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Hepatitis C: An Overview

Hepatitis C: An Overview. Maria del Rosario, MD, MPH Division of Infectious Disease Epidemiology WVDHHR/BPH/OEPS August 2011. Objectives. At the conclusion of this talk, each participant should be able to: Discuss the epidemiology of Hepatitis C.

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Hepatitis C: An Overview

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  1. Hepatitis C: An Overview Maria del Rosario, MD, MPH Division of Infectious Disease Epidemiology WVDHHR/BPH/OEPS August 2011 WVDHHR/BPH/OEPS/DIDE

  2. Objectives At the conclusion of this talk, each participant should be able to: • Discuss the epidemiology of Hepatitis C. • Describe Hepatitis C surveillance in West Virginia, to include disease investigation and reporting. • Discuss the role of public health in the management of Hepatitis C infection. WVDHHR/BPH/OEPS/DIDE

  3. Did you know… …the liver affects nearly every physiological process of the body and performs over 500 different chemical functions? WVDHHR/BPH/OEPS/DIDE

  4. The Liver Functions: • Stores vitamins and nutrients • A chemical powerplant • Produces clotting factors • Produces proteins • Filters toxins • Regulates hormones WVDHHR/BPH/OEPS/DIDE

  5. The Hepatitis C Virus (HCV) • Enveloped RNA virus (flavivirus) • Reservoir: man • Genome is highly mutable • Highly heterogeneous - • 11 genotypes (1-11) • many subtypes (a,b,c, etc.) • 100 different strains (1,2,3,etc.) WVDHHR/BPH/OEPS/DIDE

  6. Did you know… …the predominant risk factor for HCV acquisition is injection drug use? WVDHHR/BPH/OEPS/DIDE

  7. Transmission Parenteral (Blood) • Sharing needles, syringe, equipment to inject drugs • Needlestick injuries – e.g. Healthcare setting exposure – medical, dental • Born to a mother who has hepatitis C Sexual contact – rare, but risk increase when: • Multiple sex partners • STD or HIV infection • Engaged in rough sex WVDHHR/BPH/OEPS/DIDE

  8. Transmission Breached infection control • Tattooing or body piercing – less common • Household: direct through-the-skin exposure (shared personal care items) – less common • Occupational exposures • Healthcare settings medical, dental, outpatient • Safety and sanitation work • NOT SPREAD BY: • Sharing eating utensils • Breastfeeding, hugging, kissing, coughing • Through food or water WVDHHR/BPH/OEPS/DIDE

  9. Acute Hepatitis C Infection • Uncommon – decrease in new cases • Short-term illness that occurs within the 1st 6 months of exposure to the virus • Newly infected • Asymptomatic - 70% to 80% of people with acute hepatitis C • Mild to severe symptoms (6-7 weeks post-exposure) • Fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, • Dark urine, joint pains, jaundice, dark colored stools • HCV RNA detected (1-3 weeks post-exposure) • Anti-HCV seroconversion (mean: 8-9 weeks post-exposure, >97% persons at 6 mos.) WVDHHR/BPH/OEPS/DIDE

  10. Chronic Hepatitis C Infection • Long-term illness that occurs when the virus remains in the person’s body, can last a long time leading to serious liver disease or death. • SIGNIFICANCE: • Most patients are asymptomatic • Infected persons – source of transmission to others • Risk for chronic liver disease • Leading cause of liver cirrhosis and liver cancer. • Most common reason for liver transplantation in the U.S. WVDHHR/BPH/OEPS/DIDE

  11. Atypical Forms of Chronic Hepatitis C • Normal aminotransferases • Atypical serologic patterns • Decompensated liver disease • Immunosuppressed • Children colony WVDHHR/BPH/OEPS/DIDE

  12. Did you know… …that 15 to 30% of patients with chronic hepatitis C infection develop cirrhosis over the next 30 years? WVDHHR/BPH/OEPS/DIDE

  13. Progression of Hepatitis C Infection Source: pubs.niaaa.nih.gov/publications/arh25-4/245-254.htm WVDHHR/BPH/OEPS/DIDE

