Hepatitis C Presentation Resource Manual

1. Hepatitis C Presentation & Resource Manual Upon completion of the presentation the audience should have a basic understanding of: Hepatitis C virus and how it effects the liver Transmission and risk factors Diagnostic tests Natural history and progression of hepatitis C and HIV/HCV Co-infection Treatment options – western and alternative medicine, including nutritional requirements

2. HEPATITIS Focus on Hepatitis C Hepatitis Education for Opioid Treatment Providers

3. Hepatitis A, B and C

4. The Liver’s Functions Acts as a chemical powerplant Produces clotting factors Produces proteins Filters toxins Stores vitamins & nutrients Regulates hormones Miniature refinery Processes chemicals – converts carbs, fats & proteins into chemicals essential for life and growth Manufactures and exports substances needed by other organs to function Modifies and cleanses blood of toxins and waste products Aids in digestion Regulates blood’s ability to clot Stores vitamins, minerals and sugars Produces quick energy Control production and excretion of cholesterol Breaks down alcohol Maintains and controls hormone balance Helps body resist infection by producing immune factors and cleansing bacteria Stores iron Miniature refinery Processes chemicals – converts carbs, fats & proteins into chemicals essential for life and growth Manufactures and exports substances needed by other organs to function Modifies and cleanses blood of toxins and waste products Aids in digestion Regulates blood’s ability to clot Stores vitamins, minerals and sugars Produces quick energy Control production and excretion of cholesterol Breaks down alcohol Maintains and controls hormone balance Helps body resist infection by producing immune factors and cleansing bacteria Stores iron

5. The Hepatitis C Virus Genus: Flavivirus Single stranded RNA molecule Blood borne Infects the liver Mutates rapidly

6. Risk Factors( High Risk ) Injection & intranasal drug use Blood transfusion prior to 1992 Clotting factors prior to 1987 Hemodialysis 5% needle stick exposure 3-5% babies born to infected mothers Known Risk Factors Sharing needles and straws Hemodialysis equipment can be contaminated Known Risk Factors Sharing needles and straws Hemodialysis equipment can be contaminated

7. Risk Factors( Lower Risk ) Sharing personal hygiene items with an infected person. (toothbrushes, razors, scissors and nail clippers) Contaminated tattoo needles and ink Contaminated body piercing implements Unprotected sexual behavior with multiple partners * People with STD history* Viet Nam era military service* Possible Risk Factors Personal hygiene items as well as tattoo needles and body piercing implements may have dried blood on them The highest tattooing risk is prison and street tattoos The virus can live in tattoo ink The virus may live in dried blood for many days Monogamous couples have a low risk of sexual transmission Higher than average incidence of HCV found in Viet Nam Era Veterans Possible Risk Factors Personal hygiene items as well as tattoo needles and body piercing implements may have dried blood on them The highest tattooing risk is prison and street tattoos The virus can live in tattoo ink The virus may live in dried blood for many days Monogamous couples have a low risk of sexual transmission Higher than average incidence of HCV found in Viet Nam Era Veterans

8. Testing and Tests Elisa III (used since 1996) RIBA (supplemental test) HCV/RNA by PCR (confirmatory test ) Antibody Response Tests ELISA III Sensitive & Specific May have false positives RIBA Confirms Elisa Determines which antigen the antibody is reacting to If reactive against 2 antigens the patients is HCV+ Confirmatory Tests HCV/RNA by PCR – viral load test Counts virons in blood If virus is detected the patient is positive If virons not detected the patient does not have HCV or has it in such low numbers it can’t be counted Antibody Response Tests ELISA III Sensitive & Specific May have false positives RIBA Confirms Elisa Determines which antigen the antibody is reacting to If reactive against 2 antigens the patients is HCV+ Confirmatory Tests HCV/RNA by PCR – viral load test Counts virons in blood If virus is detected the patient is positive If virons not detected the patient does not have HCV or has it in such low numbers it can’t be counted

9. Symptoms Fatigue Muscle / joint pain Headache Anorexia Right Upper Quadrant Pain Many patients are asymptomatic Called the silent disease Severe symptoms happen late in the disease 1/3 of patients never have elevated liver enzymes Symptoms listed on the slide are the most common complaints of HCV patients Many patients are asymptomatic Called the silent disease Severe symptoms happen late in the disease 1/3 of patients never have elevated liver enzymes Symptoms listed on the slide are the most common complaints of HCV patients

10. Natural History of HCV Go through the schematic. Well compensated cirrhosis patients often do very well for many years.Go through the schematic. Well compensated cirrhosis patients often do very well for many years.

11. Cirrhosis Age at the time of infection Alcoholism (studies show that alcohol is a very important co-factor in the progression of chronic hepatitis to cirrhosis) Co-infection with HIV Co-infection with active hepatitis B virus. Stage IV Scar tissue replaces healthy liver cells Liver becomes hard Liver loses it’s ability to do all of it’s functions 20% of HCV patients will progress to cirrhosis Once cirrhosis occurs the patient is at increased risk for liver failure and liver cancer. Many patients with cirrhosis are stable for many years Alcohol may accelerate the progression to cirrhosis Stage IV Scar tissue replaces healthy liver cells Liver becomes hard Liver loses it’s ability to do all of it’s functions 20% of HCV patients will progress to cirrhosis Once cirrhosis occurs the patient is at increased risk for liver failure and liver cancer. Many patients with cirrhosis are stable for many years Alcohol may accelerate the progression to cirrhosis

