Hepatitis C (HCV)
hIsolated in 1988 and accounts for most cases of non-A, non-B hepatitis hSingle stranded, positive sense RNA Flavivirus, at least 6 major genotypesco-infections possible h30-40% of persons with HIV thought to be co-infected with HCV
Diagnosis
• HCV Antibody: history of exposure, possible chronic infection - follow up with viral load • HCV viral load: positive indicates infection, negative should be repeated • Liver function tests: suggestive of progress • Liver biopsy: definitive of progress
Acute Symptoms
• Absent in 65-90% • May include: - Malaise - Abdominal Pain - Jaundice
Severe Liver Disease
• Disease may be asymptomatic until advanced • Manifestations include:
Acute symptoms Fluid retention Clotting disorder Altered mental status
• Liver cancer may be ultimate outcome
HCV Outcome
Hepatitis C Antibody Positive
75-85% HCV +: Chronic Infection 2-20% Serious Liver Disease / Cirrhosis 1- 4% / Yr HCC 15-25% HCV - Clear the Virus 80-90% Asymptomatic Moderate Disease
Factors Influencing Progression
• • • • • • HIV Alcohol use Treatment Age at infection Route of infection Gender
1
Treatment
• All patients: Hepatitis A and Hepatitis B vaccines (if not immune) • All patients: counsel regarding alcohol use • Selected patients: Interferon- alpha & ribavirin
Treatment Considerations
• Abnormal liver function tests and detectable virus • HIV stage • Likelihood of progression • Contraindications
IFN/Ribavirin
• 24-48 weeks - depending on factors such as genotype, viral load and rapidity of response • 30-50% have a sustained response • Side effects: flu-like syndrome, hair loss, depression
HCV and HIV Co-Infection
• HCV is more likely to progress • HCV may progress more rapidly • HAART can be successfully used in HCV co-infection • IFN can be successful in early HIV • Combination therapy still in clinical trials
Seroprevalence For Hepatitis C
• Serum from 21,241 United States residents • Anti-HCV = 1.8% or 3.9 million • 2.7 million positive by HCV RNA
– Genotype 1a = 73% – Genotype 1b = 17%
HCV Prevalence In HIV-Infected Patients
• 213 patients, risk stratified, diverse population • HCV - 36% • Highest (50%) in age 40 - 49 years
• Estimate for New York State = 324,000
NYSDOH/BCDC 5/00 NYSDOH/BCDC 5/00
2
Seroprevalence of HCV, HBV And HIV Among IDU’s in the United States
• • • • 2255 IDU participants age 15 - 30 HCV 35% HBV 23% HIV 5%
Acute Hepatitis C Infection
• Risk Factors
– Transfusion of blood or blood products – Intravenous drug use – Transplantation of infected organs or tissues – Chronic long-term hemodialysis – Multiple sexual partners – Birth to HCV-infected mother – Occupational exposures – ? Intranasal cocaine use
NYSDOH/BCDC 5/00
NYSDOH/BCDC 5/00
Acute Hepatitis C Infection
• Less Common Risk Factors
– Monogamous relationships – Nosocomial transmission – Contaminated instruments
• Traditional medicine • Tattooing • Body piercing
Intravenous Drug Use and Hepatitis C Infection
• Highly efficient transmission
– Prevalence 60 - 90% – 4 times more common than HIV – Rapidly acquired after initiation of behavior – Can occur after single episode
– Household exposures
• Toothbrushes • Razors
NYSDOH/BCDC 5/00
NYSDOH/BCDC 5/00
Sexual Transmission and Hepatitis C Infection
• Efficiency low • Long-term monogamous relationships
– Rare – Efficiency low, not absent
Perinatal Transmission and Hepatitis C Infection
• Average risk: 5 - 6% • Breastfeeding
– Not associated with transmission
• Long-term outcome not known
• Multiple partners
– More frequent
NYSDOH/BCDC 5/00 NYSDOH/BCDC 5/00
3
Screening Recommendations for Hepatitis C Infection
• Persons who ever injected drugs • Recipients of transfusions before July 1992 • Recipients of transplants before July 1992 • Recipients of clotting factors before 1987 • Persons ever on chronic hemodialysis • Persons with persistently elevated ALT • Persons with occupational exposures • Children born to HCV-infected women
NYSDOH/BCDC 5/00
New York State Hepatitis C Reporting Requirements
• Public Health Law
– Labs must inform county of all positive confirmatory tests (RIBA or PCR-RNA) – MDS must inform county of all acute infections
• • • • Discrete onset of symptoms and Jaundice or elevated hepatic enzymes Hepatitis A and B ruled-out (+) anti-HCV
NYSDOH/BCDC 5/00
State/Local Concerns
• • • • • Difficult to distinguish new/old cases No seromarker for acute infections Limited State and County resources Need for federal funding Few new cases being reported; most old chronic cases • Targeted look back involves much time, low yield • Candidates for treatment/costs
NYSDOH/BCDC 5/00
Recommendations for County Health Departments
• Positive screening tests from blood banks, no action; file alphabetically • Positive test from hospital/commercial lab
– Form letter to physician recommending follow-up confirmation – Provide counseling to patient or provide counseling materials to physician
NYSDOH/BCDC 5/00
Recommendations for County Health Departments
• New acute case, interview patient for risk factors, provide counseling, report to NYSDOH
Suggested LHU Follow-up Of Hepatitis C Lab Reports
New Case
Complete/submit DOH 389 and CDC form Provide counseling, precautions Consider hepatitis A and B vaccine Advise patient to continue close medical supervision
Chronic
*Consider hepatitis A, B, vaccine Advise patient to continue close medical supervision Save report at county level Provide counseling/precautions
*Seroscreen first?
NYSDOH/BCDC 5/00
NYSDOH/BCDC 5/00
4
Hepatitis C Service Provision
• Education
– Literature – Speakers/Q&A
Hepatitis C Education
• What is it? • How is it transmitted? • Who is at risk? • Who should be screened? • Prognosis • Treatment • Living with HCV • Secondary prevention
• Screening • Referral
Hepatitis C Counseling Pre-Test
• • • • Disease Risk assessment Test Implications of potential results
Hepatitis C Counseling Post-Test
• • • • Prognosis Treatment Living with HCV Secondary prevention
Hepatitis C Screening
• Populations
– IDU – Transfusion/blood product recipients – HIV+
Establishing Hepatitis C Service Provision: Practical Aspects
• • • • • Targeting services Space and time Integration into existing services Staff training Marketing/Promotion
• Targeted vs. Universal Screening • Counseling • Cost
5
Hepatitis C Service Integration: NYC DOH Model
• • • • Integrated viral hepatitis services Pre/post-test counseling Targeted Screening Referral
NYS AIDS Advisory Council on Access to HIV Treatment
“It is unethical to deny access to HIV treatment based on the patient’s membership in any category or group, past or current risk behaviors, or past behavior concerning medications...”
Factors Associated with Good Response
Cases per 100,000
Estimated Incidence of Acute Hepatitis C - U.S., 1982-1993 25
20 Surrogate testing of blood donors Anti-HCV test (1st generation) licensed
• • • •
Genotype not type 1a or 1b Younger age Lower viral load Absence of cirrhosis
15 Anti-HCV test (2nd generation) licensed
10
5 0 1983
Decline among transfusion recipients Decline among injecting drug users
1985
1987
1989
1991
1993
Treatment of HCV in Chemically Dependent Patient (NIH)
• Delay treatment of active drug users and heavy alcohol users until abstinent for 2 years • Compliance and toxicity cited as reasons
6