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ABCs of Hepatitis
What is Hepatitis
• Hepatitis is inflammation of liver
• Hepatitis can be caused by a variety of factors
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Alcohol
Drugs
Chemicals
Toxins
Autoimmunity
Viral Infections (Hepatitis A, B, C, D, E, G)
The Liver
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Largest internal organ
Weighs about 3lbs
Size of football
Ability to regenerate after damage
Involved in many digestive, vascular and
metabolic activities
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
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
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, claycolored bowel movements, joint pain, jaundice
• Once resolved, protective antibodies develop and
give lifelong immunity
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
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
Recommendations for HAV vaccine
• Person’s at increased risk of HAV infection
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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
Hepatitis B
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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
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)
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
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
Recommendations for HBV Vaccine
• Person’s at increased risk of HAV infection
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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
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
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)
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
Hepatitis C
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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
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
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
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
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
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
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
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
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
Symptoms of Chronic Hepatitis
• Chronic Hepatitis
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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
Chronic Hepatitis C
• Factors promoting progression
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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
Treatment of HCV
• Medications to treat HCV
▫ Interferon (injected 3x per week) an immune booster
▫ Pegylated interferon (injected 1x per week) interferon
w/protein
▫ Ribaviron (pill several times a day) an antiviral
• Standard care is combination for 6-12 months
depending on genotype (1=12months)
• Goal no detectable virus and increased liver health
• Effectiveness varies from 40-80% (type 1 harder to
treat)
HCV Treatment continued
• Treatment has many side effects like fatigue,
depression, aches, hair loss, and nausea
• Treatment is expansive (at least 25,000 a year)
• If someone clears virus can still be reinfected if
engaging in risky behavior
• NOT EVERYINE NEEDS TREATMENT
• Coinfection w/HIV
▫ 1/3 people with HIV have HCV
▫ HCV considered OI