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X19fX19fX4VfhV+FX188XzxfPIVfXzxfPIVfhV+FX19fX19fX19fX19fX19fX19fX19fX19fX19f X19fX19fX19fXzxfPF9fX19fX19fX19fX19fX19fX19fX19fX4VfX19fPF88XzxfPF88X19fX19f X19fPF9fX19fhYVfhV9fX19fX19fX19fhV9fX19fX19fX19fX19fX4VfX1+FX4VfhV+FX4VfhV+F X188X19fX19fX19fX4VfhV+FXwMAAAAAAA== ------=_NextPart_01C63AC7.D181DE90 Content-Location: file:///C:/8809C636/Hepatitis_RH_Bengoa_2006_files/master07.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252"
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------=_NextPart_01C63AC7.D181DE90 Content-Location: file:///C:/8809C636/Hepatitis_RH_Bengoa_2006_files/master07.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C63AC7.D181DE90 Content-Location: file:///C:/8809C636/Hepatitis_RH_Bengoa_2006_files/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C63AC7.D181DE90 Content-Location: file:///C:/8809C636/Hepatitis_RH_Bengoa_2006_files/slide0029.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Viral Hepatitis in Reproductive Health - José Bengoa
Viral Hepatitis
in Reproductive Health

José Bengoa

Training in Reprod= uctive Health Resear= ch – Geneva 2006
l
l
l15 march= 2006
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Epidemiology of Hepatitis B Dr José Bengoa
Consultant Geneva University Hospital
Franco Vietnamese Hospital, Ho Chi Minh City
Epidemiology of Hepatitis C Dr Pierre Jean Malè
Consultant Geneva University Hospital
Franco Vietnamese Hospital, Ho Chi Minh City
HB Vaccination Programs Dr Steven Wiersma
WHO, FCH Medical Officer/Hepatitis Focal Point
New Interventions in Health Services   Dr Rafael Bengoa
WHO, Director of Health Systems Policies
Treatment of VHB and VHC       Dr Pierre Jean Malè
Honduras Hepatitis B project Dr Francesco Aureli
Director of Imagine Foundation, Rome
Vietnam Hepatitis B/C project <= b>Dr José Bengoa
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Epidemiology and Prevention of Viral Hepatitis
Hepatitis B
Hepatitis C
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Viral hepatitis=
worldwide
  VHB <= /span>350’000’000
VHC 200’000’000
=
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Hepatitis A
Hepatitis C/ NANB
Hepatitis B
Total
CDC
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A
“Infectious”
“Serum”
Viral hepatitis
Enterically = ;
transmitted
Parenterally
transmitted
 other
E
“NANB”
B
D
C
CDC
Viral Hepatitis – Historical Perspective
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Viral Hepatitis Overview

 =
Source of
virus
Route of
transmission
Chronic
infection
Prevention
modification
feces
blood/
blood-derived
body fluids
blood/
blood-derived
body fluids
blood/
blood-derived
body fluids
feces
fecal-oral
percutaneous
permucosal
percutaneous
permucosal
percutaneous
permucosal
fecal-oral
no
yes
yes
yes
no
pre-
exposure
immunization
pre/post-
exposure
immunization
blood donor
screening;
risk behavior
modification
pre/post-
exposure
immunization;
risk behavior
ensure safe
drinking
water
Types of Viral Hepatitis
A     B = C      D E
CDC
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<= span style=3D'font-size:133%;color:yellow'>•A
–fecal-oral spread: hygiene, drug u= se, men having sex with men, travelers, day care, food
<= span style=3D'font-size:133%;color:yellow'>–vaccine-preventable
<= span style=3D'font-size:133%;color:yellow'>•B
<= span style=3D'font-size:133%'>–sexually transmitted – = 100x more infectious than = HIV
–blood-borne (sex, injection drug u= se, mother-child, and health care)
<= span style=3D'font-size:133%;color:yellow'>–vaccine-preventable
<= span style=3D'font-size:133%;color:yellow'>•C =
<= span style=3D'font-size:133%'>–blood borne (injection drug use primarily)
<= span style=3D'font-size:133%'>– = 4-5 times mo= re common than HIV
<= span style=3D'font-size:133%;color:yellow'>–NOT vaccine-preventable!
