Hepatitis C Infection

1. Hepatitiscinfection facts, diagnosis, and interpretation Dr.T.V.Rao MD Dr.T.V.Rao MD

2. What is Hepatitis? • “Hepatitis” means inflammation of the liver • Can be caused by: • Genetic diseases • Medications (including over-the-counter) • Alcohol • Hepatitis viruses (A,B,C,D,E)

3. Identified in 1989 Blood test became available in 1992 Used to be known as “non-A, non-B” hepatitis Spread through blood-to- blood contact No vaccine available to prevent hepatitis C Hepatitis C C Dr.T.V.Rao MD

4. Structure of hepatitis c Dr.T.V.Rao MD

5. Hepatitis C- A global infection • About 3 million Americans infected • About 170 million infected worldwide • Many do not experience symptoms Dr.T.V.Rao MD

6. Sources of Infection forPersons with Hepatitis C Injecting drug use 60% Sexual 15% Transfusion 10% (before screening) Other* 5% Unknown 10% *Nosocomial; Health-care work; Perinatal Dr.T.V.Rao MD Source: Centers for Disease Control and Prevention

7. What is hepatitis c infection • Hepatitis C is a contagious liver disease that results from infection with the Hepatitis C virus. It can range in severity from a mild illness lasting a few weeks to a serious, lifelong illness. Hepatitis C is usually spread when blood from a person infected with the Hepatitis C virus enters the body of someone who is not infected Dr.T.V.Rao MD

8. Hepatitis C - Epidemiology 1999 Before 1985 Illegal Drug Use Transfusion Sexual Other Unknown Dr.T.V.Rao MD

9. Hepatitis C Infection - Natural History Dr.T.V.Rao MD

10. Dr.T.V.Rao MD

11. ·········· ·········· ·········· ·········· ·········· ·········· ·········· ·········· ·········· ·········· ·········· ····· 100 15 Infected With Hepatitis C No Chronic Disease ·········· ·········· ·········· ·········· ·········· ·········· ·········· ·········· ····· ·········· ······· ·· 17 2 85 Chronic Disease Cirrhosis Liver Cancer What Happens to People With Hepatitis C Virus? Dr.T.V.Rao MD

12. Chronic Hepatitis C Factors Promoting Progression or Severity • Increased alcohol intake • Age > 40 years at time of infection • HIV co-infection ? Other • Male gender • Other co-infections (e.g., HBV) Dr.T.V.Rao MD

13. Non-Drinker Hepatitis C Non-Drinker Drinker Without Hepatitis C Drinker With Hepatitis C Alcohol major contributor for progress of disease Chance Of Getting Cirrhosis Dr.T.V.Rao MD

14. Hepatitis c can present as acute or chronic infection • Hepatitis C can be either “acute” or “chronic.” Acute Hepatitis C virus infection is a short-term illness that occurs within the first 6 months after someone is exposed to the Hepatitis C virus. For most people, acute infection leads to chronic infection. Chronic Hepatitis C is a serious disease than can result in long-term health problems, or even death. Dr.T.V.Rao MD

15. Transmission / Exposure • Hepatitis C is spread when blood from a person infected with the Hepatitis C virus enters the body of someone who is not infected. Today, most people become infected with the Hepatitis C virus by sharing needles or other equipment to inject drugs. Before 1992, when widespread screening of the blood supply began in the United States, Hepatitis C was also commonly spread through blood transfusions and organ transplants. • People can become infected with the Hepatitis C virus during such activities as Sharing needles, syringes, or other equipment to inject drugs Needle stick injuries in health care settings • Being born to a mother who has Hepatitis C Dr.T.V.Rao MD

16. Less commonly transmitted through … • Less commonly, a person can also get Hepatitis C virus infection through Sharing personal care items that may have come in contact with another person’s blood, such as razors or toothbrushes • Having sexual contact with a person infected with the Hepatitis C virus Dr.T.V.Rao MD

17. People with risk factors for hepatitis C Those who wish to be tested Who Should Be Tested for Hepatitis C? Dr.T.V.Rao MD

18. Who should get tested for Hepatitis C? • You are a current or former injection drug user, even if you injected only one time or many years ago. • You were treated for a blood clotting problem before 1987. • You received a blood transfusion or organ transplant before July 1992. • You are on long-term hemodialysis treatment. • You have abnormal liver tests or liver disease. • You work in health care or public safety and were exposed to blood through a needle stick or other sharp object injury. • You are infected with HIV. Dr.T.V.Rao MD

19. Ever injected illegal drugs Received clotting factors made before 1987 Received blood/organs before July 1992 Ever on chronic hemodialysis Evidence of liver disease Healthcare, emergency, public safety workers after needle stick/mucosal exposures to HCV-positive blood Children born to HCV-positive women HCV Testing Routinely Recommended Based on increased risk for infection Dr.T.V.Rao MD

