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Hepatitis A, B and C: An overview with special considerations for our Veteran population Kimberly Moore, MSN, CRNP, LNC Cincinnati VA Medical Center Department.

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Presentation on theme: "Hepatitis A, B and C: An overview with special considerations for our Veteran population Kimberly Moore, MSN, CRNP, LNC Cincinnati VA Medical Center Department."— Presentation transcript:

1 Hepatitis A, B and C: An overview with special considerations for our Veteran population Kimberly Moore, MSN, CRNP, LNC Cincinnati VA Medical Center Department of Digestive Diseases and Hepatology

2 Hepatitis A Identified ,000 cases/yr in U.S. Self limiting disease in most Severe disease in: –Adults > 40 years –Patients with Chronic Liver Disease (CLD) are at risk of Fulminate Hepatic Failure (FHF) in 40% of cases Gitlin et al, AJG, 1998

3 Hepatitis A Modes of transmission –Oral fecal route –Ingestion of contaminated food/water –Close person to person contact

4 Outcome of HAV Super-infection in Patients with Chronic Viral Hepatitis Vento et al. NEJM 1998:338:

5 Hepatitis A Carries a high risk of liver failure and mortality in patients with CLD Vento et al reported: –41% of patients with Hep B or C developed liver failure Bini et al reported: – 33% fatality rate in HCV patients with superimposed HAV infection Bini et al, Hepatology 2005 Vento et al, NEJM 1998

6 Estimated risk of death from acute HAV, US, Cases (N) Deaths (N) Fatality rates (%) All pts with Acute HAV115, Acute HAV plus Chronic HBV Acute HAV plus CLD2, Acute HAV, but no liver dz113, Calculated from an estimated.2% HbsAG carrier rate in the US, and 2% prevalence of CLD in the US. Hadler et al. Viral Hepatitis and Liver Disease. Baltimore. Williams and Wilkins: 1991: Keefe EB. Viral Hepatitis 1999: 5:77-88

7 Hepatitis A-prevention HAV vaccine-indication: –Chronic liver disease –IV drug users –Men who have sex with men –Travelers to endemic areas –Kitchen workers, employees of day care centers, healthcare personnel

8 Susceptibility to Hepatitis A in Patients with CLD due to HCV: Shim et al. (2005) Hepatology. 42 (3); Missed opportunities for Vaccination

9 Hepatitis B

10 Epidemiology of hepatitis B Virus identified in 1966 Worldwide health problem million carriers worldwide 250,000 deaths annually Vaccine available 1982 >1 million die annually of HBV related CLD

11 Transmission of HBV PerinatalIVDASexualHemodialysis Close person to person contacts Infected blood children in hyperendemic areas

12 HBV - Epidemiology Risk of chronic infection

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14 Incidence of Cirrhosis in HBV/HCV Co-infection vs. HCV alone Fuiano B et al. Ital J Gastroent 1992: 24:409-11

15 Risk of HCC with HBV/HCV Co- infection in Cirrhotic Patients Koff RS J Clin Gastro 2001:33:20-26 Benvegnu L et. Al. Cancer 1994:74:

16 Estimated Incidence of Acute Hepatitis B United States, Vaccinelicensed HBsAg screening of pregnant women Infantimmunization Adolescent immunization Cases/100,000 Source: CDC Safer Injection Practices

17 Infectious Disease Burden among Released Inmates, United States, ,00034,000TB million 4.5 million HCV , million HBV (chronic) –145, ,000HIV 1739,000229,000AIDS % of Total Infected Population Infected Inmates Released Infected US Population Infection/ Disease Source: NCCHC, Hammet, Greifinger et.al. unpublished data

18 Review of Hepatitis A, B, C serological testing HBsAg - exposure HBsAb - marker for immunity HAV Ab total – marker for immunity HCVAb - exposure HCV PCR –gold standard to diagnose HCV

19 Hepatitis B Treatment Treatment is generally advised for patients with active disease Lamivudine, Entecavir, Adefovir, Pegylated Interferon, combination therapy Hepatocellular Carcinoma screen is recommended

20 Healthy people 2010 goals: Identify individuals with Hepatitis C –Education –Vaccinated against Hep A/B –Evaluate for liver disease and treat Immunize against Hepatitis B Immunize high risk groups, including illicit drug users, against Hepatitis A

