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VAKSINASI HEPATITIS

DR RAHMINI SHABARIAH SPA

Vaksinasi Hepatitis A
PASIF ; NHIG ( UMUR < 2 TAHUN)
PRA PAJANAN :
USIA < 2 TAHUN
BERKUNJUNG KE DAERAH ENDEMIS
< 3 BULAN : IG 0,02 ML/KGBB/IV
>4 BULAN : IG 0,06 ML/KGBB/IV
JANGKA PANJANG : IG 0,06 ML/KGBB SAAT
BERANGKAT DAN TIAP 5 BULAN BILA
PAPARAN (+)

Vaksinasi Hepatitis A
PRA PAJANAN :
USIA > 2 TAHUN
BERKUNJUNG KE DAERAH ENDEMIS
< 3 BULAN : IG 0,02 ML/KGBB/IV
>4 BULAN : IG 0,06 ML/KGBB/IV
JANGKA PANJANG VAKSINASI

Vaksinasi Hepatitis A
PASCA PAJANAN :
1. KURANG 2 MINGGU
KEMUNGKINAN TIDAK TERPAPAR
SEGALA UMUR IG 0,02ML/KGBB/IV
TERPAPAR > 2 TAHUN IG 0,02 ML/KGBB DAN
VAKSINASI
2. LEBIH 2 MINGGU , KEMUNGKINAN TIDAK
TERPAPAR SEGALA UMUR TIDAK PERLU
BILA TERPAPAR .> 2 THN VAKSINASI

VAKSINASI HEPATITIS A
AKTIF : HAVRIX ( > 2 THN)
USIA 2-18 THN : 720 EUI 0,5 ML ( 0-6-12)
USIA 18 THN
: 1440 EUI 1 ML (0,6,12)
AVAXIM : DOSIS SAMA

PEMERIKSAAN STATUS
IMUNOLOGIS
ANAK RISIKO TINGGI
1. IMMUNOKOMPROMAISE
2. IBU HEP B/ HBsAG (+)
3. KELUARGA DG HBsAG (+)

DIAGNOSIS
HBV KRONIS
HBs HBe IgM IgG Anti Anti DNA
Ag
Ag
HBc HBc HBs HBe
Replikasi

Non Repl

Flare up

+/-

PreCore

mutant

+
+

+
+

Superinfection
HVA, HVC,
lain2

Drugs, toxin
(acetaminophen
etc)

HBsAg (+)

Acute hepatitis

Acute HBV
HBsAg, IgM
antiHBc

Reactivation

chronic
HBV

Exacerbation
chronic HBV,

eAg conversion

Differential diagnosis HBV

PREVENTION OF SPREAD
Horizontal

transmission
Vertical

General: screening, infection control


Specific:
Pre-exposure: active immunization
Post-exposure: passive-active immunization
Long term follow up

HBV VACCINATION
Cutting chain of transmission
Newborn, adolescent
In endemic area -
maternal infection
Early infection
chronic reservoir
HCC at any age
Provide protection
adolescent - risk

High risk adults

Dialysis, transfused
IVDU, homosex, active
heterosexuals
Household contacts of
HBV carriers
Health care worker

Eliminating HBV, decreasing HCC


The only vaccine against CANCER

HBV VACCINATION
Cutting chain of transmission
Anti HBsneutralizing
Antibody HBIG
PASSIVE
Quick-short immunity
IM, safe
Acute exposure:
Newborn HBV mother
Occupational
Sexual contact
Household contact

HBsAg
immunogenik
ACTIVE
Long term immunity
Deep IM (deltoid,
thigh); safe
Seroconvert 95%
Protects (10 mIU/ml)
min 12 ys booster (-)

SEROLOGIC TESTING

Not recommended for infants - children

PREVACCINATION
Consider :
High risk
population
Adolescents
endemic area
Family members
HBV carriers
Health care staff

POSTVACCINATION
Infants - HBsAg
(+) mothers
High risk newborns
Immunodeficient
Dialysis patients
Health care
workers

RECOMMENDED DOSE

Booster not recommended for any group


GROUP
(ys)

VACCINE
HBvax-II Engerix-B Uniject
HepavacGene

Infant, children,
adolescents

5 g/

10 g/

0.5 ml

0.5 ml

Adults > 20 ys

10 g/

20 g/

1 ml

1 ml

40 g/

40 g

Dialysis

2 ml

10 g/ 0.5 ml
?
?

