Transcript Integrating Viral Hepatitis into Client

Ass
Booty
Cooker
The ABCs of Viral Hepatitis
Heather Lusk
2nd National Conference on
Methamphetamine, HIV and Hepatitis
February 2, 2007
1
Hepatitis A Virus (HAV)
Overview
In 2005, ~42,000 people infected in the US
31.3% of U.S. population have been infected
Acute disease -- no chronic infection
Symptoms common in adults
Once resolved, protective antibodies develop
and give lifelong immunity
2
HAV Transmission
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
3
Hepatitis B Virus (HBV)
Overview
In 2005 ~51,000 new infections in US
~1.25 million in US living with chronic HBV
4.9% of U.S. population have been infected
6% of infected adults develop chronic HBV
90% of infants develop chronic HBV
Often no symptoms in acute stage
If resolved, protective antibodies develop and
give lifelong immunity
4
HBV Transmission
Transmitted by blood, semen, vaginal fluids
Highly infectious, stable in environment for at
least 7 days
Most common transmission through:
 perinatal (mom to baby)
 unprotected sex
 percutaneous (through opening in skin)
Vaccine is available to prevent infection
5
Hepatitis C Virus (HCV)
Overview
In 2005, ~20,000 new infections in US
~4 million* in US have been infected
1.6% of U.S. population have been infected
55%-85% of adults have chronic infection
Often no symptoms in acute stage
If resolved, no protective antibodies
*Recent analysis indicates closer to 5 million since
NHANES didn’t include homeless, incarcerated etc.
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HCV Transmission
Transmitted by direct blood-to-blood contact
Highly infectious, stable in environment for at
least 16 hours but not longer than 4 days
Most common transmission through sharing of
injection drug use paraphernalia
Also blood transfusions & products before 1992
–
–
–
–
Perinatal transmission (4% chance, 19% HIV/HCV+)
Needle stick/healthcare exposure (1.8%)
Sexual transmission
Other blood risks low/unknown risk: tattooing/piercing
intranasal cocaine use, shared personal items
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HCV Transmission
Sharing Injection Equipment
Studies have found high rates of HCV in IDUs
who didn’t share syringe, but shared cooker,
cotton, water or other paraphernalia
People who inject other things (steroids, vitamins,
silicone and hormones) may also be at risk
IDUs should use new, sterile equipment every
time (clean hands, injection site and surface too)
It is unknown if bleach kills HCV
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HCV Transmission
Sexual Transmission
Seven US studies of long-term discordant
partners found 1.5 - 3% seroprevalence of HCV
Other studies of MSM, sex workers, and those
with history of STD found prevalence of 4-6%
Risk may be increased when trauma is present
Other factors related with sexual transmission
include # of partners, the presence of other STDs,
and use of condoms
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HCV Transmission
Low/Unknown Risks
Non-professional tattooing (prisons tattoos etc): some
studies find higher rates of HCV in persons with tattoos
Intranasal cocaine/meth use: Some studies have found
link to HCV transmission by blood getting into nasal
membrane from shared snorting items
Crack use: at least one study (Schaefer) found higher
rate of HCV in non-injecting crack users who indicated
cracked, bleeding or burned lips
Personal items with blood on them: anything that
cuts/breaks the skin or membrane (razor, clippers)
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Sources of Infection for
Persons with Hepatitis C
Injecting drug use 60%
Sexual 15%
Transfusion 10%
(before screening)
Other* 5%
Unknown 10%
*Nosocomial; Health-care work; Perinatal
Source: Centers for Disease Control
and Prevention
Source: Sentinel Counties, CDC
Estimates of Acute and Chronic Disease
Burden for Viral Hepatitis, HIV, United States
HAV
HBV
HCV
93,000
78,000
25,000
100
150
?
Chronic
infections
0
1-1.25
million
2.7
million
Deaths/year (chronic)
0
5,000
8-10,000
Acute infections
Average/year*
Fulminant
deaths/year
HIV
40,000
15,000
* Based on estimated 2001 annual incidence.
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Hepatitis D and Hepatitis E
HDV:
Coined “Delta
Hepatitis”
Rarely seen in the
United States
Found only in persons
infected with HBV and
has similar routes of
transmission as HBV
Prevention is
vaccination for HBV
HEV:
Primarily a disease of
import
Very similar to
hepatitis A with fecaloral transmission
Transmitted like HAV
with the same
symptoms
No vaccination
available
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Meth and Viral Hepatitis
Little research on meth/viral hepatitis. PubMed search:
HIV/meth = 213 abstracts and HCV/meth = 26 abstracts
Documented outbreaks of HAV and HBV in meth users
Hepatitis A - feces can be on pipes etc.
