HIV, STI AND OTHER BLOODBORNE
DISEASES
Kolářová M., EPI Autumn 2015
• Chlamydia infection
• Genital warts
• Gonorrhoea
• Hepatitis B
• Hepatitis C
• HIV infection and AIDS
• Human papillomavirus infection
• Sexually Transmitted Infections (STI)
• Syphilis
VIRAL HEPATITIS B
The hepatitis B virus is a DNA virus belonging to
the Hepadnaviridae family of viruses.
VIRAL HEPATITIS TYPE B
Hepatitis B virus, HBV, Hepadnavirus, the so-called Dane particle with a
core (formed by DNA, DNA polymerase, and a nucleocapsid protein
with the hepatitis B core antigen (HBcAg) and a coat of hepatitis B
surface antigen (HBsAg) ). The whole virus is infectious with a
diameter of 42 nm.
Two months in the ende of incubation period, the sick or carriers.
Parenteral transmission - blood, blood products and inoculation of the
infectious material are of principal significance in the transmission.
Professional risk to medical personnel (injury by needle - transmission in 7 - 30
%, contaminated instruments, blood transfusions - transmission in 90 %).
i.v. drug addicts - injury during tattooing, possibly other minute injuries of the skin
and mucosa.
By sexual intercourse in homosexuals, bisexuals, and prostitutes.
Vertical - perinatal transmission from mother to child when the mother is the
virus carrier or the sick person. About 95 % of newborns infect intranatally and 5
% intrauterinely.
General
General
The source
of infection
Route of
transmission
Susceptibility
Etiology:
Preventive measures:
VIRAL HEPATITIS TYPE B
Preventive measures:
Health education - to emphasize the extent of risk
Observance of epidemic measures in medical establishments.
Handling biological material and contaminated instruments, consistent
disinfection and sterilization, application of single-use needles and
syringes, use of closed hemodialysis systems, smoking and drinking in
workplaces with biological material is forbidden.
Postexposure prophylaxis - passive and active immunization (newborns)
Examination of blood-donors - exclusion of HBsAg carriers from blood
donation
Designation and inspection of sanitary-epidemic measures in non-medical
establishments (hair-dressing salons, barber shops, etc.)
Active immunization in persons with a high risk of infection (stated by
public notice)
The disease occurs worldwide with a very high
burden among an estimated 280 million carriers.
The symptoms can vary greatly and many of those
infected with HBV never develop any symptoms at
all.
Those who do get symptoms (30-50% of cases)
usually suffer from tiredness, loss of appetite,
abdominal discomfort, nausea, vomiting and fever.
The vast majority of healthy adults who get acute
hepatitis B will recover with no liver damage in 4–
12 weeks but the death rate can reach 2% in the
elderly. Chronic infection is most likely to develop
in young babies.
The symptoms can vary greatly and many of those
infected with HBV never develop any symptoms at
all.
Those who do get symptoms (30-50% of cases)
usually suffer from tiredness, loss of appetite,
abdominal discomfort, nausea, vomiting and fever.
The vast majority of healthy adults who get acute
hepatitis B will recover with no liver damage in 4–12
weeks but the death rate can reach 2% in the
elderly.
Chronic infection is most likely to develop in young
babies.
