Transcript Hepatitis A, B and C screening in a substance use disorder

Hepatitis A, B and C:
An overview with special
considerations for our
Veteran population
Kimberly Moore, MSN, CRNP, LNC
Cincinnati VA Medical Center
Department of Digestive Diseases and
Hepatology
Hepatitis A
Identified 1973
75,000 cases/yr in U.S.
Self limiting disease in most
Severe disease in:
– Adults > 40 years
– Patients with Chronic Liver Disease (CLD)
are at risk of Fulminate Hepatic Failure
(FHF) in 40% of cases
Gitlin et al, AJG, 1998
Hepatitis A
Modes of transmission
– Oral fecal route
– Ingestion of contaminated food/water
– Close person to person contact
Outcome of HAV Super-infection
in Patients with Chronic Viral
Hepatitis
45%
41%
%Fulminant Hep A
40%
35%
30%
25%
20%
15%
10%
5%
0%
0%
Pts with HAV + HCV
Vento et al. NEJM 1998:338: 286-290
Pts with HAV alone
Hepatitis A
Carries a high risk of liver failure and
mortality in patients with CLD
Vento et al reported:
– 41% of patients with Hep B or C developed
liver failure
Bini et al reported:
– 33% fatality rate in HCV patients with
superimposed HAV infection
Bini et al, Hepatology 2005
Vento et al, NEJM 1998
Estimated risk of death from
acute HAV, US, 1983-1988
Cases
(N)
All pts with Acute HAV
Acute HAV plus Chronic
HBV
Acute HAV plus CLD
Acute HAV, but no liver dz
Deaths
(N)
Fatality
rates (%)
115,551
381
0.3
231
27
11.7
2,311
107
4.6
113,009
247
0.2
Calculated from an estimated .2% HbsAG carrier rate in the US, and 2% prevalence of CLD in the US.
Hadler et al. Viral Hepatitis and Liver Disease. Baltimore. Williams and Wilkins: 1991: 14-20. Keefe
EB. Viral Hepatitis 1999: 5:77-88
Hepatitis A-prevention
HAV vaccine-indication:
– Chronic liver disease
– IV drug users
– Men who have sex with men
– Travelers to endemic areas
– Kitchen workers, employees of day care
centers, healthcare personnel
Susceptibility to Hepatitis A
in Patients with CLD due to
HCV:
Shim et al. (2005) Hepatology. 42
(3); 688-695
Missed opportunities for Vaccination
Hepatitis B
Epidemiology of hepatitis B
Virus identified in 1966
Worldwide health problem
350-400 million carriers worldwide
250,000 deaths annually
Vaccine available 1982
>1 million die annually of HBV related CLD
Transmission of HBV
Perinatal
IVDA
Sexual
Hemodialysis
Close person to person contacts
Infected blood
children in hyperendemic areas
HBV - Epidemiology
Risk of chronic infection
Incidence of Cirrhosis in
HBV/HCV Co-infection vs. HCV
alone
56.2%
60%
Pts with cirrhosis
50%
40%
30%
20%
12.9%
10%
0%
HCV (n=54)
Fuiano B et al. Ital J Gastroent 1992: 24:409-11
HCV + HBV (n=32)
Risk of HCC with HBV/HCV Coinfection in Cirrhotic Patients
50.0
40.0
Patients (%)
40.0
30.0
19.6
20.0
12.2
10.0
0.0
0.0
no risk
factors
HCV
Koff RS J Clin Gastro 2001:33:20-26
Benvegnu L et. Al. Cancer 1994:74:2442-48
HBV
HBV + HCV
Estimated Incidence of Acute Hepatitis B
United States, 1978-1995
80
Safer Injection
Practices
Cases/100,000
70
Infant
immunization
60
50
40
Vaccine
licensed
30
20
HBsAg
screening
of pregnant
women
10
Adolescent
immunization
0
78 7
9
8 81 82 83 84 85 8 87 8 89 9 91 9
8
0
2
0
6
9 94 95
3
Source: CDC
Infectious Disease Burden among Released
Inmates, United States, 1996
Infected US
Population
Infected
Inmates
Released
% of Total
Infected
Population
AIDS
229,000
39,000
17
HIV
750,000
98 –145,000
13-19
1.0-1.25 million
155,000
12-15
4.5 million
1.3-1.4 million
29-32
34,000
12,000
35
Infection/
Disease
HBV (chronic)
HCV
TB
Source: NCCHC, Hammet, Greifinger et.al. unpublished data
Review of Hepatitis A, B, C
serological testing
HBsAg - exposure
HBsAb - marker for immunity
HAV Ab total – marker for immunity
HCVAb - exposure
HCV PCR –gold standard to diagnose
HCV
Hepatitis B Treatment
Treatment is generally advised for patients
with active disease
Lamivudine, Entecavir, Adefovir, Pegylated
Interferon, combination therapy
Hepatocellular Carcinoma screen is
recommended
Healthy people 2010 goals:
Identify individuals with Hepatitis C
– Education
– Vaccinated against Hep A/B
– Evaluate for liver disease and treat
Immunize against Hepatitis B
Immunize high risk groups, including illicit
drug users, against Hepatitis A
Facts about Hepatitis C
Virus(HCV)
5.0 million Americans Infected
Non-A Non-B hepatitis recognized in
the 1970’s
HCV genome isolated 1989
HCVRNA mutates rapidly
No vaccine available
6 different genotypes
HCV Epidemiology: Corrected estimate
Edlin BR, et al Hepatology 2005;42:213A
 Estimated 3.9 million who have been infected (NHANES)
Number
Incarcerated
HCV Ab #
Infected
1,200,000
35%
426,000
Homeless
800,000
43%
344,000
Hospitalized
895,000
16%
132,000
Military
