4. • The hepatitis B virus (HBV), discovered in 1966,
infects more than 350 million people worldwide.
• Hepatitis B can cause acute and chronic liver
disease.
• The clinical presentation ranges from subclinical
hepatitis to symptomatic hepatitis and, in rare
instances, fulminant hepatitis.
• Long-term complications of hepatitis B include
cirrhosis and hepatocellular carcinoma.
• Perinatal or childhood infection is associated
with few or no symptoms but has a high risk of
becoming chronic
5. • A vaccine against hepatitis B has been
available since 1982.
• Hepatitis B vaccine is 95% effective in
preventing HBV infection and its chronic
consequences, and is the first vaccine against
a major human cancer.
6. HEPATITIS VIRUS
• The hepatitis B virus is a DNA virus, meaning
that its genetic material is made up of
deoxyribonucleic acids.
• It belongs to a family of viruses known as
Hepadnaviridae.
• The virus is primarily found in the liver but is
also present in the blood and certain body
fluids.
7. • Hepatitis B virus consists of a core particle
(central portion) and a surrounding envelope
(outer coat).
• The core is made up of DNA and the core antigen
(HBcAg). The envelope contains the surface
antigen (HBsAg).
• These antigens are present in the blood and are
markers that are used in the diagnosis and
evaluation of patients with suspected viral
hepatitis.
8.
9. Pathophysiology
• HBV, unlike the other hepatotropic viruses, is a
predominantly non-cytopathogenic virus that causes
injury predominantly by immune-mediated
processes.
• The first stage is immune tolerance. The duration of
this stage for healthy adults is approximately 2-4
weeks and represents the incubation period. For
newborns, the duration of this period often is
decades.
• Active viral replication is known to continue despite
little or no elevation in the aminotransferase levels
and no symptoms of illness
10. • In the second stage, an inflammatory reaction
with a cytopathic effect occurs. HBeAg can be
identified in the sera, and a decline of the
levels of HBV DNA is seen.
• The duration of this stage for patients with
acute infection is approximately 3-4 weeks
(symptomatic period).
• For patients with chronic infection, 10 years or
more may elapse before cirrhosis develops.
11. • In the third stage, the host can target the infected
hepatocytes and the HBV Viral replication no
longer occurs. HBeAb can be detected.
• The HBV DNA levels are lower or undetectable,
and aminotransferase levels are within the
reference range.
• In this stage, an integration of the viral genome
into the host's hepatocyte genome takes place.
HBsAg still is present.
12. • In the fourth stage, the virus cannot be
detected and antibodies to various viral
antigens have been produced.
• Different factors have been postulated to
influence the evolution of these stages,
including age, sex, immunosuppression, and
co-infection with other viruses.
13.
14.
15.
16.
17. Symptoms
• Hepatitis B virus can cause an acute
illness with symptoms that last several
weeks, including
• yellowing of the skin and eyes
(jaundice),
• dark urine,
• extreme fatigue, nausea, vomiting and
• abdominal pain.
• People can take several months to a
year to recover from the symptoms.
HBV can also cause a chronic liver
infection that can later develop into
cirrhosis of the liver or liver cancer.
18. • Other extrahepatic conditions associated with
HBV infections in children include polyarteritis,
glomerulonephritis, and aplastic anemia.
Jaundice, which is present in ≈25% of infected
individuals, usually begins ≈8 wk after exposure
and lasts for ≈4 wk.
• In the usual course of resolving HBV infection,
symptoms are present for 6–8 wk.
19. Hepatitis B virus and primary liver cancer
(hepatocellular carcinoma)
• Patients with chronic hepatitis B are at risk of
developing liver cancer. The way in which the
cancer develops is not fully understood.
• Patients may have no symptoms, or they may
experience abdominal pain and swelling, an
enlarged liver, weight loss, and fever.
20. • The most useful diagnostic screening tests for
liver cancer are a blood test for a protein
produced by the cancer called alpha-
fetoprotein and an ultrasound imaging study
of the liver.