• Incubation period: Average 60-90 days
Range 45-180 days
• Clinical illness <5 yrs, <10%
(jaundice): >5 yrs, 30%-50%
• Acute case-fatality rate: 0.5%-1%
• Chronic infection: <5 yrs, 30%-90%
>5 yrs, 2%-10%
• Premature mortality from
chronic liver disease: 15%-25%
Hepatitis B – Clinical Features
Outcome of HBV Infection
Infection
Asymptomatic
Symptomatic
acute hepatitis B
Resolved
Immune
Chronic infection
Asymptomatic
Cirrhosis
Liver cancer
Resolved
Immune
Chronic
infection
Asymptomatic
Cirrhosis
Liver cancer
Weeks after Exposure
Symptoms
HBeAg anti-HBe
Total anti-HBc
IgM anti-HBc
anti-HBsHBsAg
0 4 8 12 16 20 24 28 32 36 52 100
Titer Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course
IgM anti-HBc
Total anti-HBc
HBsAg
Acute
(6 months)
HBeAg
Chronic
(Years)
anti-HBe
0 4 8 12 16 20 24 28 32 36 52
Weeks after Exposure
Progression to Chronic Hepatitis B Virus Infection
Typical Serologic Course
• Sexual
• Parenteral
• Perinatal
HBV Modes of Transmission
Low/Not
High Moderate Detectable
semen
serum vaginal fluid
blood
wound exudates saliva
urine
feces
sweat
tears
breast milk
Concentration of HBV
in Various Body Fluids
 Prevent perinatal HBV
transmission
 Routine vaccination of all
infants
 Vaccination of children in highrisk
groups
 Vaccination of adolescents
 all children up through age 18
 Vaccination of adults in highrisk
groups
Strategy
Elimination of HBV Transmission, United States
• Licensed in 1982; currently recombinant (in US)
• 3 dose series, typical schedule 0, 1-2, 4-6
months - no maximum time between doses (no
need to repeat missed doses or restart)
• 2 dose series (adult dose) licensed by FDA for
11-15 year olds (Merck)
• Protection ~30-50% dose 1; 75% - 2; 96% - 3;
lower in older, immunosuppressive illnesses
(e.g., HIV, chronic liver diseases, diabetes),
obese, smokers
Hepatitis B Vaccine
• Routine infant
• Ages 11-15 “catch up”, and through age 18(VFC
eligible)
• Over 18 – high risk
– Occupational risk (HCWs)
– Hemodyalisis patients
– All STD clinic clients
– Multiple sex partners or prior STD
– Inmates in Correctional settings
– MSM
– IDU
– Institution for developmental disability
• Pre-vaccination testing – if cost effective
• Post-vaccination testing – 1-2 months after last
shot, if establishing response critical (HCW)
Hepatitis B Vaccination
ACIP Recommendations
VIRAL HEPATITIS C
VIRAL HEPATITIS TYPE C B
Hepatitis C virus is a RNA-virus measuring 50 nm. It is classed into a
separate genus, Hepacavirus of the Flaviviridae family.
Long-term in viremia (in the ende IP), chronic infections.
Parenteral transmission. Sporadically, vertical and sexual
transmissions were reported carrier or the sick person.
Susceptibility is general.
The source
of infection
Route of
transmission
Susceptibilit
y
Etiology:
Preventive measures:
The same as for HBV, exclusive immunization.
Features of Hepatitis C Virus Infection
Incubation period Average 6-7 weeks
Range 2-26 weeks
Acute illness (jaundice) Mild (<20%)
Case fatality rate Low
Chronic infection 60%-85%
Chronic hepatitis 10%-70% (most
asx)
Cirrhosis <5%-20%
Mortality from CLD 1%-5%
Age-
related
Chronic Hepatitis C
Factors Promoting Progression or
Severity
• Increased alcohol intake
• Age > 40 years at time of infection
• HIV co-infection
• Other
– Male gender
– Chronic HBV co-infection
Serologic Pattern of Acute HCV Infection
with Recovery
Symptoms +/Time
after Exposure
Titer
anti-HCV
ALT
Normal
0 1 2 3 4 5 6 1 2 3 4
YearsMonths
HCV RNA
Serologic Pattern of Acute HCV Infection with
Progression to Chronic Infection
Symptoms +/Time
after Exposure
Titer
anti-HCV
ALT
Normal
0 1 2 3 4 5 6 1 2 3 4
YearsMonths
HCV RNA
Exposures Known to Be
Associated With
HCV Infection in the United States
• Injecting drug use
• 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 and 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
• Four times more common than HIV
Posttransfusion Hepatitis C
0
5
10
15
20
25
30
1965 1970 1975 1980 1985 1990 1995 2000
