1. ABCs of Hepatitis

2. What is Hepatitis Hepatitis is inflammation of liver Hepatitis can be caused by a variety of factors ▫Alcohol ▫Drugs ▫Chemicals ▫Toxins ▫Autoimmunity ▫Viral Infections (Hepatitis A, B, C, D, E, G)

3. The Liver Largest internal organ Weighs about 3lbs Size of football Ability to regenerate after damage Involved in many digestive, vascular and metabolic activities

4. Liver Damage Inflammation – immune response Fibrosis – development of scar tissue Cirrhosis – a process where liver cells are destroyed and replaced with scar tissue Hepatocellular Carcinoma – type of liver cancer

5. Viral Hepatitis Acute infection is when the function is newly acquired Chronic infection lasts 6 months or more and is usually life long unless treated Resolved or cleared infection is the body getting rid of hepatitis infection – usually occurs in the acute stage

6. Hepatitis A Caused by hepatitis A virus In 2008 22, 000 estimated number of new infections in the U.S. HAV is an acute infection Incubation 30 days, usually lasts 2 months Symptoms include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay- colored bowel movements, joint pain, jaundice Once resolved, protective antibodies develop and give lifelong immunity

7. HAV Transmission and Prevention Primarily transmitted via fecal-oral route and rarely through blood exposure Highly infectious and stable in environment for months Most common transmission through close personal contact with an infected person Vaccine is available to prevent infection

8. HAV vaccination Vaccine began in 1995 Two doses at 0 and 6-18 months (VAQTA & HAVRIX) Also available in combination with Hep B (TWINREX) ▫Given in three doses at 0, 1, and 6 months Does not have to be given at exact timeline

9. Recommendations for HAV vaccine Person’s at increased risk of HAV infection ▫Injection and non injection drug use ▫Men who have sex with men ▫Travelers headed to HAV endemic countries ▫Persons with chronic liver disease ▫Persons with clotting factor disorders ▫Children but often not vaccinated

10. Hepatitis B Caused by hepatitis B virus In 2008 38,000 estimated number of new infection in U.S. 800,000 to 1.4 million in U.S. living with chronic HBV Incubation period 60-90 days 2-6% of infected adults develop chronic HBV Often no symptoms in acute stage but can include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, clay-colored bowel movements, joint pain, jaundice If resolved, protective antibodies develop and give lifelong immunity

11. HBV Transmission and Prevention Primarily transmitted by blood, semen, and vaginal secretions Highly infectious, stable in environment for at least 7 days Dried blood can be reconstituted Most common transmission through ▫Unprotected sex ▫Perinatal (mom to baby) ▫Percutaneous (through opening in skin)

12. Chronic HBV 2-6% adults go on to chronic infection, majority of infected infants become chronically infected if not given vaccine 15-25% of persons with chronic HBV will die prematurely (~3,000 deaths per year) Treatment and medical management is very complicated and should be referred to specialist

13. HBV Vaccine Vaccine began 1982 Three doses at 0, 1 and 6 (Recombivax & Energix-B) Also available in combination with Hep A (TWINREX) Does not have to be given at exact timeline

14. Recommendations for HBV Vaccine Person’s at increased risk of HAV infection ▫Men who have sex with men ▫Persons with more than one sex partner in a six month period ▫Persons recently diagnosed with an STD ▫Sex contacts of infected persons ▫Injection drug use ▫Household contact of chronically infected person ▫Infants born to an infected mother ▫Infants/children of immigrants from areas with high rates of HBV ▫Healthcare and public safety workers ▫Hemodialysis patients ▫People living with HIV and/or HCV

15. Lack of Access to HBV and HAV Vaccine Hepatitis A PreventionHepatitis B Prevention Prevent fecal matter from entering the mouth Wash hands Use barriers for oral sex Clean sex toys between use Prevent blood, semen, vaginal fluids from entering body Use barriers for sex Do not share needles or other equipment that may have blood on them

16. HAV &HBV Testing HAV/HBV testing ▫usually not recommended prior to vaccination ▫Can determine current infection or immunity HBV testing distinguishes between current and resolved infection Some people may benefit from post immunization testing (HIV+ persons)

