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The Alphabet of Hepatitis 101: An Overview. Jeff Wagers Program Specialist, HIV/STD Prevention & Care Branch May 19, 2009. Objectives. Define hepatitis and list the causes Describe some general facts and symptoms of hepatitis Discuss the basics of Hepatitis A, B, and C

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The alphabet of hepatitis 101 an overview l.jpg

The Alphabet of Hepatitis 101:An Overview

Jeff Wagers

Program Specialist,

HIV/STD Prevention & Care Branch

May 19, 2009


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Objectives

  • Define hepatitis and list the causes

  • Describe some general facts and symptoms of hepatitis

  • Discuss the basics of Hepatitis A, B, and C

  • Describe the prevention strategies of hepatitis A, B and C



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Causes of Hepatitis

  • Inflammation of the Liver

  • Caused by:

    • Alcohol

    • Drugs/medications

    • Toxins/chemicals

    • Autoimmune diseases

    • Bacteria

    • Viral Infections (hepatitis A, B, C, D and E)


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Viral Hepatitis

  • Hepatitis A Virus

  • Hepatitis B Virus

  • Hepatitis C Virus

  • *Hepatitis D Virus – only causes problems for people infected with HBV

  • *Hepatitis E Virus – not common in US


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Facts About Viral Hepatitis

  • Infect liver cells which causes inflammation

  • Differ in how they are transmitted and treated

  • Infection with one does not “turn” into another

  • None are airborne

  • All types may cause similar symptoms

  • Hepatitis A, B, D are vaccine preventable

  • May cause liver damage over time, esp. if severe or long-term

  • Hepatitis B and C can be chronic


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Symptoms of Hepatitis Infection

  • Jaundice

  • Fatigue

  • Abdominal Pain

  • Loss of Appetite

  • Nausea

  • Diarrhea

  • Fever

  • Dark Urine (HCV)

  • Often No Symptoms



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HAV Transmission

  • Hepatitis A is transmitted through fecal-oral contact:

    • Rimming (oral/anal sex)

    • Food preparation

    • Changing diapers

    • Contaminated water

    • Contaminated shellfish


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HAV Transmission (2)

  • Casual contact does not spread the virus

  • HAV-infected person can be considered infectious from 2 weeks before to 1 week after the onset of illness (may be longer in children)

  • Often there are no symptoms, especially in children


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Symptoms of HAV Infection

  • Takes 15-50 days to develop symptoms (average is 30 days)

  • Duration of symptoms: usually less than 2 months

  • Often abrupt onset of symptoms

  • No chronic disease

  • Once infected, always immune

  • Jaundice varies by age group


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Who is at risk for HAV infection?

  • Household and sexual contacts of infected people

  • Travel to countries and areas of the US where HAV is common

  • Men who have sex with men

  • People who engage in oral/anal sex

  • IDU and non-injecting drug users


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HAV Prevention

  • Vaccination is the best protection (2 shots)

  • Wash hands after using the restroom, changing diapers

  • Thoroughly wash food

  • Use of gloves

  • Harm reduction for oral/anal sex & IDU

  • Avoid contaminated water in high-incidence countries


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Who Should Get Vaccinated?

Those at risk, as well as:

  • Routine childhood vaccination in high risk areas

  • HIV-infected persons

  • People with chronic liver disease (Hepatitis B and C)

  • Lab workers, occupational exposure

  • Some populations (Native American, Alaskan Natives)



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HBV Prevalence

  • 1 out of 20 people have been infected

  • 1 out of 200 people are chronically infected (1.25 million)

  • Number of new infections each year has declined from about 260,000 in mid-1980s to about 60,000 in 2004 (75% reduction)

  • More than 11,000 people are hospitalized each year because of HBV infection

  • ≈5,000 people die each year from HBV-related liver disease


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Acute HBV Infection

  • About 60-70% of adults with HBV infection may experience symptoms of acute infection

  • Symptoms usually appear within 4-6 weeks

  • Infectious during acute phase

  • 90-95% will develop an effective immune response and clear virus from body

  • 5-10% develop chronic infection


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Chronic HBV Infection

  • Some may have few or no symptoms

  • 15-40% of those with chronic infection may develop liver disease, including liver cancer, cirrhosis or liver failure

  • This means that about 2-3 of 100 people with HBV infection may develop serious symptoms of liver disease, including cirrhosis or liver cancer.

