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HEPATITIS TRANSMISSION Close personal contact, Contaminated food, water, Blood exposure (rare) Hepatitis A: Clinical Aspects Onset: usually abrupt Duration: Mild lasting 1-2 weeks, Severe lasting months, Rarely fatal Children usually asymptomatic: 5-10% jaundiced, 1-2 week duration Adults are usually symptomatic: Jaundiced, Nausea, vomiting, & fever are common. HEPATITIS A, UNITED STATES -facts Most disease = community-wide outbreaks Infection transmitted: person to person in households & extended family settings, facilitated by asymptomatic infection among children. Some groups at increased risk; specific factor varies, do not account for majority of cases No risk factor identified for 40%-50% of cases PREVENTING HEPATITIS A Hygiene (e.g., hand washing) Sanitation (e.g., clean water sources) Hepatitis A vaccine (pre-exposure) Immune globulin (pre- and post post-exposure exposure) Hepatitis B Virus Modes of Transmission Sexual, Parenteral, Perinatalon Chronic Carrier State (B) 90% of infants 30% of 5 year-olds 6% of adults *Risk of chronic infection is lower after acute illness for above groups Prolonged infection can occur without signs or symptoms of acute or chronic illnesstsNA Concentration of Hepatitis B Virus in Various Body Fluids High = blood, serum, wound exudates Moderate = semen, vaginal fluid, saliva Low/not detectable = urine, feces, sweat, tears, breastmilk Hep B Prevention 1 Vaccination: highly effective, health care workers & populations at increased risk Hep B Prevention 2 Hepatitis B Immunoglobulin - used to protect persons who are exposed. - highly efficacious within 48 hours - neonates at increased risk of contracting hepatitis B (mothers are HBsAg and HBeAg positive) Hep B Prevention 3 Other measures: screening of blood donors, blood and body fluid precautions. Chronic Hepatitis C: Factors Promoting Progression or Severity Increased alcohol intake Age > 40 years at time of infection HIV co-infection Male, Chronic HBV co-infection Exposures Known to Be Associated W/ HCV Infection in US Injecting drugs Transfusion, transplant from infected donor Occupational exposure to blood: mostly needle sticks Iatrogenic (unsafe injections) Birth to HCV-infected mother Sex with infected partner: Multiple sex partners Injecting Drug Use & HCV Transmission Highly efficient: Contamination of drug paraphernalia, not just needles and syringes Rapidly acquired after initiation: 30% prevalence after 3 years, >50% after 5 years. 4x more common than HIV Occupational Transmission of HCV Inefficient by occupational exposures! 1.8% following needle stick from HCV-positive source. Prevalence 1-2% for health care workers: lower than gen pop, 10x lower than HBV infection. HCW to Pt Transmission of HCV Rare: In U.S., none related to performing invasive procedures. Most related to HCW substance abuse: reuse of needles or sharing narcotics used for self self-injection. No restrictions routinely recommended for HCV-infected HCWs Treatment hep C (1) Interferon - considered for pts w/chronic active hepatitis. Response rate = around 50% 50% of responders will relapse w/tx is stopped Treatment hep C (2) Ribavirin -recent studies suggest combo of interferon & ribavirin = more effective than interferon alone Treatment hep C (3) New drugs work directly on virus increasing chance of clearing it from body (40% - 75%) Hepatitis D: Modes of Transmission Percutanous exposures: injecting drug use Permucosal exposures: sex contact Hepatitis D - Prevention HBV-HDV Co-infection: prophylaxis to prevent HBV infection HBV-HDV Super infection: education to reduce risk behaviors w/chronic HBV infection pts. Hepatitis D - Clinical Features Co-infection: severe acute disease, low risk of chronic infection Super infection: usually develop chronic HDV, high risk = severe chronic liver disease Hepatitis E -Epidemiologic Featuresion Outbreaks usually w/fecally contaminated drinking water Minimal person-to-person transmission U.S. cases usually = hx of travel to HEV-endemic areas Acute Hepatitis: common Symptoms Malaise 76-94% Anorexia 71-96% Dark urine 65-94% Nausea 61-81% Abdominal pain 26-68% Scleral icterus 48% Vomiting 20-37% Acute Hepatitis: uncommon Symptoms Respiratory symptoms, Headache, Fever, Muscle pain, Rash, Joint pain, Itching Acute Hepatitis: Signs Jaundice 70-90% Hepatomegaly 14-69% Tender liver 20-86% Rash 40% Splenomegaly 3-21% Fever 1-8% High LFTs 100% (important) Dental Management: Viral Hepatitis Manage all patients as infected Active hepatitis: only urgent care History of Hepatitis use asepsis for all patients & screen for HBsAg? Chronic active hepatitis/carriers = bleeding/drug metabolism issues Substantial Risk of Hepatitis B, C, D Health care workers Public safety workers Hemodialysis patients Transfusion patients With increased sexual partners Illicit drug usersm Higher risk -oral surgeons vs. general dentists Dental Rx Metabolized Primarily by Liver (LA) Local anesthetics: safe for use w/liver disease, use appropriate amounts only lidocaine (Xylocaine), Prilocaine (Citanest), Mepivacaine (Carbocaine), Bupivacaine (Marcaine) Drugs Metabolized Primarily by Liver (abx) Antibiotics: Ampicillin, Tetracycline, Metronidazole, Vancomycins Drugs Metabolized Primarily by Liver (sedatives/analgesics) Sedatives: Diavepam (Valium), Barbiturates Analgesics: Aspirin, Acetaminophen, Codeine, Meperidine (Demerol), Ibuprofen (Motrin) Alcoholism/Cirrhosis -alcohol abuse Prevalence of alcohol abuse & dependence: 7.4% - 9.7%, w/lifetime 13.7% - 23.5% Liver damage progression: fatty infiltrate (reversible), alcoholic hepatitis (partially reversible), cirrhosis (irreversible) Health Problems -Alcoholism Peripheral neuropathies Psychosis Cerebeller degeneration Esophagitis Gastritis Pancreatitis Malignancies Cirrhosis Signs suggestive of Advanced Alcoholic Liver Disease (cirrhosis) Spider angiomas Jaundice (sclera, mucosa) Ankle edema Ascites (distended abdomen) Ecchymoses & petechiae Parotid gland enlargement Palmer erythema White or transverse pale band on nails Sweet, musty breath odor Sequlae/Comps of Alcoholism/Cirrhosis Liver failure (metabolic & excretory function) Malnutrition Decreased: glucose metabolism, coagulation factors (bleeding) & urea synthesis Endocrine disorders Encephalophathy Renal failure Weight loss Hypertention Oral comps: Alcoholism/Cirrhosis Liver Poor oral hygiene & neglect Glossitis Angular or labial cheilosis Candidiasis Gingival bleeding Oral cancer Petechiae/Ecchymoses Jaundiced mucosa Parotid gland enlargement Alcohol breath odor Impaired healing Bruxism Dental attrition Xerostomia Management: Alcoholism/ Cirrhosis 1 Bleeding tendency Drug metabolism: Moderate dis: increased tolerance of local anesthetics, sedatives & hypnotics (induced CYP450). Severe dis: decrease dosage due to decreases in liver metabolism. Relapse & dental products Management: Alcoholism/ Cirrhosis 2 Detected by: a. History b. clinical examinations c. alcohol odor on breath d. information from family or friends Referral or consultation with physician to: a. verify history b. check current status c. check medications d. discussion suggestions for management