20. Routine HCV Testing Not Recommended(Unless Risk Factor Identified) • Health-care, emergency medical, and public safety workers • Pregnant women • Household (non-sexual) contacts of HCV-positive persons • General population Dr.T.V.Rao MD

21. HCV Infection Testing Algorithmfor Diagnosis of Asymptomatic Persons Negative (non-reactive) STOP EIA for Anti-HCV Positive (repeat reactive) OR Negative RT-PCR for HCV RNA RIBA for Anti-HCV Positive Positive Negative Indeterminate STOP Additional Laboratory Evaluation (e.g. PCR, ALT) Medical Evaluation Negative PCR, Normal ALT Positive PCR, Abnormal ALT Source: MMWR 1998;47 (No. RR 19) Dr.T.V.Rao MD

22. How is Hepatitis C Diagnosed? • Blood testing • Hepatitis C antibody test • Hepatitis C PCR test to find virus in blood • Liver function tests Dr.T.V.Rao MD

23. Serologic tests to detect HCV antibodies: - enzyme immunoassay (EIA). False negative in pts on HD, immunodeficiency; false positive in autoimmune disorder. - recombinant immunoblot assay (RIBA) Target amplification technique to detect HCV RNA (molecular assay) - polymerase chain reaction (PCR). A positive test confirms HCV infection. LABORATORY DIAGNOSIS Dr.T.V.Rao MD

24. Currently performed testes for hepatitis c infection • Currently, the second-generation enzyme immunoassay (EIA-2) for antibodies to HCV (anti-HCV) is the most practical screening test for HCV infection. The diagnosis of HCV infection can be supported or confirmed by the recombinant immunoblots assay (RIBA) or tests for HCV RNA. RIBA detects antibodies to individual HCV antigens and confers increased specificity compared to EIA-2. Dr.T.V.Rao MD

25. Molecular methods in Diagnosis of hepatitis c infection • Qualitative reverse transcription- polymerase chain reaction (RT-PCR) assays for HCV RNA are simpler than quantitative tests and sufficient for confirmation of the diagnosis of HCV infection. Dr.T.V.Rao MD

26. Alanine Aminotransferase • Serum ALT testing is inexpensive and noninvasive. • Insensitive means of monitoring disease activity. • A single determination gives limited information, and serial measurements recommended. • Weak association between the degree of ALT elevation and severity of histopathological findings on liver biopsy. • Resolution of ALT elevation with antiviral therapy appears to indicate disease response. Dr.T.V.Rao MD

27. Serologic Pattern of Acute HCV Infection with Recovery anti-HCV Symptoms +/- HCV RNA Titer ALT Normal 6 1 2 3 4 0 1 2 3 4 5 Years Months Time after Exposure Dr.T.V.Rao MD

28. Serologic Pattern of Acute HCV Infection with Progression to Chronic Infection anti-HCV Symptoms +/- HCV RNA Titer ALT Normal 6 1 2 3 4 0 1 2 3 4 5 Years Months Time after Exposure Dr.T.V.Rao MD

29. LIVER BIOPSY • Provides useful information about the degree of fibrosis in HCV infected patients. This information is important in management decisions. • Is not used for diagnosis of HCV infection. • Used for assessment of severity of inflammation, presence of fibrosis, evaluate possible concomitant disease processes, assess therapeutic intervention. Dr.T.V.Rao MD

30. Liver Histology • Activity (necro-inflammation) – severity and progress. May fluctuate with disease activity or therapeutic intervention. • Fibrosis implies possible progression to cirrhosis. In mild cases, is limited to portal and periportal area. More advanced changes defined by ‘bridging fibrosis’. • Cirrhosis Dr.T.V.Rao MD

31. Diagnostic assessment of infected patients • In summary, the diagnostic algorithm of Hepatitis C depends on the clinical context. In asymptomatic, low-risk subjects, who are found to be anti-HCV- positive by EIA-2, the diagnosis of HCV infection needs to be confirmed, especially if the initial biochemical tests reveal normal ALT levels. Dr.T.V.Rao MD

32. Can we prevent hepatitis c infection • There is no vaccine for Hepatitis C. The best way to prevent Hepatitis C is by avoiding behaviors that can spread the disease, especially injection drug use. Dr.T.V.Rao MD

33. References • Centre for Disease Control (CDC) Atlanta USA, guidelines on basis of disease Diagnosis, and consequences of Hepatitis C Infection Dr.T.V.Rao MD

34. Created by Dr.T.V.Rao MD for Medical and Health Care workers in the Developing world • Email • doctortvrao@gmail.com Dr.T.V.Rao MD