Hepatitis Viral en Niños - Que Conocemos en 2021
Hepatitis Viral en Niños - Que Conocemos en 2021
Hepatitis Viral en Niños - Que Conocemos en 2021
PAEDIATRICS AND CHILD HEALTH xxx:xxx 1 Crown Copyright Ó 2021 Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Kelgeri C, Kelly DA, Viral hepatitis in children: what do we know in 2021?, Paediatrics and Child Health, https://doi.org/
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SYMPOSIUM: HEPATOLOGY
0.8
3.3
30
HAV
HBV
HCV
HEV
Acute
66 hepatitis
Cirrhosis
HCC
Figure 1 Deaths from Viral hepatitis - by virus and type of sequelae as globally estimated by World health organization in 2015 and published in
2016.1
Natural history
WHO targets for eliminating viral hepatitis as public Vertical (Mother to child) transmission accounts for majority of
health threat by 2030. Data from2 HBV infections in children and the risk is increased if mother is
HBV e Antigen (HbeAg) positive with high HBV DNA load. Some
WHO Impact targets by 2030
infections are acquired through horizontal transmission because
Incidence of new cases of chronic 90% reduction
of close contact with an infected index case. Sexual contact,
HBV and HCV (equivalent to 0.1%
tattooing, body piercing, drug abuse with shared needles and
prevalence of HBsAg in
syringes may account for HBV infections seen in the adolescent
children)
period.4
Mortality due to HBV and HCV 65% reduction
Perinatal infections are largely indolent, but ones acquired
Preventive targets
later, have an incubation period of around 75 days (30
HBV childhood vaccine coverage 90%
e180 days) and may have symptoms of mild to severe fulminant
Prevention of Vertical transmission 90%
hepatitis in the acute stage. The risk of ALF in babies is higher if
of HBV infection
mothers are HBV e antibody positive (anti HB e) as they may
Blood donation safety screening 100%
carry a mutant HBV strain. Co-infection or superinfection with
Safe injections in and out of health 90%
HDV also increases the risk of ALF, which is likely to require
facilities
liver transplantation.
Supply of sterile needles and syringes 300
The tendency for chronic infection depends critically upon the
per intravenous drug abuser
age of infection. About 90% of infants infected below one year of
Testing targets
age, 25e50% of those infected between 1 and 5 years of age and
HBV and HCV diagnosis 90%
less than 5% if infected beyond 5 years of life will develop
Treatment targets
chronic HBV infection, defined as persistence of HBV surface Ag
HBV and HCV treatment for eligible 80%
(HBsAg) beyond 6 months of infection. The trajectory of disease
people
progression thereafter is a complex interplay between HBV and
Table 1 the host immune system passing through fluctuating phases of
variable duration and is not well delineated in children
(Figure 3).
Advanced liver disease with its related complications, HCC
2015.1 HBV infection is less prevalent in developed countries but and HBV-related immune manifestations like glomerulonephritis
is increasing because of migration and adoption of children from and cryoglobulinemia are not common in children.4 Risk factors
endemic countries. for progression to advanced liver disease and HCC are perinatal
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SYMPOSIUM: HEPATOLOGY
Jaundice
SEROLOGY
IgG
IgM
VIRAL DYNAMICS
Viraemia
Faecal shedding
EPIDEMIOLOGY
Case interval
Incubation
Hepatic illness
Potential high infectivity
Recovery
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Weeks
acquisition, high HBV DNA load, and late seroconversion of classify the different phases and guides treatment and prognosis
HBeAg with prolonged periods of hepatitis. (Figure 3). HBeAg is a marker of virus replication and infectivity.
Occult HBV DNA persists in the liver even after spontaneous Liver biopsy is not routinely indicated unless other causes of liver
sero-clearance and may reactivate when the balance between disease are suspected.
HBV and the host immune response changes for example during
periods of immunosuppression. Treatment
Treatment of acute HBV infection is supportive. Prompt referral
Diagnosis or discussion with a transplant centre is required if ALF develops.
HBV infection is diagnosed by detecting HBsAg in blood. Further Management of chronic HBV in children continues to evolve
serology (Table 2), HBV DNA titres and liver biochemistry help and therapy should be guided by international and national
HBV DNA
20000 IU/mL
ALT
Normal ALT
HBeAg Positive HBeAg, Negative anti HBe Positive anti HBe, Negative HBeAg
HBeAg positive HBeAg positive HBeAg negative HBe Ag negative
Phase of
Infection Chronic Infection Chronic Hepatitis Chronic Infection Chronic hepatitis
Generally, not May be indicated Not indicated May be indicated
Treatment indicated
Figure 3 Phases of chronic HBV infection. ALT: alanine transaminase, HBeAg: HBV e antigen, anti HBe: HBV e antibody, HBsAg: HBV surface
antigen.
