Sandi Mitchell Nurse Educator Clinical Prevention Services BCCDC

Sandi Mitchell Nurse Educator Clinical Prevention Services BCCDC sandi.mitchell@bccdc.ca

Hepatitis A, B and C Testing Transmission Treatment

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)

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!

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

Blood Test

Hepatitis A

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

HAV 2010-2011 exposures (n=45)

Non VI Outbreak Cases VI Oubreak 80 Number of Cases 136 109 78 75 58 74 52 56 42 40 12 31 30 36 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

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

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

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%

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

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

Hepatitis B Treatment 1980 s Standard interferon (now pegylated) 1997 Lamivudine (100 mg od) 2005 Adefovir (10 mg od) 2006 Entecavir (0.5 1.0 mg od) 2006 Telbivudine (600 mg od) 2008 Tenofovir (300 mg od)

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

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

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

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

Mother anti-hcv+ Mother to Child ~ 5-6% at the time of birth (400-500 infants at-risk in BC/yr) Mother anti-hcv+ and HIV infected ~ 15% Associated with higher maternal HCV viremia Breastfeeding - plausible not found

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. 15-20% with acute HCV have history of sexual exposure but no other risk factors

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

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

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

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

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

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

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%)