  • Infectious during chronic phase


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HBVTransmission

  • Blood or body fluids from an infected person enters the body of a person who is not immune:

    • Unprotected sexual activity

    • Sharing injection drug equipment

    • Tattooing

    • During birth from infected mother to baby

    • Contact with open sores of infected person

    • Occupational exposure such as needle sticks or contaminated surgical instruments

    • Household contact such as: sharing razors, toothbrushes, nail clippers contaminated with infected person’s blood


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*Reported Risk Characteristics Among Adults with Acute Hepatitis B: United States, 2001-2003

Injection drug use

No identified risk

14%

15%

Other

7%

MSM

25%

Heterosexual

39%

*Other: Household contact, institutionalization, hemodialysis, blood transfusion, occupational exposure

Source: Sentinel Counties Study of Viral Hepatitis, CDC (n=483)


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Who is at risk for HBV infection? (and should be vaccinated!)

  • Sexual contacts of people with HBV infection

  • People with more than one sex partner within 6 months

  • History of STD/STI

  • MSM

  • IDU


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Who is at risk for HBV infection? (2) vaccinated!)

  • Healthcare workers or public safety workers who might be exposed to infected blood or body fluids

  • Certain household contacts of people with chronic HBV infection

  • Dialysis patients

  • Incarcerated persons and persons who work in correctional facilities

    TALK WITH ALL OF YOUR CLIENTS ABOUT

    HEPATITIS B!


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HBV Prevention vaccinated!)

  • Vaccination

  • Avoid sharing injection drug equipment

  • Avoid unprotected sex

  • Screen pregnant women and vaccinate all exposed infants


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Who should get vaccinated? vaccinated!)

Persons engaging in high risk activities and also:

  • 18 yrs of age or younger, including babies

  • People with HIV, Hepatitis C, and previous or current liver disease

  • People from or people traveling to countries with high rates

  • Alaska Natives and Pacific Islanders


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HBV and HAV vaccines vaccinated!)

  • HBV-3 dose over 6 months

    • One dose is better than none, two are better than one, and it’s best to get all three!

    • If a person misses a dose or gets behind schedule, provide the next dose as soon as possible. It’s not necessary to add doses or restart.

  • HAV-2 dose 6 months apart

  • Both are safe, effective, few side effects



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HCV Prevalence vaccinated!)

  • 3% of the world population infected (150-200 million)

  • 1.6% of the US population have been infected (4-5 million)

  • At least 3.2 million people are chronically infected

  • 50-90% of IDUs infected

  • 14-42% of incarcerated people infected

  • Up to 42% of homeless people may be infected

  • 8,000-10,000 Americans die each year from HCV-related complications

  • Liver failure due to HCV is leading cause of liver transplants in the US


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Acute HCV Infection vaccinated!)

  • Only 10-25% have symptoms when first infected (1 out of 4).

  • Antibody detection: typically 6-7 weeks

    • Can take up to 24 weeks (6 months)

  • 15-20% spontaneously clear the virus, within three months of infection


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Chronic Hepatitis C Infection vaccinated!)

  • Usually no symptoms until (or unless) the liver is seriously damaged

    • may be 10 to 30 years after infection.

  • More rapid progression may occur if coinfected with HIV

  • *About 80% develop chronic infection

  • Most remain stable for years

  • Of those with chronic infection:

    • 5-20% develop cirrhosis and serious illness

    • 1-4% develop liver cancer and/or need a transplant

    • 1% will die as a result of HCV disease

  • .


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Previously Acquired ( <1990s ) vaccinated!)