1,900,000
0.5%
9,000
Nursing Home
1,700,000
4.2%
79,000
Additional Infected Persons
991,000
(800,000 – 1,200,000)
Total ~ 5 million
U.S. Census Bureau of Justice, Center for Medicare, Medicaid Services
Prevalence of HCV in Select
Populations
IVDU
Alcoholics
Incarcerated
Homeless
Veterans
US population
80 - 90%
11%
16 - 41%
22%
6 - 8%
1.8%
Symptoms of HCV
Lack of energy,
Weakness
General malaise
RUQ dull pain
Nausea
Arthralgias/myalgias
Extrahepatic manifestations of hcv
Symptoms of
Advanced Liver Disease
Changes in mental
status
Anorexia
Jaundice
Weight loss
Muscle wasting
Decreased libido
Abdominal
distention
Leg swelling
SOB
Hematemesis
Abdominal pain
Diarrhea
N/V
Factors associated with Disease
Progression
Alcohol consumption
Disease acquisition at >40 years
Male gender
Coinfection with HIV or HBV
Immunosuppression
HCV disease progression
Cirrhosis
Decompensated cirrhosis
– Ascites, SBP, bleeding varices,
encephalopathy
HCC
Liver transplant
Death
Hepatitis C Care within the VA
Health Care System
Burden of HCV in US veterans
“The prevalence or Hepatitis C (5.4%) in United
States Veterans exceeds the estimate from the
general population by more than 2 – fold”
Hepatology 2005; 41:88-96 Mil Med 2002; 167: 756 759
HCV screening: VA guidelines
Vietnam-era veteran
Blood transfusion before 1992
Past or present IV drug use
Blood exposure of skin or mucous
membranes
H/o multiple sexual partners
History of intranasal cocaine use
HCV screening guidelines
(cont)
History of hemodialysis
Tattoo or repeated body piercing
Unexplained liver disease
Unexplained/abnormal ALT
Intemperate or immoderate use of alcohol
Available testing for HCV
ELISA tests for AB to HCV (HCV Ab)
Recombinant immunoblot assay (RIBA)
HCV PCR testing
Genotyping
Laboratory Testing for
Hepatitis C
HCV antibody
– Once positive, will always be positive, even if treated
and cleared. Please DO NOT keep ordering this test.
– If antibody positive but no viral load (negative HCV
bDNA and TMA,) either patient experienced
spontaneous clearance (7% occurrence rate) or the
original antibody was falsely positive. Confirm with
HCV RIBA (if returns positive, patient had and cleared
the virus; if returns negative, antibody was falsely
positive
HCV bDNA and TMA
– This is the “viral load” or amount of virus in the blood
– this is what treatment attempts to clear.
Patient Education and
Counseling
Protection of others from
transmission
Protect liver from further harm
Discussion of prognosis
Discussion of treatment options
Treatment of Hepatitis C
Liver biopsy usually required prior to treatment
for patients with genotype 1.
Weekly Interferon injections
Twice daily Ribavirin pills (dose based on
weight)
Treatment duration is 6 months for genotype 2
and 3; 12 months for genotype 1.
HCV bDNA and TMA is rechecked after tx for 3
months to see if meds are working to clear the
virus (need a 2 log drop in the bDNA to show tx
effectiveness.)
Treatment of Hepatitis C
(cont’d)
35% treatment success rate (sustained viral
response or SVR) for African Americans with
genotype 1
45% treatment success rate (SVR) for
Caucasians with genotype 1
Near 70% SVR for genotypes 2 and 3
Females do better than males; younger patients
do better than older patients (in terms of
tolerance and clearance)
Criteria: Consideration for
Treatment
Preferably no ongoing alcohol or illicit
drug use
Psychiatric diseases must be managed
and fairly well controlled
Normal or abnormal transaminases
No active medical problems with
expected mortality
Peg Interferon
blocks virus into cells
inhibits intracellular
replication
stimulates bodies
immune system
renally cleared
antifibrotic action
Ribavirin
Synergistic with
Interferon
Induces defective
replication of HCV
RNA
Better tolerated than
Interferon
Not effective
monotherapy
Side effects: Peg Interferons
Flu like symptoms
Fatigue
Depression/mood lability/insomnia
Anorexia
Injection site reactions
Can stimulate Autoimmune disease
Skin problems
Visual changes
Lab alterations
Side effects: Ribavirin
Teratogenicity
Hemolytic anemia
MI with anemia
SOB, pulmonary infiltrates or pneumonitis
Skin rash
Hepatitis C Treatment – Adverse
Events
Dose discontinuations common
Most common reasons sited for dose discontinuation:
– Psychiatric (increase in depression, anxiety, anger, nightmares,
hallucinations/delusions, decrease in impulse control)
– Systemic (fatigue, headache, arthralgias, arthritis, skin rash)
– Gastrointestinal adverse events (nausea, anorexia)
– Cytopenias
– Thyroid Dysfunction
– Liver failure
Your clients on treatment WILL experience potentially
severe side effects – expect it!
