Transcript HCV-facts for today, hope for tomorrow

Hepatitis C:
Facts for today,
Hope for tomorrow
School Nurses Training
Presented by:
Maggie Damron,RN
California HCV Task Force
Liver Disease
• 25 million Americans are or have been afflicted
with hepatitis or other liver disease
• Over 4 million infected with hepatitis C in the USA
• HCV: leading cause of liver transplantation in the USA
• 600,000 infected with HCV in California
• Most people infected with the virus do not know they have it
• Currently over 18,000 people waiting for a liver transplant
Functions of the liver

Digestive enzymes
 Metabolism
 Immune system
 >500 chemical functions
 Detoxifies
 Clotting factors
 Hormones
 Can regenerate itself!
This is the external surface of a normal liver. The color is brown and
the surface is smooth. A normal liver is about 1200 to 1600 grams.
Here is another example of macronodular cirrhosis. Viral hepatitis (B or C) is the
most common cause for macronodular cirrhosis. Wilson's disease and alpha-1antitrypsin deficiency also can produce a macronodular cirrhosis.
What is Hepatitis C ?
• Natural history evolves over decades
• A small single stranded RNA virus
• Virus mutates rapidly – evades the immune system
• Six major genotypes
• Different geographic distribution of genotypes
Acute Hepatitis C
• Incubation period averages 6 – 7 weeks
• Only 25–30% infected manifest clinical symptoms
• Can be spontaneously cleared by the immune system
• Majority will go on to develop chronic hepatitis C
• Disease progresses to cirrhosis, hepatic failure
and hepatocellular carcinoma
HEPATITIS C THE MAJOR HEALTH
CONCERN
Chronic Hepatitis C
Public Health/Financial
Implications
• Most infected individuals: 30-49 years
• By the year 2008, estimates suggest:
61%  in cirrhosis
279%  in decompensation
68%  in HCC
528%  in need for liver transplantation
223%  in liver-related deaths
Davis GL. Hepatology.
Hepatology. 1998;28(4 pt 2):390a.
Predicted Future HCV
Mortality
30000
20000
15000
10000
5000
0
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Annual Deaths
25000
Year
Wong et al Am J Public Health. 2000; 1990:1562
Risk Factors
for the transmission of
Hepatitis C
Hepatitis C is spread through blood to blood contact !
• Blood transfusion before 1992
• Blood products before 1987
• Injecting drug use
• History of multiple sex partners
• History of hemodialysis
(Risk factors contd)
• Tattoo or repeated body piercing
• History of intranasal cocaine use
• Occupational eg. Needlestick injury
• Infants born to HCV infected mom’s
• Vietnam-era veterans
•10% of unknown aetiology
Occupational Transmission:
HCV

No documented transmission from mucous
membrane or non-intact skin exposure

Two case reports from blood splash to eye
Needlestick Injuries (NSI’s)

