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OUR HEPCBC "Meet and Greet", 2007


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OUR HEPCBC "Meet and Greet", 2007

  1. 1. Working Together Against HCV HepCBC March 31, 2007 Natalie Rock RN, BSN Hepatology Nurse Clinic Director LAIR Centre
  2. 2. THE LIVER <ul><li>The Largest Organ </li></ul><ul><li>Weighs 1200-1500 grams </li></ul><ul><li>Metabolically the most active organ </li></ul>
  3. 3. THE LIVER <ul><li>Sheltered by Ribs in RUQ </li></ul><ul><li>Two Major Lobes </li></ul><ul><li>Has a Double Blood Supply </li></ul><ul><ul><ul><li>portal vein </li></ul></ul></ul><ul><ul><ul><li>hepatic artery </li></ul></ul></ul>
  4. 4. FUNCTIONS OF THE LIVER <ul><li>Manufacture </li></ul><ul><li>Filtration </li></ul><ul><li>Metabolism </li></ul><ul><li>Excretion </li></ul><ul><li>Regulation </li></ul><ul><li>Secretion </li></ul>carbohydrates proteins/fat clotting factors cholesterol/bile bacteria drugs/toxins/hormones
  5. 5. WHAT IS HEPATITIS ? <ul><li>HEPAR = LIVER </li></ul><ul><li>ITIS = INFLAMMATION </li></ul><ul><li>HEPATITIS = INFLAMMATION OF THE LIVER </li></ul>
  6. 6. WHAT ARE SOME CAUSES OF HEPATITIS? <ul><li>Alcohol </li></ul><ul><li>Drugs </li></ul><ul><li>Toxins </li></ul><ul><li>Metabolic Diseases </li></ul><ul><li>Autoimmune Diseases </li></ul><ul><li>Fatty Liver Disease </li></ul>
  7. 7. WHAT ARE SOME CAUSES OF HEPATITIS? <ul><li>Viruses </li></ul><ul><ul><ul><li>A </li></ul></ul></ul><ul><ul><ul><li>B </li></ul></ul></ul><ul><ul><ul><li>C </li></ul></ul></ul><ul><ul><ul><li>D </li></ul></ul></ul><ul><ul><ul><li>E </li></ul></ul></ul><ul><ul><ul><li>G </li></ul></ul></ul><ul><ul><ul><li>GB </li></ul></ul></ul><ul><ul><ul><li>TT </li></ul></ul></ul>
  8. 8. Signs and Symptoms <ul><li>Jaundice-yellow skin and eyes </li></ul><ul><li>dark urine </li></ul><ul><li>pale or bloody stools </li></ul><ul><li>abdominal swelling </li></ul><ul><li>prolonged itching of skin </li></ul><ul><li>chronic fatigue </li></ul><ul><li>Nausea or loss of appetite </li></ul><ul><li>vomiting of blood </li></ul><ul><li>severe, prolonged abdominal pain </li></ul><ul><li>bruising, inability to heal minor cuts and injuries </li></ul>
  9. 11. TRANSMISSION OF HEPATITIS Rare Moderate Rare Occupational Rare Moderate Rare Household Uncommon Common No Mother – Child Uncommon Yes No Sexual Rare Yes No Blood – Oral No No Yes Fecal – Oral Rare No No Blood Products Yes Yes Possibly Blood to Blood HEP C HEP B HEP A MODE
  10. 12. Hepatitis C Virus (HCV) Family: Flaviviridae Enveloped, +ve strand RNA virus 50 nm particles contain: E1 and E2 proteins on surface C protein inside HCV Genome                                                                                            
  11. 13. HCV in Canada vs BC <ul><li>~ 60,000 (1.5%) British Columbians </li></ul><ul><ul><ul><li>May 2005, 55,000 identified as anti-HCV reactive </li></ul></ul></ul><ul><ul><ul><li>~ 25% clear infection, therefore about 41,000 people are chronic </li></ul></ul></ul><ul><ul><ul><li>~ 20,000 undiagnosed, projecting 3,000 newly identified cases in 2005 </li></ul></ul></ul>
  12. 14. PHIS Reported HCV Rates - BC 1995 to 2004
  13. 15. Rate of anti-HCV reactivity/100,000 BC residents/year by age and gender including acute HCV infections BCCDC 1992 – 2002, n = 45,661 (2,168 acute) 45,661
  14. 16. alcohol obesity HIV older age males poorly tolerated support hard to identify IDU! Alter 99, Jaeckel 01, Freeman 01, Hofer 03 HCV infections ~ 25% symptomatic 75% Chronic 25 % Clear Do nothing 15% to 25% cirrhosis, ESLD, HCC, transplant early treatment feasible pegylated INF/Rib cure 50% to 60% decades Prevent infections? Prevent complications?
