ACUTE VIRAL HEPATITISACUTE VIRAL HEPATITIS

CLINICAL PRESENTATION.CLINICAL PRESENTATION.DIGNOSIS.DIGNOSIS.EPEDEMOLOGY OF VIRAL EPEDEMOLOGY OF VIRAL HEPATITIS INFECTION A,B,C IN HEPATITIS INFECTION A,B,C IN KSA.KSA.MANAGEMENTMANAGEMENT..

Viral Hepatitis - OverviewViral Hepatitis - Overview

AA BB CC DD EESource ofvirus

feces blood/blood-derived

body fluids

blood/blood-derived

body fluids

blood/blood-derived

body fluids

feces

Route oftransmission

fecal-oral percutaneouspermucosal

percutaneouspermucosal

percutaneouspermucosal

fecal-oral

Chronicinfection

no yes yes yes no

Prevention pre/post-exposure

immunization

pre/post-exposure

immunization

blood donorscreening;

risk behaviormodification

pre/post-exposure

immunization;risk behaviormodification

ensure safedrinkingwater

Type of HepatitisType of Hepatitis

Diagnosis of hepatitisDiagnosis of hepatitis

Patient historyPatient history

Physical examinationPhysical examination

Liver function testsLiver function tests

Serologic testsSerologic tests

Symptoms and SignsSymptoms and Signs Pre-icteric phase Pre-icteric phase

1.1. AnorexiaAnorexia2.2. FatigueFatigue3.3. NauseaNausea4.4. VomitingVomiting5.5. ArthralgiaArthralgia6.6. MyalgiaMyalgia7.7. HeadacheHeadache8.8. PhotophobiaPhotophobia9.9. PharangitisPharangitis10.10. 11.11.

Icteric phase::Icteric phase::1.1. Enlarged liverEnlarged liver2.2. Tender upper quadrantTender upper quadrant3.3. DiscomfortDiscomfort4.4. Splenomegaly (10-20%)Splenomegaly (10-20%)5.5. General adenopathyGeneral adenopathy

Post-icteric phasePost-icteric phase

Lab FindingsLab Findings

1.1. L FT increase >5-10 times of normalL FT increase >5-10 times of normal

2.2. Markers of hepatitis B or C or A might be Markers of hepatitis B or C or A might be positivepositive

Pathological findingsPathological findings

1.1. Pan lobular infiltration with mononuclear Pan lobular infiltration with mononuclear cellscells

2.2. Hepatic cell necrosisHepatic cell necrosis

3.3. Reticulum framework are intactReticulum framework are intact

DD:DD:

1.1. Infectious MononucleosisInfectious Mononucleosis

2.2. Drug Induced HepatitisDrug Induced Hepatitis

3.3. Chronic Hepatitis.Chronic Hepatitis.

4.4. Alcohol HepatitisAlcohol Hepatitis

5.5. Cholecystitis, CholelithiasisCholecystitis, Cholelithiasis

ComplicationsComplications

1.Chronic hepatitis 1.Chronic hepatitis cirrhosis- HCC cirrhosis- HCC

2.Fulmnant hepatitis 2.Fulmnant hepatitis

FULMINANT HEPATITISFULMINANT HEPATITIS

Definition: Hepatic Failure Within 8 Weeks Definition: Hepatic Failure Within 8 Weeks Of Onset Of Illness.Of Onset Of Illness.

Manifestation: Encephalopathy and Manifestation: Encephalopathy and Prolonged PTProlonged PT

Histopathology: Massive Hepatic Necrosis.Histopathology: Massive Hepatic Necrosis.

Hepatitis B - Clinical FeaturesHepatitis B - Clinical Features

• Incubation period: Average 60-90 daysRange 45-180 days

• Clinical illness (jaundice): <5 yrs, <10%5 yrs, 30%-50%

• Acute case-fatality rate: 0.5%-1%

• Chronic infection: <5 yrs, 30%-90%5 yrs, 2%-10%

• Premature mortality fromchronic liver disease: 15%-25%

HBV infectionHBV infectionFactors affecting transmission abilityFactors affecting transmission ability

1.Replicative status1.Replicative status - HBeAg- HBeAg - high HBVDNA- high HBVDNA

2.Route of infection2.Route of infection - percutanouse- percutanouse - Transmucosal- Transmucosal