CDC
A, B, Cs of Viral Hepatitis
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CDC
Hepatitis B Virus
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HBsAg Prevalence
³8%  - High
   2-7% - Intermediate
    <2%  - Low
CDC
Geographic Distribution of Chronic HBV Infection<= /span>
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3D"*"High (>8%): 45%  of global population
–lifetime risk of infection >60% =
–early childhood infections common <= /span>
= 3D"*"Intermediate (2%-7%): 43% of global population = ;
–lifetime risk of infection 20%-60% =
–infections occur in all age groups =
= 3D"*"Low (<2%): 12% of global population =
–lifetime risk of infection <20% =
–most infections occur in adult risk gro= ups
–
CDC
Global Patterns of Chronic HBV Infection
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Sour= ce: NNDSS
Vaccine
licensed
=
HBsAg screening of pregnant women
recommended
=
=
=
=
OSHA Rule enacted
Adolescent Immunization recommended
Decline among MSM &  HCWs
Decline among&= #13;
 injecting
 drug users
In= fant Immunization
recommended=
CDC
Hepatitis B by Year (USA 1966-2000)
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•Incubation period:     Average 60-90 days
    Rang= e 45-180 days
•Clinical illness     <5 yrs, <10%
(jaundice):     >5 yrs, 30%-50%
<= span style=3D'mso-special-format:bullet;color:#FF5008;position:absolute;left:-4= .34%'>•Acute case-fatality= rate:     = 0.5%-1%
•Chronic infection:     <= span lang=3DEN-US style=3D'font-size:133%;color:white'><5 yrs, 30%-90%
     >5 yrs, 2%-10%
•Premature mortality from
chronic liver disease:     = 15%-25%  
 
CDC
Hepatitis B – Clinical Features
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Outcome of HBV Infection
Infection<= /span>
Asymptomat= ic
Symptomatic
acute hepatitis B
Resolved
Immune
Chronic infection
Asymptomat= ic
Cirrhosis
Liver cancer
Resolved
Immune
Chronic
infection
Asymptomat= ic
Cirrhosis
Liver cancer
CDC
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3D"Text
Chronic Infection (%)
3D"Text
Symptomatic Infection (%)
100
100
Symptomatic Infection=
Chronic Infection=
Birth
1-6 mos
7-12 mos
1-4 yrs
Older Child= ren
and Adults<= /span>
0
20
40
60
80
80
60
40
20
0
CDC
= Outcome of Hepatitis B Virus Infection
by Age at Infection
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Weeks after Exposure
  Symptoms
HBeAg
anti-HBe
Total anti-HBc
IgM anti-HBc
anti-HBs
HBsAg
0
4
8
12
16
20
24
28
32
36
52
100
Titer
Typ= ical Serologic Course
CDC
Acute Hepatitis B Virus Infection with Recovery
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IgM anti-HBc
Total anti-HBc
HBsAg
Acute =
(6 months)
HBeAg
Chronic
(Years)
a= nti-HBe
0<= /b>
4<= /b>
8<= /b>
12=
16=
20=
24=
28=
32=
36=
52
W= eeks after Exposure
Titer
CDC
Progression to Chronic Hepatit= is B Virus Infection
Typical Serologic Course=
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•Sexual
•Parenteral
•Perinatal<= /div>
 
CDC
HBV Modes of Transmission
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Low/Not
High
Moderate
Detectable
semen
serum
vaginal fluid
blood
wound exudates
saliva
urine
feces
sweat
tears
breast milk
CDC
Concentration of HBV
in Various Body Fluids