  15. 17. DIAGNOSIS OF CHRONIC HEPATITIS C <ul><li>1. Anti-HCV </li></ul><ul><ul><ul><ul><li>ELISA, RIBA </li></ul></ul></ul></ul><ul><ul><ul><ul><li>3 To 6 Months Delay </li></ul></ul></ul></ul><ul><li>2. PCR: (HCV RNA) </li></ul><ul><ul><ul><ul><li>Measures Presence of the Virus </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Qualitative </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Quantitative </li></ul></ul></ul></ul>
  16. 18. DIAGNOSIS OF CHRONIC HEPATITIS C <ul><li>3. Liver Enzymes </li></ul><ul><ul><ul><ul><li>AST, ALT </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Levels Fluctuate </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Elevated 1.5 times Normal </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Over 3 Months </li></ul></ul></ul></ul><ul><li>4. Genotype </li></ul><ul><ul><ul><ul><li>Mapping of the Virus </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Type Determines Length of Treatment </li></ul></ul></ul></ul>
  17. 19. Acute HCV Infection Progressing to Chronic Infection Symptoms +/- Time after Exposure Titre anti-HCV ALT Normal 0 1 2 3 4 5 6 1 2 3 4 Years Months HCV RNA
  18. 20. Progression to Chronic Hepatitis <ul><li>Disease activity varies </li></ul><ul><li>Progression rate varies </li></ul><ul><ul><li>Older persons progress more quickly </li></ul></ul><ul><ul><li>Route of infection may affect progression </li></ul></ul><ul><ul><li>Males progress more rapidly </li></ul></ul><ul><ul><li>Alcohol enhances progression </li></ul></ul><ul><ul><li>Jaundice at acute attack progresses more rapidly </li></ul></ul>
  19. 21. Chronic Hepatitis C Progression <ul><li>Time to Chronic Hepatitis: 10 years </li></ul><ul><li>Time to Cirrhosis: 18 - 20 years </li></ul><ul><li>Time to Liver Cell Cancer: 28 years </li></ul>
  20. 22. Chronic Hepatitis C <ul><li>Cirrhosis: 25% </li></ul><ul><ul><ul><li>End stage liver disease: 5% </li></ul></ul></ul><ul><ul><ul><ul><li>Liver cell cancer: 5% </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Transplant: 3% </li></ul></ul></ul></ul></ul>
  21. 23. Pathology of Hepatitis <ul><li>Liver Biopsy: </li></ul><ul><ul><ul><ul><li>GRADE </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Inflammation </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>STAGE </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fibrosis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cirrhosis </li></ul></ul></ul></ul></ul>
  24. 26. CIRRHOSIS
  25. 27. TREATMENT <ul><li>PEGYLATED INTERFERON </li></ul><ul><ul><li>natural human protein </li></ul></ul><ul><ul><li>produced in response to viruses </li></ul></ul><ul><ul><li>inhibits viruses </li></ul></ul><ul><ul><li>increases production of antibodies </li></ul></ul><ul><ul><li>stimulates immune system </li></ul></ul><ul><li>RIBAVIRIN </li></ul><ul><ul><li>oral antiviral </li></ul></ul><ul><ul><li>potentiates the effects of interferon </li></ul></ul>
  26. 28. LENGTH OF TREATMENT <ul><li>Dependent on Genotype and Response </li></ul><ul><ul><li>Genotype 1,4,5,6 </li></ul></ul><ul><ul><ul><ul><ul><li>Treatment is up to 1 year </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cure rate approximately 50% </li></ul></ul></ul></ul></ul><ul><ul><li>Genotype 2 </li></ul></ul><ul><ul><ul><ul><ul><li>Treatment is 6 months </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cure rate approximately 88% </li></ul></ul></ul></ul></ul><ul><ul><li>Genotype 3 </li></ul></ul><ul><ul><ul><ul><ul><li>Treatment is 6 months </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cure rate approximately 65% </li></ul></ul></ul></ul></ul>Possibly longer Possibly shorter Possibly longer
