Sandi Mitchell Nurse Educator Clinical Prevention Services BCCDC

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1 Sandi Mitchell Nurse Educator Clinical Prevention Services BCCDC

2 Hepatitis A, B and C Testing Transmission Treatment

3 What Is Hepatitis? Hepatitis means inflammation of the liver Hepat (liver) + itis (inflamation)= Hepatits Viral hepatitis means there is a specific virus that is causing your liver to inflame (swell or become larger than normal)

4 The Liver Is located in the upper right quadrant of the abdomen Cleans the blood Regulates hormones Helps with blood clotting Produces bile Produces important proteins Maintains blood sugar levels It has over 500 functions The liver is essential for life!

5 Viral Hepatitis 5 Major Types: A: oral-fecal transmission B: sexual fluids & blood to blood C: blood to blood D: travels with B E: oral-fecal transmission Vaccine Preventable Adapted from Corneil, 2003 There are also other less common strains

6 Blood Test

7 Hepatitis A

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9 Hepatitis A Fecal-oral transmission: Close personal contact, oral-anal sex, diaper Contaminated food, water Self limiting disease Incubation: 1 month (15-50 days) Abrupt onset: jaundice, fever, malaise, GI upset, Killed by heating

10 HAV exposures (n=45)

11 Non VI Outbreak Cases VI Oubreak 80 Number of Cases

12 2 doses, 6 months apart Protection long term 2 doses- 20 years Virtually 100% develop protection Adverse reactions: Local soreness, OK in pregnancy Free: hemophiliacs, MSM, PWID, liver disease(hcv/hbv), PEP, First Nation children & correctional inmates, Not free: travelers and food handlers In BC we have offered HAV vaccine PEP since 2002

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14 Overall prevalence of HBV infection in Canada is low (0.7.9%) Estimates indicate 600,000 carriers in Canada Sub-populations with higher prevalence immigrants from endemic areas (particularly SE Asia) PWID

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16 Patient infected with HBV Neonates: 70-85% chronic inf n. With vaccine/hbig <5% Toddlers: 50% chronic Inf n. With vaccine 0% Treatment and monitoring are complex! ~40% symptomatic, with age Adolescents/adult: 5% chronic inf n. With vaccine 0%

17 History HBV Vaccine in BC 1982 available in Canada 1984 for neonates HBsAg +ve mothers 1990 sexual contacts, and household 1992 Grade 6, Student HCW, STD clients, STW, haemophiliacs, PWID, household contacts 1993 pre dialysis; inmates correct. facilities 2001 babes provincially (Vancouver 1998) Grade 6: Immigrants MSM, HCV, chronic liver disease etc 2009 Infant hexa-valent

18 HBV Vaccine Efficacy 95%, likely lifelong Like Hepatitis A a series of doses Adults 3 dose standard 0, 1 and 6 months Accelerated schedule 0, 7, 21 d (booster 1yr) Immunocompromised double dose for all indications

19 Hepatitis B Treatment 1980 s Standard interferon (now pegylated) 1997 Lamivudine (100 mg od) 2005 Adefovir (10 mg od) 2006 Entecavir ( mg od) 2006 Telbivudine (600 mg od) 2008 Tenofovir (300 mg od)

20 Counselling for People with Chronic Hepatitis B Encourage sexual contacts and people you are living with to be tested and vaccinated Encourage them to use clean needles each time and to dispose of them safely Advise not to donate blood, semen, organs or tissues Advise not to share razors, toothbrushes, dental floss Cover open cuts or wounds Counsel pregnant women of the importance of HBIG and vaccination of newborn

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22 HCV in BC 73,500+ individuals reported with HCV Up to 25% clear, some deceased, estimate 41,000 known chronic carriers Probably 25% unknown i.e. 14,000 Total 55,000 living with chronic HCV 90% recent infections associated with IDU

23 No vaccine available Affects each person differently Many people have the virus and do not even know it At least six different genotypes *BC Hepatitis Service 2003

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25 Transmission of HCV Percutaneous Transfusion before 1990, transplant from infected donor; (1994) Therapeutic (e.g. dialysis) Occupational (needlestick) 2% Recreational injection and non-injection drug use continues to be the predominant risk factor New IDU s - 1/2 infected within 3 yrs of initiation

26 Mother anti-hcv+ Mother to Child ~ 5-6% at the time of birth ( infants at-risk in BC/yr) Mother anti-hcv+ and HIV infected ~ 15% Associated with higher maternal HCV viremia Breastfeeding - plausible not found

27 Sex Low risk Varies on individual basis ~3% anti-hcv prevalence male-to-female transmission more efficient Possibly higher risk on population basis U.S % with acute HCV have history of sexual exposure but no other risk factors

28 Person infected with HCV 25 % clear infection Alter 99 Jaeckel 01 Do nothing 15% to 25% cirrhosis, liver cancer or need a transplant Freeman 01 ~ 25% will have symptoms 75% are chronically infected Alter 99 Multiple Decades

29 Factors promoting HCV progression Male Degree of inflammation/fibrosis at diagnosis Age >40 yrs at diagnosis Alcohol (>2-3 drinks/day) Other co-infections e.g. HBV Superinfection e.g. HAV Immunosuppression e.g. HIV coinfection

30 Who Gets Treated? no simple criterion consider persons age, risk of disease progression, symptoms, willingness to accept side effects, motivation

31 Goals of Treatment cure HCV infection suppress disease activity halt or reverse fibrosis progression reduce risk of hepatocellular carcinoma

32 HCV Treatment Pegylated Interferon + Ribavirin 45% cure rate for genotype 1 with 48 wks of Rx 75% to 80% cure rate for genotype 2, 3 with 24 wks of Rx Telaprivir or Boceprivir: Directly Acting Antivirals (DAA): Inhibit replication of HCV. Used with routine Interferon/Ribavirin therapy

33 HCV/HIV coinfection liver fibrosis is accelerated in coinfected individuals SVR rates lower in coinfected individuals: 43-62% in G2/3 with 48 wks, 30-45% with 24 wks 16-38% SVR with G1 treated with PEGIFN/RBV avoid didanosine and zidovudine during PEGIFN/RBV treatment

34 A B C Transmission Faecal-oral Blood-to-blood Body fluids Vaccine Yes Yes No Acute symptoms? Chronic infection common in adults? Common Common Rare Blood-to-blood No No (5%) Yes (75%)

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