Hepatitis CC aring Ambassadors Program by k966Xd

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									             Hepatitis C
               Caring
            Ambassadors
              Program

People Helping People
            Hepatitis C Caring Ambassadors Program
    HCV
Epidemiology


       Hepatitis C Caring Ambassadors Program
   Hepatitis C: A Global Health Problem
                         ~170 Million Infected Worldwide
                           3-4 Million New Cases/Year
                                         EUROPE
                                           9M                                            WESTERN
                                                                                          PACIFIC
                                                                                            62 M
                                                          EASTERN
          NORTH &                                      MEDITERRANEAN
           SOUTH                                                21 M
          AMERICA
                                                                                       SOUTHEAST
            13 M                                                                          ASIA
                                                                                           32 M
                                          AFRICA
                                            32 M

                                                                      AUSTRALIA
                                                                         0.2 M
Weekly Epidemiological Record. N° 49, 10 December 1999, WHO

                                                              Hepatitis C Caring Ambassadors Program
                      Hepatitis C Prevalence, U.S.
  Overall prevalence of anti-HCV in the U.S. population
   from NHANES (1999-2002)
   3.8 million (1.6%)1
  Overall prevalence of chronic infection
   derived from NHANES III (1988-1994)
   2.7 million (1.3%)2
  Correcting for patient groups not surveyed or under-
   represented in NHANES, the current estimate of
   patients with HCV viremia approaches
   5 million (~2.4%)
1Armstrong      et al. AASLD 2004; poster 31.
2Alter   et al. N Engl J Med. 1999;341(8):556-562.

                                                     Hepatitis C Caring Ambassadors Program
                                         Prevalence of HCV Infection
                                             by Age and Gender,
                                           United States, 1988-1994
                                     6
                                                                   Males
         Percent Anti-HCV Positive




                                     5

                                     4                             Total

                                     3

                                     2

                                     1                              Females

                                     0
                                         6-11   12-19   20-29   30-39   40-49   50-59    60-69    70+
                                                                Age in Years
CDC, NHANES III, NEJM 1999

                                                                           Hepatitis C Caring Ambassadors Program
 HCV Seroprevalence by Ethnicity,
United States, 1988-1994 (NHANES III)
  Group      % Anti-HCV      Est. Infections              % of
               Positive   in Millions (95% CI)         Infections
Caucasian       1.5           2.4 (1.8-3.1)                 61

  African-      3.2           0.8 (0.6-1.0)                 20
 American
 Mexican-       2.1           0.3 (0.2-0.3)                 7
 American
  Other         2.9           0.5 (0.3-1.0)                 13

 TOTAL          1.8           3.9 (3.1-4.8)                100




                             Hepatitis C Caring Ambassadors Program
   HCV Demographics, NHANES III

                       No.     HCV Seroprevalence Estimated
Characteristic        Tested      % (95% CI)      Nationwide
Below poverty level   5,345        3.2 (2.4-4.3)                937,000
At or above poverty   13,974       1.6 (1.2-2.0)               2,625,000
<12 years education   11,971       2.8 (2.1-3.6)               2,866,000
Over 12 years         4,528        1.3 (0.8-2.0)                899,000
education
Men                   10,076       2.5 (2.0-3.2)               2,586,000
Women                 11,165       1.2 (0.9-1.6)               1,289,000

                                   Hepatitis C Caring Ambassadors Program
          HCV Disease Burden

Forty to 60% of chronic liver disease in
 the U.S. is related to chronic hepatitis C
 infection.
Chronic HCV is the leading cause of adult
 liver transplantation.




                          Hepatitis C Caring Ambassadors Program
                             Liver Transplantation:
                              Demand >> Supply
     16000
     14000
     12000
     10000                                                    additions to list
       8000                                                   active waiting list
       6000                                                   liver transplants

       4000
       2000
            0
              95

              96

              97

              98

              99

              00

              01

              02

              03

              04
           19

           19

           19

           19

           19

           20

           20

           20

           20

           20


UNOS 4/19/05: www.optn.org

                                          Hepatitis C Caring Ambassadors Program
       HCV-Related Deaths, U.S.

Approximately 10-12,000 people die each year
 of HCV-related liver disease.
   This number is expected to triple by 2020.
HCV-related liver disease is the leading cause of
 death among persons with HIV disease.