21 Facts about Hepatitis C Virus(HCV) 5.0 million Americans Infected Non-A Non-B hepatitis recognized in the 1970s HCV genome isolated 1989 HCVRNA mutates rapidly No vaccine available 6 different genotypes

22 HCV Epidemiology: Corrected estimate Edlin BR, et al Hepatology 2005;42:213A Estimated 3.9 million who have been infected (NHANES) NumberHCV Ab# Infected 35% Incarcerated1,200,000 35% 426,000 Homeless 800,000 43% 344,000 Hospitalized 895,000 16% 132,000 Military1,900, % 9,000 Nursing Home1,700, % 79,000 Additional Infected Persons 991,000 (800,000 – 1,200,000) Total ~ 5 million U.S. Census Bureau of Justice, Center for Medicare, Medicaid Services

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25 Prevalence of HCV in Select Populations IVDU % Alcoholics11% Incarcerated % Homeless22% Veterans 6 - 8% US population1.8%

26 Symptoms of HCV Lack of energy, Weakness General malaise RUQ dull pain NauseaArthralgias/myalgias Extrahepatic manifestations of hcv

27 Symptoms of Advanced Liver Disease Changes in mental status AnorexiaJaundice Weight loss Muscle wasting Decreased libido Abdominal distention Leg swelling SOBHematemesis Abdominal pain DiarrheaN/V

28 Factors associated with Disease Progression Alcohol consumption Disease acquisition at >40 years Male gender Coinfection with HIV or HBV Immunosuppression

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30 HCV disease progression Cirrhosis Decompensated cirrhosis –Ascites, SBP, bleeding varices, encephalopathy HCC Liver transplant Death

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32 Hepatitis C Care within the VA Health Care System Burden of HCV in US veterans The prevalence or Hepatitis C (5.4%) in United States Veterans exceeds the estimate from the general population by more than 2 – fold Hepatology 2005; 41:88-96 Mil Med 2002; 167:

33 HCV screening: VA guidelines Vietnam-era veteran Blood transfusion before 1992 Past or present IV drug use Blood exposure of skin or mucous membranes H/o multiple sexual partners History of intranasal cocaine use

34 HCV screening guidelines (cont) History of hemodialysis Tattoo or repeated body piercing Unexplained liver disease Unexplained/abnormal ALT Intemperate or immoderate use of alcohol

35 Available testing for HCV ELISA tests for AB to HCV (HCV Ab) Recombinant immunoblot assay (RIBA) HCV PCR testing Genotyping

36 Laboratory Testing for Hepatitis C HCV antibody –Once positive, will always be positive, even if treated and cleared. Please DO NOT keep ordering this test. –If antibody positive but no viral load (negative HCV bDNA and TMA,) either patient experienced spontaneous clearance (7% occurrence rate) or the original antibody was falsely positive. Confirm with HCV RIBA (if returns positive, patient had and cleared the virus; if returns negative, antibody was falsely positive HCV bDNA and TMA –This is the viral load or amount of virus in the blood – this is what treatment attempts to clear.

37 Patient Education and Counseling Protection of others from transmission Protect liver from further harm Discussion of prognosis Discussion of treatment options

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42 Treatment of Hepatitis C Liver biopsy usually required prior to treatment for patients with genotype 1. Weekly Interferon injections Twice daily Ribavirin pills (dose based on weight) Treatment duration is 6 months for genotype 2 and 3; 12 months for genotype 1. HCV bDNA and TMA is rechecked after tx for 3 months to see if meds are working to clear the virus (need a 2 log drop in the bDNA to show tx effectiveness.)

43 Treatment of Hepatitis C (contd) 35% treatment success rate (sustained viral response or SVR) for African Americans with genotype 1 45% treatment success rate (SVR) for Caucasians with genotype 1 Near 70% SVR for genotypes 2 and 3 Females do better than males; younger patients do better than older patients (in terms of tolerance and clearance)

44 Criteria: Consideration for Treatment Preferably no ongoing alcohol or illicit drug use Psychiatric diseases must be managed and fairly well controlled Normal or abnormal transaminases No active medical problems with expected mortality

45 Peg InterferonRibavirin blocks virus into cells inhibits intracellular replication stimulates bodies immune system renally cleared antifibrotic action Synergistic with Interferon Induces defective replication of HCV RNA Better tolerated than Interferon Not effective monotherapy

46 Side effects: Peg Interferons Flu like symptoms Fatigue Depression/mood lability/insomnia Anorexia Injection site reactions Can stimulate Autoimmune disease Skin problems Visual changes Lab alterations

