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What is viral hepatitis: what you need to know and do.


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Hepatitis, a general term referring to inflammation of the liver, may result from various causes, both infectious (ie, viral, bacterial, fungal, and parasitic organisms) and noninfectious (eg, alcohol, drugs, autoimmune diseases, and metabolic diseases); this article focuses on viral hepatitis, which accounts for more than 50% of cases of acute hepatitis in the United States.
In the United States, viral hepatitis is most commonly caused by hepatitis A virus(HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV). These 3 viruses can all result in acute disease with symptoms of nausea, abdominal pain, fatigue, malaise, and jaundice. Additionally, HBV and HCV can lead to chronic infection. Patients who are chronically infected may go on to develop cirrhosis and hepatocellular carcinoma (HCC). Furthermore, chronic hepatitis carriers remain infectious and may transmit the disease for many years.
Other hepatotropic viruses known to cause hepatitis include hepatitis D virus (HDV) and hepatitis E virus (HEV). However, the term hepatotropic is itself a misnomer. Infections with hepatitis viruses, especially HBV and HBC, have been associated with a wide variety of extrahepatic manifestations. Infrequent causes of viral hepatitis include adenovirus, cytomegalovirus (CMV), Epstein-Barr virus (EBV), and, rarely, herpes simplex virus (HSV). Other pathogens (eg, virus SEN-V) may account for additional cases of non-A/non-E hepatitis.

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What is viral hepatitis: what you need to know and do.

  1. 1. What is viral hepatitis: What you need to know and do.
  2. 2. What is Hepatitis?
  3. 3. Hepatitis • Inflammation of the liver • May be self-limiting or may progress to fibrosis and cirrhosis • May be acute (lasting less than 6 months) or chronic
  4. 4. Hepatitis can be caused by: • Viruses • Other infections • Toxins and certain drugs (Tylenol) • Alcohol • Autoimmune disease • Other health conditions like obesity and diabetes 4
  5. 5. Signs and symptoms of hepatitis • Fatigue and malaise • Jaundice • Poor appetite • Nausea and vomiting • Diarrhea • Or no symptoms at all 5 Many people have viral hepatitis and don’t know it. Many of the symptoms may feel like hang-overs, dope sickness or just feeling sickish-common experiences for people with substance use disorders.
  6. 6. Hepatitis and people with SUD • Increased risk of infection with viruses that cause hepatitis – Sharing needles and other drug paraphenelia – Unprotected sex – Other unhygienic practices and conditions • Increase risk of liver damage caused by alcohol • Multiple risk factors increase the overall risk and severity of the condition 6
  7. 7. The Liver Right Lobe Ligament Left Lobe Falciform Ligament Ligamentum Teres Gallbladder
  8. 8. Liver Functions • Digestion: the liver produces bile – critical for the digestion of fats-where is the bile stored? In the gall bladder • Metabolism: the liver turns all digested food into ENERGY • Detoxification: the liver monitors the content of the blood and can break down many potentially harmful substances. • Storage: the liver stores many essential nutrients, vitamins and minerals • Production: the liver produces several critical components of blood plasma • Immunity: the liver produces a specific type of macrophage that is essential to a healthy immune system
  9. 9. Viral Hepatitis • Inflammation of the liver caused by group of viruses that infect the liver • Viral hepatitis A B C D E • Leading cause of liver cancer • Most common reason for liver transplant • Over 4.4 million Americans are infected and most do not know it 9
  10. 10. 10 Hepatitis A
  11. 11. Hepatitis A • Caused by the Hepatitis A Virus (HAV) • Spread though food or water contaminated by feces from an infected person or very rarely though blood contact-very contagious • Not chronic and usually resolves on its own • There is a Hepatitis A vaccination 11 Hepatitis A is not chronic but a person can get very sick and it can take a month to feel well enough to work. Hepatitis A vaccinations are given to all children in the US and adults who were not vaccinated as children and are a higher risk for infection.
  12. 12. Who’s at Risk for Hepatitis A? • International travelers • People intimate with an infected person • Living where people are not vaccinated • Day care children and workers during an outbreak • Men who have sex with men • Drug users 12 International travelers-especially to developing countries with poor infrastructure (don’t drink the water)-some travelers get the vaccine before traveling to places that have high rates of Hepatitis A. By intimate we mean living together, sharing a kitchen or bathroom, having sex with an infected person. Remember it’s the feces that spreads HAV.
  13. 13. How to Prevent HAV Infection • Good hygiene-hand washing • Avoiding tap water from unreliable sources • Routine vaccination 13
  14. 14. 14 Hepatitis A
  15. 15. Hepatitis B • Caused by the Hepatitis B virus (HBV) • Spread through contact with infected blood, sex with infected person, mother to child in childbirth • Infection usually resolves on its own-fewer than 10% will develop chronic hepatitis B infection • There is a HBV vaccine 15
  16. 16. Who is at Risk for HBV Infection? • People who live with or have sexual contact with an infected person • Men who have sex with men • People who have multiple sex partners • Injection drug users • Health care workers • Infants born to mothers with HBV infection 16
  17. 17. How to Prevent HBV Infection • Hepatitis B vaccination • Using latex condoms • Not sharing needles and other equipment • Not sharing personal items like toothbrushes, razors, nail clippers 17
  18. 18. 18 Hepatitis A
  19. 19. Hepatitis C • Caused by the Hepatitis C virus (HCV) • Spread through blood • HCV is the most common blood-borne illness in the US • Risk of sexual transmission are lower that HAV and HBV • 75-85% develop chronic Hepatitis. C • There is no vaccine for Hepatitis C 19 Sharing needles and other drug paraphernalia is the most common risk factor for acquiring HCV. 40% of chronic liver disease is caused by HCV.
