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1
It’s Time: Integrate Viral
Hepatitis Into your Work
Tamara Brickham, MPH
Adult Viral Hepatitis
Prevention Coordinator
Ho...
2
Housekeeping
 We will take short, frequent breaks, please return
on time.
 Please sign the participant list.
 If you ...
3
Tell us……
 Your name
 Experience providing hepatitis or HIV
counseling and/or education
 A challenge you have experie...
4
Goal of this course
To enhance the counseling skills of health
educators, outreach workers, HIV
counselors, STD workers,...
5
Course Objectives
Participants will:
 Define the functions of the liver and different
types of viral hepatitis
 Identi...
6
Course Overview
 Section 1: Overview of the Liver and Viral
Hepatitis
 Section 2: Focus on Hepatitis C
 Section 3: Gu...
7
The Liver
8
Liver
 Largest internal organ
 Weighs about 3lbs
 Located on right side under ribcage
 Ability to regenerate
 Has o...
9
The Golden Fleece and the Heroes
Who Lived before Achilles Prometheus Bound
For Prometheus to be set free:
•An Immortal ...
10
Liver Functions
 Stores: iron, vitamins, minerals, sugars
 Produces: bile, cholesterol and lymph
 Regulates: blood c...
11
Liver Functions Cont’d
 Processes: food, alcohol and other drugs
 Converts: food and drink into forms the body
can us...
12
Liver Damage
 Inflammation – immune response
 Fibrosis – development of scar tissue
 Cirrhosis – a process where liv...
13
Defining Viral Hepatitis
14
What is Hepatitis?
 Inflammation of the liver
 Caused by viruses, alcohol, medications, and other
toxins
 This train...
15
16
ABCs… of Viral Hepatitis
 Hepatitis A Virus (HAV)
 Hepatitis B Virus (HBV)
 Hepatitis C Virus (HCV)
 Hepatitis D Vi...
17
Viral Hepatitis Language
 Acute infection is when the infection is newly acquired,
and is less than 6 months
 Chronic...
18
Hepatitis A Overview
 In 2006, ~32,000 newly infected people in the US
 Acute disease -- no chronic infection
 Prima...
19
Reported Cases of Hepatitis A
in Texas 1990-2007
Hepatitis A vaccine licensed in 1995
Hepatitis A vaccine requirements
20
Hepatitis A
 Found in the stool (feces) of persons infected with
hepatitis A virus
 HAV is usually spread by “fecal-o...
21
Signs and Symptoms of HAV
 jaundice
 fatigue
 abdominal pain
 loss of appetite
 nausea
 diarrhea
 fever
Adults h...
22
Persons at Risk for HAV
 Household contacts of infected persons
 Sex contacts of infected persons
 Persons traveling...
23
Preventing HAV Infection
 Get vaccinated for hepatitis A
 Always wash your hands with soap and
water after using the ...
24
Summary of Hepatitis A
 HAV is spread the fecal-oral route through
contaminated food or water
 There is no long-term ...
25
Hepatitis B Overview
 In 2006 ~ 46,000 new infections in US
 ~1.4 million in US living with chronic HBV
 Primarily t...
26
Reported Cases of Acute Hepatitis B in
Texas, 1980-2008
Hepatitis B recombinant vaccine
licensed in 1986
Universal infa...
27
Hepatitis B
 Inflammation of the liver caused by the hepatitis B
virus (HBV)
 Can cause lifelong infection, cirrhosis...
28
Transmission of HBV
 Being in contact with infected blood or
body fluids while you are not immune
 Having sex with an...
29
Persons at Risk for HBV

Persons with multiple sex
partners or diagnosis of a
sexually transmitted
disease (STD)

Men...
30
Symptoms of HBV
 jaundice
 fatigue
 abdominal pain
 loss of appetite
 nausea, vomiting 
 joint pain
About 30% of ...
31
Preventing HBV Infection
 Get vaccinated with Hepatitis B vaccine
 Use latex condoms correctly and every time you
hav...
32
Preventing HBV Infection
 Do not shoot drugs; never share drugs, needles,
syringes, water, or "works"
 Consider the r...
33
Summary of HBV
 HBV is spread through
unprotected sex with an infected person
by sharing drugs, needles, or "works" ...
34
HCV Overview
 An estimated 4 million Americans have been
infected with HCV, of whom 3 million are
chronically infected...
35
Hepatitis C
 Inflammation of the liver caused by the hepatitis C
virus (HCV)
 HCV can be found in the blood of a pers...
