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HCV Training Workshop. Join us on Twitter & Facebook – HCVAdvocate BLOG: hcvadvocate.blogspot.com/. People Who Make a Difference. Irina Gavrilova Clara Maltras Kate Frye Patrick Daniel. C.D. Mazoff Lucinda Porter Rose Christensen Liz Highleyman Leslie Hoex. www.hcvadvocate.org.

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HCV Training Workshop


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    1. HCV Training Workshop Join us on Twitter & Facebook – HCVAdvocate BLOG: hcvadvocate.blogspot.com/ www.hcvadvocate.org

    2. People Who Make a Difference • Irina Gavrilova • Clara Maltras • Kate Frye • Patrick Daniel • C.D. Mazoff • Lucinda Porter • Rose Christensen • Liz Highleyman • Leslie Hoex www.hcvadvocate.org

    3. www.hcvadvocate.org www.hcvadvocate.org

    4. Numbers Web site average : Average 550,000 hits/week Educational Materials: 600,000 pieces Not counting web site downloads Fact Sheets – 400-500 downloads weekly www.hcvadvocate.org

    5. Legend: Completed; Planned www.hcvadvocate.org

    6. Effect on HCV Community HCSP Educators: more than 10,000 50 people: In one year outcome is 500,000 people Ultimate goal: Improved education, support and services www.hcvadvocate.org

    7. The Liver www.hcvadvocate.org

    8. 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 • Chemical factory > 500 functions • Bile-regulates hormones- immune system cells THE LIVER www.hcvadvocate.org

    9. Liver Functions - continued Sugar & fat metabolism & Nutrient storage Stores some vitamins & minerals Fat soluble vitamins: A,D,E, & K Minerals: copper & iron Clotting factors: makes proteins to help the blood clot Filters – breathed in the air, absorbed through the skin and taken by mouth *** Regenerates—grows or shrinks*** www.hcvadvocate.org

    10. 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 56,000 emergency room visits & 500 deaths a year NSAIDs: 16,500 annual deaths Eat a healthy, balanced diet: www.choosemyplate.gov www.hcvadvocate.org

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

    12. Hepatitis A (HAV) US—New infections: 21,000 (US – 2009) 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

    13. HEPATITIS B (HBV) US - 38,000 new infections (CDC – 2009) Vaccine available since 1982 –3 doses (0,1, & 6 months) US chronic: 800,000 –1.4 MILLION Worldwide: 350-400 million US - 3,000 deaths a year Worldwide 660,000 annual deaths www.hcvadvocate.org

    14. HBV Transmission Blood borne – can live outside the body for at least 7 days Highly infectious in semen and vaginal secretions – 50% - sexual transmission Sharing needles to inject drugs Needle stick and blood exposure accidents Sharing personal items Mother-to-child transmission www.hcvadvocate.org

    15. 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

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

    17. HCV Transmission / Prevention The hepatitis C virus lives for at least 16 hours – but no longer than 4 days – outside the body In syringes up to 63 days www.hcvadvocate.org

    18. Transmission/Prevention Sharing needles and drug preparation tools Blood products & solid organ transplantation before 1992 Clotting factors before inactivation in 1987 Sexual transmission (0-3%) Mother-to-child (~4-5%) Healthcare workers (~2%) Hemodialysis www.hcvadvocate.org

    19. Possible Transmission Routes • Tattoo & piercing* • Personal care salons • Shared household (hygiene) items • Coke/crank straws & crack 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

    20. Safer Tattoos – www.hepatitistattoos.org Version 12.3 www.hcvadvocate.org

    21. Little or no data……. • Dental and other procedures before universal precautions • Jet gun injections • Transgender people • Sharing needles and operations www.hcvadvocate.org

    22. 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

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

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

    25. 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

    26. More Prevention • Health care workers • blood borne 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

    27. 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

    28. 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

    29. Lifecycle • Single stranded RNA virus • Mainly infects liver cells—but also found in other cells of the body • Difficult to culture—complete lifecycle is unknown www.hcvadvocate.org

    30. 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

    31. Increased Diagnosis and Treatment The Tipping Point? OraQuick HCV Antibody Test New Antivirals Aged-Based Testing Templates • Finger Prick • Whole Blood Draw • Oral Swab • Results available within 20 minutes • More testing within clinics and mobile sites can lead to increased consultations about care, management and treatment • New HCV Treatments • An HCV protease inhibitor combined with pegylated interferon, plus ribavirin increases the cure rates up to 79% • Higher cure rates will mean more treatment naïve and prior non-responders will seek treatment • The Centers for Disease Control has recommended a one-time test for persons born between 1946 and 1965 Version 12.3 www.hcvadvocate.org