  20. 20. Who Is at Risk for HCV Infection? • Injection drug users • People who have sex with an infected person • Health care workers • People who received a transfusion of blood before 1992 20
  21. 21. How to Prevent HCV Infections • Using latex condoms • Not sharing needles or other equipment, like straws • Not sharing personal items like toothbrushes, razors, nail clippers 21
  22. 22. Co-Infection with HIV and Viral Hepatitis 22 HAV/HIV HBV/HIV HCV/HIV HIV
  23. 23. Co-Infection with HIV and Viral Hepatitis 23 HAV/HIV co-infection may make it necessary to suspend HIV treatment temporarily. HIV treatment drugs are hard on the liver and an HAV infection may cause the liver to have difficulty metabolizing HIV drugs. HAV infection may be more severe and last longer in people who have both infections than in people who do not have HIV As many as 90% of people with HIV have also been infected with HBV and 10-15% of these people will become chronic carriers. Most studies suggest that this co-infection does not significantly increase the risk that HIV will progress to AIDS. However the co-infection increases the likelihood that HBV infection will become chronic and progress quickly and that liver damage may be more severe. HIV infection may increase a person’s risk of contracting HCV through sexual contact. Approximately 25- 33% of people with HIV are co-infected with HCV People with co-infections are more likely to develop cirrhosis, liver cancer and liver failure that those with HCV only. Hepatitis increase the risk of liver toxicity from HIV medications but the benefits of a stronger immune system outweighs the risks.
  24. 24. Screening for Viral Hepatitis • Hepatitis screening involves testing a small sample of blood to test for antigens and antibodies to each type of hepatitis 24
  25. 25. Hepatitis A Screening • Tests for antibodies to HAV • Positive test means person has or has had HAV infection or that the person has been vaccinated for HAV • Negative test means person has not be infected or vaccinated for HAV 25
  26. 26. Hepatitis B Screening • Test for HBV involves measuring HBV antibodies and antigens • Lab workers will interpret results to determine if the person is infected, if the infection is acute or chronic, or if the person has immunity • Presence of surface antibodies means that the person is immune either because the virus has cleared the body or because of vaccinations 26 Testing positive for surface antigens means that the person is currently infected and can pass the infection to others Testing positive for core antigen means that the person has been infected, but and may have not cleared the virus from their bodies Test positive for HBV antibodies
  27. 27. Hepatitis C Screening 27 HCV Screening Antibodies test Positive result Person has been infected Conduct HCV RNA Test Negative Results No detectable infection Test again in 6 Months Positive Person is infected with HCV) Negative No sign of infection. Test again in 6 months The first test for Hep C tests for the presence of antibodies (antibodies would tell us that the person has been infected but not whether the person is still infected-it is possible that the virus has cleared. Other tests the HCV RNA tests- one can tell whether the virus is still present and another test determines the viral load MTP: It’s important for the person to be re-tested in 6 months because a person who is infected with HCV may not have antibodies to the virus for up to 6 months (especially if the person has an impaired immune system).
  28. 28. Screening is an Opportunity Screening is more than just a blood test. • Discuss beliefs about viral hepatitis • Discuss screening for the first time • Educate about viral hepatitis • Identify patterns of risky behavior • Motivate to change risky behaviors 28 Screening is a huge opportunity to discuss, educate and motivate patients. Most patients entering substance use treatment do not know their hepatitis status. They may not be aware of the last time they were screened or they could be confusing HIV screening with viral hepatitis screening.
  29. 29. Discussing Screening Results • Medical personnel, not counselors usually discuss the test results • Negative results: talk about on-going testing, risky behavior, and vaccinations for HAV and HBV • Positive results: check on medical referrals, emphasize the potential for cure and importance of self-care 29
  30. 30. Evaluation of Chronic Hepatitis • Liver panel and other blood tests • Viral load test • Genotype test • Fibrosis assessment – Liver biopsy – Fibroscan (liver imaging, non invasive) – FibroTest (blood test) – FibroSure (blood test) 30 Liver panel will give a picture of the functioning of the liver. Viral load tells us how much virus the person has. Genotype test tells us much more about the specific Hep C virus that is causing the infection-more on this in just a minute. Practitioners don’t always have to do a liver biopsy to determine how sick the liver is-how fibrotic or hardened.
