ABCs of Hepatitis

1. ABCs of Hepatitis

2. 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)

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

4. 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

5. 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

6. 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, clay-colored bowel movements, joint pain, jaundice • Once resolved, protective antibodies develop and give lifelong immunity

7. 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

8. 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

9. 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

10. 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

11. 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)

12. 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

13. 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

14. 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

15. 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

16. 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)

17. 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

18. Hepatitis C • Caused by Hepatitis C virus • In 2008, 18,000 estimated new infection in U.S. • ~4.1 million in U.S. have been infected • An estimated 115,000 infected in WA • 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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