• These two tests are used to screen patients
with chronic hepatitis B, especially if they have
cirrhosis or a family history of liver cancer.
21. Who is most at risk for chronic
disease?
• The likelihood that an HBV infection will become chronic
depends upon the age at which a person becomes infected,
with young children who become infected with HBV being
the most likely to develop chronic infections.
• About 90% of infants infected during the first year of life
develop chronic infections; 30% to 50% of children infected
between one to four years of age develop chronic
infections.
• About 25% of adults who become chronically infected
during childhood die from HBV-related liver cancer or
cirrhosis.
• About 90% of healthy adults who are infected with HBV will
recover and be completely rid of the virus within six
months.
22. Transmission
• Hepatitis B virus is transmitted
between people by contact with the
blood or other body fluids (i.e.
semen and vaginal fluid) of an
infected person.
• Modes of transmission are the same
for the human immunodeficiency
virus (HIV), but HBV is 50 to 100
times more infectious Unlike HIV,
HBV can survive outside the body
for at least 7 days.
• During that time, the virus can still
cause infection if it enters the body
of a person who is not infected.
23. Hepatitis B Perinatal Transmission
• If mother positive for HBsAg and HBeAg
– 70%-90% of infants infected
– 90% of infected infants become chronically
infected
• If positive for HBsAg only
– 5%-20% of infants infected
– 90% of infected infants become chronically
infected
24. • Laboratory testing during the acute
phase reveals elevations in the concentration
of alanine and aspartate aminotransferase
levels (ALT and AST); values up to 1000 to 2000
IU/L are typically seen during the acute phase
with ALT being higher than AST.
• The serum bilirubin concentration may be
normal in patients with anicteric hepatitis.
• The prothrombin time is the best indicator of
prognosis. In patients who recover,
normalization of serum aminotransferases
usually occurs within one to four months.
25. • Persistent elevation of serum ALT for more than
six months indicates progression to chronic
hepatitis.
• The rate of progression from acute to chronic
hepatitis B is primarily determined by the age at
infection. The rate is approximately 90 percent
for perinatally acquired infection
• 20 to 50 percent for infections between the age
of one and five years.
• Less than 5 percent for adult-acquired infection .
26. Marker Interpretation
HBsAg
Exposure to Hepatitis B virus. Present in
acute or chronic infection
Anti-HBs antibody
Immunity acquired via natural infection or
immunisation
HBeAg
Marker of infectivity. It correlates with high
level of viral replication
Anti-HBe antibody
It correlates with low level of viral
replication
Anti-HBc IgM antibody Infection in previous 6 months
Anti-HBc IgG antibody
Distant HBV infection or chronic HBV
infection
Hep B DNA >105 copies
Rapid viral replication
28. TREATMENT
• Acute hepatitis B infection does not usually require
treatment because most adults clear the infection
spontaneously.
• Early antiviral treatment may only be required in fewer
than 1% of patients, whose infection takes a very
aggressive course (fulminant hepatitis) or who are
immunocompromised.
• On the other hand, treatment of chronic infection may
be necessary to reduce the risk of cirrhosis and liver
cancer.
• Chronically infected individuals with persistently
elevated serum alanine aminotransferase, a marker of
liver damage, and HBV DNA levels are candidates for
therapy.
29. • Although none of the available drugs can clear
the infection, they can stop the virus from
replicating, thus minimizing liver damage.
• Currently, there are seven medications licensed
for treatment of hepatitis B infection .
• These include antiviral drugs lamivudine (Epivir),
adefovir (Hepsera), tenofovir (Viread), telbivudine
(Tyzeka) and entecavir (Baraclude) and the two
immune system modulators interferon alpha-2a
and PEGylated interferon alpha-2a (Pegasys).
• The use of interferon, which requires injections
daily or thrice weekly, has been supplanted by
long-acting PEGylated interferon, which is
injected only once weekly.
