This document discusses hepatitis B and hepatitis C, including their background, epidemiology, screening guidelines, clinical tests, and patient management. It provides an overview of each virus, explaining their transmission, disease progression, screening algorithms and tests used. The screening guidelines and phases of chronic hepatitis B are reviewed. Treatment depends on the disease phase. New diagnoses of hepatitis C are addressed, including counseling, vaccination status evaluation, lifestyle interventions and monitoring.

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

3. HEPATITIS B
CHRONIC VIRAL INFECTION
SEXUALLY TRANSMITTED DISEASE
HIGHLY INFECTIOUS VIRUS
LIVER DISEASE

4. Hepatitis B Virus – Background
and Epidemiology

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/

9. HBV Screening Guidelines

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

11. Testing Specificity and
Sensitivity
Specificity Sensitivity
 False-Positives  Limit of Detection
Low(er) Limit of Detection
More Sensitive
High(er) Limit of Detection
Less Sensitive

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)

13. Hepatitis B Screening
Guidelines
SCREENING ALGORITHM
www.hepb.org Hepatitis B

14. Indications for HepB Screening
and Vaccination
& recipient
•HCV-positive patients
•Individuals incarcerated
•Health Care Worker
Hepatitis B Foundation www.hepb.org

15. Hepatitis B Patient
Management

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

20. HEPATITIS C
Chronic Viral Infection
HIV Co-Infection
Injection Drug Use
Cirrhosis
Liver Failure

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/

25. HCV Screening Guidelines

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)

35. Liver Disease Progression
Healthy Fibrotic Liver
Liver
Cirrhotic Liver Liver
Cancer

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