------=_NextPart_01C63AC7.D181DE90 Content-Location: file:///C:/8809C636/Hepatitis_RH_Bengoa_2006_files/slide0015.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Viral Hepatitis in Reproductive Health - José Bengoa
Source:  NNDSS/VHSP
*Other: Surgery, dental surgery, acupunct= ure, tattoo, other percutaneous injury
CDC
Risk Factors Associated with <= br> Reported Hepatitis B, 1990-2000, USA
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Prevalence of V= HB
HBV serologic markers in USA
3D"*" Chinese/S= EA    13%
3D"*" drug user= s          6% <= /div>
3D"*" homosexual males            6%
3D"*" HIV infec= ted              8%
3D"*" pregnant females              0.4 – 1.5 %&#= 13;
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Phases of hepatitis B infection
3D"*" immunotolerance
– -  virus is non pathogenic for liver cell= s
– -   may last several years
3D"*" immunoelimination
l   -   active hepatitis, high ALT, fibrosis, cirrhosis
l   -   HBeAg positive chronic hepatitis =
3D"*" inactive carrier of HBsA= g
l   -   = low viremia, HBeAg negative
3D"*" reactivation =
l   -   viral mutation, HBeAg negative
------=_NextPart_01C63AC7.D181DE90 Content-Location: file:///C:/8809C636/Hepatitis_RH_Bengoa_2006_files/slide0025.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Viral Hepatitis in Reproductive Health - José Bengoa
Complications of viral hepatitis
Cirrhosis
in HBeAg +      3% per year
HCC  (hepatoc= ellular carcinoma)
        ri= sk of 2 % per year
        in= creased risk in VHB high viremia
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N Engl J Med  September 15, 2005
Major Causes of D= eath among Men
and = Women in China
Jiang = He, M.D., Ph.D., Dongfeng Gu, M.D., Xigui Wu,et al
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Take home messages=
<= span class=3DBB>3D"*" hepatitis B is a wor= ld wide public health issue
<= span class=3DBB>3D"*" major country differ= ences in prevalence exist
<= span class=3DBB>3D"*" transmission: sexual, perinatal and parenteral
3D"*" it is a vaccine prev= entable disease
3D"*" cirrhosis and liver = cancer will represent a major challenge in terms of health care costs
<= span class=3DBB>3D"*" breakthroughs in the= rapy but very high cost
------=_NextPart_01C63AC7.D181DE90 Content-Location: file:///C:/8809C636/Hepatitis_RH_Bengoa_2006_files/master01.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252"
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[SLIDE 5] Acute Viral Hepatitis A, B and C/NANB by Year, United States, 1952-2000 Acute cases of viral hepatitis have been reported since 1952 = by the CDC.  Wi= th the characterization of hepatitis B surface antigen, blood samples containing hepatitis virus could be identified as HBV starting in the mid-60’s.  With the isolation and characterizatio= n of HCV in the early 80’s, blood samples could be differentiated between HAV, HBV, HCV and non A-n= on B hepatitis virus by serologic testing.  Successive generations of assays for sero= logic markers of viral hepatitis infections yield more specific and more sensitive results that further develop the population-based surveillance study of acute viral hepatitis = to define the epidemiologic characteristics of each= type of viral hepatitis.