17. Hepatitis C History ▫Blood samples stored since 1948 contain antibodies to HCV earliest known HCV ▫1970 the virus appears in enough people to be noticed, called non A, non B hepatitis ▫1987 Identified as hepatitis C ▫1990 Antibody test helps identify people exposed to the virus and is used to screen the blood ▫1992 Better test to insure the safety of the blood supply

18. Hepatitis C Caused by Hepatitis C virus In 2008, 18,000 estimated new infection in U.S. ~4.1 million in U.S. have been infected An estimated 115,000 infected in WA Incubation period average 6-7 weeks 75%-85% infected adults progress to chronic infection Often no symptoms If resolved, no protective antibodies, can get reinfected

19. HCV Transmission Primarily transmitted by direct blood to blood contact Highly infectious, stable environment for at least 16 hours, but not more than 4 days (alive but can’t transmit) Most common transmission through sharing of drug paraphernalia Also blood transfusions and products before 1992 ▫Perinatal transmission ▫Needle stick/healthcare exposure ▫Other blood risks low/unknown risk: tattooing,/piercing, intranasal cocaine use, shared personal items

20. Prevention of HCV Avoid blood exposure: ▫New syringe, cooker, cotton, water, every time for injection ▫Use universal precautions ▫Don’t share personal items that may contain blood (tooth brush/razor) ▫Use barriers and lubricant ▫Cover open cuts and wounds ▫Ensure instruments for tattooing, piercing, acupuncture are new or sterilized

21. HCV and Sharing of Injection Drug Equipment Studies have found high rates of HCV in IDUs who didn’t share needles but shared cookers, cottons, and water, and other equipment People who inject steroids, vitamins, and hormones and share equipment are also at risk IDUs should use new sterile equipment every time (wash hands and injection site and surface area) It is unknown if bleach kills HCV

22. HCV and Sexual Transmission Seven U.S. studies of long term discordant partners found 1.5-3% seroprevalence of HCV Other studies of MSM, sex workers, and those with a history of HCV found prevalence of 4-6% Other factors related with sexual transmission include #of partners, the presence of STDs, and use of condoms

23. More HCV transmission Risk with pregnancy mother to child 5-6% Breast feeding ok unless cracked nipples Most risk for tattooing is non professional tattooing, very common during incarceration New ink containers, needles, and equipment Intranasal cocaine and meth use: some studies have found a link when blood gets in the nasal membrane Smoking crack and meth use: burnt, cracked, or bleeding lips

24. CDC Recommendations for HCV Testing Test routinely based on risk ▫Ever injected drugs (even once) ▫Transfusions/organ transplants before 1992 ▫Selected medical conditions (chronic hempdialysis, elevated liver enzymes) ▫Received clotting factors before 1987 CDC unsure of testing needs  History of tattooing, STDs, body piercing, intranasal cocaine or meth use, long term HCV partner

25. HVC Testing and Diagnosis EIA (Enzyme immunoassay) ▫Detects antibodies to HCV ▫97% of people have antibodies 6 months after infection RIBA (Recombinant immunoblot assay) ▫Confirms positive initial anti-HCV HCV RNA ▫Looks for actual virus in blood

26. Positive Test Result Confirmed Positive ▫Client has been infected with HCV in the past and probably is still living with it ▫Further Evaluation is recommended  Determine if HCV is still in blood  Establish the health of the liver  Discuss treatment options ▫Discuss prevention and health messages  Avoiding alcohol

27. Symptoms of Chronic Hepatitis Chronic Hepatitis ▫Fatigue ▫Depression ▫Loss of appetite ▫Nausea/indigestions ▫Muscle/joint pain ▫Mood swings ▫Abdominal Pain ▫Fever Late stages of cirrhosis ▫All of the symptoms of chronic hepatitis ▫Vomiting ▫Jaundice ▫Cognitive dysfunction ▫Fluid retention ▫Frequent urination ▫Lack of concentration ▫Confusion ▫Dizziness

28. Chronic Hepatitis C Factors promoting progression ▫Alcohol intake ▫Age >40 at time of infection ▫HIV or HBV co infection ▫Male gender Vaccinate for HAV/HBV HCV leads to ~10,000 deaths per year from chronic liver disease