An Introduction to Hepatitis C Leslie Wightman Hepatitis C Council of SA Inc. www.hepccouncilsa.asn.au

Topics Background Hepatitis Transmission Standard Precautions Testing Natural History Symptoms Treatment Disclosure / Discrimination Contacts

Hepatitis ‘Hepatitis’ means inflammation of the liver Alcohol, chemicals, autoimmune disease, drugs and a number of viruses can lead to hepatitis 6 known hepatitis viruses: A, B, C, D, E & G - Different modes of transmission, effects on the body & treatments

A..B..C..D..E.. ..G !! A – Faecal-oral route B – Blood and body fluids C – Blood-to-blood D – Blood and body fluids E – Faecal-oral route G – Blood-to-blood

Background-Hepatitis C Hepatitis C - in existence for a long time First named non-A, non-B hepatitis in 1973 and hepatitis C in 1989 Antibody testing commenced 1990

An estimated 250,000 Australians have been exposed to hepatitis C Approximately 14,000 South Australians diagnosed Approximate 1% prevalence in Australia

In Australia 16,000 estimated new infections per year Hepatitis C Virus Projections Working Group Estimates and Projections of the Hepatitis C Virus Epidemic in Australia 2002, ANCAHRD Hepatitis C Sub-Committee In Australia that’s approximately a bus load of people each day (approx 40) newly infected with hepatitis C

Hepatitis C Transmission ‘It’s a Blood Thing’ A blood borne virus Transmitted by blood to bloodstream contact Hepatitis C is primarily transmitted via the parenteral route. Most effectively transmitted when the blood percutaneously enters the bloodstream. Originally know as non-A, non-B hepatitis and non specific hepatitis.

Principles of Transmission Hepatitis C virus must exit the body Hepatitis C virus must survive in the environment in which it has been placed Sufficient concentration of virus (viral load) must be present to cause infection Hepatitis C virus must enter the bloodstream of another person

Transmission Hepatitis C and injecting drug use: Approx 90% of new infections due to the sharing and reusing of injecting drug equipment Not just about the syringe - all equipment used for injecting can facilitate transmission

Transmission Blood transfusion or blood products before 1990 Place of birth (eg.Mediterranean; South East Asia) History of imprisonment Unsterile tattooing or body piercing Occupational transmission – needlestick injury (2% - 10% risk) In approximately 90% of newly acquired HCV infections injecting drug use is the primary risk factor. As mentioned previously 80% of people currently living with hepatitis C acquired it through the sharing and reusing of injecting drug equipment. A number of other risk factors exist all of which involve the potential for blood to bloodstream contact. Whilst an activity such as the sharing of household grooming items is considered to present a very low risk - LOW RISK DOESN’T MEAN NO RISK. Hepatitis C is rarely sexually transmitted and is not classified as an STI.

Transmission Mother to baby (during pregnancy or at birth - 5% - 8% risk) Risk increased if hepatitis C contracted during pregnancy HIV co-infection increases risk 4-fold Sharing personal grooming items (razors, toothbrushes ) Fighting Breach of standard precautions – unsterile medical procedures

Who Is Affected Of infections in Australia: 83% were a result of injecting drugs 5% were a result of receiving blood transfusions or blood products prior to 1990 12% were a result of other factors - high prevalence country of birth, vertical transmission, unsterile tattooing Hepatitis C Virus Projections Working Group - Estimates and Projections of the Hepatitis C Virus Epidemic in Australia 2002 -ANCAHRD Hepatitis C Sub-Committee

Hepatitis C - Not an STI Hep C is not classified as an STI Hep C is rarely sexually transmitted There has to be blood present for transmission to happen When there are other sexually transmitted infections present such as herpes the risks of transmission may be higher

Hep C is not Transmitted via.. Public toilets Swimming pools Coughing or sneezing Kissing or hugging Mosquito or animal bites Sharing food

Who is at Risk Young People People in Prison Indigenous People Diagnosis among 15 -19 year olds doubled from 1996 –2001 (NCHECR - Annual Surveillance Report 2001) People in Prison 40% of males and 65% of women are estimated to have hepatitis C (Butler, T, Inmate Health Survey 2002) Indigenous People In 2000, 10% of new diagnoses were Aboriginal and Torres Strait Islander where ethnicity recorded (NCHECR 2001)

Significance of Standard Precautions People with Hepatitis C are commonly discriminated against Correct application of Standard Precautions break the links in the chain of infection, preventing the transmission of Hepatitis C Standard precautions allow HCW’s to provide care to all patients safely and without discrimination (Previous presentations: Sue Gore and Christine Hunt)

Standard Precautions Hand Hygiene Use of Personal Protective Equipment (PPE’s) Waste Management Care with sharps Reprocessing of Equipment Environmental Controls Routine preoperative testing of patients is not recommended

Testing Antibody test ‘Window period’ – 2 weeks up to 6 months, but on average 6 to 12 weeks. Indicates a person has been exposed to the virus. Doesn’t determine if infection is current or what genotype is present PCR tests Qualitative – virus detected/not detected Quantitative – viral load Genotype

Natural History

Natural History

Natural History

Hepatitis C Treatment ? Combination Therapy – (pegylated interferon and ribavirin) Treatment Regime weekly self administered injections of pegylated interferon & daily ribavirin tablets taken orally Treatment adherence is critical to achieve sustained viral response (SVR) 6 months – 12 months (depending on genotype / cirrhosis) Overall across genotypes, 60% viral clearance – and up to 80% viral clearance in genotype 2 & 3

Disclosure Only people with hepatitis C who are working with exposure prone procedures are required to disclose their hepatitis C status All other people with hepatitis C are not required to disclose their hepatitis C status (exceptions on insurance forms, to blood banks,on armed forces applications)

Health Care Workers with Hepatitis C Transmission of BBV from HCW to Patients is extremely rare Standard precautions protect patients and staff HCW’s performing exposure-prone procedures should be aware BBV status HCW’s performing exposure-prone procedures who are positive for BBV may need to modify their work practices

Social Implications Social Stigma Discrimination Family Fear Isolation Poverty Impact on health and well-being

Useful Websites Hepatitis C Council of SA http://www.hepccouncilsa.asn.au Australian Hepatitis Council http://www.hepatitisaustralia.com Australian Society for HIV Medicine (ASHM) http://www.ashm.org.au National Hepatitis C Resource Manual http://www.health.gov.au/internet/wcms/publishing.nsf/Conten health-pubhlth-strateg-hiv_hepc-hepc-manual.htm National Hepatitis C Treatment Awareness Week http://www.hepcawareness.net.au

Contact Details Hepatitis C Council of South Australia Inc. 8362 8443, (Free Call Rural SA 1800 02 11 33) Hepatitis Helpline – 1800 621 780 Mosaic Counseling - 8223 4566 / 1800 182 325 SAVIVE - 8362 9299 Aboriginal Drug and Alcohol Council SA - 8362 0395 PEACE Project - Service for CALD communities 8245 8100 Clinic 275 - 8226 6025 / 1800 80 64 90