36
Transmission of HCV
 Sharing needles or "works" when
"shooting" drugs
 Through needlesticks or sharps exposures
on th...
37
Persons at Risk for HCV
 Injecting drug users
 Recipients of blood and/or solid organs
before 1992
 Recipients of cl...
38
Symptoms of HCV
 jaundice
 fatigue
 dark urine
 abdominal pain 
 loss of appetite
 nausea
80% of persons have no ...
39
Preventing HCV Infection
 There is no vaccine
 Best prevention is behavior change
Do not shoot drugs
Do not share p...
40
Summary of HCV
 HCV is spread through blood contact with an
infected person
 HCV positive individuals should be evalu...
41
Hepatitis D Overview
 Caused by hepatitis D virus (HDV)
 Coined “Delta Hepatitis”
 Rarely seen in the United States
...
42
Hepatitis E Overview
 Caused by hepatitis E virus
 Primarily a disease of import
 Very similar to hepatitis A with f...
43
Disease Burden
Deaths /yr
New infections /yr
Chronic infections
Outcome
4,000
46,000
1.4
(million)
HBV
10,000
19,000
3....
44
Chronic Viral Hepatitis Disease
Burden = 409,400 cases
Hepatitis B Hepatitis C
Prevalence in General Population 5% or 1...
45
Comparison of the big three
Virus Prevalence % of
Population
Unaware of
Infection
Status
Deaths in 2006
Related to
Infe...
46
Populations at increased risk
Asian/Pacific Islanders – in the US,
1 out of 10 API are chronically
infected with hepati...
47
Domestic HIV
69%
TB 14%
STD 15%
National Center for HIV/AIDS, Viral Hepatitis, Sexually
Transmitted Disease, and Tuberc...
48
Current Hepatitis Surveillance
Activities in Texas
 What does the state require to be reported
to the health departmen...
49
Focus on Hepatitis C
Transmission and
Prevention
50
Sexual 15%
Other* 5%
Unknown 10%
Injecting drug use 60%
Transfusion 10%
(before screening)
*Nosocomial; Health-care wor...
51
Sharing Injection Equipment
 Studies have found high rates of HCV in IDUs who didn’t share
syringe, but shared cooker,...
52
Sexual Transmission
 Seven US studies of long-term discordant partners found
1.5 - 3% seroprevalence of HCV
 Other st...
53
 There is a risk with pregnancy (5-6%)
 Post-exposure prophylaxis not available
 Coinfection with HIV risk increases...
54
Tattooing and Body Piercing
 While some studies have found an association between
tattooing and HCV in select populati...
55
Low/Unknown Risks
 Intranasal cocaine/meth use: Some studies have found link
to HCV transmission by blood getting into...
56
HCV Survival Outside the Body
 One study has been done
 Study found HCV alive outside body at 16
hours, 4 days, and 7...
57
HIV vs. HCV
 Both HIV and HCV are blood-borne infections
 HCV is 10 times more infectious than HIV by
blood-to-blood ...
58
Video
HIV and HCV
59
HCV and HIV Coinfection
 Up to 240,000 people in the U.S. are co-infected with
HIV/HCV
 Majority have chronic disease...
60
Potential Co-infection Effect of HIV
on HCV Disease
 HIV infection may worsen HCV disease
Weakened immune system allo...
61
Potential Co-Infection Effect of HCV
on HIV Disease
 HCV disease does not appear to accelerate HIV
disease
 Higher to...
62
63
Guidelines for Viral Hepatitis Testing
and Vaccination
64
Overview of HAV Vaccine
 Began usage in 1995
 Two manufacturers of inactivated vaccine:
 VAQTA®
(Merck) and HAVRIX®
...
65
Side Effects of HAV Vaccine
• No severe adverse reactions
• Most common side effects
− Soreness/ tenderness at injectio...
66
Hepatitis A Vaccine Recommendations
Hepatitis A vaccine is recommended for:
• All children at age 1 year
• Travelers to...
67
Overview of HBV Vaccine
 Began usage in 1982
 Two manufacturers of recombinant vaccine:
Recombivax HB
®
(Merck) and ...
68
Side Effects of HBV Vaccine
• No severe adverse reactions
• Most common side effects
− Soreness/ tenderness at injectio...
69
Hepatitis B Vaccine Recommendations
Hepatitis B vaccine is recommended for:
 All infants within 12 hours of birth
 Ol...
70
What is the recommendation in Texas
for vaccinating infants for hepatitis B?
The dosing schedule for infants whose
moth...