    32. 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

    33. OraQuick HCV Rapid Antibody Test FingerPrick & whole blood: FDA and CLIA Waiver approved – 2011 Oral swab – Pending fda and clia approval – 2012? www.hcvadvocate.org

    34. www.hcvadvocate.org

    35. www.hcvadvocate.org

    36. 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

    37. How is Viral Load Used? Confirm active infection Soft predictor of treatment response Confirm HCV medications are working and dictate treatment duration ***Does Not Correlate with Disease Progression*** www.hcvadvocate.org

    38. Genotype & Quasi-species • Six major genotypes (plus sub-types) • Genotypes numbered 1,2,3,4,5,6, (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 www.hcvadvocate.org

    39. 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

    40. Liver Biopsy *Measures liver health *Treatment decisions *Benchmark Metavir Scoring System – 0, 1, 2, 3, 4 No activity Severe activity www.hcvadvocate.org

    41. HCV Symptoms, Disease Progression & Management “Living with hcv is often easy, often difficult and sometimes impossible” Peter Mare Latham www.hcvadvocate.org

    42. 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 *http://www.iom.edu/Reports/2010/Hepatitis-and-Liver-Cancer-A-National-Strategy-for-Prevention-and-Control-of-Hepatitis-B-and-C.aspx **http://www.milliman.com/expertise/healthcare/publications/rr/pdfs/consequences-hepatitis-c-virus-RR05-18-09.pdf ***GL Davis and colleagues; PMID: 19861128 [PubMed - as supplied by publisher] www.hcvadvocate.org

    43. 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

    44. Liver Specialists GASTROENTEROLOGIST HEPATOLOGIST THE FUTURE? Primary care, infectious disease specialists and others www.hcvadvocate.org

    45. Acute HCV • Initial or acute infection • Many people have no symptoms • Flu-like—fatigue, nausea, fever, indigestion, loss of appetite, night sweats, jaundice • Lasts up to 6 months • Spontaneous (natural) clearing by gender: • Women ~40% • Men ~19% • Treatment of acute HCV—the majority of people with acute HCV can clear the virus with interferon monotherapy www.hcvadvocate.org

    46. Chronic Infection Longer than 6 months Does not mean severe disease progression CDC ~75%–85% of casesbecome chronic Studies – 55% to 85% become chronic 10 to 25% have serious disease progression over a 10 to 40 year period – disease progression is not linear Fibrosis / Cirrhosis / Steatosis www.hcvadvocate.org

    47. Chronic Symptoms • Fatigue – mild to severe • “Brain Fog” • Flu-like symptoms • Depression • Liver pain • Loss of appetite • Headaches • Gastro problems • And more…. Symptoms don’t necessarily correlate with disease progression with the exception of end-stage liver disease www.hcvadvocate.org

    48. HCV Infection: Extrahepatic Manifestations • Hematologic • Mixed cryoglobulinemia • Aplastic anemia • Thrombocytopenia • • Non-Hodgkin’s b-cell lymphoma • Salivary • Sialadenitis • Ocular • Corneal ulcer • Uveitis • Dermatologic • Porphyria cutanea tarda • Lichen planus • Cutaneous necrotizing vasculitis • Vascular • Necrotizing vasculitis • Polyarteritis nodosa • Neuromuscular • Weakness/myalgia • Peripheral neuropathy • Arthritis/arthralgia • Renal • Glomerulonephritis • Nephrotic syndrome • Endocrine • Anti-thyroid antibodies • Diabetes mellitus • Autoimmune • Phenomena • CREST syndrome Hadziyannis SJ. J Eur Acad Dermatol Venereol. 1998;10:12-21.

    49. U. S. Statistics: CDC New (acute) infections: 16,000 Total chronic infections: UP TO 3.9 million ~15,000 deaths annually *Not factored into above: Prisoners, homeless, people in mental institutions www.hcvadvocate.org

    50. Disease Progression • Compensated—extensive scarring, but liver is still working fairly well • Decompensated—very extensive scarring and liver function has become severely compromised • Conditions • Portal Hypertension / Ascites & Edema / Varices / Encephalopathy • Liver Cancer • 3% to 5% of people with chronic HCV will develop liver cancer –after severe fibrosis or cirrhosis • Transplantation: 250,000 to $314,000 – up to $500,000 – Annual costs of medications: ~$21,900 www.hcvadvocate.org