Hep B and C Screening & Management Simons Towns


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  • Brief overview of todayHCV Patient Management – Lisa Townshend, Nurse Practitioner will be going over in further detail including treatment in one of the breakout sessions
  • Key phrases for HepB – definitely a different disease / viral infection than HepC, including risk factors and transmission
  • HepB is one nasty virus – highly infectious with side effects that include cancerVirus is stable for days – unlike hCV or HIV – surfaces, minimal contact with open woundsFocus will be on Chronic HBV Diagram of Virus: (1) S Antigen outside of virus (2) E and Core Antigen inside of virus (3) HBV is a DNA virus - just a reference when we discuss clinical testing
  • Acute Hepatitis B Infection in the US has declined dramatically - thanks to the HepB Vaccination program
  • HBV Cases by racial/ethnic groups in the U.S.Alaska Cases even higher prior to vaccination
  • A few facts to consider even though we are now 20 years out from Universal HBV VaccinationSome of these factors can be very region-specific (example of immigration , populations present in the community)In Anchorage and several areas of Alaska – higher proportions of Asian populations and African populationsWill go into further information regarding screening and vaccination guidelines later on
  • The main clinical tests we will discuss today involve detection of infection, and/or detection of burden of infectionAntigen detection tests are searching for the actual ‘bug’ or pathogen – this can apply to all different categories of bugs – Viruses such as HepB, Bacterial such as Chlamydia, or Parasites such as nematods/worms
  • Also, test children of mothers with HCV after the age of 1.If you look for it you will find it. Think age, risk factors, elevated LFTs. Sx are vagueAPRI calculation next page
  • Explain Metavir scoring
  • Be ready to give your patients these tips to help them manage hepatitis C…
  • In hepatitis C, you do not get liver cancer until you develop cirrhosis. This is not the same for hepatitis B where you can develop liver cancer without cirrhosis. And we know that alcohol will shorten the time to the development of cirrhosis. So you have INFLAMMATION…
  • At ANMC, AFP has been used for many years and we have found it to be very helpful in picking up on HCC early. If it is high, you’re alerted to look for HCC through imaging. Cite Mike’s paper
  • The good news about hepatocellular carcinoma is that IF you catch it early when tumors are small, it is treatable. Here are the treatments for HCC
  • Hep B and C Screening & Management Simons Towns

    1. 1. HEPATITIS B AND HEPATITIS CBrenna Simons PhDLisa Townshend-Bulson, MSN, FNP-C Screening Guidelines, Understanding Tests & Patient Management.Alaska Native Tribal Health ConsortiumLiver Disease and Hepatitis Program
    2. 2. What We Will be Discussing Hepatitis B Virus  Background & Epidemiology  Screening Guidelines  Understanding Tests  Patient Management Hepatitis C Virus  Background & Epidemiology  HIV-HCV Co-Infection  Screening Guidelines  Understanding Tests  Patient Management
    4. 4. Hepatitis B Virus – Backgroundand Epidemiology
    5. 5. Thank Goodness for Vaccines! Hepatitis B Virus One Nasty Virus HBeAg  Highly infectious and stable virus  Acute HepatitisHBcAg  Chronic Hepatitis  Cirrhosis/fibrosis  Hepatocellular Carcinoma http://pathmicro.med.sc.edu
    6. 6. Hepatitis B Infection in the U.S. HBV Universal Vaccination http://www.cdc.gov/hepatitis/Statistics/ Nationwide
    7. 7. Hepatitis B Infection in the U.S. byRace http://www.cdc.gov/hepatitis/StatisticsU.S. State of Alaska 220 200 Yukon Kuskokwim Delta 180 Statewide 160 Rate per 100,000 140 120 100 80 60 40 20 0 81 83 85 87 89 91 93 95 97 99 01 03 05 07 19 19 19 19 19 19 19 19 19 19 20 20 20 20 Year Statewide Vaccine Program Dr. Brian McMahon