  27. 29. GOALS OF TREATMENT <ul><li>Normal AST and ALT </li></ul><ul><li>HCV RNA by PCR Negative </li></ul><ul><li>Liver Biopsy Inactive/Improvement </li></ul><ul><li>Quality of Life, Stopping Complications </li></ul>
  28. 30. TREATMENT <ul><li>Pharmacare </li></ul><ul><ul><ul><li>Fair Pharmacare </li></ul></ul></ul><ul><li>Extended Health </li></ul><ul><li>Peg-Care and PegAssist </li></ul>Cost of Treatment $1,800/ month!
  29. 31. SIDE EFFECTS
  30. 32. SIDE EFFECTS <ul><li>Flu-Like Symptoms </li></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Chills </li></ul></ul><ul><ul><li>Muscle Aches </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul>
  31. 33. SIDE EFFECTS <ul><li>Weight Loss </li></ul><ul><ul><ul><li>nausea, abnormal taste in mouth </li></ul></ul></ul><ul><ul><ul><li>loss of appetite </li></ul></ul></ul><ul><li>Skin Changes </li></ul><ul><ul><ul><li>dry, itchy, rash, psoriasis </li></ul></ul></ul><ul><li>Hair Loss </li></ul><ul><ul><ul><li>comes back! </li></ul></ul></ul><ul><li>Decreased Libido </li></ul><ul><ul><ul><li>comes back! </li></ul></ul></ul>
  32. 34. SIDE EFFECTS <ul><li>Anemia (decrease in hemoglobin) </li></ul><ul><ul><ul><li>shortness of breath </li></ul></ul></ul><ul><ul><ul><li>cough </li></ul></ul></ul><ul><li>Neutropenia (decrease in white blood cells) </li></ul><ul><ul><ul><li>risk of infection </li></ul></ul></ul><ul><ul><ul><li>fever </li></ul></ul></ul><ul><li>Thrombocytopenia (decrease in platelets) </li></ul><ul><ul><ul><li>possible risk of bruising </li></ul></ul></ul><ul><ul><ul><li>possible risk of bleeding </li></ul></ul></ul>
  33. 35. SIDE EFFECTS <ul><li>Exacerbation/Precipitation of: </li></ul><ul><ul><ul><li>Autoimmune Diseases </li></ul></ul></ul><ul><ul><ul><ul><ul><li>diabetes </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>arthritis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>thyroid </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Mood Alterations </li></ul></ul></ul><ul><ul><ul><ul><ul><li>anxiety </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>irritability </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>depression </li></ul></ul></ul></ul></ul>
  34. 36. Prevention <ul><li>Get Vaccinated for Hepatitis A and B </li></ul><ul><li>Abstain from Alcohol </li></ul><ul><li>Smoking (??) </li></ul><ul><li>Nutrition </li></ul><ul><li>Exercise </li></ul><ul><li>Do not share personal care items </li></ul>
  35. 37. FUTURE THERAPIES <ul><li>Interferon Variants </li></ul><ul><li>Vaccines </li></ul><ul><li>Antisense Oligonucleotides </li></ul><ul><li>Proteases </li></ul><ul><li>Helicases </li></ul><ul><li>Polymerase Inhibitors </li></ul><ul><li>Traditional Chinese Medicine </li></ul>
  36. 38. BC Hepatitis Strategy <ul><li>The goal is to </li></ul><ul><ul><li>Support </li></ul></ul><ul><ul><li>Counsel </li></ul></ul><ul><ul><li>Educate </li></ul></ul><ul><ul><li>Assist </li></ul></ul><ul><li>Directed to: </li></ul><ul><ul><li>Patient </li></ul></ul><ul><ul><li>Caregiver </li></ul></ul><ul><ul><li>General public </li></ul></ul>
  37. 39. Integrated Hepatitis Program <ul><ul><ul><ul><ul><li>Care Surveillance & </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Management Prevention </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Education & Research & </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Support Evaluation </li></ul></ul></ul></ul></ul>Information Management