                             Hepatitis C Caring Ambassadors Program
          Predicted HCV-Related Mortality
                    through 2019
                     Non HCC liver-related
30,000
                     HCC


20,000


10,000


  5,000

          0
          1992       1995      1998      2001       2004      2007     2010     2013     2016    2019
                                                           Year
Wong et al. Am J Public Health. 2000;90(10):1562-1569.

                                                                  Hepatitis C Caring Ambassadors Program
         Exposures Associated with
              HCV Infection
 injecting drug use and other shared drug paraphernalia
 transfusion or organ transplant from infected donor
 occupational exposure to blood (needle sticks)
 iatrogenic (unsafe injections)
 birth to an HCV-infected mother
 sex with infected partner (rare; risk associated with multiple
  sexual partners and exposure to blood)
 combat exposure, especially among veterans of the Vietnam
  conflict


                                      Hepatitis C Caring Ambassadors Program
                              HCV Transmission

                   Injecting drug use 60%
                                                           Sexual 15%



                                                                 Transfusion 10%
                                                                 (before screening)

                                                        Occupational 4%
                                                    Other 1%*
                                Unknown 10%
                                                                * Nosocomial; iatrogenic; perinatal
Source: Centers for Disease Control & Prevention


                                                   Hepatitis C Caring Ambassadors Program
Source: Centers for Disease Control & Prevention


                                                   Hepatitis C Caring Ambassadors Program
                          Injecting Drug Use
                         & HCV Transmission
   HCV transmission is highly efficient among injection
    drug users.

   Transmission of HCV via IDU is at least 4-times more
    common than with HIV.

   HCV infection is rapidly acquired after initiation of
    IDU.

   Prevalence HCV is >80% after 5 years of IDU
Source: Centers for Disease Control & Prevention

                                                   Hepatitis C Caring Ambassadors Program
        Nosocomial Transmission of HCV
       recognized primarily in context of outbreaks
              reported in hemodialysis* units, hospital inpatient
               wards, home therapy, and private practice
       contaminated equipment
       unsafe injection practices with cross-contamination
              plasmapheresis,* phlebotomy
              multiple dose medication vials
              therapeutic injections – reused needles and syringes


*Reported in US
Source: Centers for Disease Control and Prevention

                                                     Hepatitis C Caring Ambassadors Program
   Occupational Transmission of HCV
       HCV inefficiently transmitted by occupational
        exposures
       average incidence is 1.8% following needle stick from
        HCV-positive source
              associated with hollow-bore needles and deep needle
               penetration
       case reports of transmission from blood splash to eye
       prevalence of HCV is 1-2% among health care workers
              lower than adults in the general population



Source: Centers for Disease Control and Prevention

                                                     Hepatitis C Caring Ambassadors Program
             Health Care Worker (HCW) to
             Patient Transmission of HCV
    rare
    most appear related to HCW substance abuse
           reuse of needles or sharing narcotics used for self-
            injection
    no restrictions routinely recommended for HCV-
     infected HCWs




Source: Centers for Disease Control and Prevention

                                                     Hepatitis C Caring Ambassadors Program
             Perinatal Transmission of HCV

      transmission only from women HCV-RNA positive at
       delivery
             average rate of infection 6%
             higher (17%) if mother is coinfected with HIV

      no association with delivery method or breast feeding

      infected infants do well; severe hepatitis is rare



Source: Centers for Disease Control and Prevention

                                                     Hepatitis C Caring Ambassadors Program
                Sexual Transmission of HCV
       data from case-control, cross sectional studies
              infected partner, multiple partners, early sex,
               non-use of condoms, other STDs, sex with trauma
               have variably been associated with increased risk
              MSM no higher risk than heterosexuals
       data from partner studies
              low prevalence (1.5%) among long-term partners
                   • infections might be due to common percutaneous exposures
                     (e.g., unsafe injections, drug use)
              male to female transmission more efficient
                   • more indicative of sexual transmission


Source: Centers for Disease Control and Prevention

                                                     Hepatitis C Caring Ambassadors Program
                Sexual Transmission of HCV

        occurs, but efficiency is low
               rare between long-term steady partners
               factors that facilitate transmission between partners
                are unknown (e.g., viral titer)
        accounts for 15-20% of acute and chronic infections
         in the United States
               sex is a common behavior
               large chronic reservoir provides multiple
                opportunities for exposure to potentially infectious
                partners