71
Adult Hepatitis B Vaccination Initiative
72
Fun with Hepatitis B Tests
 HBV Antibody Test
 Appears 1-3 months after HBsAG is
detected.
 Immunity to hepatitis B....
73
Fun with Hepatitis B Tests
 Anti HBcIgM Test
 May be present in the absence of anti-HB or HBsAg.
 Positivity indicat...
74
Acute infection
with resolution
Chronic Carrier
75
Hepatitis B Serology Interpretation
Exercise
Review the six blood test results to determine which ones
are:
Susceptible...
76
Describing HBV Test Results
77
Immune due to Vaccination
PH Follow up & counseling:
 Seize the opportunity to educate on Hepatitis and other STIs.
Ac...
78
Chronic Active HBV
PH follow up & counseling:
 Screen the contact for HBV and educate on the stages of the
disease, si...
79
HCV Testing Recommendations
CDC recommendings testing the following for HCV:
 Current or former injection drug users (...
80
 EIA (Enzyme immunoassay)
 Detects antibodies to HCV (anti-HCV)
 97% of people have antibodies 6 months after infect...
81
Reactive (Positive) EIA
 Reactive EIAs are considered confirmed by:
 RIBA
 Viral test that looks for the virus
 Sig...
82
83
Describing HCV Test Results
84
Negative Antibody Test
 Client is NOT infected (unless recent infection
during window period, 4-10 weeks)
 If risk be...
85
Positive Antibody Test
Confirmed (w/RIBA or S/CO)
 Client has been infected with HCV in the past and
probably is still...
86
Positive Antibody Test
Not Confirmed or Low/No Risk
 Client may have been infected with HCV
 Recommend further evalua...
87
Indeterminate Result
 Explain that test results are inconclusive
 May indicate recent infection if risk has
occurred ...
88
Client Centered Counseling Skills
and Risk Reduction Planning
89
ADDICTOPHOBIA
The fear of
persons
associated with, or
thought to be
associated with,
substance abuse
or illicit drug us...
90
Goals of Viral Hepatitis
Risk Reduction Counseling
 Decrease risk for transmission and/or
acquisition of viral hepatit...
91
How to Support Behavior Change
 Meet person where they are at
 Options, options, options
 Support any positive chang...
92
Factors that Influence Behavior
 Access to resources
 Attitudes/Beliefs
 Consequences
 Discrimination
 Drug use
 ...
93
Safer Goal Behavior
 Goal should be big
 A behavior that will reduce the risk of or
prevent transmission of disease
...
94
Action Plan
 Composed of small, attainable action steps
 Explore potential barriers and supports needed
for each step...
95
Skills Practice!!
 You will be counseling someone who is at
risk for or living with viral hepatitis
 Utilize the pre ...
96
97
Conclusion and Evaluation
 Evaluation and comments
 Please include your e-mail, phone number
and address if you need ...
98
It’s Time: Integrate Viral Hepatitis Into
your Work
 Tamara Brickham, MPH
Adult Viral Hepatitis Prevention Coordinator...
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  1. 1. 1 It’s Time: Integrate Viral Hepatitis Into your Work Tamara Brickham, MPH Adult Viral Hepatitis Prevention Coordinator Houston Department of Health and Human Services tamara.brickham@cityofhouston.net 823-393-4706 Larry Cuellar Adult Viral Hepatitis Prevention Coordinator Texas Department of State Health Services Larry.cuellar@dshs.state.tx.us 512-533-3124
  2. 2. 2 Housekeeping  We will take short, frequent breaks, please return on time.  Please sign the participant list.  If you want a certificate, please write your name clearly and include your mailing address.  We encourage you to ask questions and have fun.
  3. 3. 3 Tell us……  Your name  Experience providing hepatitis or HIV counseling and/or education  A challenge you have experienced or anticipate doing hepatitis education and/or counseling  What you expect from this course?
  4. 4. 4 Goal of this course To enhance the counseling skills of health educators, outreach workers, HIV counselors, STD workers, etc. that will create opportunities to integrate viral hepatitis prevention and control messages into counseling sessions.