HBV IMMUNIZATION
in infants
HBsAg
Mother

Immuni-

Schedule

zation
Active

(+)
(-)

Dose
Engerix-B,Uniject 10 g

12 hours,

HBVax-II 5 g

month 1,6

Passive

HBIg 100 U -0.5 ml

Active

Engerix-B,Uniject 10 g

ASAP

HBVax-II 2.5 g

BW 2kg
Age 2 mo

Active*

Engerix-B,Uniject 10 g

12 hours,

HBVax-II 5 g

month 1,6

POST-EXPOSURE
Sexual contact acute or HBV carrier
EXPOSED
CONTACT

SOURCE:
ACUTE HBV

Unvaccinated/ HBIG 0.06 ml/kg or


Anti HBs (-)

HBIG & vaccine or


test if high risk

Vaccinated
Unknown
anti HBs test

None
Anti HBs (-):
HBIG & vaccine

SOURCE:
CARRIER
HBIG &
vaccine
Or test
None
Similar
application

POST-EXPOSURE to BLOOD
HBsAg-HBeAg (+)
clinical hepatitis 22 31%
sero-evidence HBV 37 61%
Exposed

Treatment if

Vaccine, AB

HBsAg +

HBsAg ??

Unvaccinated/
AB response ?

HBIG-vaccine or
test if high risk

Vaccine or
Test if high risk

None

None

Responder

source is

Non

HBIG x2 or

High risk source:

responder

HBIG-vaccine

As in HBsAg (+)

VACCINE NONRESPONDERS

< 5% vaccinees persistent non-responders

Complete the 2nd series of 3 doses


Usual schedule
Retest 1 2 months after completion
Check HBsAg & HBeAg status
If exposed, treat as nonresponder
with postexposure prophylaxis

THIMEROSAL - HVB VACCINE


Stabilizes, perservative,
ethil mercury/EM (inactive) HVB
vaccine - 25 g
Active mercury methil mercury (MM)
MM: 3.3 g/kg/wk
WHO: theoritical autism (-),

DECISION MAKING

HBeAg

DNA

LFT
Th/

N
IFN ()

IFN IFN
other antivirus ?!

Observed

CHRONIC HBV INFECTION


(HBsAg positive > 6 months)
HBeAg

DNA

LFT

Th/

IFN () IFN

other antivirus

N
IFN Observ?! ed

HEPATITIS C VIRUS (HCV)


The silent killer
Intrafamilial 4.3%; sexual 5%
Vertical transmission 6% (2-11%)
Risk factors: maternal RNA titer RNA

viremia +/- (8 vs 3%),


Pervaginam/SC (6 vs 0%)
Infant anti HVC after aged
7/12

Exposure

(acute phase)

Resolved

Chronic
Stable
Slowly
progressive

HIV and
alcohol
Cirrhosis
HCC
Transplant
Death

SEROLOGY
ACUTE HCV - RESOLVED
Anti
HVC

symptom

SEROLOGY
CHRONIC HCV
symptom
HVC RNA

HVC RNA

SGPT

SGPT
Normal
Months

Anti
HVC

Normal
Years

Months

Years

PREVENTION
High rate of mutation vaccine (-)
General HBV
Screening:
Donor, children
carrier mother,
IVDU, close contact,
sexual behavior,
multi-transfused,
medical staff ,
LTx recipient

SPECIFIC
Identify new
cases : pregnant
mother, baby HCV
mom,
chronic hep, HCC,
cirrhosis, ALT ?
SC ?!
Immunization (-) ?

HCV VACCINE
Still far from completion

Failure to develop a vaccine

Which is the neutralizing antibody


E2, CAP, NS3 peptide?

E2 highly mutational
No identified antigen peptide that
produces adequate immune response

!! Prevention

HCV RNA
Liver biopsy
Cirrhosis

Moderate-severe

Offer th/

Th/ 3/12
Repeat biopsy

RefusedPrefer Th/
Follow-up

(+)

Stop Th/

Repeat PCR
(-)
Th/ 1 yr

Mild
Observed

SOME WAYS

TO LOVE YOUR

LIVER
SAY NO TO: Alkohol rokok narkotik
sex
Jangan berbagi jarum suntik dg orang lain
Makan obat hanya bila sangat perlu.
Hindari pemakaian beberapa obat sekaligus
Hindari zat kimia
Diet sehat dan seimbang, hindarkan
kegemukan

FINAL MESSAGE

Get yourself vaccinated


Get your family vaccinated
Get your patients vaccinated
Get your community vaccinated
Spread the knowledge