ABCs of Hepatitis What is Hepatitis Hepatitis is

ABCs of Hepatitis

What is Hepatitis • Hepatitis is inflammation of liver • Hepatitis can be caused by a variety of factors ▫ ▫ ▫ Alcohol Drugs Chemicals Toxins Autoimmunity Viral Infections (Hepatitis A, B, C, D, E, G)

The Liver • • • Largest internal organ Weighs about 3 lbs Size of football Ability to regenerate after damage Involved in many digestive, vascular and metabolic activities

Liver Damage • Inflammation – immune response • Fibrosis – development of scar tissue • Cirrhosis – a process where liver cells are destroyed and replaced with scar tissue • Hepatocellular Carcinoma – type of liver cancer

Viral Hepatitis • Acute infection is when the function is newly acquired • Chronic infection lasts 6 months or more and is usually life long unless treated • Resolved or cleared infection is the body getting rid of hepatitis infection – usually occurs in the acute stage

Hepatitis A • Caused by hepatitis A virus • In 2008 22, 000 estimated number of new infections in the U. S. • HAV is an acute infection • Incubation 30 days, usually lasts 2 months • Symptoms include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, claycolored bowel movements, joint pain, jaundice • Once resolved, protective antibodies develop and give lifelong immunity

HAV Transmission and Prevention • Primarily transmitted via fecal-oral route and rarely through blood exposure • Highly infectious and stable in environment for months • Most common transmission through close personal contact with an infected person • Vaccine is available to prevent infection

HAV vaccination • Vaccine began in 1995 • Two doses at 0 and 6 -18 months (VAQTA & HAVRIX) • Also available in combination with Hep B (TWINREX) ▫ Given in three doses at 0, 1, and 6 months • Does not have to be given at exact timeline

Recommendations for HAV vaccine • Person’s at increased risk of HAV infection ▫ ▫ ▫ Injection and non injection drug use Men who have sex with men Travelers headed to HAV endemic countries Persons with chronic liver disease Persons with clotting factor disorders Children but often not vaccinated

Hepatitis B • Caused by hepatitis B virus • In 2008 38, 000 estimated number of new infection in U. S. • 800, 000 to 1. 4 million in U. S. living with chronic HBV • Incubation period 60 -90 days • 2 -6% of infected adults develop chronic HBV • Often no symptoms in acute stage but can include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored bowel movements, joint pain, jaundice • If resolved, protective antibodies develop and give lifelong immunity

HBV Transmission and Prevention • Primarily transmitted by blood, semen, and vaginal secretions • Highly infectious, stable in environment for at least 7 days • Dried blood can be reconstituted • Most common transmission through ▫ Unprotected sex ▫ Perinatal (mom to baby) ▫ Percutaneous (through opening in skin)

Chronic HBV • 2 -6% adults go on to chronic infection, majority of infected infants become chronically infected if not given vaccine • 15 -25% of persons with chronic HBV will die prematurely (~3, 000 deaths per year) • Treatment and medical management is very complicated and should be referred to specialist

HBV Vaccine • Vaccine began 1982 • Three doses at 0, 1 and 6 (Recombivax & Energix -B) • Also available in combination with Hep A (TWINREX) • Does not have to be given at exact timeline

Recommendations for HBV Vaccine • Person’s at increased risk of HAV infection ▫ Men who have sex with men ▫ Persons with more than one sex partner in a six month period ▫ Persons recently diagnosed with an STD ▫ Sex contacts of infected persons ▫ Injection drug use ▫ Household contact of chronically infected person ▫ Infants born to an infected mother ▫ Infants/children of immigrants from areas with high rates of HBV ▫ Healthcare and public safety workers ▫ Hemodialysis patients ▫ People living with HIV and/or HCV

Lack of Access to HBV and HAV Vaccine Hepatitis A Prevention Hepatitis B Prevention • Prevent fecal matter from entering the mouth • Wash hands • Use barriers for oral sex • Clean sex toys between use • Prevent blood, semen, vaginal fluids from entering body • Use barriers for sex • Do not share needles or other equipment that may have blood on them

HAV &HBV Testing • HAV/HBV testing ▫ usually not recommended prior to vaccination ▫ Can determine current infection or immunity • HBV testing distinguishes between current and resolved infection • Some people may benefit from post immunization testing (HIV+ persons)

Hepatitis C • History ▫ Blood samples stored since 1948 contain antibodies to HCV earliest known HCV ▫ 1970 the virus appears in enough people to be noticed, called non A, non B hepatitis ▫ 1987 Identified as hepatitis C ▫ 1990 Antibody test helps identify people exposed to the virus and is used to screen the blood ▫ 1992 Better test to insure the safety of the blood supply

