Hepatitis C Post-exposure Management

The risk of transmission of HCV after a needle stick exposure from a hepatitis C-positive source is estimated at between 2-10%

At time of exposure:
• Determine the type of exposure and assess the associated risk.
• Wash wounds with soap and water; flush mucous membranes with water.
• No post-exposure prophylaxis (immune globulin or antiviral medications) is recommended.
• Counsel the exposed person regarding hepatitis C transmission risk.
• Test source and exposed individual for hepatitis C virus antibody and liver enzymes for exposed individual. If source is not available or refuses testing, treat exposed person as if source has active hepatitis C infection.
• If source is hepatitis C virus antibody positive, or is antibody negative and is immunocompromised, test source for qualitative HCV RNA.
• If source is negative for hepatitis C antibody (and HCV RNA, if indicated), no further testing is necessary and no further action beyond initial HCV testing, is necessary for the exposed person.
After exposure
• If source is positive for hepatitis C antibody and HCV RNA , and exposed person is negative, follow up of exposed person should be done after one month for qualitative HCV RNA and retest liver enzymes
• If positive consider treatment with pegylated interferon +/- ribavirin.
• If negative retest exposed after three Months for anti-HCV, qualitative HCV RNA and liver enzymes
• If still negative reassure the patient and no further testing is required





SURVEILLANCE
Patient with cirrhosis due to HCV should be screened for hepatocellular carcinoma (HCC) with alpha-fetoprotein (AFP) testing and hepatic ultrasound imaging at least once or twice yearly [96].
PROGNOSIS
• If patient has chronic hepatitis C, it is an indolent, often subclinical disease that may lead to cirrhosis and hepatocellular carcinoma after decades. Indeed, the mortality rate from transfusion-associated hepatitis C may be no different from that of an age-matched control population
[120].
• Acute HCV typically leads to chronic infection; 60 to 80 percent of cases develop chronic hepatitis (abnormal liver enzymes).
• Chronic HCV infection is usually slowly progressive; it may not result in clinically apparent liver disease in many patients if the infection is acquired later in life. Approximately 20 to 30 percent of chronically infected individuals develop cirrhosis over a 20- to 30-year period of time
• If patient has chronic hepatitis C,mortality rates clearly rise once cirrhosis develops, and mortality from cirrhosis and hepatocellular carcinoma due to hepatitis C is expected to triple in the next 10–20 years.


COUNCELLING
• Patients with chronic HCV infection should be counseled regarding lifestyle modifications and prevention of transmission.
• There are no specific dietary measures that have been shown to have any effect on the progression of chronic hepatitis C. However, heavy use of alcohol (>50 g/day) has been associated with higher ALT levels and development of cirrhosis. In addition, the development of cirrhosis and HCC occurs at a younger age in heavy drinkers with chronic hepatitis C.
• Persons who are HCV-positive should

7. Use barrier protection during sexual intercourse
8. Not share toothbrushes or razors
9. Cover open cuts and scratches
10. Clean blood spills with detergent or bleach
11. Not donate blood, organs or sperms
• Children and adults who are HCV-positive:
4. Can participate in all activities including contact sports
5. Should not be excluded from daycare or school participation and should not be isolated from other children
6. Can share food, utensils or kiss others
• Patients should be aware that over-the-counter medications can be hepatotoxic and that they should discuss medication use with a medical provider.
• Patients should be made aware that no herbal products have yet been shown to delay progression of hepatitis C and that some herbs are hepatotoxic.
• Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, have been have been associated with hepatitis C flares
HEPATITIS E
DEFINITION
Hepatitis E virus (HEV) is a self-limited, enterically-transmitted acute viral hepatitis caused by nonenveloped single stranded RNA virus [121].

DIAGNOSTIC CONSIDERATIONS [122]
• Prodrome of anorexia, nausea, vomiting, malaise, aversion to smoking.
• Fever, enlarged and tender liver, jaundice.
• Normal to low white cell count; abnormal liver tests, especially markedly elevated aminotransferases early in the course.
• Evidence of transmission by the fecal-oral route, either by direct contact with a person who is infected with hepatitis E virus or by ingestion of food or water that has been contaminated with the virus or travel to endemic area.
• Mortality specially high in pregnant females
• Hepatitis E IgM is positive
• Hepatitis never goes into chronic stage.
• The incubation period following exposure to HEV ranges from 3 to 8 weeks, with a mean of 40 days

EPIDEMIOLOGY


• The highest prevalence of infection occurs in regions where low standards of sanitation promote the transmission of the virus [123]
• The prevalence of antibody to HEV in suspected or documented endemic regions has been much lower than expected (3 - 26%) [124]
• Screening of blood donors in central Europe and North America has shown a prevalence of anti-HEV antibodies of 1.4 - 2.5%, in South Africa of 1.4%, in Thailand of 2.8%, in Saudi Arabia of 9.5%, and in Egypt of 24.0%.
• The prevalence of antibody to HEV in non endemic regions (like the US) has been much higher than anticipated (1 - 3%) [124, 125]
• HEV infections account for >50% of acute sporadic hepatitis in some high endemic areas.
Race:
• Infection has no apparent racial predilection.
Sex:
• Although predilection is unknown, pregnant women are prone to complications.
Age:
• It predominantly affects those aged 15-40 years.
• It may affect younger age groups but generally is not recognized and may be subclinical.
• No chronic cases have been described.
TRANSMISSION

• HEV is spread by the oral-faecal route. This enterically transmitted virus has been implicated in several food and waterborne outbreaks [126]
• Consumption of faecally contaminated drinking water has given rise to epidemic cases, and the ingestion of raw or uncooked shellfish has been the source of sporadic cases in endemic areas [124]
• The low amount of intact HEV particles present in patient stools accounts for the generally lower rate of person-to-person transmission of hepatitis E when compared with that of hepatitis A [127]
• Naturally acquired HEV antibodies have been detected in primates, rodents and swine [124,128]. Swine HEV cross-reacts with antibodies to the human HEV capsid antigen.
• Person-to-person transmission is uncommon, ranging from 0.7 to 2.2 percent
• HEV can be transmitted by blood transfusion, particularly in endemic areas [129]
• HEV infection can be transmitted from mother to newborn with substantial perinatal morbidity and mortality [130,131]
CLINICAL FEATURES

Risk groups
Here is a list of groups of people who are at risk of contracting HEV:
• persons residing in areas where extended community outbreaks exist
• international travellers to regions of the world where HEV is endemic
• refugees residing in overcrowded temporary camps following catastrophies, especially in Sudan, Somalia, Kenya and Ethiopia
• persons who have chronic liver disease
• possibly persons working with non-human primates, pigs, cows, sheep and goats