Hepatitis C:

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Hepatitis C

• The silent assassin!
• By Heather Dobie

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Learning Objectives

• Historical perspective
• Global patterns of transmission
• Current state of epidemic
• Transmission
• Risk of Hep C
• Chronic Hep C Symptoms

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Learning Objectives

• HCV Natural History and significance
• Diagnosis
• HCV Treatment. Who, When,Why and How
• Strategys Prevention and Control of Hep C
  transmission

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Hepatitis C Epidemiology

• Historical perspective
• Non A non B hepatitis from 1970,s
• HCV identified in 1989
• HCV antibody test available in 1990

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Hepatitis C Epidemiology

• Estimated 170 million people living with HCV
• Probable transmission for several centuries
• Diverse regional epidemiology

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Global patterns of transmission

• IDU BT Unsafe injection/other
• Australia
• USA
• Italy
• Japan
• Egypt

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Current state of epidemic

• gt 200,000 diagnosed cases of HCV
• 15-20,000 new diagnoses each year 1994-2004
• 240,000 estimated people living with HCV
• 16,000 estimated new HCV infections per year
• Expanding burden of liver disease
• Increasing number of HCV related deaths

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Transmission of Hep C

• Primarilary via the parenteral route
• The main modes of transmission are
• Reusing syringes and needles and contact with
  other injecting equipment.
• Tattooing
• Needlestick
• Blood transfusion

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Transmission of Hep C

• 5.In many developing countries, unscreened blood
  and blood products are still being used
• 6. Traditional scarification and circumcision
  practices .

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Risk Group Level of Risk

• Regular IDU( lifetime) 50-60
• Regular IDU( lt 3 years) 20-40
• Occasional IDU 10-20
• Born in highly endemic country10-20Egypt
• 5 South East Asia

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Risk group Level of Risk

• Infant of HCV mother 3-5
• Infant of HIV/ HCV mother 10-15
• Heterosexual partner of HCV 1-2 over
  10-20 years

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Transmission

• Sexual contact
• House hold transmission
• Mother to child transmission
• Verticle transmission/ delivery
• Breast feeding

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Estimates of BBV prevalence in Australia

• HCV 250,000
• Chronic HCV 90-160,000
• HIV 15,000

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Chronic HCV infection gt6 Months Symptoms

• Most patients are asymptomatic, or have mild
  non-specific symptoms
• Most common are fatigue , tiredness, lethargy (
  20-30)
• Exhaustion

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Symptoms

• Symptoms do not reliably reflect disease
  activity, however do appear to be more common
  once cirrhosis develops
• Other symptoms can include anorexia, nausea,
  abdominal discomfort and swelling, pruritis,
  intolerance of alcohol, and jaundice
• Fluid retention and signs of coagulation
  disorder
• (Bruising and epistaxis)

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Testing

• Blood test.
• Positive Serum HCV antibody test
• And Elevated ALT
• Plus or minus ? known risk factors
• gtPCR Viral load. High or low
• gtGenotype 1, 2, 3 or 4

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HCV natural history summary

• HCV natural history highly variable, but on
  average
• 75 of those infected will fail to clear the
  virus
• risk of cirrhosis is between 15-30 over 30
  years
• Heavy alcohol intake, older age at infection, and
  HBV or HIV are major factors in accelerated
  disease progression

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HCV natural history summary

• HCV infection in Australia is associated with
  significant excess mortality- liver related
• All cause
• Projected expanding burden of liver disease

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HCV natural history significance

• All people with chronic HCV infection should be
  assessed for determination of prognosis and
  consideration of treatment
• Alcohol reduction, weight reduction, and HCV
  treatment should be considered to alter natural
  history
• Access to HCV treatment needs to be improved to
  reduce population- level liver disease burden

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Diagnosis

• Blood tests
• ALT and AST elevated
• Further testing-HBV or HBC
• HCV antibody positive
• Follow up

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Diagnosis given

• Often Shock
• Stigma attached to HCV
• Cant believe infected?
• Think back ? Risk factors
• Many questions need to be answered
• Important to handle with compassion and give
  right information

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Questions ?

• Infected family- tooth brushes, razors, blood to
  blood transmission
• Sexual transmission
• Vertical transmission
• Employer- confidentiality ?
• Shame / Embarrassment !!
• Death, hepatoma ..TREATMENT?

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AnswersPlan

• Important Patient needs to go home with a plan
• gtGenotype and Viral Load
• Offer Hep C telephone Councelling
• Information / Hand outs
• Arrange Review Date
• Caution in discussing diagnosis

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TREATMENT

• Role
• Help patients to make a decision regarding
  treatment
• Does treatment work? Yes
• People can be cured of HCV infection

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TREATMENT

• Genotype 1 and 4
• Peg interferon plus ribavirin
• 48 weeks
• 50-60 chance of SVR
• Genotype 2 and 3
• Peg interferon plus ribavirin
• 24 weeks
• 70-80 chance of SVR

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Why treat?