[SLIDE 2] Viral Hepatitis: Historical Perspective
Before the discovery of hepatitis= A virus (HAV) and hepatitis B virus (HBV) during the 1960s and 1970s, patients with viral hepatitis were classified based on epidemiologic studies as having either infectious (transmitted person to person by the fecal-ora= l route) or serum (transmitted by transfu= sion of blood products) hepatitis.  When <= /span>diagnostic tests for hepatitis A virus = (HAV) and hepatitis B virus (HBV) infection were developed, HAV was found to be the major cause of infectious hepatitis and HBV was found to be the major cause of serum hepatitis.  Hepatitis Delta virus (HDV), discovered in 1977, is  a defective virus req= uiring the presence of HBV in order to replicate.  However, some patients with typical si= gns and symptoms of viral hepatitis did not have serologic markers of HAV, HBV or HDV infection and were categoriz= ed based on epidemiologic characteristics = as having either parenterally transmitted non-A, non-B hepatitis or enterically transmitted non-A, no= n-B hepatitis.  During the past decade, two additional viruses have been discovered: hepatitis C virus (HCV) and hepatitis E virus (HEV).  HCV is the major cause of parenterally transmitted non-A, non-B hepatitis and HEV is the major ca= use of enterically transmitted non-A, non-B hepatitis.  In addition, so= me patients with typical signs and symptoms of acute viral hepatitis do not have serologic markers= of any of these types of viral hepatitis and can be classified as having non-ABCDE hepatitis.  Recently,  new viruses have been discovered in patients with non-ABCDE hepatitis.  Characterization of the epidemiology and clinical features of these and other possible ag= ents of viral hepatitis will await the development of diagnostic assays.
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[SLIDE 41, SLIDE 42] Global Patterns of Chronic HBV Infection, Geographic Distribution of Chronic HBV infection*
Approximately 45% of the global population live in areas with a high prevalence of chron= ic HBV infection (> 8% of the population is HBsAg‑positive); 43% in areas with a moderate prevalence (2%‑7% of the population is HBsAg‑positive); and 12% in areas with a low prevalence (< 2% of the population is HBsAg‑positive).  In high prevalence areas, the lifetime risk of HBV infection is >60%, and most infections are acquired at birth or during early childho= od when the risk of developing chronic infection is greatest.  In these areas, because most infection= s in children are asymptomatic, very little acute disease related to HBV occurs, but rates of chronic liver disease and liver cancer in adults are very hig= h.  In moderate prevalence areas, the life= time risk of being infected is 20%‑60% and infections occur in all age groups.  Acute disease related to = HBV is common in these areas because many infections occur in adolescents and adu= lts; however, the high rates of chronic infection are maintained mostly by infections occurring in infants and children.  In low prevalence areas, the lifetime risk of infection is <20%.  Most HBV infections in t= hese areas occur in adults in relatively well defined risk groups. 
 *(Note: The map of HBsAg prevalence generalizes available data and patterns may vary within countries.) 
[SLIDE 41, SLIDE 42] Global Patterns of Chronic HBV Infection, Geographic Distribution of Chronic HBV infection*
Approximately 45% of the global population live in areas with a high prevalence of chron= ic HBV infection (> 8% of the population is HBsAg‑positive); 43% in areas with a moderate prevalence (2%‑7% of the population is HBsAg‑positive); and 12% in areas with a low prevalence (< 2% of the population is HBsAg‑positive).  In high prevalence areas, the lifetime risk of HBV infection is >60%, and most infections are acquired at birth or during early childho= od when the risk of developing chronic infection is greatest.  In these areas, because most infection= s in children are asymptomatic, very little acute disease related to HBV occurs, but rates of chronic liver disease and liver cancer in adults are very hig= h.  In moderate prevalence areas, the life= time risk of being infected is 20%‑60% and infections occur in all age groups.  Acute disease related to = HBV is common in these areas because many infections occur in adolescents and adu= lts; however, the high rates of chronic infection are maintained mostly by infections occurring in infants and children.  In low prevalence areas, the lifetime risk of infection is <20%.  Most HBV infections in t= hese areas occur in adults in relatively well defined risk groups. 
 *(Note: The map of HBsAg prevalence generalizes available data and patterns may vary within countries.) 
