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HCV Training Workshop

HCV Training Workshop. Alan Franciscus Executive Director, Hepatitis C Support Project Join us on Twitter & Facebook – HCVAdvocate BLOG: hcvadvocate.blogspot.com. HEPARDY!. Answer in the form of a question Right answer = earn points Wrong answer = lose points Daily Double

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HCV Training Workshop

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  1. HCV Training Workshop Alan Franciscus Executive Director, Hepatitis C Support Project Join us on Twitter & Facebook – HCVAdvocate BLOG: hcvadvocate.blogspot.com www.hcvadvocate.org

  2. HEPARDY! • Answer in the form of a question • Right answer = earn points • Wrong answer = lose points • Daily Double • Wager points earned or up to 1000 points • Right answer – double points • Wrong answer – lose points wagered • First person who buzzes in has 10 seconds to answer Judge’s decision final! www.hcvadvocate.org Version 17.5

  3. People Who Make a Difference • C.D. Mazoff • Lucinda Porter • Rose Christensen • Liz Highleyman • Leslie Hoex • Irina Gavrilova • Christine M. Kukka • Clara Maltras • Kate Frye www.hcvadvocate.org

  4. www.hcvadvocate.org www.hcvadvocate.org

  5. Numbers Website: Average 660,000 hits/week Educational Materials: 350,000 pieces Not counting website downloads Fact Sheets – 400-500 downloads weekly www.hcvadvocate.org

  6. Legend: Completed www.hcvadvocate.org

  7. Effect on HCV Community HCSP Educators: more than 15,000 50 people: In one year outcome is 750,000 people Ultimate goal: Improved education, support and services www.hcvadvocate.org

  8. The Liver www.hcvadvocate.org

  9. About 3 lbs (men) – size of a football • Located in the upper right side – beneath the rib cage • 1.5 quarts of blood flow through it every minute • Regenerates –grows or shrinks • Chemical factory > 500 functions THE LIVER www.hcvadvocate.org

  10. LIVER Sugar & fat metabolism & nutrient storage Stores some vitamins and minerals Fat soluble vitamins: A,D,E, & K People with HCV should be tested for deficiencies Minerals: copper and iron www.hcvadvocate.org

  11. LIVER Bile – regulates hormones – immune system cells Clotting factors: Makes proteins to help the blood clot Filters substances: Breathed in the air Absorbed through the skin Taken by mouth www.hcvadvocate.org

  12. Healthy People: Healthy people—no more than: 2 alcoholic drinks a day for men; 1 alcoholic drink a day for women HCV – NO ALCOHOL Be cautious about mixing drugs especially with alcohol— Acetaminophen (Tylenol) – 600 products Over 78,000 emergency room visits & 300 deaths a year (150 accidental) NSAIDs: ~4000 annual deaths (little data) Eat a healthy, balanced diet: www.choosemyplate.gov www.hcvadvocate.org

  13. Are you sure your doctor said we can have two drinks a day? www.hcvadvocate.org

  14. HEPATITIS Means: Inflammation of the liver Causes: Viruses, toxins, genetic disorders, bacteria and parasites, alcohol and diet www.hcvadvocate.org

  15. Hepatitis A (HAV) US—New infections: 3,050 (CDC – 2012) 180,000 in 1997 Vaccine available since 1995 – 2 doses (0 & 6 months) Estimated 33% have been infected with HAV Resolves (not chronic) Transmission: fecal/oral www.hcvadvocate.org

  16. HEPATITIS B (HBV)HCV AND HBV REDUCE SURVIVAL BY MORE THAN 20 YEARS US –18,760 new infections (CDC – 2012) Vaccine available since 1982 –3 doses (0, 1, & 6 months) US chronic: 700,000-1.4 Million Worldwide: 350-400 million US – 3,000 deaths a year Worldwide 660,000 annual deaths www.hcvadvocate.org

  17. HBV Transmission Bloodborne – can live outside the body for at least 7 days Highly infectious in semen and vaginal secretions – the majority of US infections Sharing needles to inject drugs Needlestick and blood exposure accidents Sharing personal items Mother-to-child transmission www.hcvadvocate.org

