Download What Is This Virus Called Hepatitis C?

Frances Cieslak
Victorian Viral Hepatitis Educator
[email protected]
Impact of Hepatitis
Hepatitis can be caused by:
Harmful consumption of alcohol
Some chemicals and drugs
Viruses – 5 known A, B, C, D & E
Inflammation of the liver – natural
response to injury
Scar tissue = Fibrosis
Extensive scarring = Cirrhosis
HBV & HCV require long term monitoring
One in 12 people worldwide are
living with chronic hepatitis B or C
World Hepatitis Alliance
Chronic hepatitis B & C are responsible for
over 80% of the worlds liver cancer (HCC)
ASHM/NSWCC 2008
Hepatitis B At A Glance
ASHM/CCNSW 2008
 2 billion people infected world wide (350 million chronic)
 1 million HBV related deaths each year
 A leading cause of hepatocellular carcinoma (HCC)
 Screening people at risk is critical
 Treatment is available to control the virus
 Vaccination prevents NEW cases but will not impact on
current chronic hepatitis B burden
Global Prevalence of chronic
HBV CDC 2006
Chronic Hepatitis B in Australia
 Low prevalence (<2%), but high in some populations:
 Eg. People from China & Vietnam; sub-Saharan Africa &
Indigenous Australians
 ~ 50-65% of chronic HBV (in Aus) – in people born in Asia
 ~ 160,000 Australians have chronic HBV
(Gidding 2007)
 ~ 45,000 people with chronic HBV in Victoria
~1500-2000 new cases notified in Victoria each year (Cowie 2008)
Transmission of HBV
Percutaneous or mucosal exposure to:
infected blood & body fluids
Semen, vaginal secretions, saliva & breast milk*
Mother to child
 Globally – perinatal transmission is most common
 *HBIG & vaccine should eliminate theoretical risk of
acquisition through breast feeding
 Foetal scalp monitoring should NOT be used
 No evidence that mode of delivery (vaginal or caesarean)
affects risk of infection
CHB - Who Should Be Screened?
GESA Chronic Hepatitis B Recommendations 2008
HIGH risk populations
 Any person born in/parents born in an endemic country
 Indigenous populations
 IDU’s (previous or current)
 Household/sexual contacts of HBsAg positive person
 History of HCV or HIV
 All pt’s undergoing chemo/immuno-suppressive therapy
 Those on renal dialysis
Antenatal screen for ALL pregnant ♀ (RANZCOG)
Pre & Post test discussion
Natural History of HBV Acquired at Birth
Digestive Health Foundation 2000
HBV DNA ( pg/mL)
CHRONIC HEPATITIS
CIRRHOSIS (30%)
HCC
ALT
HBeAg
+ + + + + + + ++ +
---------------
Clearance phase
ALT normal
range
10
Immune tolerant
Replicative phase
20
AGE (years)
30
40
Immune escape
Immune control
Immune clearance
ReactivationImmuno-active phase Low replicative phase
Pre-core mutant
Diagnosis & Treatment
Mum: HBV Serology & LFT’s
Infant: If mum HBV+ HBV serology & LFT’s – at 2-6 mnths
S100 medications - Currently Liver biopsy required
Pegylated interferon (weekly injection)–**side effects**
Antiviral medication – (tablets) Long term – usually well
tolerated, viral resistance is possible
Mum – Preferably NOT treated during pregnancy but may
be if high viral load – resistance is an issue
Infant – Not usually treated due to disease phase, viral
resistance , need for further research in children
Vaccination
 Advised for ALL people at risk of contact with blood or
body fluids
 Funded for some groups – encourage IDU’s
 Can ↓ perinatal transmission risk from 90% to 5%
if
HBIG (12hrs) &1st HB vaccination (24hrs no > 7 days)
(when mum has active HBV markers - HBsAg + and HBeAg)
 Adult – 3 injections – Now, 1 & 5 months later
 Infants – 4 injections – birth, 2, 4 6 (or 12 months)
Hepatitis C at a glance
 ~ 170 million people chronically infected globally
(3-4 million new infections each year)
WHO
 ~ 284,000 Australians infected with HCV
 ~ 211,700 people chronically infected
(~ 17,444 people are living with HIV) NCHECR 2009
 NO VACCINE – However treatment is available &
CURE is possible
 A leading cause of liver transplant in Australia
NCHECR 2008
 Slow acting virus – often asymptomatic
Prevalence of Hepatitis C infection
6 Genotypes
>10%
2.5–10%
1–2.5%
WHO. Wkly Epidemiol Rec 2002; 77: 41
Transmission of HCV - Blood to blood
Risk Factors
 Sharing injecting equipment
 Recipient of blood products < 1990
 History of incarceration
 Unsafe tatooing & body piercing (traditional practices)
 Place of birth – mass vaccination programs
 Sharing of blood contaminated household items
Mother to child - 5% risk
- Foetal scalp NOT to be used No
- Mode of delivery – no affect on risk
- Breastfeeding OK except if nipples
cracked
Natural history of hepatitis C
Potential outcomes
Approximately 1 of every 4 people (25%) who contract hepatitis C will clear their
infection naturally within the first 6-12 months. The remaining 3 out of 4 people
(75%) will develop chronic hepatitis C.