Estimated 600,000 - 800,000 per year

Recent studies of underreporting found rates
range 20-50%
How is HCV not spread ??
According to the CDC, HCV is NOT spread by:
• Sneezing
• Coughing
• Hugging
• Food or water
• Sharing eating utensils
• Sharing drinking glasses
• Casual contact
Diagnosis of Hepatitis C
• Diagnosis can no longer be ignored
• Patients need to understand that HCV is a progressive disease
• Treatment is available
• Testing should be done if there are any known risk factors
•Testing should be done if there are possible risk factors
•Elevated liver enzymes should be evaluated further
Reasons to identify persons
with HCV Infection
Medical management
• Evaluate for chronic liver disease
• Treatment, if indicated
• Substance abuse treatment, if appropriate
• Immunization
Counsel to prevent disease transmission
• Household contacts
• Sexual contacts
• Drug use contacts
Antibody Tests
EIA – enzyme immunoassay
• Highly sensitive with 99% sensitivity
• In acute phase, may take up to 12 weeks to become positive
• Does not detect the presence of active infection
• Indicates exposure to the virus
• Result will be “positive” or “negative”
• False positive: - autoimmune hepatitis
- hypergammaglobulinemia
- normal liver enzymes/no risk facotrs
• False negative: - immunosuppressed patients
- chronic dialysis patients
RIBA (recombinant immunoblot assay) test
• Confirmatory
• May become obsolete with HCV RNA testing
Hepatitis C Virus RNA test
• Determines the presence of HCV virus present
• Helpful when antibody tests inconclusive
• Expensive and requires special handling
• Result in copies/ml or iu/ml
• Used to confirm active HCV infection
• Used to confirm medications are working once
treatment has started
• Does not correlate with disease progression
• Possibly may effect transmission
HCV Genotype
• Six major genotypes
• Within genotypes, there are subtypes and quasispecies
• Valuable when making treatment decisions
• Genotype 1a and 1b most common in the USA
• Genotype 1a and 1b most difficult to treat
• Disease progression similar for all genotypes
• Determined by a blood test
• Genotype 2 and 3 respond well to current treatment
Liver Biopsy
• Can help determine the extent of liver damage
• Measures the degree of inflammation
• Measures the degree of fibrosis or cirrhosis
• Biopsy results can help guide decisions about treatment
• Can help gauge how well HCV treatment is working
• Four histological stages of liver damage
• Liver damage may be present even when ALT’s are normal
• Can be used to measure progression of the disease
Risk factors for
Fibrosis/Cirrhosis
• Alcohol consumption
•Age at acquisition
•Male gender
•Longer duration of infection
•Coinfection with HBV or HIV
•Immunosupression
•Organ transplant
Treatment of HCV
Who should NOT be treated ?
• Clinically decompensated cirrhosis
• Persons with uncontrolled neuropsychiatric syndromes
• Active substance or alcohol abuse
• Autoimmune not well controlled
• Inability to practice birth control
• Anemia
• Pregnancy
• Thyroid abnormalities not controlled by therapy
• Deteriorated cardiac function
• Opthalmologic disorders esp in diabetes and hypertension
The goals of Treatment
Primary: HCV RNA undetectable
Secondary: Inhibit the progression of the disease
Current Therapies Available
• Intron A monotherapy
•Rebetron Combination therapy
•PegIntron and Rebetol (Ribavirin)
•Pegasys and Copegus (Ribavirin)
Factors predicting patient
adherence to treatment
• Patient health beliefs
•Ease of access to health provider
•Familiarity of clinic setting
•Existence of social support system
•Perceived support from clinical staff
•Simplicity of medication regime
Potential side effects of Interferon
• Fatigue
• Flu-like symptoms
• Nausea, vomiting, diarrhea
• Skin irritation at injection site
• Appetite loss and taste changes
• Depression
• Insomnia
• Alopecia
• Skin sensitivity to the sun
• Changes in menstrual cycle
• Mild bone marrow suppression
• Low grade fever
• Headaches
Potential side effects of
Ribavirin
• Anemia
• Fatigue
• Irritability
• Itching
• Skin rash
• Dry, irritating cough
• Nasal stuffiness, sinusitis
• Teratogenicity
Nursing Care and
Considerations
• TLC! TLC! TLC ! … we need to reach out
• Educate… how the disease is and is not spread
pregnancy and contraception guidelines
the need to avoid alcohol
skin sensitivity to the sun
diet
water consumption during treatment
• Side effect management
(Nursing considerations continued)
• Lab monitoring
• Immunization against HAV and HBV
• Encourage healthy lifestyle
• TLC! TLC! TLC! to family and significant
others supporting patient through treatment
Most difficult task: keeping messages given to
patient factually correct!
Issues to consider regarding
HCV infection and children
• Psychosocial impact on child if parent is the one infected
• Impact on child while parent is going through treatment
• Disclosure to school if child is infected
• Fear attached to the disease, treatment and possible
discrimination - confidentiality
• Impact on school attendance if on treatment
• Medication use during school hours
Communication In the
schools!
• Pass along facts about HCV - teachers
- parents
- children
• Teach about risk factors
• Teach prevention strategies
• Be a caring adult – you may be the only person a child
feels he/she can safely talk to
For more information on current
blood borne pathogen research, visit
the CDC’s web site at www.cdc.gov/
or consult the latest version of
OSHA’s blood borne pathogen
standard.
Save a life!
omote
organ
donation
A Community Response To A Major
Health Concern
THE CALIFORNIA HEPATITIS C TASK FORCE
www.californiahcvtaskforce.org