47 Side effects: Ribavirin Teratogenicity Hemolytic anemia MI with anemia SOB, pulmonary infiltrates or pneumonitis Skin rash

48 Hepatitis C Treatment – Adverse Events Dose discontinuations common Most common reasons sited for dose discontinuation: –Psychiatric (increase in depression, anxiety, anger, nightmares, hallucinations/delusions, decrease in impulse control) –Systemic (fatigue, headache, arthralgias, arthritis, skin rash) –Gastrointestinal adverse events (nausea, anorexia) –Cytopenias –Thyroid Dysfunction –Liver failure Your clients on treatment WILL experience potentially severe side effects – expect it!

49 Barriers to HCV Antiviral Therapy

50 Show rates and Treatment Eligibility in Consecutive Veterans referred to HCV clinic (N=557) Evaluated and treated (13.8%) Evaluated and not treated (29.6%) No show for HCV clinic (56.6%) Cawthorne et al, Am J Gastroenterol 2002;97:

51 Reasons for exclusion of patients from HCV antiviral therapy Psychiatric disease35 (21)% Undecided28 (17) Active alcohol abuse23 (14) Refused17 (10) Multiple reasons17 (10) Medical comorbidity11 (6) Normal LFTs8 (5) Medication noncompliance8 (5) Active drug abuse6 (3) Treated outside VA6 (3) HCV RNA negative6 (3) Am J Gastroenterology 2002;97:

52 Psychiatric disorders among veterans with hepatitis C infection El-Serag HB, Kunik M, Richardson P, Rabeneck L. Gastroenterology 2002;123: N=33,824 hospitalized HCV+ veterans identified Psychiatric and substance-use disorders identified from computerized records. Random non-HCV+ controls identified from hospitalized patients

53 Psychiatric disorders among veterans with Hepatitis C infection 86.4% of 33,824 pts had at least one past or present psychiatric, drug- or alcohol-related disorder recorded Active disorders: 31% HCV+ cases more likely than controls to have depression, PTSD, anxiety, alcohol and drug-use disorders.

54 What Happens if Treatment Doesnt Work? Remember, most treatment for Hepatitis C doesnt actually work! Help your patients have realistic expectations without encouraging a defeatist attitude. Patients are followed in clinic to monitor for HCC and liver decompensation (which occurs in 20% of patients with Hepatitis C.) Liver transplantation is a consideration

55 Liver Transplant stats: Liver transplant numbers: 81,634 done Currently 16,961 waiting 05: : 6650

56 Location of VA Transplant Centers Heart Cleveland, OH * + Madison, WI * Nashville, TN * + Richmond, VA Salt Lake City, UT * Palo Alto, CA * Lung Richmond, VA + Madison, WI * Bone Marrow Nashville, TN San Antonio, TX Seattle, WA * Sharing Agreement Sites + Temporarily InactiveKidney Iowa City, IA Nashville, TN Pittsburgh, PA Portland, OR Liver Nashville, TN * Pittsburgh, PA Portland, OR * Richmond, VA *

57 Transplants – All VATCs

58 Liver Transplantation 6 months free from: –Tobacco, alcohol and all illicit substances with documented attendance at AA or in similar program Patients do not have to be off Methadone. Need complete psychological, social and dental evaluations plus a myriad of laboratory and radiological testing. Must have support person able to attend all liver transplant evaluations, provide transportation, attend surgery, out of town, evaluations and commit to indefinite post-operative care. Specific criteria for patients being referred for transplantation secondary to HCC – lesion size and number and evidence of metastasis determine eligibility.

59 Projecting future complications of chronic HCV in United States Liver Transplantation 2003; 9:

60 Burden of Disease Hepatocellular Carcinoma (Liver cancer) is the most common primary hepatic malignancy The vast majority of patients with Hepatocellular Carcinoma (HCC) have underlying Cirrhosis Risk of HCC in patients with HCV is 17 times higher than HCV negative controls

61 Take Home Points Screen for Hepatitis A, B, C Immunize against Hepatitis A and B as appropriate Patient Education Refer quickly for Hepatitis B and C positivity Screen all positive Hepatitis B and C patients for HCC

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63 Thanks! Questions? Contact Information: –Kimberly Moore, MSN, CRNP, LNC Cincinnati VA Medical Center Cincinnati VA Medical Center Department of Digestive Diseases and Hepatology Department of Digestive Diseases and Hepatology –(513)


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