Hepatitis C • Caused by Hepatitis C virus • In 2013, 30, 000 estimated new infection in U. S. • ~3. 5 million in U. S. currently infected • An estimated 115, 000 infected in WA ▫ 721 newly diagnosed cases in Clark County in 2015

Hepatitis C • Incubation period average 6 -7 weeks • 75%-85% infected adults progress to chronic infection • Often no symptoms • If resolved, no protective antibodies, can get reinfected

HCV Transmission • Primarily transmitted by direct blood to blood contact • Highly infectious, stable environment for at least 16 hours, but not more than 4 days (alive but can’t transmit) • Most common transmission through sharing of drug paraphernalia • Also blood transfusions and products before 1992 ▫ Perinatal transmission ▫ Needle stick/healthcare exposure ▫ Other blood risks low/unknown risk: tattooing, /piercing, intranasal cocaine use, shared personal items

Prevention of HCV • Avoid blood exposure: ▫ New syringe, cooker, cotton, water, every time for injection ▫ Use universal precautions ▫ Don’t share personal items that may contain blood (tooth brush/razor) ▫ Use barriers and lubricant ▫ Cover open cuts and wounds ▫ Ensure instruments for tattooing, piercing, acupuncture are new or sterilized

HCV and Sharing of Injection Drug Equipment • Studies have found high rates of HCV in IDUs who didn’t share needles but shared cookers, cottons, and water, and other equipment • People who inject steroids, vitamins, and hormones and share equipment are also at risk • IDUs should use new sterile equipment every time (wash hands and injection site and surface area) • It is unknown if bleach kills HCV

HCV and Sexual Transmission • Seven U. S. studies of long term discordant partners found 1. 5 -3% seroprevalence of HCV • Other studies of MSM, sex workers, and those with a history of HCV found prevalence of 4 -6% • Other factors related with sexual transmission include #of partners, the presence of STDs, and use of condoms

More HCV transmission • Risk with pregnancy mother to child 5 -6% • Breast feeding ok unless cracked nipples • Most risk for tattooing is non professional tattooing, very common during incarceration • New ink containers, needles, and equipment • Intranasal cocaine and meth use: some studies have found a link when blood gets in the nasal membrane • Smoking crack and meth use: burnt, cracked, or bleeding lips

CDC Recommendations for HCV Testing • Test routinely based on risk ▫ Ever injected drugs (even once) ▫ Transfusions/organ transplants before 1992 ▫ Selected medical conditions (chronic hempdialysis, elevated liver enzymes) ▫ Received clotting factors before 1987 • CDC unsure of testing needs � History of tattooing, STDs, body piercing, intranasal cocaine or meth use, long term HCV partner

HVC Testing and Diagnosis • EIA (Enzyme immunoassay) ▫ Detects antibodies to HCV ▫ 97% of people have antibodies 6 months after infection • RIBA (Recombinant immunoblot assay) ▫ Confirms positive initial anti-HCV • HCV RNA ▫ Looks for actual virus in blood

Positive Test Result • Confirmed Positive ▫ Client has been infected with HCV in the past and probably is still living with it ▫ Further Evaluation is recommended �Determine if HCV is still in blood �Establish the health of the liver �Discuss treatment options ▫ Discuss prevention and health messages �Avoiding alcohol

Symptoms of Chronic Hepatitis • Chronic Hepatitis ▫ Fatigue ▫ Depression ▫ Loss of appetite ▫ Nausea/indigestions ▫ Muscle/joint pain ▫ Mood swings ▫ Abdominal Pain ▫ Fever • Late stages of cirrhosis ▫ All of the symptoms of ▫ ▫ ▫ ▫ chronic hepatitis Vomiting Jaundice Cognitive dysfunction Fluid retention Frequent urination Lack of concentration Confusion Dizziness

Chronic Hepatitis C • Factors promoting progression ▫ ▫ Alcohol intake Age >40 at time of infection HIV or HBV co infection Male gender • Vaccinate for HAV/HBV • HCV leads to ~10, 000 deaths per year from chronic liver disease

Treatment • Old School ▫ AWFUL!!! �But sometimes life saving �Multiple pills and weekly injections �~50% cure rate • New School- January 2014 ▫ One pill for each major strain of Hep C � 8 -12 weeks of treatment ▫ ~90% cure rate

What does this mean? • Cure Rate ▫ For Hepatitis C �No detectable virus in the body ▫ Less liver damage • Does cure = immunity? ▫ Nope ▫ Reinfection can occur at anytime

Show me the $$$$ • Cost of new treatment ▫ Depends on strain ▫ Somewhere from $80, 000 to 100, 000 �That’s ~1200 dollars a pill ▫ Will it go down? �Probably not anytime soon

WHY? • New drugs are expensive to bring to market • Patents prevent generic from being made • Insurance companies drive down cost ▫ Most folks with Hep C get treatment through government funded healthcare