Download Hepatitis C

Hepatitis C
Joyce Sutton, M.D.
HIV and HCV in CDC
 1994 and 1999 anonymous tests of all
inmates entering prison during a two month
period. 5000+ each time.
Results
 1994
 1999
HIV 2.5% HCV 41%
HIV 1.4% HCV 34.6%
 NYC inmates 16% positive for HIV
Incidence of HCV in other
populations
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US overall 1.8%
NYC Oral Surgeons-9% 1990
Egypt overall 18%
Sacramento clinic for IVDU 95% 2000
California state hospital patients 25%
Psychiatric outpatients in US 5-20%
Sacramento Co. Jail 1999- 28%
History of HCV
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1970’s non-A, non-B hepatitis
1989 HCV cloned, blood tests available
1990 Interferon approved for Tx
1990 ribaviron added to Tx
2001 Pegelated interferon approved
Hepatitis review
 Hep A
. Food borne (oysters, etc)
 Oral-fecal spread (un-washed hands,
dishes)
 Acute symptoms (fever, jaundice, malaise)
 Most persons recover completely
Hep B
 Blood to blood transmission (needles,
transfusions)
 Most persons recover, 5-20% develop
chronic infection, 5% cirrhosis and death
 10x more contagious than HCV 100x more
than HIV
 1990 vaccine approved for Hep A and
Hep B
 Before then, infection of health care
personnel was common
 State hospital and CDC dentists- 75%
became infected 25 years ago
 Royal Air Force, England 1940’s and
1960’s outbreaks of jaundice and
hepatitis in troupes from re-use of
injection syringes
Hep C (HCV)
 Rapidly mutating RNA virus, develops many
sub-populations of HCV “quasi-species”
 Difficult for immune system to eradicate, and
difficult to develop vaccine or effective
treatment
 Blood to Blood transmission
Methods of transmission in US
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IV drug use
65% of patients
Transfusions 15% (before 1989)
Dialysis
7%
Fetus
2%
Needle stick
1% (accidents)
Unknown
10%
Sexual Transmission- low risk
Transmission in prison
 Shared needles
 Tattoos ink is saved and re-used
 Other shared personal items (toothbrushes,
razors, nail clippers)
Transmission to Fetus
 3-7% of babies of HCV+ mothers
 No medication to prevent this
 Interferon and ribaviron both cause severe birth
defects
 Most babies do well without treatment
 50% eradicate virus by 6 months
 75% eradicate virus by one year.
Natural History of HCV infection
 No symptoms for many years or decades,
most cases detected by blood test.
 Mild symptoms may occur: fatigue, itching,
RUQ discomfort
 25% clear virus, 75% chronic infection
 25% progress to Fibrosis-Cirrhosis
 5% develop liver cancer
 25%+ will develop type II Diabetes
 ANY alcohol use accelerates
progression to Fibrosis and Cirrhosis
 HIV co-infection greatly accelerates
progression of HCV (decreases immune
response) 30%+ of HIV patients also
have HVC. HCV is becoming a major
cause of death in treated HIV patients.
6 genotypes and over 50
subtypes
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1 Most common US and Canada 60-75%
2+3 25% Us and Canada
4,5 +6 less then 5% US and Canada
4 most common type in Egypt
Treatment
 Least effective (45% SVR) for the most common
HCV genotype (type I- 75% of cases)
 Most effective (80% SVR) for the least common
genotypes (2&3-25%)
 Many side effects, very unpleasant
 Can delay Tx if disease not progressing rapidly
and hope for better Tx later.
Early Treatment Recommended
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Genotypes 2+3- better results 80% SVR
Shorter treatment duration 24 weeks
Possible lower dose ribavirin
Consider treatment after needle stick injury
if infection results
Absolute Contraindications to
Treatment
 Age less than 3
 Poor compliance
 Decompensated liver Disease (except pretransplant)
 Ongoing and Untreated Substance Abuse
 Pregnancy or nonadherence to
contraceptive use during Tx and 6mos after
Co-existing Medical Disorders
and contraindications
 Uncontrolled seizure disorder
 Uncontrolled severe Psychiatric Disorder
 Autoimmune diseases, including SLE and
Rheumatoid Arthritis
 Solid Organ Transplantation (except liver)
 Severe Anemia, Neutropenia,
Thrombocytopenia
 Uncontrolled Heart disease (angina,
congestive failure, significant
arrhythmias)
 Cerebrovascular disease
 Advanced Renal failure
Serologic Testing
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HCV antibodies (anti-HCV) EIA
95-99% sensitivity- inexpensive
6-8 weeks after exposure
HCV-RNA assay (qualitative-PCR)
Detects viral RNA - expensive
1-3 weeks after exposure
Who should be tested for HCVRNA
 Inconclusive anti HCV PCR
 Immunocompromised (HIV, transplant
patient, hemodialysis)
 Suspected acute infection (needle stick)
 Positive HCV, but persistently low normal
ALT (may have cleared virus)
Monitoring
 Follow LFT, especially ALT(indicates
inflammation)
 Follow FBS and 2h pp glucose (glucose
intolerance increases as disease
progresses)
 Test for genotype and viral titer
 Liver biopsy before Tx (Only way to know
how far disease has progressed)
Course of Treatment
 Goal- complete irradication of virus
sustained for 6 months after Tx stopped
 Studies at 3 and 13 years after SVR indicate
durable results
 Length of Tx and dose depends on
genotype
 Type I (75%)
 Continue Tx for 48 weeks+
 Peg Interferon (weekly sub-Q ) and
Ribaviron 1000-1200mg daily
 Type 2 & 3 (25%)
 Continue Tx 24 weeks
 Peg Interferon (weekly Sub Q) and
Ribaviron 800mg daily
12 week treatment test
 All genotypes, repeat viral titer at 12 weeks
 If less than 2 LOG decrease in viral titer,
STOP TREATMENT
 Less than 3% chance of response, does not
justify risks of treatment
24 week treatment test
 All genotypes, repeat viral titer at 24 weeks.
