1. Hepatitis C Best Practice Guidelines Susan Thompson, RN, MPH September 2009

2. For clients known to have HCV or for those testing positive for HCV, the following should be provided: 1.HCV education and risk reduction information to prevent additional liver damage 2.Control measure to prevent the spread of HCV to others 3.Hepatitis A and hepatitis B vaccine (Twinrix®) 4.Referral for medical evaluation (if available in your area)

3. Screening and Testing

4. Who Should be Tested ? Persons with any history of injection drug use (even once) Recipients of blood transfusion or solid organ transplant before July 1992; recipients of blood clotting factor concentrates made before 1987 Persons on long-term dialysis Children born to HCV positive women Healthcare, emergency medical, and public safety workers after needle sticks, or exposure to HCV positive blood Anyone who is HIV+ Patients with S/S of liver disease CDC National Hepatitis C Prevention Strategy, 2001

5. Laboratory tests to detect HCV Hepatitis C antibody EIA…may be reported as S/CO ratio CIA…may be reported as S/CO ratio RIBA…confirmatory test, now less important HCV RNA Qualitative test to detect presence of virus (HCV RNA PCR) Quantitative test to detect amount of virus (HCV RNA PCR)

6. Education and Counseling

7. Keeping your liver healthy No alcohol or reduce intake as much as possible Get vaccinated against Hepatitis A and B Monitor diet-avoid fats Drink lots of water and other fluids Reduce stress with exercise Develop a support network Learn all you can…knowledge is power

9. Preventing HCV Transmission CDC recommends: -- Covering cuts and sores on the skin -- Never sharing items that might have blood on them * personal care (razors, toothbrushes) * home therapy (needles) -- Never donating blood, body organs, other tissue Individuals who test positive for HCV should take every precaution to make sure that no one has direct exposure to their blood.

10. Injection drug use If active users…Works, sets, gizmos, rigs. Cooker, spoon, cotton, water, filter—whatever you call them, use them safely if you inject drugs. Take care of yourself and your friends. Always provide risk reduction counseling, education -- Help client develop a risk reduction plan -- Encourage to decrease or stop using and injecting -- Encourage active participation in substance abuse treatment program

11. Risk is generally low, but increases in the presence of high risk sexual behaviors Sexual Transmission of HCV To reduce risk –Limit number of partners –Use latex condoms –Get vaccinated against hepatitis B -- Also get vaccinated if at risk for hepatitis A (MSM)

12. Mother-to-Infant Transmission of HCV Risk of transmission about 4-6% Risk increases in the presence of HIV co-infection No need to avoid pregnancy or breastfeeding –Consider bottle feeding if nipples cracked/bleeding Test infants born to HCV-positive women (not before 18 months) Consider testing any children born since mother became HCV+

13. Occupational Exposures The risk of anti-HCV seroconversion after a needlestick injury is 1.8% For the source: baseline testing for anti-HCV For the person exposed: Baseline testing for anti-HCV and ALT level Follow-up testing at 4-6 months for anti-HCV and ALT

14. More important messages… HCV is not spread by: –sneezing,hugging, coughing, sharing eating utensils or drinking glasses, or casual contact HCV + persons should not be excluded from: work, school, play, child-care or other settings on the basis of their HCV status. HCV+ persons are not required to disclose their status to employers

15. Surveillance and Reporting

16. HCV Case Classification Past or Present (non-acute) HCV cases are not currently reportable in NC. Only Acute HCV cases that meet CDC clinical case definition are reportable by physicians in North Carolina. There is no “probable” status.

17. Hepatitis C, Acute CDC Case Definition, 2007 Clinical Case Definition: An acute illness with a discrete onset of any sign or symptom consistent with acute viral hepatitis (eg., anorexia, abdominal discomfort, nausea, vomiting) and either a) jaundice, or b) serum alanine aminotransferase (ALT) levels > 400 IU/L. Laboratory Criteria for Diagnosis: One or more of the following three criteria: 1.Antibodies to hepatitis C virus (Anti-HCV) screening-test-positive with a signal to cut-off ratio predictive of a true positive as determined for the particular assay as defined by CDC. OR 2.Hepatitis C virus Recombinant Immunoblot Assay (HCV RIBA) positive OR 3.Nucleic Acid Test (NAT) for HCV RNA positive AND, meets the following two criteria: 1.IgM antibody to hepatitis A virus (IgM anti-HAV) negative, AND 2.IgM antibody to hepatitis B core antigen (IgM anti-HBc) negative CONFIRMED: a case that meets clinical case definition, is laboratory confirmed, and is not known to have chronic HCV

19. QUESTIONS