hands thoroughly with soap and water after encountering blood, body fluids, or contaminated surfaces.

• Get vaccinated if working in a high-risk occupational setting.

• Contact tracing to identify and manage exposed individuals.

PART 4: HEPATITIS C (HCV)

Section 9: Hepatitis C – Transmission and Disease Course (Page 11)

9.1. Mode of Transmission:

• Transmitted by contact with infected blood.

• Most Common Routes:

  • Reuse or inadequate sterilisation of medical equipment, especially syringes and needles.

  • Transfusion of unscreened blood and blood products.

  • Drug use through the sharing of injection equipment.

  • Sexual practices that lead to exposure to blood (less common).

9.2. Disease Course:

• Acute Infections: Usually asymptomatic and most do not lead to life-threatening disease.

• Spontaneous Clearance: Approximately 30% of infected persons spontaneously clear the virus within 6 months of infection without any treatment.

• Chronic Infection: The remaining 70% will develop chronic infection.

• Long-Term Complications: Of those with chronic infection, the risk of cirrhosis ranges from 15% to 30% within 20 years.

Section 10: Hepatitis C – Treatment and Prevention (Page 12)

10.1. Treatment:

• No vaccine is available for hepatitis C.

• Treatment: Antiviral medications (e.g., sofosbuvir and daclatasvir) with a 90% success rate (cure rate). These are direct-acting antivirals (DAAs) that target specific steps in the HCV life cycle.

10.2. Prevention:
The best way to prevent the disease is to avoid contact with the virus.

• Safe and appropriate use of healthcare injections.

• Safe handling and disposal of needles and medical waste.

• Harm-reduction services for people who inject drugs, such as:

  • Needle exchange programs

  • Substance use counselling

• Testing of donated blood for HCV and other viruses.

• Training of health personnel in infection control.

• Practicing safe sex by using barrier methods such as condoms.

Section 11: The Infected Blood Scandal (Page 13)

11.1. Historical Context (1970s-1991):

• In the 1970s, the NHS could not meet the demand for blood domestically.

• Obtained approximately 50% of its blood and blood-derived products from abroad, including the USA.

• Donors were paid for giving blood, which attracted people from groups which were more likely to have hepatitis C or HIV.

• Blood was initially not screened for these viruses.

11.2. Consequences:

• An estimated 27,000 people were infected with hepatitis C.

• An estimated 80-100 people were infected with HIV.

11.3. Screening Introduced:

• 1972: Routine screening for hepatitis B began.

• 1985: Routine screening for HIV began.

• 1991: Routine screening for hepatitis C began.

Section 12: Hepatitis C Elimination Efforts (Page 14)

12.1. WHO and NHS Targets:

• The World Health Organization (WHO) has a target to eliminate Hepatitis C by 2030.

• NHS England are on track to meet this target.

12.2. Community Pharmacy Role:

• An advanced service for community pharmacy started in September 2020: The Community Pharmacy Hepatitis C Antibody Testing Service (pilot).

• Testing is also offered via:

  • Home testing kits

  • GPs

  • Sexual health clinics

  • Genitourinary medicine (GUM) clinics

  • Drug treatment services

12.3. Why Community Pharmacy-Based Testing Works:

1. Geographic Accessibility: Community pharmacies are geographically close to populations most at risk of hepatitis C (people who inject drugs).

2. Established Relationships: Strong, positive relationships between community pharmacists and people who inject drugs.

3. High-Frequency Contact: People who inject drugs regularly (often daily) attend community pharmacies, providing multiple opportunities for engagement and testing.

PART 5: HEPATITIS D AND HEPATITIS E

Section 13: Hepatitis D (HDV) – The "Dependent" Virus (Page 15)

13.1. Unique Characteristics:

• Defective Virus: Hepatitis D is a "satellite" virus that only affects people who are already infected with hepatitis B. It requires the hepatitis B virus to provide its envelope proteins (specifically, the hepatitis B surface antigen, HBsAg) to be able to survive and replicate in the body.