12. End-Stage Liver Disease Ascites Jaundice Bleeding - varices Mental confusion Weight loss Severe itching Edema Ascites – fluid retention in the abdomen Jaundice – buildup of bilirubin that makes the patient yellow Varices – swollen veins caused by the backup of blood due to scarred blood vessels in the liver and portal vein Mental Confusion – Encephalopathy is caused by the buildup of toxins and waste products. This causes cognitive and personality changes in the brain Itching – may occur when the bilirubin is elevated and jaundice occurs Ascites – fluid retention in the abdomen Jaundice – buildup of bilirubin that makes the patient yellow Varices – swollen veins caused by the backup of blood due to scarred blood vessels in the liver and portal vein Mental Confusion – Encephalopathy is caused by the buildup of toxins and waste products. This causes cognitive and personality changes in the brain Itching – may occur when the bilirubin is elevated and jaundice occurs

13. Ways to Slow Progression NO ALCOHOL Heart healthy diet Moderate exercise Vaccinate for HAV & HBV Prudent use of all medications (prescription and over the counter)

14. Possible Related Problems Kidney Damage Cryoglobulinemia Autoimmune Disorders Skin Conditions Thyroid Disease Type II Diabetes Liver Cancer Kidney Damage - Glomerulonephritis – HCV immune complexes lodge in the kidney Cryoglobulinemia – causes skin rashes, fever, kidney damage, ulcerations of fingers and toes. Treatment is interferon. Autoimmune Conditions – the body attacks itself causing arthritis, joint and muscle pain, rashes, lupus-like symptoms Skin conditions – lichen planus Thyroid Disease – may be caused by HCV or interferon treatment Hepatocellular Carcinoma – People with cirrhosis are at increased risk of this type of liver cancer * HCV testing should be considered in people with the above disorders when no other reason can be found. These disorders are seen more frequently in HCV patients than in the general population Kidney Damage - Glomerulonephritis – HCV immune complexes lodge in the kidney Cryoglobulinemia – causes skin rashes, fever, kidney damage, ulcerations of fingers and toes. Treatment is interferon. Autoimmune Conditions – the body attacks itself causing arthritis, joint and muscle pain, rashes, lupus-like symptoms Skin conditions – lichen planus Thyroid Disease – may be caused by HCV or interferon treatment Hepatocellular Carcinoma – People with cirrhosis are at increased risk of this type of liver cancer * HCV testing should be considered in people with the above disorders when no other reason can be found. These disorders are seen more frequently in HCV patients than in the general population

15. HCV/HIV Co-Infection HCV impacts 30% of HIV patients HIV may accelerate the progression of HCV HCV impacts 30% of HIV patients HIV may accelerate the progression of HCV

16. Treatment Age of the patient General state of health Risk of cirrhosis Likelihood of response Other medical conditions that may decrease life expectancy or contraindicate the use of interferon or ribavirin. Patients with moderate/severe necro-inflammation and/or fibrosis should be treated Treatment issues are debatable Some physicians and patients want to treat early Some physicians and patients want to wait for better treatment options Whether to treat or not is a complex issue and depends on the above mentioned variables. Treatment issues are debatable Some physicians and patients want to treat early Some physicians and patients want to wait for better treatment options Whether to treat or not is a complex issue and depends on the above mentioned variables.

17. Treatment Options Interferon / Ribavirin (combination) Pegylated Interferon / Ribavirin (combination) Interferon + Ribavirin are the only available treatments Treatment is not recommended for everyone Complex decision Needle based May cause depression Has side effects Should be tailored to the individual Contact private physician to discuss treatment More methadone patients are entering clinical trials Interferon + Ribavirin are the only available treatments Treatment is not recommended for everyone Complex decision Needle based May cause depression Has side effects Should be tailored to the individual Contact private physician to discuss treatment More methadone patients are entering clinical trials

18. Alternative Treatment Massage therapy Aroma therapy Milk thistle ( data anecdotal ) Senna Heliotropium Jin Bu Huan Sassafras Skullcap Germander Comfrey Valerian Pennyroyal NIH created an office to study alternatives Encourage patients to discuss all treatment with their physicians Some vitamins in high doses are toxic Patients should not take extra iron NIH created an office to study alternatives Encourage patients to discuss all treatment with their physicians Some vitamins in high doses are toxic Patients should not take extra iron

19. Dietary Guidelines No special diet needed for non-cirrhotic patients No salt or protein restrictions Patients with de-compensating cirrhosis need to follow their doctor’s advice May advise limiting protein & salt A multiple vitamin without iron may be taken No special diet needed for non-cirrhotic patients No salt or protein restrictions Patients with de-compensating cirrhosis need to follow their doctor’s advice May advise limiting protein & salt A multiple vitamin without iron may be taken

20. Counseling Guidelines Encourage at risk patients to get tested Encourage changes in life style Encourage the sharing of HCV status with clinical staff Have current and accurate information available to the patients Have support resources available to the patients Provide referral services Make patients aware of high risk behavior Encourage follow-up lab testing Encourage patients to take advantage of support programs Get Tested – Referrals provided (handout) Lifestyle changes very important Avoid alcohol Avoid smoking Prudent use of all medications Disclose your status to physicians & staff Don’t put others at risk Cover open wounds Clean up blood spills Don’t share toothbrushes, razors Encourage safer sex Attend support groups See physician regularly Get Tested – Referrals provided (handout) Lifestyle changes very important Avoid alcohol Avoid smoking Prudent use of all medications Disclose your status to physicians & staff Don’t put others at risk Cover open wounds Clean up blood spills Don’t share toothbrushes, razors Encourage safer sex Attend support groups See physician regularly

21. Thank You For Listening Any Questions?Thank You For Listening Any Questions?