  5. 5. 5 Course Objectives Participants will:  Define the functions of the liver and different types of viral hepatitis  Identify recommendations for hepatitis testing and vaccination  Demonstrate skill in discussing viral hepatitis and supporting risk reduction
  6. 6. 6 Course Overview  Section 1: Overview of the Liver and Viral Hepatitis  Section 2: Focus on Hepatitis C  Section 3: Guidelines for Viral Hepatitis Testing & Vaccination  Section 4: Client-Centered Risk Reduction Planning  Course Conclusion and Evaluation
  7. 7. 7 The Liver
  8. 8. 8 Liver  Largest internal organ  Weighs about 3lbs  Located on right side under ribcage  Ability to regenerate  Has over 500 vital functions  Involved in many digestive, vascular and metabolic activities
  9. 9. 9 The Golden Fleece and the Heroes Who Lived before Achilles Prometheus Bound For Prometheus to be set free: •An Immortal would have to give up his life for Prometheus – Chiron (centaur) •A mortal would have to slay the liver-eating eagle - Hercules Zeus’s punishment of Prometheus
  10. 10. 10 Liver Functions  Stores: iron, vitamins, minerals, sugars  Produces: bile, cholesterol and lymph  Regulates: blood clotting, glucose, and hormone levels  Cleans: the blood of bacteria and toxins
  11. 11. 11 Liver Functions Cont’d  Processes: food, alcohol and other drugs  Converts: food and drink into forms the body can use  Oxidizes: triglycerides to produce energy Basically, the liver processes everything we eat, drink, swallow, breathe and/or absorb!
  12. 12. 12 Liver Damage  Inflammation – immune response  Fibrosis – development of scar tissue  Cirrhosis – a process where liver cells are destroyed and replaced with scar tissue  Hepatocellular Carcinoma – type of liver cancer
  13. 13. 13 Defining Viral Hepatitis
  14. 14. 14 What is Hepatitis?  Inflammation of the liver  Caused by viruses, alcohol, medications, and other toxins  This training will focus on viral hepatitis
  15. 15. 15
  16. 16. 16 ABCs… of Viral Hepatitis  Hepatitis A Virus (HAV)  Hepatitis B Virus (HBV)  Hepatitis C Virus (HCV)  Hepatitis D Virus (HDV)  Hepatitis E Virus (HEV) These viruses all affect the liver but otherwise are unique
  17. 17. 17 Viral Hepatitis Language  Acute infection is when the infection is newly acquired, and is less than 6 months  Chronic infection lasts 6 months or more and is usually life-long unless treated  Resolved or cleared infection is the body getting rid of the hepatitis infection – usually in the acute stage
  18. 18. 18 Hepatitis A Overview  In 2006, ~32,000 newly infected people in the US  Acute disease -- no chronic infection  Primarily transmitted fecal- oral route  Vaccine is available to prevent infection
  19. 19. 19 Reported Cases of Hepatitis A in Texas 1990-2007 Hepatitis A vaccine licensed in 1995 Hepatitis A vaccine requirements
  20. 20. 20 Hepatitis A  Found in the stool (feces) of persons infected with hepatitis A virus  HAV is usually spread by “fecal-oral transmission”  Putting something in the mouth (food, water, hands) that has been contaminated with the stool of a person with hepatitis A  Most infections come from contact with a household member or sex partner who has hepatitis A  Highly infectious and stable in environment for months
  21. 21. 21 Signs and Symptoms of HAV  jaundice  fatigue  abdominal pain  loss of appetite  nausea  diarrhea  fever Adults have signs and symptoms more often than children Incubation Period: 15-50 days (average 28 days)
  22. 22. 22 Persons at Risk for HAV  Household contacts of infected persons  Sex contacts of infected persons  Persons traveling to countries where hepatitis A is common  Men who have sex with men  Injecting and non-injecting drug users
  23. 23. 23 Preventing HAV Infection  Get vaccinated for hepatitis A  Always wash your hands with soap and water after using the bathroom, changing a diaper, and before preparing and eating food
  24. 24. 24 Summary of Hepatitis A  HAV is spread the fecal-oral route through contaminated food or water  There is no long-term infection and you cannot get it again  The best way to protect against HAV is vaccination and hand washing
  25. 25. 25 Hepatitis B Overview  In 2006 ~ 46,000 new infections in US  ~1.4 million in US living with chronic HBV  Primarily transmitted through blood and bodily fluids  Vaccine is available to prevent infection
  26. 26. 26 Reported Cases of Acute Hepatitis B in Texas, 1980-2008 Hepatitis B recombinant vaccine licensed in 1986 Universal infant vaccination Universal adolescent vaccination Adult recommendation
  27. 27. 27 Hepatitis B  Inflammation of the liver caused by the hepatitis B virus (HBV)  Can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death  Highly infectious, stable in environment for at least 7 days