  14. Natural History of Hepatitis C Virus Source: NEJM 2011; 364:2429 - 2438 WVDHHR/BPH/OEPS/DIDE

  15. HCV RNA HCV RNA HCV RNA HCV RNA WVDHHR/BPH/OEPS/DIDE

  16. Hepatitis C Surveillance West Virginia • Passive surveillance • Reportable disease condition (64-CSR-7) • Acute hepatitis c – report within 1 week • Hepatitis c laboratory results – report within 1 week • Case investigation – Protocol guide • Report through WVEDSS and hepatitis C registry • Case ascertainment (CSTE definitions) and review • Summary data WVDHHR/BPH/OEPS/DIDE

  17. Did you know… …about the most recent changes to the case definition of Acute Heptitis C and Chronic Hepatitis C? WVDHHR/BPH/OEPS/DIDE

  18. Acute Hepatitis C: Case Definition2011 CSTE Clinical Presentation • Acute illness with discrete onset of any sign/symptom consistent with acute viral hepatitis (e.g., anorexia, abdominal discomfort, nausea, vomiting), and EITHER • Jaundice/ dark urine, OR • Serum ALT level >400 IU/L Laboratory criteria for diagnosis • 1 or more of the following criteria: • Anti-HCV screen-test-positive with a s/co predictive of true positive … OR • HCV RIBA positive, OR • NAT for HCV RNA positive (including genotype) • AND, meets the following two criteria: • IgM anti-HAV negative, AND • IgM anti-HBc negative WVDHHR/BPH/OEPS/DIDE

  19. Acute Hepatitis C: Case Classification2011 CSTE • Confirmed: • meets the clinical case definition, AND • laboratory confirmed, AND • not known to have chronic hepatitis C WVDHHR/BPH/OEPS/DIDE

  20. Chronic Hepatitis C: Case Definition2011 CSTE Clinical Case Definition • No symptoms are required. Laboratory criteria for diagnosis • One or more of the following: • Anti–HCV positive (repeatedly reactive) by EIA verified by at least 1 additional more specific assay, OR • HCV RIBA positive, OR • NAT positive for HCV RNA (including genotype), OR • Anti-HCV screen-test-positive with a s/co predictive of a true positive. WVDHHR/BPH/OEPS/DIDE

  21. Chronic Hepatitis C: Case Classification2011 CSTE • Confirmed: laboratory confirmed and does not meet the case definition for acute hepatitis C. • Probable: anti-HCV positive (repeat reactive) by EIA, and ALT or SGPT values above the upper limit of normal, but anti-HCV EIA result has not been verified by an additional more specific assay or s/co unknown. WVDHHR/BPH/OEPS/DIDE

  22. Hepatitis C Testing - 1 SEROLOGIC TESTS • Enzyme Immunoassay (EIA) for Anti-HCV • Positive: past or current infection • Verification of Anti-HCV (+) screening test • Reflex supplemental testing*: follow-up with more specific serologic test, e.g. HCV RIBA or NAT • Signal-to-cut-off ratio (s/co): predict supplemental test-positive results ≥95% of the time, s/co dependent on test type • HCV RIBA* (Recombinant Immunoblot Assay) • Detects antibodies to individual HCV antigens and confers increased specificity compared to EIA-2 • Some RIBA-positive patients are HCV RNA-negative WVDHHR/BPH/OEPS/DIDE

  23. Hepatitis C Testing - 2 VIRAL LOAD TESTS -measure HCV RNA (genetic material), types: • Qualitative test • Nucleic Acid Test (NAT)* for HCV RNA using RT-PCR • Detects HCV RNA in the blood, very sensitive B. Quantitative test • Branched-chain DNA (bDNA) • Measures viral loads greater than 50 IU/ml • Transcription-mediated Amplification (TMA) • Measure viral loads as few as 5-10 IU/ml WVDHHR/BPH/OEPS/DIDE

  24. Hepatitis C Testing - 3 GENOTYPING • HCV Genotype • 6 genotypes, >50 subtypes • clinical importance: counseling and treatment • epidemiology LIVER FUNCTION TEST • ALT • SGPT WVDHHR/BPH/OEPS/DIDE

  25. Reported Confirmed and Probable Cases of Hepatitis C, by Year of Diagnosis, WV, 2000-2010 *provisional WVDHHR/BPH/OEPS/DIDE