30. • Infants born to mothers known to carry
hepatitis B can be treated with antibodies to
the hepatitis B virus (HBIg).
• When given with the vaccine within twelve
hours of birth, the risk of acquiring hepatitis B
is reduced 90%.This treatment allows a
mother to safely breastfeed her child.
32. Prevention
Hepatitis B Vaccine
• Composition Recombinant HBsAg
• Efficacy 95% (Range, 80%-100%)
• Duration of
Immunity 20 years or more
• Schedule 3 Doses
• Booster doses not routinely recommended
33. Dose Infants** Teens and Adults***
1 16%-40% 20%-30%
2 80%-95% 75%-80%
3 98%-100% 90%-95%
Protection* by Age Group and Dose
* Anti-HBs antibody titer of 10 mIU/mL or higher
** Preterm infants less than 2 kg have been shown to respond to
vaccination less often
*** Factors that may lower vaccine response rates are age older than
40 years, male gender, smoking, obesity, and immune deficiency
34. Dose+
Primary 1
Primary 2
Primary 3
Usual Age
Birth
1- 2 months
6-18 months*
Minimum
Interval
- - -
4 weeks
8 weeks**
Hepatitis B Vaccine
Routine Infant Schedule
* infants who mothers are HBsAg+ or whose HBsAg status is
unknown should receive the third dose at 6 months of age
** at least 16 weeks after the first dose
+an additional dose at 4 months is acceptable if the clinician prefers to
use a combination vaccine that contains hepatitis B vaccine
35. Preterm Infants
• Birth dose and HBIG if mother HBsAg positive
(within 12 hours of birth)
• Preterm infants who weigh less than 2,000
grams have a decreased response to vaccine
administered before 1 month of age
• Delay first dose until chronologic age 1 month
if mother HBsAg negative
36. Prevention of Perinatal Hepatitis B
Virus Infection
• Begin treatment within 12 hours of birth
• Hepatitis B vaccine (first dose) and HBIG at
different sites
• Complete vaccination series at 6 months of
age
• Test for response after completion of at least 3
doses of the HepB series at 9 through 18
months of age (generally at the
next well-child visit)
37. Nursing management
• History taking
• General physical examination- for signs and
symptoms .
• Convalescence may be prolonged, with
complete symptomatic recovery sometimes
requiring 3 to 4 months or longer.
• During this stage, gradual resumption of
physical activity is encouraged after the
jaundice has resolved
38. Nursing management
• The nurse identifies psychosocial issues and
concerns, particularly the effects of separation
from family and friends if the patient is
hospitalized during the acute and infective stages.
• Even if not hospitalized, the child will be unable
to work. Planning is required to minimize
alterations in sensory perception. Planning that
includes the family helps to decrease their fears
and anxieties about the spread of the disease.
39. Nursing management
• Ensure immunization of the family members
with Hep Vaccine if they are not immunized.
• Counsel parents regarding home care of the
child.
• Teach infection prevention strategies, disposal
of body secretions etc.
• Provision for adequate rest and nutrition
must be ensured.
40. Nursing management
• The nurse informs family members and friends
who have had intimate contact with the patient
about the risks of contracting hepatitis B and
makes arrangements for them to receive hepatitis
B vaccine or hepatitis B immune globulin as
prescribed.
• Those at risk must be aware of the early signs of
hepatitis B and of ways to reduce risk to
themselves by avoiding all modes of
transmission.
• Patients with all forms of hepatitis should avoid
drinking alcohol
41. Nursing management
• Follow-up visits by a home care nurse may be
needed to assess the patient’s progress and
answer family members’ questions about disease
transmission.
• The nurse also reinforces previous instructions.
Because of the risk of transmission strategies to
prevent exchange of body fluids are advised.
• The nurse emphasizes the importance of keeping
follow-up appointments and participating in
other health promotion activities and
recommended health screenings.