  28. 28. 28 Transmission of HBV  Being in contact with infected blood or body fluids while you are not immune  Having sex with an infected person without using a condom  Sharing needles to inject drugs or works (e.g., spoons, cotton, water)
  29. 29. 29 Persons at Risk for HBV  Persons with multiple sex partners or diagnosis of a sexually transmitted disease (STD)  Men who have sex with men  Sex contacts of infected persons  Injection drug users  Hemodialysis patients  Household contacts of chronically infected persons  Infants born to infected mothers  Infants/children of immigrants from areas with high rates of HBV infection  Health care and public safety workers
  30. 30. 30 Symptoms of HBV  jaundice  fatigue  abdominal pain  loss of appetite  nausea, vomiting   joint pain About 30% of persons have no signs or symptoms Incubation Period: 45-160 days (average 120 days)
  31. 31. 31 Preventing HBV Infection  Get vaccinated with Hepatitis B vaccine  Use latex condoms correctly and every time you have sex  If you are pregnant, you should get a blood test for hepatitis B  Do not share personal care items that might have blood on them (razors, toothbrushes)
  32. 32. 32 Preventing HBV Infection  Do not shoot drugs; never share drugs, needles, syringes, water, or "works"  Consider the risks if you are thinking about getting a tattoo or body piercing  If you are a health care or public safety worker, always follow routine barrier precautions and safely handle needles and other sharps
  33. 33. 33 Summary of HBV  HBV is spread through unprotected sex with an infected person by sharing drugs, needles, or "works" when using drugs through needlesticks or sharps exposures on the job from an infected mother to her baby during birth  The best way to protect against HBV is vaccination
  34. 34. 34 HCV Overview  An estimated 4 million Americans have been infected with HCV, of whom 3 million are chronically infected  Most infections are due to illegal injection and drug use  55%-85% of adults have chronic infection  If resolved, no protective antibodies  No vaccine available
  35. 35. 35 Hepatitis C  Inflammation of the liver caused by the hepatitis C virus (HCV)  HCV can be found in the blood of a person with hepatitis C  People with hepatitis C may carry the HCV in their blood for the rest of their lives, and could pass the virus on to others  Highly infectious, stable in environment for at least 16 hours but not longer than 4 days
  36. 36. 36 Transmission of HCV  Sharing needles or "works" when "shooting" drugs  Through needlesticks or sharps exposures on the job  From an infected mother to her baby during birth
  37. 37. 37 Persons at Risk for HCV  Injecting drug users  Recipients of blood and/or solid organs before 1992  Recipients of clotting factors made before 1987  Hemodialysis patients  Infants born to infected mothers
  38. 38. 38 Symptoms of HCV  jaundice  fatigue  dark urine  abdominal pain   loss of appetite  nausea 80% of persons have no signs or symptoms Incubation Period: 14-180 days (average 45 days)
  39. 39. 39 Preventing HCV Infection  There is no vaccine  Best prevention is behavior change Do not shoot drugs Do not share personal items such as razors or toothbrushes Avoid tattoos or body piercing
  40. 40. 40 Summary of HCV  HCV is spread through blood contact with an infected person  HCV positive individuals should be evaluated by a doctor for liver disease
  41. 41. 41 Hepatitis D Overview  Caused by hepatitis D virus (HDV)  Coined “Delta Hepatitis”  Rarely seen in the United States  Found only in persons infected with HBV and has similar routes of transmission as HBV  Prevention is vaccination for HBV
  42. 42. 42 Hepatitis E Overview  Caused by hepatitis E virus  Primarily a disease of import  Very similar to hepatitis A with fecal-oral transmission  Transmitted like HAV with the same symptoms  No vaccination available
  43. 43. 43 Disease Burden Deaths /yr New infections /yr Chronic infections Outcome 4,000 46,000 1.4 (million) HBV 10,000 19,000 3.2 (million) HCV 14,000 56,000 1.1 (million) HIV HCV is the most common bloodborne viral infection. *2006 CDC estimates for US
  44. 44. 44 Chronic Viral Hepatitis Disease Burden = 409,400 cases Hepatitis B Hepatitis C Prevalence in General Population 5% or 1,115,000 1.6% or 368,000 % Chronic Hepatitis 10% or 115,000 80% or 294,400 Texas 2006 population est. 23 million
  45. 45. 45 Comparison of the big three Virus Prevalence % of Population Unaware of Infection Status Deaths in 2006 Related to Infection HBV 800,000 –1.4 million About 65% 3,000 HCV 2.7–3.9 million About 75% 12,000 HIV 1.1 million About 21% 14,016
  46. 46. 46 Populations at increased risk Asian/Pacific Islanders – in the US, 1 out of 10 API are chronically infected with hepatitis B Injecting Drug Users – 60% - 90% of IDUs are infected with hepatitis C What are some of the other populations at high risk?