    8. 8. Although Hep B Vaccine Effectivethere are Other Factors toConsider…• Without intervention, up to 25% of chronically infected individuals with HBV die of complications• 3,000-5,000 U.S.-acquired cases of chronic HBV/year since 2001• ~53,800 new cases of chronic HBV imported to the U.S. between 2004 and 2008• Vaccine longitudinal research ongoing• Healthcare Workers - Increased risk of needle stick So Make Sure Your Patient is• Vaccination History sometimes difficult to and Mitchell et. al. 201 Covered !! http://www.cdc.gov/hepatitis/Statistics/
    9. 9. HBV Screening Guidelines
    10. 10. Antigens and AntibodiesAntigen (Ag) Antibody (Ab) Detection of the „Bug‟  Patient Immune Response to the  Virus,bacteria,parasite… specific „Bug‟ Antigen Ag+ : bug is present  Ab+ : Patient Immune Response to „Bug‟ Ag- : too little of bug to detect – OR- bug is not there  Ab- : No Patient Immune Response to specific „bug‟ antigenViral Load (DNA or RNA)Genetic Material of „Bug‟(detected) : bug is present(below limit of detection) : bug may be present, too low to detect(not detected): bug is not there
    11. 11. Testing Specificity andSensitivitySpecificity Sensitivity False-Positives  Limit of Detection Low(er) Limit of Detection More Sensitive High(er) Limit of Detection Less Sensitive
    12. 12. Hepatitis B (HBV) ScreeningTests TEST WHAT IS IT?SAG Hepatitis B Surface AntigenHbsAgHep B Surface Ag HBeAgAnti-HbS Hepatitis B S AntibodySABHbsAb HBcAgHepB Surface AbAnti-HBc Hepatitis B Core AntibodyHBc Ab, IgM/Total IgM Total (IgM + IgG)
    13. 13. Hepatitis B ScreeningGuidelinesSCREENING ALGORITHM www.hepb.org Hepatitis B
    14. 14. Indications for HepB Screening and Vaccination & recipient•HCV-positive patients•Individuals incarcerated•Health Care Worker Hepatitis B Foundation www.hepb.org
    15. 15. Hepatitis B PatientManagement
    16. 16. Four Main Phases of Chronic HBV Disease…. But it‟s complicated S Ag+ E Ag+ S Ag+ E Ag- Anti-HE+ S Ag- E Ag-2009 Hepatology McMahon
    17. 17. HBV Treatment Dependent on Phase Inactive • Maintain HBV Viral Load < 2,000 IU/mL • Normal ALT Active • HBV Viral Load > 20,000 IU/mL • Elevated ALT Immune Tolerant • HBV Viral Load > 20,000 IU/mL • Normal ALTHBsAg Clearance Phase • HBV Viral Load generally undetected, but can be present and <2,000 IU • HBsAg NEGATIVE • Normal ALT
    18. 18. Hepatitis B (HBV) Clinical Tests inPersons who are HBsAg-Positive TEST WHAT IS IT? NAMEAnti-HBE Anti-Hepatitis B E-Antigen Antibody HBeAgHepB E Ag Hepatitis B E-Antigen (Viral Protein)HBeAg HBcAgHBV DNA Hepatitis B Viral DNA (Viral Load) International Unit / mL (IU/mL)ALT Alanine aminotransferase Liver Enzyme
    19. 19. The HBsAg+ Test is Positive…NowWhat? Evaluating and Monitoring Chronic Hepatitis B www.hepb.org Hepatitis B Foundatio
    20. 20. HEPATITIS CChronic Viral InfectionHIV Co-InfectionInjection Drug UseCirrhosisLiver Failure
    21. 21. Hepatitis C Virus – Backgroundand EpidemiologyHepatitis C Risk FactorsHepatitis C Co-Infection with HIV
    22. 22. No Vaccine for “Non-A, Non-B”Hepatitis C Virus Distinctive Risk Factors  IV Drug Use (IDU), Incarceration, blood transfusion before 1992, tattoos, some sexual contact  Acute Infection  Often asymptomatic  Chronic Infection  Develops in 75-85% of those infected  Chronic liver disease  Cirrhosiswww.prn.org  Liver Cancer
    23. 23. Acute Hepatitis C in the U.S. • Urban populations affected more prevalently • In Alaska, our program has identified over 2,300 anti-HCV positive AN/AI, approxima tely equivalent to US prevalence. • Some programs report up to 11- 12% prevalence in urban communities. http://www.cdc.gov/hepatitis/Statistics
    24. 24. Prevalence of HIV-HCV Co-infection Estimated 25% of individuals infected with HIV in the US are also infected with Hepatitis C Approximately 80% (50-90%) of IDUs with HIV infection also have Hepatitis C Hepatitis C infection progresses more rapidly to liver damage in HIV-infected persons HCV infection also impacts the course and management of HIV infection U.S. guidelines recommend that all HIV- infected persons be screened for HCV infection http://www.cdc.gov/hepatitis/
    25. 25. HCV Screening Guidelines
    26. 26. Hepatitis C Clinical Tests TEST WHAT IS IT?Anti-HCV Ab Anti-HCV AntibodyHCV RNA Quant HCV Viral Load RNA Te QUANTITATIVE