Year
%ofRecipientsInfected
All volunteer donors
HBsAg
Donor Screening for HIV Risk Factors
Anti-HIV
ALT/Anti-HBc
Anti-HCV
Improved
HCV Tests
Adapted from HJ Alter and Tobler and Busch, Clin Chem 1997
Occupational Transmission of
HCV
• Inefficient 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; one from exposure to nonintact
skin
• Prevalence 1-2% among health care workers
– Lower than adults in the general population
– 10 times lower than for HBV infection
HCV Related to Health Care
Procedures
United States
• Recognized primarily in context of outbreaks
– Chronic hemodialysis
– Hospital inpatient setting
– Private practice setting
– Home therapy
• Unsafe injection practices
– Reuse of syringes and needles
– Contaminated multiple dose medication vials
HCW to Patient Transmission of
HCV
• Rare
– In U.S., none related to performing invasive
procedures
• Most appear related to HCW substance
abuse
– Reuse of needles or sharing narcotics used for
self-injection
• No restrictions routinely recommended for
HCV-infected HCWs
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
Sexual Transmission of HCV
• Case-control, cross sectional studies
– Infected partner, multiple partners, early sex, nonuse
of condoms, other STDs, sex with trauma,
BUT
– MSM no higher risk than heterosexuals
• Partner studies
– Low prevalence (1.5%) among long-term partners
• infections might be due to common
percutaneous exposures (e.g., drug use), BUT
– Male to female transmission more efficient
• more indicative of sexual transmission
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
Household Transmission of HCV
• Rare but not absent
• Could occur through percutaneous/mucosal
exposures to blood
– Contaminated equipment used for home therapies
• IV therapy, injections
– Theoretically through sharing of contaminated
personal articles (razors, toothbrushes)
Other Potential Exposures to
Blood
• No or insufficient data showing increased risk
– intranasal cocaine use, tattooing, body piercing,
acupuncture, military service
• No associations in acute case-control or populationbased
studies
• Cross-sectional studies in highly selected groups
with inconsistent results
– Temporal relationship between exposure and infection
usually unknown
– Biologically plausible, but association or causal
relationship not established
Sources of Infection for
Persons With Hepatitis C
Sexual 15%
Other 1%*
Unknown 10%
Injecting drug use 60%
Transfusion 10%
(before screening)
* Nosocomial; iatrogenic; perinatal
Source: Centers for Disease Control and Prevention
Occupational 4%
Reduce or Eliminate Risks for
Acquiring HCV Infection
• Screen and test donors
• Virus inactivation of plasma-derived products
• Risk-reduction counseling and services
– Obtain history of high-risk drug and sex behaviors
– Provide information on minimizing risky behavior,
including referral to other services
– Vaccinate against hepatitis A and/or hepatitis B
• Safe injection and infection control practices
HCV Prevention and Control
MMWR 1998;47 (No. RR-19)
Reduce Risks for Disease Progression
and Further Transmission
• Identify persons at risk for HCV and test to
determine infection status
– Routinely identify at risk persons through history,
record review
• Provide HCV-positive persons
– Medical evaluation and management
– Counseling
• Prevent further liver damage
• Prevent transmission to others
HCV Prevention and Control
MMWR 1998;47 (No. RR-19)
HCV Testing Routinely
Recommended
• Ever injected illegal drugs
• Received clotting factors made before 1987
• Received blood/organs before July 1992
• Ever on chronic hemodialysis
• Evidence of liver disease
• Healthcare, emergency, public safety workers after
needle stick/mucosal exposures to HCV-positive
blood
• Children born to HCV-positive women
Based on increased risk for infection
Based on need for exposure management
Postexposure Management for
HCV
• IG, antivirals not recommended for prophylaxis