  18. HBV Prevention Get vaccinated Do not share needles or works Safer sex Standard safety precautions Do not share personal items HBV-infected mother-to-child intervention www.hcvadvocate.org

  19. Chronic HBV Chronic ~5-6% Adults – 90% Infants *These drugs are recommended as first line of treatment www.hcvadvocate.org

  20. HCV Transmission / Prevention Hepatitis C is spread by blood-to-blood contact HCV is the most common blood-borne pathogen in U.S. www.hcvadvocate.org

  21. HCV Survival • Hepatitis C virus lives on surfaces for up to 6 weeks • In syringes up to 63 days • Commercially available disinfectants kill HCV • Collected shared swabs – ~ 83% tested positive for HCV • HCV detected in used water for greater than 3 weeks • In bottles – HCV RNA detected even after rinsing out – plastic and aluminum retained HCV RNA longer • ~10% of filters wrapped in foil had HCV RNA after 24 and 48 hours www.hcvadvocate.org

  22. Transmission/Prevention Sharing needles and drug preparation tools Blood products & solid organ transplantation before July 1992 Clotting factors before inactivation in 1987 Sexual transmission (0-3%) Mother-to-child (~4-10%) Healthcare workers (~2%) Hemodialysis www.hcvadvocate.org

  23. Possible Transmission Routes • Tattoo & piercing* • Personal care salons • Shared household (hygiene) items • Coke/crank straws & crack/meth pipes • 10% of routes can not be identified * Higher in unsafe non-commercial settings: prisons/mental institutions/on the streets/home grown www.hcvadvocate.org

  24. Safer Tattoos – www.hepatitistattoos.org Version 17.5 www.hcvadvocate.org

  25. Little or no data……. • Dental and other procedures before universal precautions • Jet gun injections • Transgender people • Sharing needles and re-assignment surgeries www.hcvadvocate.org

  26. HCV is Not Spread by: Breast feeding Food or water Sharing eating utensils or drinking glasses Sneezing Hugging *Not spread by casual contact* www.hcvadvocate.org

  27. Prevention: Do not share anything: Needles, cookers, cotton, tourniquets, water, water containers, etc. – Wash hands www.hcvadvocate.org

  28. Prevention – more • Do not share non-injection drug equipment • Coke/crank straws • Crack/Meth pipes • Tattoo / Piercing • Sterilization, autoclave, separate ink pot, new needles www.hcvadvocate.org

  29. Prevention – more Sexual: 0-3% – monogamous partners– counsel Safer sex – additional risk through sex: Multiple partners Coinfection with HIV or HBV Having herpes, lesions, sores, open cuts, wounds Sexually transmitted diseases Mother-to-child www.hcvadvocate.org

  30. More Prevention • Health care workers • bloodborne pathogen protection • Razors / toothbrushes covered • Cover all wounds • Transfusions – estimated that less than one per 2 million transfused units of blood tainted with HCV • People with HCV: Do not donate blood, sperm, eggs or organs – EXCEPTIONS….. www.hcvadvocate.org

  31. Lifecycle • Single-stranded RNA virus • Mainly infects liver cells—but also found in other cells of the body • Cell culture discovered and available www.hcvadvocate.org

  32. HCV Diagnostic Tools Hcv Identified in 1989 Important: Interpretation of test results and decisions about healthcare are a collaboration between a medical provider and a patient www.hcvadvocate.org www.hcvadvocate.org

  33. Baby Boomers Account for the Majority of HCV Cases in United States Estimated Prevalence by Age Group 1.6 Number With Chronic HCV Infection (millions) 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0 1990+ 1980s <1920 1920s 1970s 1940s 1950s 1930s 1960s Birth Year Group www.hcvadvocate.org

  34. Increased Diagnosis and Treatment The Tipping Point? Aged-Based Testing OraQuick HCV Antibody Test Newly FDA-Approved Antivirals Templates • Cure rates up to 90% • In Development • Approval estimated – end of 2014 • Interferon-free therapies will mean that almost everyone will want to be treated The Centers for Disease Control (CDC) & the United States Preventive Services Task Force (USPSTF) have recommended a one-time test for persons born between 1945 and 1965 >800,000 people • Finger Prick & Whole Blood Draw FDA Approved • Results available within 20 minutes • More testing within clinics and mobile sites can lead to increased consultations about care, management and treatment Version 17.5 www.hcvadvocate.org