Hepatitis B - transmitted like HIV so similar links
Hepatitis C - IDU but what about bloodier sex? Blood
into open wounds (incl. Nose/mouth)?
Scheinmann, R. et al., Non-injection drug use and
Hepatitis C Virus: A systematic review, Drug and Alcohol
Dependence (2006)
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Prevention of Viral Hepatitis
Vaccinate against hepatitis A
and hepatitis B
If no access to vaccine:
Wash hands!
Prevent fecal matter from
entering mouth
Use barriers for oral/anal sex
Clean sex toys between use
Prevent blood, semen and
vaginal fluids from entering
body
Avoid blood exposure:
New syringe, cooker, cotton
etc. every time for injection
Use universal precautions
Don’t share personal items
that may contain blood
(toothbrush/razor)
Hydration and lubricants
Cover open cuts/wounds
Ensure instruments used for
tattoos, piercing, acupuncture
are new or sterilized
Viral hepatitis prevention methods include HIV prevention but
HIV prevention methods don’t necessarily prevent viral hep. 15
Hepatitis A and Hepatitis B
Vaccines
Hepatitis A vaccine began usage in 1995
– Two dose series at 0 and 6-18 months
Hepatitis B vaccine began usage in 1982
– Usually three dose series at 0, 1 and 6
months
No severe adverse reactions. Most common
side effects include site of injection soreness,
headache, malaise
Combination vaccine available called TWINRIX
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Recommendations for
Hepatitis A Vaccine
Injection and non-injection drug users
Men who have sex with men (MSM)
Travelers to HAV endemic countries
Persons with chronic liver disease
Persons with clotting-factor disorders
Children living in communities with historically
increased rates of hepatitis A
Household and sex contacts of HAV+ persons
(People living with HIV – not a formal rec. but
should be!)
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Recommendations for
Hepatitis B Vaccine
Men who have sex with men
Persons with more than one sex partner in a six month period
Persons diagnosed recently with an STD
Sex contacts of infected persons
Injection drug users
Household contacts of chronically infected persons
Infants born to infected mothers
Infants/children of immigrants from areas with high HBV rates
Health care and public safety workers
Hemodialysis patients
Developmentally disabled in long-term care settings
People living with HIV
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New Hepatitis B Immunization
Recommendations
“A Comprehensive Immunization Strategy to
Eliminate Transmission of Hepatitis B Virus Infection
in the U.S.” MMWR Dec. 8, 2006. Vol. 55 No. RR-16
Venue-based immunizations: all persons should
be vaccinated in STD/HIV sites, drug treatment
programs, correctional settings and clinics that
see large amounts of IDU or MSM
Recommends all unvaccinated adults at-risk
should be vaccinated
All adults who ask for vaccine should be
immunized without having to self-disclose risk
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Viral Hepatitis Testing
Tests
Hepatitis A
Type of Tests HAV antibody
and antigen
Hepatitis B
Hepatitis C
HBV surface
and core
antibody and
antigen
HCV antibody
Interpretation Determines
Determines
current infection current infection
and immunity
and immunity
status
status
Testing Rec’s Symptomatic
Rarely pre-vac
testing, some
post-vac testing
Foreign born
Rarely pre-vac
testing, some
post-vac testing
HCV RNA
Determines if
ever infected.