  31. 31. Evaluation of Chronic Hepatitis • Liver panel and other blood tests • Viral load test • HCV genotype test • Liver biopsy or Fibroscan 31 The top three options are simple blood tests. Genotype refers to the type or strain of HCV-there are at least 6 types and types 1,2 &3 are most common. Each type causes the same disease-one is not worse in terms of progress of the disease but genotype has implications for treatment. A liver biopsy involves a local anesthetic on the right side and inserting a needle into the liver to remove a very small piece of liver. This test can reveal the extent of liver inflammation, the amount of scarring (fibrosis), presence or absence of cirrhosis, lesions in the liver. A iver biopsy is the best way to evaluate the health of the liver, provides information about whether antiviral treatment is advisable or needed and can help a person decide whether to continue antiviral treatment.
  32. 32. Options for Hepatitis Treatment • Treat with potent antiviral medications • Defer antiviral treatment • No treatment 32 There are 3 generic options –treat-wait-don’t treat MTP: Many treatments now do not require injections so we’re going to have to remove the syringe. It’s important to help people make informed decisions about treatment for hepatitis. How do you currently help people to make decisions about hepatitis treatment?
  33. 33. Treatment for HCV • Harvoni-one pill a day, very effective and few side effects – Effective cure for genotype 1 only – Treatment costs between $63,000 and $189,000 depending on duration • Sovaldi-taken with ribavirin and/or PEG – Effective cure for genotypes 1, 2, 3, 4, and 5 – Also very expensive 33 PEG is peginterferon-it’s an administered through an infection.
  34. 34. Treatment for HCV in MA • MassHealth will pay for new treatments, but not for everyone, all at once – Prior Authorization Request Form • HDAP • Self-pay 34 Hand out prior aurthorization form HDAP is HIV Drug Assistance Program
  35. 35. Considerations for Hepatitis Treatment • Timing • Treatment contraindications • Presence of more urgent problems • Cost, lack of health insurance • Likelihood of treatment success 35 There was a time when medical providers would deny hepatitis treatment to people with substance use disorders but now it is considered good practice to screen and evaluate people with SUD for anti-viral treatment. Now that treatment is easier there are fewer reasons to wait. Adherence is greatly improved with the newer HCV treatment. It’s important to help people make informed decisions about treatment for hepatitis. How do you currently help people to make decisions about hepatitis treatment?
  36. 36. Supporting Client Actions •Encourage client to obtain reliable information in order to make decisions about hepatitis treatment •Encourage better self-care-rest, eating well avoiding alcohol and drugs •Avoiding Tylenol in larger than recommended doses •Getting vaccinated against hepatitis A & B 36
  37. 37. Counseling/Support •Providing reliable information •Developing therapeutic relationship •Increasing understanding •Incorporating needs into treatment •Developing a prevention plan •Using motivational approaches •Addressing social factors •Confronting relapse •Building a support system •Providing case management/ advocacy 37
  38. 38. Providing Reliable Information •Gather a range of reliable patient information about screening, evaluating and treatment options •Develop group information sessions •Dispel myths and misinformation about hepatitis 38
  39. 39. Developing a Therapeutic Relationship •Unconditional non-judgmental positive regard •Respond to person’s emotional experience of the diagnosis •Assist person in negotiating treatment system •Helping person to overcome barriers to treatment •Inspire hope for recovery •Demonstrate credible support 39
  40. 40. Increasing Understanding about Hepatitis and Recovery •Help people understand their diagnoses •Help person to understand treatment options, risks of spreading the illness, and how diagnostic status effects relationships in their lives •Have person restate in his/her own words their understanding 40
  41. 41. Incorporating Health Needs into Treatment and Recovery Plans •Education and support for improved self-care •Self-advocacy skills and strategies to help person obtain treatment •Education about reinfection and transmitting the virus 41
  42. 42. Developing Prevention Plan • Identify high risk incidents • Identify a situation when the client minimizes his/her risk • Develop incremental and achievable steps to minimize risks for transmitting viral hepatitis • Revisit the plan often • Include vaccination and prevention for other infections 42
  43. 43. Using Motivational Techniques • Help person understand the relationship between good health and achieving their recovery goals • Identify the strengths of the person-including the supports that he/she is currently using 43
  44. 44. Addressing Social Factors • Social consequences of hepatitis C diagnosis may be challenging • Negative attitudes about people who have chronic hepatitis remain, even among some medical professionals • Internalized stigma and shame generated by these negative attitudes • Important to discuss and teach about disclosing hepatitis 44
  45. 45. Addressing Relapse • Diagnosis of viral hepatitis may increase a client’s potential for relapse to alcohol and drug use • Treatment for HCV may increase potential for relapse • Re-infection with HCV often happens during relapse 45
  46. 46. Building a Support System • Provide on-site support groups • Help clients locate community- based support groups • Peer support may be available • Facilitating family support through education and counseling • On-line resources for support 46
  47. 47. Performing Case Management/Advocacy • Help to understand and complete written documents and consent forms • Help to obtain medical care and ancillary supports • Help to find sources for financing medical treatment and medications for hepatitis 47
  48. 48. 48(only 12% adults in US have basic health proficiency)
  49. 49. Education-Patient • Currently most SUD treatment programs do not provide hepatitis education • Treatment as an opportunity for hepatitis education • Groups or 1-to-1 • Educational materials-print, multimedia, posters 49