Newly Acquired ( 1995-2000 )

Injection Drug Use

Injection Drug Use

60%

68%

Sexual

15%

Unknown

Transfusion

Sexual

Unknown

Other *

Other *

10%

10%

9%

Occupational

18%

1%

Occupational

4%

Sources of Infection for Hepatitis C

1%

4%

* In a medical setting; healthcare work, perinatal

Based on Sentinel Counties, NHANES III


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HCV Transmission vaccinated!)IDU

  • Most efficient route is percutaneous (direct passage of blood into skin)

  • Sharing of needles, syringes and other paraphernalia from injection drug use is the greatest risk for HCV

  • Injection drug use, even once many years ago, is a risk

  • As many as 90% of IDUs are infected with HCV within 5 years of first injecting

  • IDU accounts for >65% of all new infections


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HCV Transmission vaccinated!)Transfusions/ Intranasal Drug Use

  • Transfusions:

    • Blood transfusion or organ transplant prior to 1992

    • Clotting factor prior to 1988

    • 90% of hemophiliacs treated before 1988 became infected

  • Intranasal Drug Use

    • Transmission may occur.

    • More studies are needed to determine as an independent factor


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HCV Transmission vaccinated!)Sexual

  • Sexual transmission occurs, but it is not the most efficient route

  • Accounts for 10-18% of HCV+ cases

  • Increased risk for people having sex that involves tearing and blood contact

  • Multiple partners and active STDs can increase risk

  • MSMs not at higher risk


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HCV Transmission vaccinated!)Perinatal

  • Risk of infected mother to infant at birth is less than 5%

  • HIV/HCV coinfection increases risk of HCV transmission up to 20%

  • No data to suggest that C-section is more effective than vaginal delivery in lowering perinatal transmission

  • Breast-feeding not a risk

    • unless nipples are cracked / bleeding


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HCV Transmission vaccinated!)Tattooing/ Healthcare Workers

  • Tattooing and Body Piercing

    • Use of contaminated and homemade equipment increases risk

    • tattooing in prisons or in street settings

    • shared ink

  • Healthcare Workers:

    • Risk from needlestick:

      HIVHCVHBV

      0.3% 2% 30%

    • Prevalence of HCV in healthcare workers is same as in general population

    • Standard universal precautions


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HCV Transmission vaccinated!)Household Contact

  • Transmission may occur by sharing items contaminated with blood

    • razors, toothbrushes, clippers

  • Casual contact does not transmit HCV

    • kissing, hugging, sharing food, etc.


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HCV Diagnosis vaccinated!)

  • Antibody Test

    • EIA or RIBA

      • A positive antibody test does not necessarily mean that someone has chronic HCV infection

      • Confirmatory testing must be done.

  • HCV RNA (PCR)

    • Qualitative

      • Confirmatory test

    • Quantitative (viral load)

      • Determines viral load


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HCV Diagnosis (2) vaccinated!)

  • Genotype (genetic strain)

    • 75% of US infections are Genotype 1

    • Six known genotypes

    • Genotype testing only needs to be performed once

      • a person’s HCV genotype doesn’t change

    • Knowing your genotype is important when considering treatment


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HCV Prevention – IDU vaccinated!)

  • Stop injecting!

  • Use a new sterile syringe to prepare and inject drugs obtained from a reliable source

  • Use sterile water

  • Use a new or disinfected cooker and a new piece of cotton

  • If must reuse, clean with bleach and water

  • Clean injection site before injection with alcohol swab

  • Always dispose syringes safely after one use


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HCV Prevention - Sex vaccinated!)

  • If you are having sex

    • Have sex with one uninfected person or not at all

    • Use a latex condom correctly each time


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HCV Prevention - General vaccinated!)

  • There is no vaccine

  • Do not donate blood, body organs, other tissue or semen

  • Do not share items that might have blood on them

    • personal care (e.g., razor, toothbrush)

    • home therapy (e.g., needles)

  • Cover cuts and sores on the skin


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Questions? vaccinated!)

Email questions to hepatitis@dshs.state.tx.us


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