Need RNA to
see if currently
infected
CDC rec’s
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HCV Testing Recommendations
from CDC
Test routinely based on risk for infection:
Ever injected drugs (even once)
Transfusions/organ transplants before 1992
Selected medical conditions (chronic hemodialysis,
elevated liver enzymes)
Received clotting factors before 1987
Test routinely based on a recognized exposure:
Healthcare or public safety workers after exposure to
HCV-positive blood
Children born to HCV-positive women
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HCV Testing Recommendations
from CDC
Routine testing of uncertain
need:
Recipients of transplanted
tissue
History of tattooing or body
piercing
History of multiple sex
partners or STDs
Long-term steady sex
partners of HCV-positive
persons
Users of intranasal cocaine
or other non-injection drugs
Routine testing is not
recommended:
Health care and public
safety workers
Pregnant women
Household contacts of
HCV-positive persons
General population
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Chronic Hepatitis B and C
Top causes of liver cancer and liver transplant
Symptoms include fatigue,depression,loss of appetite,
nausea/indigestion,muscle/joint pain,mood swings,
abdominal pain, fever, vomiting,jaundice,cognitive
dysfunction,fluid retention,lack of concentration
Slowly progresses over decades (sometimes slow,
fast, or little progression) often leading to liver damage
Monitoring important: liver, imaging, diagnostic tests
Drug-based and complimentary therapies available for
both hepatitis B and hepatitis C
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Chronic Hepatitis C
Factors promoting HCV progression:
– alcohol intake
– age >40 at time of infection
– HIV or HBV co-infection
– male gender
Vaccinate for HAV/HBV when appropriate
Not everyone needs drug-based therapies
Liver and self-care essential
Emotional support, empowerment and education
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Drug-based Therapies for HCV
Medications to treat HCV:
– Interferon (injected 3x week): an immune booster
– Pegylated Interferon (injected 1x week): interferon w/ protein
– Ribavirin (pill several times a day): an antiviral
Standard of care is combination therapy for 24-48
weeks, depending on genotype (type 1=48 weeks)
Effectiveness varies from about 40-80% (type 1 is hard
to treat and ~40% of type 1 has sustained response)
Treatment can have many side effects like fatigue,
depression, aches, hair loss and nausea
Treatment is expensive ($25,000 + a year)
Many drug users are denied access despite federal
guidance otherwise
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HIV and Hepatitis C
Liver disease is #1 cause of death and
hospitalizations in people living with HIV
Up to 1/3 of those living with HIV also have HCV
(1/10 of those with HCV have HIV)
HIV infection may promote HCV disease
progression (and sometimes vice versa)
Anti-HIV medications may cause hepatitis –
especially in those with viral hepatitis
HCV treatment in HIV+ becoming more effective
HIV may impact HCV transmission (sex/perinatal)
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Integrate Viral Hepatitis!
If We Don’t, Who Will?
Researchers: test for hepatitis B and C, ask
about knowledge of serostatus, add hepatitis
risks to surveys etc.
Front line staff: comprehensive disease model
approach based on identified risks
Programs: include hepatitis questions on intake
forms, risk assessments, case management
forms, client surveys etc.
Advocates: CDC DVH budget less than 20
million - we need a funded national response!
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Do You Know Your
Hepatitis C Coordinator?
Most states and several major cities (NYC, Chicago,
Philly, D.C.) have CDC-funded Hepatitis C
Coordinators
While HCV Coords may or may not have $$, they
can provide data, presentations, brochures and
other resources and want to collaborate with you!
http://www.cdc.gov/ncidod/diseases/hepatitis/resour
ce/coordinators.htm
National Alliance of State and Territorial AIDS
Directors (NASTAD) viral hepatitis working group,
advocacy etc. www.nastad.org
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Viral Hepatitis Resources
Guidelines: NIH Consensus Statement on
Hepatitis C, AASLD treatment guidelines, EASL
and VA HIV/HCV treatment guidelines
Strategic Plans: National Viral Hepatitis
Roundtable “A Call to Action: Eliminating Viral
Hepatitis” (many states also have plans)
Websites: www.hcvadvocate.org,
www.natap.org, www.hivandhepatitis.com,
www.hepcnetwork.org, www.hepcproject.org
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ABCs of Viral Hepatitis
Viral
Hepatitis
Transmission
Prevention
Living with
A is for ass Fecal to
oral
2 shot
vaccine
Acute
B is for
blood and
booty
Blood and
sexual
fluids
3 shot
vaccine
C is for
cookers
Blood
Most acute
5% chronic
in adults
No vaccine Most
New equip. chronic
everytime (55-85%)
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Recommendations for Viral
Hepatitis Testing and Vaccinations
People who have injected
drugs and other substances
(hormones, steroids,
vitamins):
Test for hepatitis C
Get vaccinated against
hepatitis A and B
People who use noninjection drugs:
Get vaccinated against
hepatitis A
Maybe test for hepatitis C
(depends on blood risk – with
meth for example)
Men who have sex with Men:
Get vaccinated against
hepatitis A and B
People living with HIV:
Get vaccinated against
hepatitis A and B
Test for hepatitis C
People with multiple sex
partners or recent STD:
Get vaccinated against
hepatitis B
People born in countries in
Asia, Africa or the Pacific:
Get tested for hepatitis B
Transgenders:
Get vaccinated against
hepatitis A and B
Test for hepatitis C if injected
hormones
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Mahalo!
For more information, contact
Heather Lusk at
[email protected]
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