[SLIDE 15] Hepatitis B by year, United States, 1966 – 2000
Since hepatitis B vaccine was licensed for use in the United States in 1981, the incidence of acute hepatitis B has changed dramatically. During the 1980s,= use of hepatitis B vaccine had little impact on disease incidence, which actua= lly increased during the early 1980s. The incidence declined between 1985 and 1988, and between 1988 and 1991, when fewer cases were reported among men = who have sex with men and among injecting drug users, respectively. In both of these groups the decline in incidence was likely related to behavioral cha= nges in response to the epidemic of acquired immunodeficiency syndrome (AIDS) rather than to vaccine use. The incidence has continued to decline during = the first half of the 1990s; a likely contributing factor for this most recent decline is the widespread use of hepatitis B vaccine in response to regulations issued by the Occupational Safety and Health Administration. Future declines in incidence are expected to occur as a result of the implementation of routine infant and routine adolescent vaccination, which have been recommended in the 1990s.
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[SLIDE 34] Acute Hepatitis B Virus Infection with Recovery: Typical Serologic Cou= rse
Serologic markers of HBV infection vary depending on whether the infection is acute = or chronic. <= /span>
The first serologic marker to appear following acute infection is HBsAg, which= can be detected as early as 1 or 2 weeks and as late as 11 or 12 weeks (mode, = 30‑60 days) after exposure to HBV.  In persons who recover, HBsAg is no lo= nger detectable in serum after an average period of about 3 months.  HBeAg is generally detectable in patie= nts with acute infection; the presence of HBeAg in serum correlates with higher titers of HBV and greater infectivity.  A diagnosis of acute HBV infection can be made on the basis of the detection of IgM class antibody to hepatitis B core antigen (IgM anti‑HBc) in serum; IgM anti‑HBc is generally detectable at the time of clinical onset and declines to subdetectable levels within 6 months.  IgG anti‑HBc persists indefinitely as a marker of pa= st infection.  Anti‑HBs becomes detectable during convalescence after the disappearance of HBsAg in patients who do not progress to chronic infection.   The presence of anti<= /span>‑HBs following acute infection generally indicates recovery and immunity from reinfection. 
[SLIDE 35] Progression to Chronic Hepatitis B Virus Infection: Typical Serologic Course <= /span>
In patients with chron= ic HBV infection, both HBsAg and IgG anti‑HBc remain persistently detectable, generally for life.  HBeAg is variably present in these patients.  The presence of HBsAg for 6 months or = more is generally indicative of chronic infection.  In addition, a negativ= e test for IgM anti‑HBc together with a positive test for HBsAg= in a single serum specimen usually indicates that an individual has chronic HBV infection.
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[Slide 8] Risk Factors Associated with Reported Hepatitis B, 1990-2000, United States
Of persons with acute hepatitis B reported in the National Notifiable Diseases Surveillance System and the Viral Hepatitis Surveillance Program from 1990= ‑2000, 36% had a sexual risk factor (>1 s= ex partner during the previous 6 months, sex contact with a person with hepatitis, or men who have sex with men), 14% reported injecting drug use,= and 18% had other risk factors (e.g., household contact with a hepatitis patie= nt, health care employment). No risk factor could be identified for 32% of reported cases.