  35. HCV Antibody Tests HCV Elisa III (EIA), CIA: Detects antibodies Signal to cut off ratio = 95% chance true antibody positive Home Access test kit Window period – 2-26 weeks www.hcvadvocate.org

  36. OraQuick HCV Rapid Antibody Test Finger Prick & whole blood: FDA and CLIA Waiver approved – 2011 www.hcvadvocate.org

  37. www.hcvadvocate.org

  38. www.hcvadvocate.org

  39. HCV RNA – Viral Load • PCR (polymerase chain reaction) – lowest range • TMA (transcription mediated amplification) – lowest range • DNA (bDNA) assay – highest range • Amount of virus per milliliter of blood • International units • Low – less than 800,000 IU/mL • High – more than 800,000 IU/mL www.hcvadvocate.org

  40. How is Viral Load Used? Confirm active infection Soft predictor of treatment response Confirm HCV medications are working Dictate treatment duration for some HCV Medications ***Does Not Correlate with Disease Progression*** www.hcvadvocate.org

  41. Genotype & Quasi-species • Seven major genotypes (plus sub-types) • Genotypes numbered 1, 2, 3, 4, 5, 6, 7* (1a, 1b, etc.) • Genotype 1 – 70% of US population with HCV • Genotypes 2, 3 – 30% of US population with HCV • Quasi-species • High error prone virus – mutates quickly * Discovered in 2013 www.hcvadvocate.org

  42. Liver Tests ALT: a non-specific marker of liver inflammation Not a good test to monitor people with HCV AST, AP, GGT, bilirubin, platelet, prothrombin time (PT) www.hcvadvocate.org

  43. Liver Biopsy *Measures liver health *Treatment decisions** *Benchmark Note: Fewer biopsies are being performed because of newer therapies with cure rates > 90% and the use of the Fibroscan Metavir Scoring System – 0, 1, 2, 3, 4 No activity Severe activity www.hcvadvocate.org

  44. FIBROSCAN FDA Approved – April 2013 Imaging technology that uses a sonogram to measure the speed of sound waves directed through the liver to measure stiffness Measures either minimal damage or severe damage Version 17.5 www.hcvadvocate.org

  45. HCV Symptoms, Disease Progression & Management HCV AND hbv REDUCE SURVIVAL BY MORE THAN 20 YEARS www.hcvadvocate.org

  46. Drug Based Therapies Social Stigma Health Policies Housing Support HCV Positive Health Access Mental Health Addiction HAV & HBV Vaccine What may be needed even before considering treatment CAM Ann Shindo www.hcvadvocate.org

  47. Future Disease Burden • *Institute of Medicine (IOM) Report – 2010 • **Milliman Report – Annual cost of advanced liver disease to $85 billion in the next two decades and Medicare costs will increase 500%, from $5 billion to $30 billion • ***Aging of the Hepatitis C Virus-Infected Persons in the United States: A Multiple Cohort Model of HCV Prevalence and Disease Progression – Progression to cirrhosis will peak at 1.0 million in 2020 • ****Viral Hepatitis Action Plan www.hcvadvocate.org

  48. U. S. Statistics CDC - New (acute) infections: 21,870 Cdc - Total chronic infections: 2.7 to 3.9 million (not factored into above: prisoners, homeless, people in mental institutions) Populations not accounted for in above studies – True Prevalence?: 5.2 to 7.1 Million Americans– (SEE NOTE PAGE) www.hcvadvocate.org

  49. Prevalence • U.S. Population • Baby Boomers • PWID > 10 yrs • PWID < 10 yrs • Homeless persons • Prisoners • Mental illness • Black American men (40-50 yo) • ~2% • 3.25% (76% of HCV population) • 90% • 66% • 19-69% • 29% • 20% • 10% www.hcvadvocate.org

  50. HCV Deaths ~15,000 deaths annually* 2007: deaths from HCV (>15,000) surpassed deaths from HIV (>12,000) *Note: deaths underreported – HCV accelerates deaths from other causes and is a contributing factor in deaths, but not listed on many certificates www.hcvadvocate.org

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