• Eradicate infection
• Alter natural history of infection
• Reduce progression to cirrhosis
• Reduce progression to hepatocellular carcinoma
• Improve survival
• Symptom relief

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Models of treatment delivery

• Hospital liver Clinics
• Private Gastroenterology Practices
• Outreach Clinics eg HCV treatment service within
  methadone services
• Shared care arrangements between liver clinics
  and GPs
• In conjunction with sexual health clinics

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Adverse reactions

• Injection site 23
• Hypothyroidism 4
• Fatigue 65
• Nausea / Vomiting 25
• Anaemia 11
• Nuetropaenia 27
• Irritability/anxiety 33
• Insomnia 30

• Depression 20
• Alopecia 28
• Fever 41
• Dose modification 21
• Discontinuation of therapy 10
• Dry itchy skin irritation common

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Treatment Summary

• Genotype main predictor of treatment response
• Significantly improved response rates with
  combination therapy
• Adherence to therapy optimizes response rates
• Challenging side effects profile
• Careful selection of patients and thorough
  assessment prior to treatment
• Multidisciplinary team approach maximises chance
  of treatment adherence and assists in management
  of side effects

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HCV newly acquired infections by risk factor
Victoria 2000- 2005

• 2000- 60 Injecting Drug Users 78
• 2001- 58 IDU 60
• 2002-56 IDU 53
• 2003-89 IDU 82
• 2004-86 IDU 86
• 2005-143 IDU 83

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Victorian Hepatitis C Strategy

• Key priority area 1
• Prevention and Control of Hepatitis C
• Improve access to needle and Syringe programs,
  especially out of hours access
• Improve access to hepatitis C prevention and
  education for youth
• Strengthen prevention and education programs in
  Victorian adult and juvenile correctional services

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Key priority area 1continued

• Expand the role of peer education and community
  development approaches in relation to hepatitis C
  prevention and education initiatives

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Victorian Hepatitis C Strategy

• Key priority area 2
• Preventing discrimination and reducing stigma and
  isolation
• Improve education programs for general
  practitioners and health care workers in relation
  to hepatitis C and related issues to meet the
  service and treatment needs of all affected
  people including people who inject drugs.

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Victorian Hepatitis C Strategy

• Key priority area 3
• Health maintenance, care and support of people
  affected by Hepatitis C
• Develop a best practice treatment and care model
  for the management of hepatitis C to increase the
  quality and access of service provision in
  Victoria.

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Victorian Hepatitis C Strategy

• Key priority area 4
• Research and surveillance
• Develop innovative methods of identifying and
  delivering education and prevention messages in a
  timely manner to vulnerable groups with or at
  risk of hepatitis C

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Victorian Hepatitis C Strategy

• Key priority Area 4
• Research and surveillance
• Identify ways to improve access to hepatitis C
  treatment, in particular, for marginalised groups
  such as injecting drug users, individuals on
  pharmacotherapy, people from culturally and
  linguistically diverse backgrounds and prisoners

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Victorian Hepatitis C Strategy

• Key priority Area 4
• Research and surveillance
• Explore ways to reduce unsafe injecting
  practices, particularly focussing on the early
  years of injecting when injecting drug users are
  most vulnerable to Hepatitis C infection

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Victorian Hepatitis C Strategy

• Key priority Area 4
• Research and surveillance
• Explore the adequacy of current services and
  systems in meeting the Hepatitis C related needs
  ( including prevention) of people released from
  adult and juvenille correctional services.

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Victorian Hepatitis C Strategy

• Key priority Area 4
• Research and surveillance
• Identify factors affecting the integration of
  hepatitis C issues within pharmacotherapy
  prescribers practice

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Victorian Hepatitis C Strategy

• Key priority Area 5
• Pharmaceutical treatments
• Increase the number of referrals from general
  practitioners to liver clinics for newly
  diagnosed patients especially in the Aboriginal
  community and from prison health service
  providers.

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Victorian Hepatitis C Strategy

• Key priority Area 5
• Pharmaceutical treatments
• Develop and implement education and training
  programs for health care workers with respect to
  available hepatitis C treatment and support
  services.

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Victorian Hepatitis C Strategy

• Key priority Area 5
• Pharmaceutical treatments
• Improve assess to hepatitis C treatment services
  for patients in regional areas
• Acknowledgement of DHS Communicable Diseases
  Control.

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Facts

• Most people who acquire HCV do not clear virus
  spontaneously and most infections are not
  diagnosed acutely.
• Lifestyle modification is valuable in most
  patients
• Therapy for HPV is improving but remains toxic,
  difficult to take and about 50 effective in some
  groups

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Facts

• Negative HCV AB does not equate to no infection
• Normal ALT levels are eligible for treatment
• Liver biopsy currently remains useful in some
  patients

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Education is the key

• Need a combined effort
• To prevent the transmission
• To diagnose
• To Cure it
• To improve quality of life, physically and
  emotionally

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The End

• Questions?