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gSldJumpIdx =3D ""; win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref ) } } } function _KDH() { if( event.keyCode =3D=3D 8 ) { event.returnValue =3D 0; parent.GoToPrevSld(); } } function DocumentOnClick() { if( IsNts() || parent.HideMenu() ) return; if( ( g_allowAdvOnClick && !parent.IsFramesMode() ) || (event && (event.keyCode=3D=3D32) ) ) parent.GoToNextSld(); } var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""= , g_bgSound=3D"", g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser = =3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1; var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w= indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va= r g_animManager =3D null; var g_animUseRuntime =3D false; var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime; var g_animMainSequence =3D null; var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram= es", gIsEndShow=3D0, NUM_VIS_SLDS=3D25, SCRIPT_HREF=3D"script.js", FULLSCR_= HREF=3D"fullscreen.htm"; var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO= tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true window.gPPTHTML=3DSupportsPPTHTML() var gMainDoc=3Dnew Array(new hrefList("slide0029.htm",1,-1,1),new hrefList(= "slide0028.htm",1,-1,1),new hrefList("slide0020.htm",1,-1,1),new hrefList("= slide0023.htm",1,-1,1),new hrefList("slide0016.htm",1,-1,1),new hrefList("s= lide0017.htm",1,-1,1),new hrefList("slide0018.htm",1,-1,1),new hrefList("sl= ide0019.htm",1,-1,1),new hrefList("slide0004.htm",1,-1,1),new hrefList("sli= de0005.htm",1,-1,1),new hrefList("slide0006.htm",1,-1,1),new hrefList("slid= e0007.htm",1,-1,1),new hrefList("slide0008.htm",1,-1,1),new hrefList("slide= 0009.htm",1,-1,1),new hrefList("slide0010.htm",1,-1,1),new hrefList("slide0= 011.htm",1,-1,1),new hrefList("slide0012.htm",1,-1,1),new hrefList("slide00= 13.htm",1,-1,1),new hrefList("slide0014.htm",1,-1,1),new 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FULLSCR_HREF = : FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref; if(PPTNav.event.ctrlKey) { var w =3D (window.screen.availWidth * 1.0) / 2.0 var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top= =3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } else { win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } } function ToggleVNarration() { rObj=3DPPTSld.document.all("NSPlay") if( rObj && !PPTSld.g_animUseRuntime ) { if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) ) rObj.Play() else if( rObj.playState =3D=3D 2 ) rObj.Pause() else return; } else if( PPTSld.g_animUseRuntime ) { narObj =3D PPTSld.document.all("narrationID") if( narObj ) narObj.togglePause() } } function GetCurSldNum() { =20 obj=3DGetHrefObj(gCurSld) if( obj.mOrigVis =3D=3D 1 ) return obj.mSldIdx else =20 return gCurSld } function GetNumSlds() { =20 if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 ) return GetSldList().mNumVisSlds; else return GetSldList().mList.length } function GetSldNum( href ) { for(ii=3D0; ii 1 ) PopSldList(); else if( !IsFramesMode() ) { if( gLoopCont ) GoToFirst() else EndShow() } } function GoToPrevSld() { ii=3DgCurSld-1 if( ii > 0 ) { obj=3DGetHrefObj(ii) while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) ) obj=3DGetHrefObj(--ii) if( ii =3D=3D 0 ) ii=3D1 GoToSldNum(ii) } } function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) } function GoToLast() { ii=3DGetSldList().mList.length if( ii !