  26. Did you know… …that West Virginia’s Hepatitis C Surveillance is evolving? WVDHHR/BPH/OEPS/DIDE 26

  27. Hepatitis C Surveillance, WV (1) WVDHHR/BPH/OEPS/DIDE

  28. Hepatitis C Surveillance, WV (2) WVDHHR/BPH/OEPS/DIDE WVDHHR/BPH/OEPS/DIDE 28

  29. Disease Prevention • No hepatitis C vaccine • IG prophylaxis – not effective PEP • No antiviral therapy for PEP • Primary preventive measures • Secondary preventive measures WVDHHR/BPH/OEPS/DIDE

  30. Preventive Measures • Education, counsel • Prevention practices – barrier precautions • Test using FDA-cleared tests • If HCV infected, refer or evaluate for active infection WVDHHR/BPH/OEPS/DIDE

  31. Hepatitis C and the Healthcare Setting • Risk for infection after a needlestick or cut exposure = 1.8% • Risk following blood exposure to eye, nose, mouth = probably very small • Report of HCV transmission from exposure to non-intact skin • No known risk from exposure to intact skin. Source: http://www.cdc.gov/ncidod/dhqp/pdf/bbp/Exp_to_Blood.pdf WVDHHR/BPH/OEPS/DIDE

  32. Occupational Exposures 1. Following exposure to blood • Wash needlesticks and cuts with soap and water • Flush splashes to the nose, mouth, or skin with water • Irrigate eyes with clean water, saline, or sterile irrigants 2. Report the exposure WVDHHR/BPH/OEPS/DIDE

  33. Occupational Exposures 3. Follow-up after the exposure • Obtain baseline ASAP for HCV antibody and liver enzymes, and at 4-6 months later • Check for infection, test for HCV RNA 4-6 weeks post-exposure • Inquire about symptoms suggestive of hepatitis WVDHHR/BPH/OEPS/DIDE

  34. Who should get tested • Injection drug user (current or former) • Treated for blood clotting problem before 1987 • Blood transfusion or organ transplant before July 1992 • Longterm hemodialysis • Abnormal liver test or liver disease • Work in healthcare or public safety and exposed to blood through sharp object injury –percutaneous or permucosal exposure • HIV-infected • Born to HCV-positive mother WVDHHR/BPH/OEPS/DIDE

  35. HCV and Pregnancy 6 of every 100 HCV infants born to HCV-infected woman become infected • Infection occur during or near delivery • None of delivery method decreases risk to infant • Increase risk with maternal HCV viremia • Increase risk with HIV co-infected mom • HCV not transmitted to breastmilk, but abstain if nipples are cracked or bleeding • Test infants born to HCV-positive mom WVDHHR/BPH/OEPS/DIDE

  36. Did you know… …that children and personnel should not be excluded from daycare centers, school or sports just because they are HCV-positive? 36 WVDHHR/BPH/OEPS/DIDE

  37. Advice to HCV-positive Persons: • Do NOT donate blood, organs, tissue, semen • NOT share personal items that may have blood (razors, etc.) • Cover cuts and sores • With long-term, steady sex partner – no need to change practice WVDHHR/BPH/OEPS/DIDE

  38. Recommendations to Injectable Drug Users (1) • Counseling • Never reuse or share syringes, water, drug preparation equipment • Only use syringe from reliable source (e.g. pharmacy) • Use new, sterile syringe to prepare and inject drugs • If possible, use sterile water, or, clean water from reliable source WVDHHR/BPH/OEPS/DIDE

  39. Recommendations to Injectable Drug Users (2) • Use new or disinfected container and a new filter to prepare drugs • Clean the infection site prior to injection • Safely dispose of syringe after one use • Get vaccinated for hepatitis A and hepatitis B (if not yet immune) • Get tested for HIV WVDHHR/BPH/OEPS/DIDE

  40. Medical Management • Pegylated interferon + Ribavirin • Protease inhibitor WVDHHR/BPH/OEPS/DIDE

  41. CONCLUSION • HCV infection can have debilitating long-term effects. • Education and counseling, especially of high-risk persons, is the best way to prevent and control HCV infection. • Improved surveillance assist in identifying high-risk groups and prioritizing resources. WVDHHR/BPH/OEPS/DIDE

  42. Thank you Comments and Questions WVDHHR/BPH/OEPS/DIDE

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