 Titer should be ZERO. If not, STOP
TREATMENT
 Less than 3% chance of response and
continued treatment does not justify the
risks
Adverse effects of Treatment
 Bone marrow suppression- Neutropenia,
anemia, decreased platelets
 Contraindicated with clozaril
 Problematic with HIV patients who are
immunosuppressed. However, many HIV
patients have been successfully treated.
Response rates are similar to other patients.
 Flu-like symptoms-can be severe: malaise,
headache, muscle aches, nausea, fever,
anorexia,
 Psychiatric symptoms: depression and
irritability, can be severe. 60% of non
psychiatric patients become depressed.
 SSRI medications helpful (prozac, etc.)
 Relative contraindication in psychiatric
patients. However, many state hospital
patients have been successfully Tx. Requires
close observation and increased medications.
(increased suicide risk)
Needle Sharing
 Sacramento drug Tx clinics 2000
 Meth users- 30% inject 43% often did not
sterilize
 Meth users- shared with 11 strangers /yr
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casual sex with 8 partners
 Heroin users- shared with 3.4 strangers /yr
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casual sex with 2.6 partners
Needle Exchange Programs
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2002 Mar 13 Int. J of STD and AIDS
New Haven, Co.
Needles were “tagged” to identify “owner”
31.5% were returned by different “owner”
Unsafe Injections and Blood
Bourne Disease
World Wide Problem
 Developing world (Africa, Asia, Central and South
America, Mexico, Romania)
50% of injections are un-sterile, and other medical
practices are un-safe
Developed countries-Shared Needles of drug users
Unsafe cosmetic practices (nail salons, piercing,
tattoos)
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Cultural Differences
 Nothing of value is thrown away or wasted
 Injections are “magic”
 Are the most effective way to deliver
powerful and expensive medicine
 Overuse of injections 90% not needed
(vitamins,antibiotics,analgesics) 10%
vaccinations
 Lack of understanding of sanitation and
blood bourne disease
Unsafe injections may spread
HIV more than sex
 Controversial -Interesting data
 “Deep” injuries may be 10X more likely to infect
than superficial needle pricks. Account for over
50% of infections in health care workers, yet are
only 10% of accidents.
 HIV+ children- 20% have HIV- mothers
 Pre-natal care and delivery (Kenya,Zimbabwe,S.
Africa) 5-19% of HIV- women become HIV+
 Puerperal fever rates in Vienna 1841-46
616% (Semmelweis)
 Romania 1990- 14% of orphans 0-3 yrs old
tested HIV+ (1000+ )
 Origin- imported gamaglobulin given to a few
kids and spread to rest by un-safe injections.
 One orphanage records: 1989 Given- 4457
injections Sterilized- 810 syringes (82% Not
sterilized)
 Pediatric clinics in Africa re-use needles 3-20%
of children are HIV+
 Infants have viral loads 10-100x adults
 No investigation of infections is done
 Thousands of paid blood donors in China are
infected with HIV.
 One Chinese village, 50-70% of older people
have HCV from clinic injections before 1985
 Egypt- 18% of population is HCV+ -injections for
shistosomiasis 1920-1980
 1950,s-1980’s massive increase in Medical
injections in Africa- vaccinations and treatment
of yaws. Time of silent spread of HIV
 The River- Source of HIV may have been early
polio vaccine trials in Africa using monkey kidney
cultures
Hepatitis C and diabetes
Incidence of Hepatitis C
 CDC 35-38% of inmates at reception center
1994 + 1999
 DMH 25-30% state hospital patients
 US population 1.8%
 US Psychiatric outpatients 5-20%
 Sacramento drug tx program 95%
 Egypt general population 18%
Diabetes and Hepatitis
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Hep C increases insulin resistance
Hep C is an independent risk factor
Hep C is additive to other risk factors
Diabetes risk increases as the liver disease
advances (13-33%non-cirrhotic mean 25%)
 (50%+ cirrhotic)
 No-one has studied the diabetes risk of Hep C in
Psychiatric patients or the interactions with
Psychiatric medications
Eli Lilly
(Olanzapine)
 Clinical trials eliminated any patients with
known liver disease
 They had not thought about the combined
effects of Hep C and Olanzapine re diabetes
 They are interested in funding clinical
studies
 Diabetes may increase the progression
of HCV to cirrhosis
 Test all patients for HCV and HBV
 Consider medications with less potential
for weight gain in HCV+
 Monitor HCV+ more closely for diabetes
SGA’S and weight gain
Drug
Weight gain
Clozapine
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Olanzapine
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Risperidone
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Quetiapine
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Aripiprazole
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Ziprasidone
+/-
amantadine
 Has some antiviral activity against Hep C
 Helps to prevent depression during Hep C
treatment
 May stop weight gain from antipsychotics
 As effective as cogentin or artane for EPS
side effects
HVC Self Care
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Abstain from all alcohol
Maintain normal body weight
Exercise
Avoid Herbal Products, especially Kava- these are
not effective and many are toxic to the liver
 Do not take Iron supplements (buy senior
vitamins)
 Avoid NSAIDS
HCV Prevention
 Do not share needles
 Do not use Health Care in developing countries
(includes blood tests and acupuncture) buy
Medical Evacuation Insurance (SOS, AAA)
 Evaluate carefully nail salons- bring your own
tools. (also tattoo and piercing parlors)
 Do not use nail salons in Developing countries