3. Exposure frequency : Single vs. Multiple3. Exposure frequency : Single vs. Multiple

4. Inoculums size : transfusion vs. needle stick4. Inoculums size : transfusion vs. needle stick

Hepatitis BHepatitis B

Hepatitis B serologyHepatitis B serology

anti-HBcanti-HBc exposure (IgM = acute) exposure (IgM = acute)

HBsAgHBsAg infection (carrier) infection (carrier)

anti-HBs anti-HBs immunity immunity

HBeAgHBeAg viral replication viral replication

anti-HBe anti-HBe seroconversion seroconversion

HBV-DNA HBV-DNA viral replication viral replication

Natural HistoryNatural History

Gow, BMJ 2001

• Sexual

• Parenteral

• Perinatal

Hepatitis B Virus Modes of Transmission

Hepatitis B Virus Modes of Transmission

Concentration of Hepatitis B Virus in Various Body Fluids

Concentration of Hepatitis B Virus in Various Body Fluids

High ModerateLow/Not

Detectable

blood semen urineserum vaginal fluid feces

wound exudates saliva sweat

tearsbreastmilk

Possible transmission route of HBV Possible transmission route of HBV in KSAin KSA

1-Horisontal transmission (person to person) is the main 1-Horisontal transmission (person to person) is the main transmission route transmission route 2-Perintal transmission (positive HBSAG mothers) 2-Perintal transmission (positive HBSAG mothers) especially if they are HBEAG positiveespecially if they are HBEAG positive3- Heterosexual transmission 3- Heterosexual transmission 4-Illegal injection drug use 4-Illegal injection drug use 5- Contaminated equipment used for therapeutic 5- Contaminated equipment used for therapeutic injections and other health care related proceduresinjections and other health care related procedures6- Folk medicine practice 6- Folk medicine practice 7-Blood and blood products transfusion without prior 7-Blood and blood products transfusion without prior screening screening

HBV INFECTIONHBV INFECTIONbefore and after before and after

vaccination programvaccination program

OVERALL PREVALENCE OF HBsAg AMONG OVERALL PREVALENCE OF HBsAg AMONG SAUDIS IN THE 80’S ACCORDING TO REGIONSSAUDIS IN THE 80’S ACCORDING TO REGIONS

5.5

8.99.6

8.3

0

2

4

6

8

10

Central (n=6649) South-western(n=7235)

Eastern(n=8300)

Total (n=32183)

Pos

itiv

ity

(%)

Al-Faleh. Annals of Saudi Medicine, 1988

PREVALENCE OF HBeAg AMONG HBsAg POSITIVE PREVALENCE OF HBeAg AMONG HBsAg POSITIVE SAUDIS PREGNANT WOMEN (n = 20920)SAUDIS PREGNANT WOMEN (n = 20920)

3.7

5.4

0

1

2

3

4

5

6

% of HBsAg pos. % of HBeAg Pos.

Al-Faleh, Annals of Saudi Medicine, 1988

FREQUENCY OF HBeAg AMONG HBsAg FREQUENCY OF HBeAg AMONG HBsAg POSITIVE SAUDI CHILDREN (n=307)POSITIVE SAUDI CHILDREN (n=307)

17.2

19.4

17.1

17.9

15.5

16

16.5

17

17.5

18

18.5

19

19.5

Perc

ent

1-3 years(93/16)

4-6 years(103/20)

7-10 years(111/19)

Total(307/55)

Al-Faleh et al. Journal of Infection, 1992

PREVENTION STRATEGIES OF PREVENTION STRATEGIES OF MINISTRY OF HEALTH IN KSAMINISTRY OF HEALTH IN KSA

Introducing HBV vaccine in EPI program; andIntroducing HBV vaccine in EPI program; and

Mandatory screening of blood donors Mandatory screening of blood donors and expatriates.and expatriates.

Vaccination of risk groups.Vaccination of risk groups.

Health education especially among Health education especially among

medical personnelmedical personnel..