Image Description (Page 15): A diagram showing the Hepatitis D virus (HDV) with its internal delta antigen and RNA genome, surrounded by an envelope coat provided by Hepatitis B surface antigen (HBsAg) . This illustrates the dependence of HDV on HBV.

13.2. Transmission:

• Usually spread through blood-to-blood contact or sexual contact.

13.3. Epidemiology:

• Uncommon in the UK, but more widespread in other parts of Europe, the Middle East, Africa, and South America.

13.4. Prevention:

• There is no vaccine specifically for hepatitis D.

• However, the hepatitis B vaccine can help protect from it (by preventing HBV infection, which is a prerequisite for HDV infection).

Section 14: Hepatitis E (HEV) (Page 16)

14.1. Epidemiology in the UK:

• The number of cases in Europe has increased in recent years.

• It is now the most common cause of acute hepatitis in the UK.

14.2. Transmission:

• Transmission is primarily through the consumption of raw or undercooked:

  • Pork meat or offal

  • Wild boar meat

  • Venison

  • Shellfish

14.3. Clinical Course:

• Symptoms are typically mild and short-lived.

• It does not require treatment in immunocompetent individuals.

• However, it can be serious in those who have a weakened immune system (e.g., transplant recipients, people with HIV).

14.4. Prevention:

• There is no vaccine available.

• When travelling to parts of the world with poor sanitation, practice good food and water hygiene measures (e.g., ensure meat is thoroughly cooked).

PART 6: CASE STUDY AND REVISION

Section 15: Case Study (Page 17)

Scenario:
Joseph is a 32-year-old nurse who is going to volunteer with a charity group in a field hospital in Myanmar for 6 months. He would like some advice with regards to viral hepatitis:

1. What vaccinations would you advise Joseph to have before travelling?

2. What advice would you give to Joseph to help prevent him developing hepatitis?

Model Answer:

1. Vaccinations Advised:

• Hepatitis A Vaccine: Myanmar is a country where hepatitis A is endemic (common) due to poor sanitary conditions. The vaccine is recommended for all travellers to such areas. He should receive the first dose before travel (providing short-term protection) and the booster 6-12 months later for long-term protection.

• Hepatitis B Vaccine: As a healthcare worker volunteering in a field hospital, Joseph is at occupational risk of exposure to blood and bodily fluids. He should receive the full course of the hepatitis B vaccine (3 doses over 6 months, or an accelerated schedule if time is limited). This will protect him from a potential needlestick injury or other exposure.

• Note: There is no vaccine for hepatitis C, D, or E. Hepatitis D vaccine is not needed if he is vaccinated against hepatitis B (as HDV depends on HBV).

2. General Advice to Prevent Hepatitis:

• Food and Water Hygiene (Hepatitis A and E):

  • Drink only bottled or boiled water. Avoid tap water, ice cubes, and salads washed in local water.

  • Eat only thoroughly cooked food. Avoid raw or undercooked meat, especially pork and shellfish (risk of Hepatitis E).

  • Practice frequent handwashing with soap, especially before eating and after using the toilet.

• Blood and Body Fluid Precautions (Hepatitis B, C, D):

  • As a nurse, follow universal precautions strictly: use gloves, handle sharps safely, and dispose of medical waste properly.

  • Be prepared for post-exposure prophylaxis (HBIG and/or vaccine booster) in case of a needlestick injury.

  • Avoid sharing needles or any equipment that may be contaminated with blood.

• Safe Sex Practices: Use condoms to reduce the risk of sexual transmission of hepatitis B and (less commonly) C.

• Avoid Tattoos/Piercings: Avoid getting tattoos or piercings in settings where sterilisation may be inadequate.

Section 16: Revision Diagram (Page 18)

The slide presents a revision diagram with keywords:

• A → Acute (Hepatitis A is typically acute)

• Blood/bodily fluids, Birth, Between sexual partners → Hepatitis B (modes of transmission)

• Circulation (blood) → Hepatitis C (primarily blood-borne)

• Depends on B → Hepatitis D (depends on HBV for replication)

• Eating → Hepatitis E (faecal-oral, foodborne transmission)

SUMMARY TABLE: COMPARISON OF VIRAL HEPATITIS STRAINS