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Hep B and C Screening & Management Simons Towns
1. HEPATITIS B AND
HEPATITIS C
Brenna Simons PhD
Lisa Townshend-Bulson, MSN, FNP-C Screening Guidelines, Understanding Tests &
Patient Management.
Alaska Native Tribal Health Consortium
Liver Disease and Hepatitis Program
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
5. Thank Goodness for Vaccines!
Hepatitis B Virus One Nasty Virus
HBeAg Highly infectious and
stable virus
Acute Hepatitis
HBcAg
Chronic Hepatitis
Cirrhosis/fibrosis
Hepatocellular
Carcinoma
http://pathmicro.med.sc.edu
6. Hepatitis B Infection in the U.S.
HBV Universal
Vaccination http://www.cdc.gov/hepatitis/Statistics/
Nationwide
7. Hepatitis B Infection in the U.S. by
Race
http://www.cdc.gov/hepatitis/Statistics
U.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. Although Hep B Vaccine Effective
there are Other Factors to
Consider…
• 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/
10. Antigens and Antibodies
Antigen (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‟
antigen
Viral 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
12. Hepatitis B (HBV) Screening
Tests
TEST WHAT IS IT?
SAG Hepatitis B Surface Antigen
HbsAg
Hep B Surface Ag
HBeAg
Anti-HbS Hepatitis B S Antibody
SAB
HbsAb
HBcAg
HepB Surface Ab
Anti-HBc Hepatitis B Core Antibody
HBc Ab, IgM/Total
IgM
Total (IgM + IgG)
14. Indications for HepB Screening
and Vaccination
& recipient
•HCV-positive patients
•Individuals incarcerated
•Health Care Worker
Hepatitis B Foundation www.hepb.org
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. 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 ALT
HBsAg Clearance Phase
• HBV Viral Load generally undetected, but can be present and <2,000 IU
• HBsAg NEGATIVE
• Normal ALT
18. Hepatitis B (HBV) Clinical Tests in
Persons who are HBsAg-Positive
TEST
WHAT IS IT?
NAME
Anti-HBE Anti-Hepatitis B E-Antigen
Antibody
HBeAg
HepB E Ag Hepatitis B E-Antigen (Viral Protein)
HBeAg
HBcAg
HBV DNA Hepatitis B Viral DNA (Viral Load)
International Unit / mL (IU/mL)
ALT Alanine aminotransferase
Liver Enzyme
19. The HBsAg+ Test is Positive…Now
What?
Evaluating and Monitoring Chronic
Hepatitis B
www.hepb.org Hepatitis B Foundatio
21. Hepatitis C Virus – Background
and Epidemiology
Hepatitis C Risk Factors
Hepatitis C Co-Infection with HIV
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
Cirrhosis
www.prn.org Liver Cancer
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. 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/
26. Hepatitis C Clinical Tests
TEST WHAT IS IT?
Anti-HCV Ab Anti-HCV Antibody
HCV RNA Quant HCV Viral Load RNA Te
QUANTITATIVE
27. Hepatitis C Screening
Guidelines
SCREENING ALGORITHM
• Screen for HIV
Patient is HCV Positive • Collect HepA and HepB Vaccination History
Consult with Specialist • Screen for HepA and B
• HepC Viral Genotyping
AASLD AND CDC GUIDELINES and the ANTHC Liver Disease and Hepatitis Program
28. Hepatitis C Genotyping
TEST WHAT IS IT? INTERPRETATION
HCV 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. Management of HEPATITIS C
Lisa Townshend-Bulson, MSN, FNP-C
Alaska Native Tribal Health Consortium
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. 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. Key Messages for Patient
About 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. Helpful Patient Tips After
Hepatitis 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. 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)
36. Who Should be Screened for
Hepatocellular 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. Effective Treatment Regimes for
HCC
Surgical resection
Tumor ablation
Radiofrequency Ablation
Chemoembolization
Liver Transplantation:
Almost all patients get reinfected with
HCV if not treated before transplant
38. Conclusions
Hepatitis 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. Alaska Native Tribal Health Consortium
Liver Disease and Hepatitis Program
ANTHC LiverConnect
www.anthc.org/chs/crs/hep
40. Thank You!
Brenna Simons PhD
bcsimons@anthc.org
The ANTHC Liver Disease and Hepatitis Program
Lisa Townshend ANTHC LiverConnect
MSN, FNP-C www.anthc.org/chs/crs/hep
Editor's Notes
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
PLEASE KNOW THESE FACTS.
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