THE CURRENT EPI IN THE THE CURRENT EPI IN THE KINGDOM OF SAUDI ARABIAKINGDOM OF SAUDI ARABIA

1.1. At birthAt birth BCG +BCG + HB1HB1

2.2. At 6 weeksAt 6 weeks DPT1 + OPV1DPT1 + OPV1 Hb2Hb2

3.3. At 3 monthsAt 3 months DPT2 + OPV2DPT2 + OPV2

4.4. At 5 monthsAt 5 months DPT3 + OPV3DPT3 + OPV3

5.5. At 5monthsAt 5months MeaslesMeasles HB3HB3

6.6. At 12 monthsAt 12 months MMRMMR

7.7. At 18 monthsAt 18 months (DPT + OPV)(DPT + OPV) Booster 1Booster 1

8.8. At 4-6 yearsAt 4-6 years (DPT + OPV)(DPT + OPV) Booster 2Booster 2

COMPARISON OF PREVALENCE OF HBsAg COMPARISON OF PREVALENCE OF HBsAg AMONG SAUDI CHILDREN IN 1989 (n=4575) AMONG SAUDI CHILDREN IN 1989 (n=4575) AND 1997 (n=5355) – ACCORDING TO AGEAND 1997 (n=5355) – ACCORDING TO AGE

9.68

0 0

6.54

0.16

7.24

0.3

5.06

0

6.35

0

7.57

0.2

6.51

0.82

7.2

0.93

5.81

2.31

0

66.71

0.310

2

4

6

8

10

Perc

enta

ge

1 2 3 4 5 6 7 8 9 10 11 12

Tota

l

(Age in years)

1989 1997Al Faleh, J Infect 1999

COMPARISON OF PREVALENCE OF HBsAg COMPARISON OF PREVALENCE OF HBsAg AMONG SAUDI CHILDREN IN 1989 (n=4575) AMONG SAUDI CHILDREN IN 1989 (n=4575)

AND 1997 (n=5355) – ACCORDING TO REGIONAND 1997 (n=5355) – ACCORDING TO REGION

8.63

0

3.48

0.52

2.87

0

5.83

0.83

5.71

0

10.29

1.52

7.59

0

8.83

0.77

5.22

0

9.04

0

12.67

0.47

3.14

0

3.73

0.3

7.53

0

6.71

0.31

-1

1

3

5

7

9

11

13

Per

cent

age

Riy

adh

Qas

sim

Hai

l

Mak

kah

Med

ina

Ase

er

Al-B

aha

Giz

an

Naj

ran

Al-J

ouf

Tab

ouk

Dam

mam

Jedd

ah Tai

f

Tot

al

1989 1997

Al Faleh, J Infect 1999

Prevalence Of HBsAg Among Saudi Population Prevalence Of HBsAg Among Saudi Population Before & After Vaccination over 18 yBefore & After Vaccination over 18 y

6.70%

0%0.16%

0%0%

2%

4%

6%

8%

10%

1989 1992 1997 2007/8

After

Before

1-10yr4575

1-2yr637

1-12yr 3666

Agenumbers

16-18yr1365

CHANGING PATTERNS OF HBsAg POSITIVITY CHANGING PATTERNS OF HBsAg POSITIVITY AMONG BLOOD DONORS IN MOH,CENTRAL AMONG BLOOD DONORS IN MOH,CENTRAL

BLOOD BANK 1994-2005BLOOD BANK 1994-2005

4.4

3.25

1.5

00.5

11.5

22.5

33.5

44.5

1994n=9690

2000n=91695

2005n=177037

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Po

siti

vity

%

4.7

3

1.4

1.91.7

2 2.2

1 1

PREVALENCE OF HBsAg POSITIVITY AMONG PREVALENCE OF HBsAg POSITIVITY AMONG BLOOD DONORS IN KKUH FROM 1987 TO 2005BLOOD DONORS IN KKUH FROM 1987 TO 2005

HBSAg positively Among Blood donors HBSAg positively Among Blood donors in in KKUH ( 18-21y)KKUH ( 18-21y)

0

0.2

0.4

0.6

0.8

1

1.2

1.4

po

siti

vity

%

2000 n= 647(18- 20)

2004 n=1371(18-20)

2005 n=1504(18-21)

1.24

0.6 0.6

HCV INFECTIONHCV INFECTION

Transmission of HCV Percutaneous

– Injecting drug use– Clotting factors before viral inactivation– Transfusion, transplant from infected donor – Therapeutic (contaminated equipment, unsafe

injection practices)– Occupational (needlestick)

Permucosal– Perinatal– Sexual

Features of Hepatitis C Virus InfectionFeatures of Hepatitis C Virus Infection

Incubation periodIncubation period Average 6Average 6--7 weeks7 weeksRange 2Range 2--26 weeks26 weeks

Acute illness (jaundice)Acute illness (jaundice) Mild (Mild (<<20%)20%)

Case fatality rateCase fatality rate LowLow

Chronic infectionChronic infection 75%75%--85%85%

Chronic hepatitisChronic hepatitis 70% (most asx)70% (most asx)

CirrhosisCirrhosis 10%10%--20%20%

Mortality from CLDMortality from CLD 1%1%--5%5%

*Reported in U.S.