• Follow-up after needlesticks, sharps, or
mucosal exposures to HCV-positive blood
– Test source for anti-HCV
– Test worker if source anti-HCV positive
• Anti-HCV and ALT at baseline and 4-6 months
later
• For earlier diagnosis, HCV RNA at 4-6 weeks
– Confirm all anti-HCV results with RIBA
• Refer infected worker to specialist for medical
evaluation and management
Routine HCV Testing Not
Recommended
(Unless Risk Factor Identified)
• Health-care, emergency medical, and public
safety workers
• Pregnant women
• Household (non-sexual) contacts of HCVpositive
persons
• General population
Routine HCV Testing of Uncertain
Need
• Recipients of transplanted tissue
• Intranasal cocaine or other non-injecting
illegal drug users
• History of tattooing, body piercing
• History of STDs or multiple sex partners
• Long-term steady sex partners of HCVpositive
persons
Not confirmed as risk factor/prevalence low or unknown
Confirmed risk factor but prevalence of infection low
HCV Infection Testing Algorithm
for Diagnosis of Asymptomatic Persons
Screening Test for Anti-HCV
Negative
STOP
Positive
OR
RIBA for Anti-HCV NAT for HCV RNA
Negative
STOP
Additional Laboratory
Evaluation (e.g. PCR, ALT)
Negative PositiveIndeterminate
Medical
Evaluation
Positive
Negative PCR,
Normal ALT
Positive PCR,
Abnormal ALT
Source: MMWR 1998;47 (No. RR 19)
Medical Evaluation and
Management
for Chronic HCV Infection
• Assess for biochemical evidence of CLD
• Assess for severity of disease and possible
treatment, according to current practice
guidelines
– 40-50% sustained response to antiviral
combination therapy (peg interferon, ribavirin)
– Vaccinate against hepatitis A
• Counsel to reduce further harm to liver
– Limit or abstain from alcohol
HCV Counseling
• Prevent transmission to others
– Direct exposure to blood
– Perinatal exposure
– Sexual exposure
• Refer to support group
Preventing HCV Transmission to
Others
• Do not donate blood, body organs, other
tissue or semen
• Do not share items that might have blood on
them
– personal care (e.g., razor, toothbrush)
– home therapy (e.g., needles)
• Cover cuts and sores on the skin
Avoid Direct Exposure to Blood
HCV Counseling
Persons Using Illegal Drugs
• Provide risk reduction counseling, education
– Stop using and injecting
– Refer to substance abuse treatment program
– If continuing to inject
• Never reuse or share syringes, needles, or drug
preparation equipment
• Vaccinate against hepatitis B and hepatitis A
• Refer to community-based risk reduction
programs
HCV Counseling
Mother-to-Infant Transmission of
HCV
• Postexposure prophylaxis not available
• No need to avoid pregnancy or
breastfeeding
– Consider bottle feeding if nipples cracked/bleeding
• No need to determine mode of delivery
based on HCV infection status
• Test infants born to HCV-positive women
– >15-18 months old
– Consider testing any children born since woman
became infected
– Evaluate infected children for CLD
HCV Counseling
Persons with One Long-Term Steady Sex Partner
HCV Counseling
Sexual Transmission of HCV
• Do not need to change their sexual practices
• Should discuss with their partner
– Risk (low but not absent) of sexual transmission
– Counseling and testing of partner should be
individualized
• May provide couple with reassurance
• Some couples might decide to use barrier
precautions to lower limited risk further
Persons with High-Risk Sexual Behaviors
HCV Counseling
Sexual Transmission of HCV
• At risk for sexually transmitted diseases,
e.g., HIV, HBV, gonorrhea, chlamydia, etc.
• Reduce risk
– Limit number of partners
– Use latex condoms
– Get vaccinated against hepatitis B
– MSMs also get vaccinated against hepatitis A
Other Transmission Issues
• HCV not spread by kissing, hugging,
sneezing, coughing, food or water, sharing
eating utensils or drinking glasses, or casual
contact
• Do not exclude from work, school, play,
child-care or other settings based on HCV
infection status
HCV Counseling