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SYMPOSIUM: HEPATOLOGY
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SYMPOSIUM: HEPATOLOGY
NS3/4 Protease inhibitors High Potency, Limited genotype coverage, Low Grazoprevir, Voxelaprevir, Glecaprevir
barrier to resistance
NS5B Nucleoside polymerase inhibitor Intermediate potency, Pan genotype, High Sofusbuvir
barrier to resistance
NS5A Nucleoside polymerase inhibitor High Potency, Multi genotype, Intermediate Ledipasvir, Elbasvir, Pibrentasvir, Velpasvir
barrier to resistance
Drug combinations Genotype and age recommendations
Table 3
Infected children and families should be educated regarding is recommended that infants with positive anti HCV are tested
care of bleeding wounds, use of sterile needles, syringes and safe with HCV RNA beyond 3 months of age and repeated at 6
sex by using barrier contraception to prevent spread of the virus. e12 months to diagnose chronicity.
Children with chronic HCV infection are monitored annually
Hepatitis C for clinical symptoms, liver biochemistry, AFP, HCV RNA (for
spontaneous clearance). Older children should have a fibroscan.
HCV is a single stranded RNA virus transmitted through blood and
They should have a liver ultrasound scan every 3e5 years.
sexual contact. Six genotypes with various subtypes are known
that differ in drug susceptibility influencing medical therapy.
Treatment
One of the success stories of this century is the availability of safe
Epidemiology
and effective direct acting antiviral (DAA) drugs that eliminate
Approximately 70 million people are thought to be chronically
the virus achieving cure in adults with chronic HCV infection.6
infected with HCV worldwide,1 3.5 to 5 million are children.
These results are replicated in children as evidenced by recent
Natural history clinical trials. FDA and EMA approved DAA regimens (Table 3)
HCV infection in children is commonly acquired through peri- are now available for children with chronic HCV aged 3 years or
natal transmission. Blood products and iatrogenic transmission more. Though children are asymptomatic it is cost effective to
through infected needles and surgical instruments occur in low- treat them early to avoid progression of liver disease and long-
income countries while tattooing, illicit intravenous drug use term complications. Children with extrahepatic manifestations,
and sexual contact may be the route of infection in adolescents. advanced fibrosis or cirrhosis, co morbidities should be priori-
There is an incubation period of 7e9 weeks. tized for treatment.
The risk of perinatal transmission is about 5% and the risk is Treatment should be in collaboration with a specialist team
greater with maternal high HCV RNA tires or HIV co infection. Of who have expertize in treating and monitoring children. The
these, 80% will remain chronically infected. As infections in choice of DAA and duration of therapy is guided by age and weight
children are asymptomatic, many are unaware of being infected. of the child, HCV genotype, presence or absence of cirrhosis, prior
ALT may be normal or may fluctuate above ULN. Extrahepatic treatment with interferon and ribavirin. The duration of therapy is
manifestations like cryoglobulinemia, glomerulonephritis, joint longer in children with cirrhosis. A paediatric multidisciplinary
pain and skin rashes may be seen in a few children. Liver fibrosis Operational Delivery network was launched in April 2021 by
is minimal in childhood unless associated with co morbid factors National Health Service in England to offer HCV treatment advice
like obesity or concomitant use of hepatotoxic drugs. Although and support to clinicians and families in England.
rare in children, chronic liver disease will develop in about 30%
and HCC in 5% of adults.5 Prevention
There is no vaccine for HCV. As chronic HCV infections are
Diagnosis asymptomatic in children, screening of populations at risk
Children at risk are screened for HCV infection by testing for HCV including antenatal screening is an effective strategy for early
antibody (anti-HCV) and if positive with HCV RNA and genotype diagnosis and treatment.
to distinguish between a chronic and a resolved infection.6 HCV Effective donor screening for blood donation exists in devel-
antibodies remain positive in infants born to infected mothers up oped countries but this is still a risk factor in some countries and
to 18 months of age due to trans placental passage and HCV RNA one of the preventive targets by WHO is to achieve 100% safe
may take up to a few weeks to reach detectable levels. Hence, it donor screening by 2030.1
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Please cite this article as: Kelgeri C, Kelly DA, Viral hepatitis in children: what do we know in 2021?, Paediatrics and Child Health, https://doi.org/
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SYMPOSIUM: HEPATOLOGY
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Please cite this article as: Kelgeri C, Kelly DA, Viral hepatitis in children: what do we know in 2021?, Paediatrics and Child Health, https://doi.org/
Descargado para Anonymous User (n/a) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en octubre 29, 2021. Para uso
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SYMPOSIUM: HEPATOLOGY
FURTHER READING C Hepatitis A and E are transmitted mostly through the faeco-
Abdel-Hady M, Kelly DEDS, Kuipers EJ. Hepatitis B and C in children oral route while Hepatitis B, D and C through parental and
in: encyclopaedia of gastroenterology 2nd edition 2019; vol. 3; sexual route.
113e21. C Nucleoside analogues are indicated in a select few children
Dalton H, Webb G. Hepatitis E: an underestimated emerging threat. with Hepatitis B to achieve functional cure.
Ther Adv Infect Dis 2019; 6: 1e18. C Direct acting antiviral drugs are now licenced and available
HCV Guidance: Recommendations for Testing, Managing, and to treat Hepatitis C in children above 3 years of age.
Treating Hepatitis C https://www.hcvguidelines.org/.
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Please cite this article as: Kelgeri C, Kelly DA, Viral hepatitis in children: what do we know in 2021?, Paediatrics and Child Health, https://doi.org/
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