Household Transmission of HCV

Rare but not absent

Could occur through percutaneous/mucosal exposures to blood– Theoretically through sharing of contaminated

personal articles (razors, toothbrushes)

– Contaminated equipment used for home therapies• Injections*• Folk remedies

Sexual Transmission of HCV

Occurs, but efficiency is low– Rare between long-term steady partners– Factors that facilitate transmission between

partners unknown (e.g., viral titer)

Accounts for 15-20% of acute and chronic infections in the United States– Sex is a common behavior – Large chronic reservoir provides multiple

opportunities for exposure to potentially infectious partners

* Reported in U.S.

Nosocomial Transmission of HCV

Recognized primarily in context of outbreaks Contaminated equipment

– hemodialysis*– endoscopy

Unsafe injection practices– plasmapheresis,* phlebotomy– multiple dose medication vials– therapeutic injections

Transmission of HCVTransmission of HCV

EGYPT, mass campaigns of parenteral EGYPT, mass campaigns of parenteral antischistosomal therapy(discontinued antischistosomal therapy(discontinued only in the 1980 ) may represent the only in the 1980 ) may represent the WORLD, largest iatrogenic transmission of WORLD, largest iatrogenic transmission of BLOOD BORNN PATHOGENS BLOOD BORNN PATHOGENS frank c,Moh m k et all lancet 2000 frank c,Moh m k et all lancet 2000

Natural historyNatural history

Marcellin, J Hepat 1999

COMPARISON OF PREVALENCE OF ANTI-HCV IN COMPARISON OF PREVALENCE OF ANTI-HCV IN SAUDI CHILDREN IN 1989 AND 1997 STUDIESSAUDI CHILDREN IN 1989 AND 1997 STUDIES

1989198919971997

No. of childrenNo. of childrenPositivePositive(%) (%) No. of childrenNo. of childrenPositivePositive(%) (%)

449644963939))0.87%0.87%((

5350535022))0.04%0.04%((

Diagnostic test only byDiagnostic test only by11st-st-generation EIA kitgeneration EIA kit . .

Diagnostic test byDiagnostic test by33rdrd-generation EIA kit and -generation EIA kit and confirmatory test by RIBA confirmatory test by RIBA

kitkit..

198919891997199720082008

No. of No. of childrenchildrenPositivePositive(%) (%) No. of No. of

childrenchildrenPositivePositive(%) (%) No. of No. of studentsstudentsPositivePositive(%) (%)

449644963939**))0.87%0.87%((

5350535022****))0.04%0.04%((13571357

))55((330.22%0.22%

Diagnostic test Diagnostic test only byonly by

11st-st-generation EIA generation EIA kitkit . .

Diagnostic test byDiagnostic test by33rdrd-generation EIA -generation EIA

kit and confirmatory kit and confirmatory test by RIBA kittest by RIBA kit..

Diagnostic test byDiagnostic test byPCR for anti- HCVPCR for anti- HCV

Positive casesPositive cases..

Overall prevalence rate of HCV infection in KSA Overall prevalence rate of HCV infection in KSA among children and adolescent during the last among children and adolescent during the last

18 yrs18 yrs..

* ALFaleh et al. Hepatology 1991** ALFaleh Ann Saudi Med. 2003

Prevalence of HCV Among Saudi Prevalence of HCV Among Saudi Blood donors (1998- 2002)Blood donors (1998- 2002)

1.2

0.9

1.31.2

0.7

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Pre

ce

nta

ge

1998(n=104003)

1999(n=110608)

2000(n=114122

2001(n=115090)

2002(n=113993)

Shobokshi et al , SMJ 2003

HCV positivity among blood donors in 2005 in HCV positivity among blood donors in 2005 in central blood bank of MOH in KSA according to central blood bank of MOH in KSA according to

regionsregions

0.2

0.5

0.6

0.4

0.1

0.3

0.2

0.3 0.3

0

0.1

0.2

0.3

0.4

0.5

0.6

Riyadh(n=31268)

Makkah (n=23348)

Aseer (n=20840)

Albaha (n=9848)

Najran (n=12750)

Jezan (n=5314)Eastren Provience (n=29674)

Alqaseem

(n=26094)

Total(n=17265)

