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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

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    1. The Alphabet of Hepatitis 101:An Overview Jeff Wagers Program Specialist, HIV/STD Prevention & Care Branch May 19, 2009

    2. 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

    3. Hepatitis and the Liver

    4. 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)

    5. 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

    6. 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

    7. Symptoms of Hepatitis Infection • Jaundice • Fatigue • Abdominal Pain • Loss of Appetite • Nausea • Diarrhea • Fever • Dark Urine (HCV) • Often No Symptoms

    8. Hepatitis A

    9. HAV Transmission • Hepatitis A is transmitted through fecal-oral contact: • Rimming (oral/anal sex) • Food preparation • Changing diapers • Contaminated water • Contaminated shellfish

    10. 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

    11. 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

    12. 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

    13. 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

    14. 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)

    15. Overview of Hepatitis B

    16. 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

    17. 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

    18. 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

    19. 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

    20. *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)

    21. 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

    22. Who is at risk for HBV infection? (2) • 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!

    23. HBV Prevention • Vaccination • Avoid sharing injection drug equipment • Avoid unprotected sex • Screen pregnant women and vaccinate all exposed infants

    24. Who should get 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

    25. HBV and HAV vaccines • 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

    26. Overview of Hepatitis C: a blood-borne pathogen

    27. HCV Prevalence • 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

    28. Acute HCV Infection • 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

    29. Chronic Hepatitis C Infection • 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 • .

    30. Previously Acquired ( <1990s ) 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

    31. HCV TransmissionIDU • 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

    32. HCV Transmission 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

    33. HCV TransmissionSexual • 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

    34. HCV TransmissionPerinatal • 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

    35. HCV TransmissionTattooing/ 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

    36. HCV TransmissionHousehold Contact • Transmission may occur by sharing items contaminated with blood • razors, toothbrushes, clippers • Casual contact does not transmit HCV • kissing, hugging, sharing food, etc.

    37. HCV Diagnosis • 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

    38. HCV Diagnosis (2) • 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

    39. HCV Prevention – IDU • 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

    40. HCV Prevention - Sex • If you are having sex • Have sex with one uninfected person or not at all • Use a latex condom correctly each time

    41. HCV Prevention - General • 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

    42. Questions? Email questions to