Of 100 people with chronic hepatitis C who
remain untreated:
45 may not
develop liver
After 20 years damage
47 may develop
mild to moderate
liver damage
45 may not
After 40 years develop liver
damage
31 may develop
mild to moderate
liver damage
7 may develop
cirrhosis of the
liver
20 may develop
cirrhosis of the
liver
1 may develop
liver failure or
liver cancer
4 may develop
liver cancer or
liver failure
Hepatitis C is a highly stigmatised condition
Support from health professionals is important
Disclosure
In most situations there is no legal obligation to disclose
Examples of discrimination & lack of knowledge:
 Mum wearing ‘colored’ arm band & baby’s cot labelled
‘universal precautions’
 Labelling expressed breast milk “Hepatitis C”
 Education is key
Diagnosis
Antenatal screen for recommended in pregnant ♀ (RANZCOG)
Pre & Post test discussion
Mum: HCV serology (Ab’s + Virus) & LFT’s
Infant: Counselling – Implications of testing
Can check for virus with PCR test > 2 months
Can check Ab’s > 18mnths due to maternal
If Mum positive for virus – refer to liver clinic
If infant positive – refer to paediatric gastroenterologist
Treatment
S100 Medications - NOT during pregnancy or breast feeding
Pegylated Interferon - weekly S/C injection **side effects**
Ribavirin = tablets BD - teratogenic – contraception!
Infants not usually treated – some children - compassionately
Aim: Sustained Virological Response (SVR)
100%
- undetected virus
80%
- > 6 months = CURE
60%
40%
80%
24 weeks
50%
48 weeks
20%
0%
Genotype 1
Genotype 2/3
How can you help?
Educate
Transmission & prevention (including vaccination)
Tests available
Treatments available to control (HBV) & cure (HCV)
Importance of monitoring for possible liver damage & HCC
Refer
To GP for screening/testing – refer on to specialists
For ongoing monitoring for liver damage & HCC
For counselling – mental health, drug & alcohol services
Thank you
Any questions or comments?
Education and Support Services
Victorian Viral Hepatitis Educator
Information for Health Professionals
0407 865 140 or 9288 3586
[email protected]
Hepatitis C Victoria
Ph: 9380 4644
InfoLine 1800 703 003
Refer to Commonwealth Infection Control Guidelines (ICG)
The Australian Immunisation Handbook
Key Documents
 B Positive: all you wanted to know about hepatitis B –
A guide for primary care providers (2008) Produced & funded by: ASHM & The
Cancer Council NSW
 C Change - Report of the enquiry into hepatitis C related discrimination
Anti-discrimination board of NSW 2001
 Giles, M.L, Pedrana, A, Jones, C, Garland, S., Hellard, M. and Lewin, S.R.
‘Antenatal screening practice for infectious diseases by general practitioners in
Australia’ Australian and New Zealand Journal of Obstetrics and Gynaecology
2009, 49, 39-44
 Hepatitis viruses and the newborn: Clinical manifestations and treatment,
http://www.uptodate.com Uptodate January 2009 – American Continued Medical
Education Program – Royal College Association of Physicians
 HIV, Viral hepatitis and STI’s – A guide for primary care ASHM 2008
 HIV/Aids, Viral Hepatitis and Sexually Transmissible Infections in Australian
Annual Surveillance Report NCHECR 2008
Key Documents
 Impact – Information about Heptatits C 5th Ed. Hepatitis Victoria 2008
 National Hepatitis C Resource Manual 2nd Ed. Dept. of Health & Ageing 2008
 Overview of hepatitis B virus infection in children Uptodate January 2009 –
American Continued Medical Education Program – Royal College Association of
PhysiciansVictorian Infectious Diseases Bulletin 11 (3) Sep 2008 DHS Victoria
 Temple-Smith, M., Jenkinson, K., Lavey, J., Gifford, SM & Morgan, M.
Discrimination or discretion? Explorying dentists’ views on treating patients with
hepatitis C Australian Dental Journal 2006 51 (4) 918-929
 Wiseman, E., Fraser, MA, Holden, S, Glass, A, Kidson, BL, Heron, LG, Maley,
MW, Ayres, A, Locarnini, SA, Levy, MT Perinatal transmission of hepatitis B virus:
An Australian Experience MJA ‘Research’ 2009 190: 489-492
 Wallace, J., McNally, S., & Richmond, J. (2007) National Hepatitis B Needs
Assessment ARCSHS Latrobe University
Hepatitis Treatment Centres
•Geelong Liver Clinic
•Maroondah Hospital
 Bayside Hepatitis Clinic
(Cheltenham)
•Monash Medical Centre - Clayton
Aubury / Wodonga – by appt
- Springvale Liver Clinic
Austin Hospital
- Cranbourne Liver Clinic
Ballarat Liver Clinic
• Northern Hosp. Liver Clinic
Bairnsdale Hospital
• Royal Melbourne Hospital
Bayside Gastroenterology
(Frankston)
• St. Vincent’s Hospital
Bendigo Health Infectious Diseases •St. Kilda – First Step
Liver Clinic
• Warrnambool – Western Region
Box Hill Hospital
Alcohol and Drug (WRAD) centre
Fitzroy – Inner Space
• Werribee Hepatitis Clinic
Footscray – Western Hospital
Frankston – Peninsula Liver Clinic
 Alfred Hospital - Prahran
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Frances Cieslak Victorian Viral Hepatitis Educator