HCV positivity among Saudi blood donors from HCV positivity among Saudi blood donors from 1996 – 2005 in KKUH (n=58910)1996 – 2005 in KKUH (n=58910)

0.58 0.55

0.360.22

0.28 0.3 0.3

0.140.2

0

0.2

0.4

0.6

0.8

Perc

enta

ge

1996 (n=40)

1997 (n=35)

1998 (n=22)

1999 (n=13)

2000 (n=18)

2002(n=15)

2003(n=17)

2004(n=11)

2005(n=19)

KKUH Blood bank

HCV POSITIVITY AMONG SAUDI BLOOD DONORS HCV POSITIVITY AMONG SAUDI BLOOD DONORS FROM 1996 TO 2000 IN KKUHFROM 1996 TO 2000 IN KKUH

ACCORDING TO AGE GROUPSACCORDING TO AGE GROUPS

0.170.53 0.69

4.4

0.38

0

1

2

3

4

5

Per

cent

age

20-30 30-40 40-50 > 50 Total

(Age in years)

No. of blood donors = 32793KKUH Blood bank

Prevalence of HCV Positivity Prevalence of HCV Positivity Among Different Saudi populationAmong Different Saudi population

Type of patientType of patientnumbernumberPrevalencePrevalence(%)(%)

Children from 1-18yChildren from 1-18y385438540.10.1

Pregnant womenPregnant women312731270.70.7

Hemodialysis patientsHemodialysis patients 290542905455.855.8

Drug addictsDrug addicts913791371414

Shobokshi et al , SMJ 2003

Prevention Of HCV TransmissionPrevention Of HCV Transmission

Avoiding shared use of Razors or brushes Avoiding shared use of Razors or brushes and any item that pierces the skin.and any item that pierces the skin.

Strict adherence of the universal Strict adherence of the universal precautions in health facilities.precautions in health facilities.

Educating and training of HCW’s to the Educating and training of HCW’s to the proper use of standard precautions proper use of standard precautions

Folk medicine?! Folk medicine?!

HAV INFECTIONHAV INFECTION

COMPARISON OF PREVALENCE OF ANTI-HAV AMONG COMPARISON OF PREVALENCE OF ANTI-HAV AMONG SAUDI CHILDREN IN 1989 (n=4375) AND 1997 (n=5255) – SAUDI CHILDREN IN 1989 (n=4375) AND 1997 (n=5255) –

ACCORDING TO AGEACCORDING TO AGE

23.7

13.4

34.8

17.6

41.6

20.3

43.9

23.4

48.5

24

54.1

26.7

59.8

28

59.7

30.6

63.5

33.1

72.6

34.5

26.4

48.850.5

24.9

0

10

20

30

40

50

60

70

80

Per

cent

age

1 3 5 7 9 11 Total

(Age in years)

1989 1997

Al-Faleh et al. Saudi Med. J, 1999

COMPARISON OF PREVALENCE OF ANTI-HAV COMPARISON OF PREVALENCE OF ANTI-HAV AMONG SAUDI CHILDREN IN 1989 (n=4375) AND AMONG SAUDI CHILDREN IN 1989 (n=4375) AND

1997 (n=5255) – ACCORDING TO REGION1997 (n=5255) – ACCORDING TO REGION

39

16.1

62.7

31.6

56

20.4

55

20.1

59.5

28.2

44.5

19

43.6

25.4

81.682.279.1

51.3

64.4

47.9

76

45.638.4

18.2

51.1

17.5 19

9.6

50.5

24.9

1112131415161718191

Per

cent

age

Riy

ad

h

Qa

ssim

Ha

il

Ma

kka

h

Me

din

a

Ase

er

Al-

Ba

ha

Giz

an

Na

jra

n

Al-

Jou

f

Ta

bo

uk

Da

mm

am

Jed

da

h

Ta

if

To

tal

1989 1997

COMPARISON OF PREVALENCE OF ANTI-HAVCOMPARISON OF PREVALENCE OF ANTI-HAVIN ASEER REGION AMONG SAUDI CHILDRENIN ASEER REGION AMONG SAUDI CHILDREN

IN 1989 (n=476) AND 1997 (n=411)IN 1989 (n=476) AND 1997 (n=411)

44.5

19

1112131415161718191

Per

cent

age

1989 1997

PREVALENCE OF ANTI-HAV IN SAUDI PREVALENCE OF ANTI-HAV IN SAUDI CHILDREN IN 1997 ACCORDING TO SEXCHILDREN IN 1997 ACCORDING TO SEX