=3D gCurSld ) GoToSld( GetHrefObj(ii).mSldHref ) } function GoToSldNum( num ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue obj =3D GetHrefObj( num ) obj.mVis=3D1 gPrevSld=3DgCurSld gCurSld =3D num; PPTSld.location.replace(MHTMLPrefix+obj.mSldHref) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function GoToSld( href ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue GetHrefObj( GetSldNum(href) ).mVis=3D1 PPTSld.location.replace(MHTMLPrefix+href) } function SldUpdated( id ) { if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return gPrevSld=3DgCurSld gCurSld=3DGetSldNum(id) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) } function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO= bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) } function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) } function CloseWindow() { if( HideMenu() ) return; =09 var event =3D PPTSld.event; if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D= =3D32 || event.type=3D=3D"click" ) ) window.close( self ); CatchNumKeys( self, event ); } function Unload() { gIsEndShow=3D0; } function SetupEndShow() { gIsEndShow=3D1; PPTSld.document.body.scroll=3D"no"; PPTSld.document.onkeypress=3DCloseWindow; PPTSld.document.onclick=3DCloseWindow; PPTSld.document.oncontextmenu=3D_CM; } function EndShow() { if( IsFramesMode() ) return if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue doc=3DPPTSld.document var dir =3D doc.body.dir if( dir !=3D "rtl" ) dir =3D "ltr"; doc.open() doc.writeln('


' + ENDSHOW_MESG + '

') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(); /********************************************* Navigation button implementation There are 2 types of buttons: ImgBtn, TxtBtn implemented as function objects. They share a similiar interface so the event handlers can call SetActive, for example, on a button=20 object without needing to know exactly=20 what type of button it is. **********************************************/ //---------------------------------- function ImgBtn( oId,bId,w,action ) //---------------------------------- { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0=20 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { =20 obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0=20 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } =20 } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } //----------------------------------------- function TxtBtn( oId,oeId,action,chkState ) //----------------------------------------- { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { =20 this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) {=20 if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } =20 } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1=20 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etPressed() } function _BSetA_BorderImg() {=20 b =3D gBtnArr[this.mBorderId]=20 if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _BSetI_BorderImg() {=20 b =3D gBtnArr[this.mBorderId] if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN= tsPane ) gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg; gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg; gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.= ToggleNtsPane,GetNtsState ) gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To= ggleNtsPane,GetNtsState ) gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n= b_prevBorder",30,parent.GoToPrevSld ) gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n= b_nextBorder",30,parent.GoToNextSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice= ","nb_voiceBorder",18,parent.ToggleVNarration ) gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT= xt","nb_otlTxtBorder",23,parent.ToggleOtlText ) gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts" gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState /********************************************* Context menu implementation _CM() is the function that's hooked up to the oncontextmenu event. Once we're asked to show the menu, we first build it by creating DIVs on-the-fly. Then we position it=20 within the screen area so it doesn't get clipped. Creating the DIVs using createElement() means we don't have to write out any extra HTML into the slide HTML files. **********************************************/ var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr= row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval" function ShowMenu() { BuildMenu(); var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y= =3DPPTSld.event.clientY+doc.scrollTop m =3D PPTSld.document.all.item("ctxtmenu") m.style.pixelLeft=3Dx