Source: Centers for Disease Control and Prevention

                                                     Hepatitis C Caring Ambassadors Program
           Household Transmission of HCV

      rare but not absent
      could occur through percutaneous/mucosal exposures
       to blood
             theoretically through sharing of contaminated personal
              articles (razors, toothbrushes)
             contaminated equipment used for home therapies
                  • Injections
                  • IV therapies
                  • Folk remedies



*Reported in US
Source: Centers for Disease Control and Prevention

                                                     Hepatitis C Caring Ambassadors Program
       Other Potential Exposures to Blood
     no or insufficient data showing increased risk with:
            intranasal cocaine use, tattooing, body piercing,
             acupuncture, military service
     no associations in acute case-control or population-
      based studies
     cross-sectional studies in highly selected groups with
      inconsistent results
            biologically plausible, but association or causal
             relationship not established


Source: Centers for Disease Control and Prevention

                                                     Hepatitis C Caring Ambassadors Program
                Prevention of HCV Infection
    screen and test blood donors
    virus inactivation of plasma-derived products
    risk-reduction counseling and services
           obtain history of high-risk drug and sex behaviors
           provide information on minimizing risky behavior,
            including referral to other services
           vaccinate against hepatitis A and/or hepatitis B
    safe injection and infection control practices

Source: Centers for Disease Control and Prevention. MMWR 1998;47 (No. RR-19)


                                                              Hepatitis C Caring Ambassadors Program
    Reduce Risks for Disease Progression
        and Further Transmission
    identify persons at risk for HCV and test to determine
     infection status
           routinely identify at risk persons through history, record
            review
    provide HCV-positive persons with:
           medical evaluation and management
           counseling
                • prevent further harm to the liver
                • prevent transmission to others


Source: Centers for Disease Control and Prevention. MMWR 1998;47 (No. RR-19)


                                                              Hepatitis C Caring Ambassadors Program
        Counseling HCV-Positive Persons:
         Preventing HCV Transmission
    protect others from direct exposure to infected blood
           do not donate blood, body organs, other tissue or semen
           do not share items that might have blood on them
                • personal care (e.g., razor, toothbrush)
                • home therapy (e.g., needles)
           cover cuts and sores on the skin
    to prevent sexual transmission (if not in a monogamous,
     long-term relationship) use latex condoms correctly and
     every time

Adapted from Centers for Disease Control and Prevention. MMWR 1998;47 (No. RR-19)

                                                              Hepatitis C Caring Ambassadors Program
         Harm Reduction Counseling for IDU

    Stop using and injecting.
           Refer to substance abuse treatment program.
           If not immune, vaccinate against hepatitis A and B.
    If continuing to inject:
           Never reuse or share syringes, needles, or drug
            preparation equipment.
           If not immune, vaccinate against hepatitis A and B
           Refer to community-based risk reduction programs.



Source: Centers for Disease Control and Prevention. MMWR 1998;47 (No. RR-19)

                                                              Hepatitis C Caring Ambassadors Program
              Vertical Transmission of HCV
     post-exposure prophylaxis not available
     no need to avoid pregnancy or breastfeeding
            consider bottle feeding if are nipples cracked/bleeding
     no need to determine mode of delivery based on HCV
      infection status
     test infants (>15-18 months old) born to HCV-positive
      women
            consider testing any children born since woman became
             infected
            evaluate infected children for chronic liver disease

Source: Centers for Disease Control and Prevention

                                                     Hepatitis C Caring Ambassadors Program
                Sexual Counseling in HCV:
              One, long-term, steady sex partner
     no need to change sexual practices
     should discuss HCV-status with his/her partner
            Risk of sexual transmission is low but not absent.

            Routine testing is not recommended, but counseling
             and testing of partner should be individualized.

            Some couples might decide to use barrier precautions to
             further lower limited risk.


Source: Centers for Disease Control and Prevention

                                                     Hepatitis C Caring Ambassadors Program
                      Sexual Counseling in HCV:
                      High-Risk Sexual Behaviors

     reduce risk
              limit number of sex partners
              use latex condoms every time
              get vaccinated against hepatitis B
              MSMs should also get vaccinated against hepatitis A




Source: Centers for Disease Control and Prevention

                                                     Hepatitis C Caring Ambassadors Program
           Other HCV Transmission Issues

     HCV is not spread by kissing, hugging,
      sneezing, coughing, food or water, sharing
      eating utensils or drinking glasses, or casual
      contact,
     Do not exclude from work, school, play,
      child-care or other settings based on HCV
      infection status.

Source: Centers for Disease Control and Prevention

                                                     Hepatitis C Caring Ambassadors Program

								
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