25.7524

0

5

10

15

20

25

30

Per

cent

Male (n=2642) Female (n=2713)

No. of children = 5355

PREVALENCE OF ANTI-HAV IN SAUDI CHILDREN IN 1997 PREVALENCE OF ANTI-HAV IN SAUDI CHILDREN IN 1997 ACCORDING TO LOCATIONACCORDING TO LOCATION

20.98

33.04

0

5

10

15

20

25

30

35

Per

cent

Urban (n=3635) Rural (n=1715)

No. of children = 5255

AGE SPECIFIC PREVALENCE OF ANTI-HAV IN SAUDIS AGE SPECIFIC PREVALENCE OF ANTI-HAV IN SAUDIS FROM RIYADH, CENTRAL REGIONFROM RIYADH, CENTRAL REGION

AgeAge(Years)(Years)

1986198619941994

PPNo. Positive/ No. Positive/ No. TestedNo. Tested%%

No. Positive/ No. Positive/ No. TestedNo. Tested%%

11 – – 99103/194103/19453.053.081/21081/21038.638.63.43.4 x 10.3x 10.3

1010 – – 1919164/193164/19385.085.0110/180110/18061.161.111 x 10.4x 10.4

2020 – – 3030182/200182/20091.091.0188/240188/24078.378.333 x 10.4x 10.4

TotalTotal449/587449/58776.576.5379/630379/63060.260.211 x 10.4x 10.4

Arif et al. Saudi J Gastroenterology, 1995

Changing pattern of Hepatitis A prevalence Changing pattern of Hepatitis A prevalence within the Saudi population over 18 yrswithin the Saudi population over 18 yrs

53

24.318.1

0

10

20

30

40

50

60

1989 1999 2008

Age Region

1-10 YRS 13

1-12 yrs 13

16-18 yrs 3

*

** ***

*AlRashed R. Ann SM 1997** AlFaleh et al SMJ 1999*** AlFaleh et al WJG 2008

THANK THANK YOUYOU

Perinatal Transmission of HCV Transmission only from women HCV-RNA

positive at delivery– Average rate of infection 6%– Higher (17%) if woman co-infected with HIV– Role of viral titer unclear

No association with– Delivery method– Breastfeeding

Infected infants do well– Severe hepatitis is rare

Occupational Transmission of HCV

Inefficiently transmitted by occupational exposures Average incidence 1.8% following needle stick from

HCV-positive source – Associated with hollow-bore needles

Case reports of transmission from blood splash to eye– No reports of transmission from skin exposures to blood

Prevalence 1-2% among health care workers – Lower than adults in the general population– 10 times lower than for HBV infection

Presence of recognized risk factor does not necessarily equate with “increased risk”

Occupational Transmission of HCV

Inefficiently transmitted by occupational exposures Average incidence 1.8% following needle stick from

HCV-positive source – Associated with hollow-bore needles

Case reports of transmission from blood splash to eye– No reports of transmission from skin exposures to blood

Prevalence 1-2% among health care workers – Lower than adults in the general population– 10 times lower than for HBV infection

Presence of recognized risk factor does not necessarily equate with “increased risk”

Perinatal Transmission of HCV Transmission only from women HCV-RNA

positive at delivery– Average rate of infection 6%– Higher (17%) if woman co-infected with HIV– Role of viral titer unclear

No association with– Delivery method– Breastfeeding

Infected infants do well– Severe hepatitis is rare

• High (8%): 45% of global population– lifetime risk of infection >60%– early childhood infections common

• Intermediate (2%-7%): 43% of global population– lifetime risk of infection 20%-60%– infections occur in all age groups

• Low (<2%): 12% of global population– lifetime risk of infection <20%– most infections occur in adult risk groups

Global Patterns of Chronic HBV InfectionGlobal Patterns of Chronic HBV Infection

• High (8%): 45% of global population– lifetime risk of infection >60%– early childhood infections common

• Intermediate (2%-7%): 43% of global population– lifetime risk of infection 20%-60%– infections occur in all age groups

• Low (<2%): 12% of global population– lifetime risk of infection <20%– most infections occur in adult risk groups

Global Patterns of Chronic HBV InfectionGlobal Patterns of Chronic HBV Infection

Chronic Hepatitis C Factors Promoting Progression or Severity

Increased alcohol intake

Age > 40 years at time of infection

HIV co-infection

?Other– Male gender– Other co-infections (e.g., HBV)

Hepatitis CHepatitis C