Barriers to HCV
Antiviral Therapy
Show rates and Treatment Eligibility in
Consecutive Veterans referred to HCV clinic
(N=557)
Evaluated and treated (13.8%)
Evaluated and not
treated (29.6%)
No show for
HCV clinic (56.6%)
Cawthorne et al, Am J Gastroenterol 2002;97:149-155
Reasons for exclusion of patients from
HCV antiviral therapy
Psychiatric disease
Undecided
Active alcohol abuse
Refused
Multiple reasons
Medical comorbidity
Normal LFTs
Medication noncompliance
Active drug abuse
Treated outside VA
HCV RNA negative
35 (21)%
28 (17)
23 (14)
17 (10)
17 (10)
11 (6)
8 (5)
8 (5)
6 (3)
6 (3)
6 (3)
Am J Gastroenterology 2002;97:149-155
Psychiatric disorders among
veterans with hepatitis C infection
El-Serag HB, Kunik M, Richardson P, Rabeneck L.
Gastroenterology 2002;123:476-482
N=33,824 hospitalized HCV+ veterans
identified 1992-1999.
Psychiatric and substance-use disorders
identified from computerized records.
Random non-HCV+ controls identified from
hospitalized patients
Psychiatric disorders among veterans
with Hepatitis C infection
86.4% of 33,824 pts had at least one
past or present psychiatric, drug- or
alcohol-related disorder recorded
Active disorders: 31%
HCV+ cases more likely than controls
to have depression, PTSD, anxiety,
alcohol and drug-use disorders.
What Happens if Treatment
Doesn’t Work?
Remember, most treatment for Hepatitis C
doesn’t actually work! Help your patients
have realistic expectations without
encouraging a defeatist attitude.
Patients are followed in clinic to monitor
for HCC and liver decompensation (which
occurs in 20% of patients with Hepatitis
C.)
Liver transplantation is a consideration
Liver Transplant stats:
Liver transplant numbers: 81,634 done
Currently 16,961 waiting
05: 6443
06: 6650
Location of VA Transplant Centers
Kidney
Iowa City, IA
Nashville, TN
Pittsburgh, PA
Portland, OR
Heart
Cleveland, OH * +
Madison, WI *
Nashville, TN * +
Richmond, VA
Salt Lake City, UT *
Palo Alto, CA *
Liver
Nashville, TN *
Pittsburgh, PA
Portland, OR
Richmond, VA *
Lung
Richmond, VA +
Madison, WI *
* Sharing Agreement Sites
Bone Marrow
Nashville, TN
San Antonio, TX
Seattle, WA
+ Temporarily Inactive
Transplants – All VATCs
160
140
FY 2000
FY 2001
FY 2002
FY 2003
FY 2004
FY 2005
FY 2006*
120
100
80
60
40
20
0
Kidney **
Liver **
Heart **
Lung
Bone
Marrow
Liver Transplantation
6 months free from:
– Tobacco, alcohol and all illicit substances with documented
attendance at AA or in similar program
Patients do not have to be off Methadone.
Need complete psychological, social and dental
evaluations plus a myriad of laboratory and radiological
testing.
Must have support person able to attend all liver
transplant evaluations, provide transportation, attend
surgery, out of town, evaluations and commit to indefinite
post-operative care.
Specific criteria for patients being referred for
transplantation secondary to HCC – lesion size and
number and evidence of metastasis determine eligibility.
Projecting future complications of
chronic HCV in United States
Liver Transplantation 2003; 9: 331 - 338
Burden of Disease
Hepatocellular Carcinoma (Liver cancer) is
the most common primary hepatic
malignancy
The vast majority of patients with
Hepatocellular Carcinoma (HCC) have
underlying Cirrhosis
Risk of HCC in patients with HCV is 17
times higher than HCV negative controls
Take Home Points
Screen for Hepatitis A, B, C
Immunize against Hepatitis A and B as
appropriate
Patient Education
Refer quickly for Hepatitis B and C
positivity
Screen all positive Hepatitis B and C
patients for HCC
www.hepatitis.va.gov
Thanks!
Questions?
Contact Information:
– Kimberly Moore, MSN, CRNP, LNC
Cincinnati VA Medical Center
Department of Digestive Diseases and
Hepatology
– (513) 487-6034