if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) ) m.style.pixelLeft=3Dx-m.scrollWidth m.style.pixelTop=3Dy if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) ) m.style.pixelTop=3Dy-m.scrollHeight m.style.display=3D"" } function _CM() { if( !parent.IsFullScrMode() ) return; if(!PPTSld.event.ctrlKey) { ShowMenu() return false } else HideMenu() } function BuildMenu() { if( PPTSld.document.all.item("ctxtmenu") ) return var mObj=3DCreateItem( PPTSld.document.body ) mObj.id=3D"ctxtmenu" mObj.style.visibility=3D"hidden" var s=3DmObj.style s.position=3D"absolute" s.cursor=3D"default" s.width=3D"120px" SetCMBorder(mObj,"menu","black") var iObj=3DCreateItem( mObj ) SetCMBorder( iObj, "threedhighlight","threedshadow" ) iObj.style.padding=3D2 CreateMenuItem( iObj,sNext,M_GoNextSld,M_True ) CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld ) =09 CreateSeparator( iObj ) CreateMenuItem( iObj,sEnd,M_End,M_True ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();= PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; s.fontFamily=3DsFont s.fontSize=3D"9pt" s.paddingLeft=3D2 } function CreateSeparator( node ) { var sObj=3DCreateItem( node ) SetCMBorder(sObj,"menu","menu") var s=3DsObj.style s.borderTopColor=3D"threedshadow" s.borderBottomColor=3D"threedhighlight" s.height=3D1 s.fontSize=3D"0px" } function CreateItem( node ) { var elem=3DPPTSld.document.createElement("DIV") node.insertBefore( elem ) return elem } function SetCMBorder( o,ltClr,rbClr ) { var s=3Do.style s.backgroundColor=3D"menu" s.borderStyle=3D"solid" s.borderWidth=3D1 s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr } ------=_NextPart_01C63AC7.D181DE90 Content-Location: file:///C:/8809C636/Hepatitis_RH_Bengoa_2006_files/fullscreen.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" ------=_NextPart_01C63AC7.D181DE90 Content-Location: file:///C:/8809C636/Hepatitis_RH_Bengoa_2006_files/buttons.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhWAESAPf4AAAAAIAAAACAAICAAAAAgIAAgACAgICAgAQEBISEBASEBISEhAQEhMTExAQE /KTM9Pz8/ERERPz8BAT8/KSkpGRkhMTcxCRkxAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAMDAwP8AAAD/AP//AAAA//8A/wD//////yH5BAEAAPgALAAAAABYARIA QAj/APEJHEiwoMGDCBMqXMiwocOHECNKnEixosWLGCEiQKCRo8YDIEHig2DxAD4LKD1avDDhgUuV GUOGbHBR5QGYFBG4fHAB58EKECJEwCfUYAWPFGAygLCRKQIIUKM6WAohKUGgCikcFWh1INWoYKVS 7SrQ41GbIhGYLAuVQVOoC+IyXUuUAkG1HE3KFDhAwkgJc5/qDZmxsOHDiBMrXsy4sePDGyP7lChT 5MULmDPnlDw5YmW6FTNrfgi0aNGEZPEtbfo2bNTUpYeeRph69dPWrqvCNFuBIGG1A59CYPAVQtwF cw0OxWdTIOiBCQAjaAB17fOFII8voGmRc+eOkilm/z9OvTtnjN4hYk1YoT3H2rnBOphPAB9skgq3 2lcaX/5YnJVt9BloAar12UEIRGCZdQghMABI1Tn32IQUVthYexhmqGGGMBHAgIfEhSiiiATAtOGJ GnYI4ogsEldicAYOGNJGZaml3Y0L3NTZUBz1xlB0PUoUI0jlVWRSVN89xBKSGB1YU1TMoRfVBEle hR9HQs1GEHxQ3RZZbveZthxt/LEmXHyp5XWABSCpaRJwbM13gAACPHVccgJFgF+NEhqUAEkQSCfc ddhVhh5dVTaEAEsTUNlkZUWKN9BNGDE6QU8OrSdbllzpxyVTTrU21Uj3scfhp7nNpyoDaTIEJ3P9 If8J2kbLNYegg9JRBwGhFvbq66+ZUiDssMQWK2yHxiZLrInKNotss8l+B5yBrr5p2UIJvortANoC 6+234IbLla/elRtZjeamh5CC3Sb0YLvixivvYkDFGlZqBNh7r4n6goVvv6/ZlCicN+kL71ALTnpQ dCIZp7CihkLA3UQmoWRBogyxtBPGCTnZncVR1rSTo5nuydC/Eo8kUH+lOoTyyvjoCuZu+PjYIKLD rZybtrM1d10C0QXKEVz48GrQkEeWdFJKlbb0UmEeV0SzyC6RvNB646LWIVjUNeC1zAFb+RDKXksM 9r531bwmpQW9+hQDDsx5pqwDRWBXcFES2hc+gEn/wJGdEEWdE6LoWcoxQweaTNmkhydkKaYMYY2Q p1unbLl/pPKbn3v7EZRvrKvqlja2ONvrtoIw9tn2g32/tQBlhtYkU+MNikZ7QYlPDPuMldpOmuJX nVo5VF3HjI+q89mteX5IDd/fVFClma5kiE4f2XUJhlz09gj2NbTDRifkmu7zXjR++RVJ/lPznuvr QH2iD6S+UewP9Dnon6d2NLwN8n90BB6hC68cFMCHoe+ACASP9c4DowUyEF0OPFcDI0ij/VXPaAKC UfhS95AKGoQ7IBRICI1HwhGaUIQoLGEKT6jCFrLwhSuMoQtlCMMZ2rCGOKShDm+4wxzy8Ic+DGIP B4cIRCKGMCAAOy== ------=_NextPart_01C63AC7.D181DE90 Content-Location: file:///C:/8809C636/Hepatitis_RH_Bengoa_2006_files/frame.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Viral Hepatitis in Reproductive Health - José Bengoa ------=_NextPart_01C63AC7.D181DE90 Content-Location: file:///C:/8809C636/Hepatitis_RH_Bengoa_2006_files/outline.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252"
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Outline
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