  47. 47. 47 Domestic HIV 69% TB 14% STD 15% National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention Funding $1 Billion Total Hepatitis 2%Source: CDC The Fiscal Issues
  48. 48. 48 Current Hepatitis Surveillance Activities in Texas  What does the state require to be reported to the health department regarding hepatitis infection? Hepatitis A, B, C, D, E (acute) Hepatitis B (acute and chronic) identified prenatally or at delivery
  49. 49. 49 Focus on Hepatitis C Transmission and Prevention
  50. 50. 50 Sexual 15% Other* 5% Unknown 10% Injecting drug use 60% Transfusion 10% (before screening) *Nosocomial; Health-care work; Perinatal Source: Centers for Disease Control and Prevention HCV Transmission Sources of Infection
  51. 51. 51 Sharing Injection Equipment  Studies have found high rates of HCV in IDUs who didn’t share syringe, but shared cooker, cotton, water or other paraphernalia  People who inject other things (steroids, vitamins and hormones) may also be at risk  IDUs should use new, sterile equipment every time (clean hands, injection site and surface too)  CDC recommendation for blood spill clean up  1 part bleach, 10 parts water
  52. 52. 52 Sexual Transmission  Seven US studies of long-term discordant partners found 1.5 - 3% seroprevalence of HCV  Other studies of MSM, sex workers, and those with history of STD found prevalence of 4-6%  Risk may be increased when trauma is present  Other factors related with sexual transmission include # of partners, the presence of other STDs, and use of condoms
  53. 53. 53  There is a risk with pregnancy (5-6%)  Post-exposure prophylaxis not available  Coinfection with HIV risk increases risk up to 17%  Test infants born to HCV-positive women  Consider testing any children born since woman became infected  Evaluate infected children for chronic liver disease  Breastfeeding ok unless nipples are cracked and/or bleeding Mother-to-Infant Transmission
  54. 54. 54 Tattooing and Body Piercing  While some studies have found an association between tattooing and HCV in select populations, (mostly incarcerated) it is unknown if these can be generalized to the whole population.  Major concern is non-professional tattooing and/or piercing  Should use new separate ink containers and new and sterile needles and other equipment
  55. 55. 55 Low/Unknown Risks  Intranasal cocaine/meth use: Some studies have found link to HCV transmission by blood getting into nasal membrane from shared snorting items  Crack use: at least one study (Schaefer) found higher rate of HCV in non-injecting crack users who indicated cracked, bleeding or burned lips  Personal items with blood on them: anything that cuts/breaks the skin or membrane (razor, clippers)
  56. 56. 56 HCV Survival Outside the Body  One study has been done  Study found HCV alive outside body at 16 hours, 4 days, and 7 days  16 hour sample caused infection, 4 day sample did not cause infection
  57. 57. 57 HIV vs. HCV  Both HIV and HCV are blood-borne infections  HCV is 10 times more infectious than HIV by blood-to-blood contact  Most co-infected drug users probably were infected with HCV years before HIV  HIV is more transmissible between sexual partners and from mother to infant
  58. 58. 58 Video HIV and HCV
  59. 59. 59 HCV and HIV Coinfection  Up to 240,000 people in the U.S. are co-infected with HIV/HCV  Majority have chronic disease (85%)  1/3 of HIV+ people are co-infected with HCV  10% of HCV+ people are co-infected with HIV  In urban areas, up to 90% of HIV+ IDUS are co- infected with HCV
  60. 60. 60 Potential Co-infection Effect of HIV on HCV Disease  HIV infection may worsen HCV disease Weakened immune system allows HCV to replicate faster More infectious because higher viral load Accelerates and increases disease progression  May not respond well to HCV treatment
  61. 61. 61 Potential Co-Infection Effect of HCV on HIV Disease  HCV disease does not appear to accelerate HIV disease  Higher toxicity from HAART  As people live longer with HIV, many more HIV deaths are caused by HCV-related end stage liver disease  There is still a lot of research to be done on these effects
  62. 62. 62
  63. 63. 63 Guidelines for Viral Hepatitis Testing and Vaccination
  64. 64. 64 Overview of HAV Vaccine  Began usage in 1995  Two manufacturers of inactivated vaccine:  VAQTA® (Merck) and HAVRIX® (GSK)  Two dose series at 0 and 6-18 months  Also available in combination with hepatitis B vaccine called TWINRIX ®