  38. 40. Significance of the Infection <ul><li>Impacts on individual, families and society </li></ul><ul><ul><li>Physical </li></ul></ul><ul><ul><li>Social-Emotional </li></ul></ul><ul><ul><li>Financial </li></ul></ul><ul><ul><li>These impacts may be associated with the disease itself, the reactions of and implication for others, and the effects and costs of treatment. </li></ul></ul>
  39. 41. Physical <ul><li>Liver disease can affect every aspect of an individual’s physical well-being, including the ability to eat and maintain adequate nutrition, obtain comfort and rest, have intact skin, work, and carry out activities of daily living and may be unable to care for their families or continue in their jobs. </li></ul>
  40. 42. Social Emotional <ul><li>A diagnosis of a chronic illness has a tremendous emotional impact. </li></ul><ul><ul><li>reactions that commonly follow a diagnosis: </li></ul></ul><ul><ul><ul><li>denial, fear, anger, guilt, grief, depression, and a sense of hopelessness </li></ul></ul></ul>
  41. 43. Social Emotional <ul><li>The uncertainty of living with a disease whose course and effects differ for each person </li></ul><ul><li>concern over the health and safety of family members </li></ul><ul><li>uncertainty and fear related to treatments and the risks associated with a possible liver transplant </li></ul><ul><li>side effects of treatment </li></ul>
  42. 44. Social Emotional <ul><li>Fear of isolation and social exclusion if relatives, friends, and people at work find out about the diagnosis </li></ul><ul><li>misinformation from physicians, nurses, and other care providers </li></ul><ul><li>family members may be affected in ways similar to the person receiving the diagnosis; they may also experience distress arising from the revelation that a loved one may have contracted HCV by engaging in risky behavior (unprotected sex, intravenous drug use, etc.) </li></ul>
  43. 45. Societal <ul><li>Potential costs in terms of morbidity, quality of life, mortality </li></ul><ul><li>the direct economic costs associated with Liver Disease for individuals, families and communities </li></ul><ul><li>the burden on the medical and social care systems--est. 4,000 new cases identified annually of (HCV) </li></ul><ul><li>lives lost prematurely </li></ul>
  44. 46. Financial <ul><li>The financial impact on the individual and family can be devastating. The individual may be unable to work consistently. The treatments may be expensive, ranging in the thousands of dollars. Pharmacare will cover some of the costs of for those who meet criteria. </li></ul>
  45. 47. Factors that interfere or assist with prevention <ul><li>Attitudes </li></ul><ul><li>knowledge and skills </li></ul><ul><li>social context of health and illness (ie poverty, education and social support) </li></ul><ul><li>resources and tools (how and where to access clean equipment) </li></ul>
  46. 48. Attitudes <ul><li>Attitudes--your own and those of others--can interfere with education, making wise choices, and applying knowledge and skills. </li></ul><ul><li>Attitudes arise from the ideas, beliefs, and values you hold. </li></ul>
  47. 49. Web Sites <ul><li>Canadian Liver Foundation: </li></ul><ul><li>Health Canada: </li></ul><ul><li>Hepatitis C Society of Canada: http://web-idirect,com/~hepc </li></ul><ul><li>HepCBC: </li></ul><ul><li>Hepatitis Foundation International: </li></ul><ul><li>The Canadian Medical Association: </li></ul><ul><li>Hepatitis Information Network: </li></ul>