    27. 27. Hepatitis C ScreeningGuidelinesSCREENING ALGORITHM • Screen for HIVPatient is HCV Positive • Collect HepA and HepB Vaccination HistoryConsult with Specialist • Screen for HepA and B • HepC Viral Genotyping AASLD AND CDC GUIDELINES and the ANTHC Liver Disease and Hepatitis Program
    28. 28. Hepatitis C Genotyping TEST WHAT IS IT? INTERPRETATIONHCV Genotype There are 6 major Genotype 1 genotypes of HCV. Genotype 2 This test will give you Genotype 3 dominant HCV genotype the patient Genotype-Specific is infected with. This Treatment Eligibility and will affect treatment Options options. Uncommon in the U.S. Genotype 4 Genotype 5 Genotype 6 Consult with Specialist
    29. 29. Management of HEPATITIS CLisa Townshend-Bulson, MSN, FNP-CAlaska Native Tribal Health Consortium
    30. 30. New Diagnosis of Hepatitis C Counsel patient about new diagnosis, review risk factors to estimate length of infection Determine hepatitis A and B status; vaccinate Begin educating patient about hepatitis C Brief lifestyle interventions: alcohol and weight loss Consider referral for liver biopsy  Genotype 1 patients  Those who may have had the disease ≥10 years Consider hepatitis C treatment Follow patient, liver labs every 6 – 12 months
    31. 31. AST to Platelet Ratio Index(APRI) Poor man‟s biopsy Calculation = Patient‟s AST/ULN AST (40) x 100 Platelet counts (109/L) Interpretation < 0.5 rule out significant fibrosis (Metavir F0-F1) > 1.5 rules in significant fibrosis (Metavir F2-F4) > 2.0 probable cirrhosis (Metavir F4) Repeat yearly, track APRI trend Loaeza-del-Castillo, A., et al., Annals of Hepatology 2008; 7(4), 350-357
    32. 32. Key Messages for PatientAbout HCV Diagnosis HCV does not make your liver sick over night HCV is not spread by casual contact Low rate of sexual transmission (< 5%) Low rate of vertical transmission (< 5%) Follow up labs/evaluation every 6-12 months are important to prevent complications  Reiteratelifestyle intervention at each visit  Continue educating patients
    33. 33. Helpful Patient Tips AfterHepatitis C Diagnosis  Avoid alcohol  Do not share needles, toothbrushes or razors  Eat a healthy diet, maintain healthy weight  Stop smoking  Get plenty of rest/reduce stress  Take in adequate vitamin D  Coffee is good  Do not combine alcohol and acetaminophen  Milk thistle won‟t get rid of hepatitis C  Stay informed
    34. 34. Liver Disease Progression Inflammation Fibrosis – Scar tissue forms Cirrhosis – Scar tissue replaces healthy tissue and blocks blood flow through the liver and decreases its function (20-30 years) Hepatocellular Carcinoma (HCC) – Occurs in hepatitis C after development of cirrhosis (20+ years)
    35. 35. Liver Disease Progression Healthy Fibrotic Liver Liver Cirrhotic Liver Liver Cancer
    36. 36. Who Should be Screened forHepatocellular Carcinoma (HCC) with HCV?  Those with cirrhosis or bridging fibrosis (advanced fibrosis)  Screen with liver ultrasound every 6 months, adding alpha-fetoprotein (AFP) blood test optional, may increase effectiveness of screening  In persons in whom stage of fibrosis is unknown, AFP can be used  If AFP > 8ng/ml, US should be added every 6 months Bruix et al. Hepatology 2010; at aasld.org/practice guidelines Bruce et al. J Viral Hepatitis 2007; 25:6958-64
    37. 37. Effective Treatment Regimes forHCC Surgical resection Tumor ablation  Radiofrequency Ablation  Chemoembolization Liver Transplantation:  Almost all patients get reinfected with HCV if not treated before transplant
    38. 38. ConclusionsHepatitis B Hepatitis C Screening for  Screening for hepatitis B infection hepatitis C is a 2- and/or vaccine status is critical for step process protection  HCV genotype is Assess patients important to patient completely to management determine acute &  Remember to chronic infection, immunity to hepatitis screen for HIV co-  B Both infections require life-long infection monitoring
    39. 39. Alaska Native Tribal Health ConsortiumLiver Disease and Hepatitis ProgramANTHC LiverConnectwww.anthc.org/chs/crs/hep
    40. 40. Thank You!Brenna Simons PhDbcsimons@anthc.org The ANTHC Liver Disease and Hepatitis ProgramLisa Townshend ANTHC LiverConnectMSN, FNP-C www.anthc.org/chs/crs/hep