  65. 65. 65 Side Effects of HAV Vaccine • No severe adverse reactions • Most common side effects − Soreness/ tenderness at injection site − Headache − Malaise • Safety in pregnancy not known - likely ok • Contraindications - Severe adverse reaction to previous dose vaccine; allergy to vaccine components
  66. 66. 66 Hepatitis A Vaccine Recommendations Hepatitis A vaccine is recommended for: • All children at age 1 year • Travelers to HAV endemic countries • Men who have sex with men (MSM) • Injection and non-injection drug users • Persons with chronic liver disease • Persons with clotting-factor disorders
  67. 67. 67 Overview of HBV Vaccine  Began usage in 1982  Two manufacturers of recombinant vaccine: Recombivax HB ® (Merck) and Energix-B ® (GSK)  Usually three dose series at 0, 1 and 6 months  Also available in combination with hepatitis A vaccine called TWINRIX ®
  68. 68. 68 Side Effects of HBV Vaccine • No severe adverse reactions • Most common side effects − Soreness/ tenderness at injection site − Headache − Malaise • Safe in pregnancy • Contraindications - Severe adverse reaction to previous dose vaccine or bakers yeast
  69. 69. 69 Hepatitis B Vaccine Recommendations Hepatitis B vaccine is recommended for:  All infants within 12 hours of birth  Older children not previously vaccinated  Sex contacts of infected persons  Persons with more than one sex partner in a six month period  Persons diagnosed recently with an STD  Men who have sex with men  Injection drug users  Household contacts of chronically infected persons  Health care and public safety workers  People with chronic liver disease, including those with HCV  People living with HIV  Travelers to areas with high rates of HBV  Hemodialysis patients
  70. 70. 70 What is the recommendation in Texas for vaccinating infants for hepatitis B? The dosing schedule for infants whose mothers have not been infected with hepatitis B is as follows: - Birth - 1 to 4 months of age (must be at least one month after the first dose) - 6 to 18 months of age The dosing schedule for infants whose mothers have been infected with hepatitis B is as follows: - Within 12 hours at birth - 1 to 2 months of age - 6 months of age
  71. 71. 71 Adult Hepatitis B Vaccination Initiative
  72. 72. 72 Fun with Hepatitis B Tests  HBV Antibody Test  Appears 1-3 months after HBsAG is detected.  Immunity to hepatitis B.  Not able to tell whether this is because of vaccination or previous exposure.  Anti-HBc Total  Used as a marker for past infection.  Never appears in those vaccinated, almost always present in previous infections.  HBsAg  First marker of infection.  May appear as early as 1 -2 weeks after infection.  High levels = chronic or acute infection.
  73. 73. 73 Fun with Hepatitis B Tests  Anti HBcIgM Test  May be present in the absence of anti-HB or HBsAg.  Positivity indicates recent infection (< 6 months)  Rarely occurs in chronic infection.  Negative with positive HBsAg means chronic HBV infection  Anti HBeAb  Present in patients with a resolved infection  Anti HBeAg  Found in acute and chronic.  Presence indicates viral replication.  Generally associated with a high degree of infectivity.  Undetectable, if resolved.
  74. 74. 74 Acute infection with resolution Chronic Carrier
  75. 75. 75 Hepatitis B Serology Interpretation Exercise Review the six blood test results to determine which ones are: Susceptible Immune through a previous infection Immune through vaccination Acute HBV Chronic HBV Other
  76. 76. 76 Describing HBV Test Results
  77. 77. 77 Immune due to Vaccination PH Follow up & counseling:  Seize the opportunity to educate on Hepatitis and other STIs. Acute HBV PH Follow up & counseling:  Get a list of contacts both in the home and outside the home.  Screen the contact for HBV and educate on the stages of the disease, signs and symptoms and have them retest after incubation period is over.  Seize the opportunity to educate on Hepatitis and other STIs.
  78. 78. 78 Chronic Active HBV PH follow up & counseling:  Screen the contact for HBV and educate on the stages of the disease, signs and symptoms and health issues associated with being a chronic carrier.  Seize the opportunity to educate on Hepatitis and other STIs. Immune (Previous infection) PH follow up & counseling  Seize the opportunity to educate on Hepatitis and other STIs. Susceptible PH follow up & counseling:  Vaccinate and seize the opportunity to educate on Hepatitis and other STIs.
  79. 79. 79 HCV Testing Recommendations CDC recommendings testing the following for HCV:  Current or former injection drug users (even once)  Recipients of clotting factors before 1987  Recipients of blood transfusions or donated organs before 1992  Long-term hemodialysis patients  Persons with known exposures to HCV  HIV infected persons  Children born to HCV infected mothers (do not test before age 18 months)  Patients with signs or symptoms of liver disease (abnormal liver enzyme tests)  Donors of blood, plasma, organs, tissues, semen
  80. 80. 80  EIA (Enzyme immunoassay)  Detects antibodies to HCV (anti-HCV)  97% of people have antibodies 6 months after infection  RIBA (Recombinant immunoblot assay) Confirms positive initial anti-HCV  HCV RNA Looks for actual virus in the blood Testing & Diagnosis of HCV
  81. 81. 81 Reactive (Positive) EIA  Reactive EIAs are considered confirmed by:  RIBA  Viral test that looks for the virus  Signal-to-cut-off-ratio (S/CO)  S/CO: Repeats EIA two more times. If all three are reactive with high (>95%) S/CO then considered confirmed. Samples with <95% S/CO require a RIBA confirmation
  82. 82. 82
  83. 83. 83 Describing HCV Test Results
  84. 84. 84 Negative Antibody Test  Client is NOT infected (unless recent infection during window period, 4-10 weeks)  If risk behavior occurred in the past 6 months encourage to re-test  If risk behavior is ongoing, explore risk reduction
  85. 85. 85 Positive Antibody Test Confirmed (w/RIBA or S/CO)  Client has been infected with HCV in the past and probably is still living with it  Recommend further evaluation and testing: determine if HCV is still in the blood establish the health of the liver discuss treatment options  Discuss prevention and health messages
  86. 86. 86 Positive Antibody Test Not Confirmed or Low/No Risk  Client may have been infected with HCV  Recommend further evaluation and testing to: confirm positive result (RIBA or viral test) determine if the HCV virus is in the blood establish the health of the liver discuss treatment options  Discuss prevention and health messages
  87. 87. 87 Indeterminate Result  Explain that test results are inconclusive  May indicate recent infection if risk has occurred in past few months  Need to wait and retest
  88. 88. 88 Client Centered Counseling Skills and Risk Reduction Planning
  89. 89. 89 ADDICTOPHOBIA The fear of persons associated with, or thought to be associated with, substance abuse or illicit drug use.
  90. 90. 90 Goals of Viral Hepatitis Risk Reduction Counseling  Decrease risk for transmission and/or acquisition of viral hepatitis  Increase quality of life for those living with chronic hepatitis  Identify larger goal and small, reasonable steps to get to goal  Partner with client to identify options to reduce harm
  91. 91. 91 How to Support Behavior Change  Meet person where they are at  Options, options, options  Support any positive change  Focus on the factors that influence behaviors and behavior change  Explore the pros and cons of changing behavior (or not changing)
  92. 92. 92 Factors that Influence Behavior  Access to resources  Attitudes/Beliefs  Consequences  Discrimination  Drug use  Competing issues  Emotions  Intentions  Knowledge  Policy  Priorities  Self-efficacy  Self-esteem  Skills  Social Norms  Social Support
  93. 93. 93 Safer Goal Behavior  Goal should be big  A behavior that will reduce the risk of or prevent transmission of disease  Doesn’t need to be something client is ready to do now  Should be something client wants to move towards in future
  94. 94. 94 Action Plan  Composed of small, attainable action steps  Explore potential barriers and supports needed for each step  Prioritize first step  Explore “what ifs”  Validation and support
  95. 95. 95 Skills Practice!!  You will be counseling someone who is at risk for or living with viral hepatitis  Utilize the pre test / post test counseling points  Transition into viral hepatitis  Conduct brief risk assessment  Identify and give core health messages  Negotiate risk reduction plan
  96. 96. 96
  97. 97. 97 Conclusion and Evaluation  Evaluation and comments  Please include your e-mail, phone number and address if you need a certificate of attendance. Thank you for participating!
  98. 98. 98 It’s Time: Integrate Viral Hepatitis Into your Work  Tamara Brickham, MPH Adult Viral Hepatitis Prevention Coordinator Houston Department of Health and Human Services tamara.brickham@cityofhouston.net 823-393-4706  Larry Cuellar Adult Viral Hepatitis Prevention Coordinator Texas Department of State Health Services Larry.cuellar@dshs.state.tx.us 512-533-3124

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