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Hepatitis C Infection Anand Medicos
- 1. HEPATITIS C INFECTION FACTS, DIAGNOSIS, AND INTERPRETATION anandmedicos.com
- 2. WHAT IS HEPATITIS? • “Hepatitis” means inflammation of the liver • Can be caused by: • Genetic diseases • Medications (including over-the-counter) • Alcohol • Hepatitis viruses (A,B,C,D,E) anandmedicos.com
- 3. HEPATITIS C ▪ Identified in 1989 ▪ Blood test became available in 1992 ▪ Used to be known as “non-A, non-B” hepatitis ▪ Spread through blood-to- blood contact ▪ No vaccine available to prevent hepatitis C anandmedicos.com
- 4. STRUCTURE OF HEPATITIS C anandmedicos.com
- 5. HEPATITIS C - A GLOBAL INFECTION • About 3 million Americans infected • About 170 million infected worldwide • Many do not experience symptoms anandmedicos.com
- 6. SOURCES OF INFECTION FOR PERSONS WITH HEPATITIS C Sexual 15% Other* 5% Unknown 10% Injecting drug use 60% Transfusion 10% (before screening) anandmedicos.com
- 7. • Hepatitis C is a contagious liver disease that results from infection with the Hepatitis C virus. It can range in severity from a mild illness lasting a few weeks to a serious, lifelong illness. Hepatitis C is usually spread when blood from a person infected with the Hepatitis C virus enters the body of someone who is not infected WHAT IS HEPATITIS C INFECTION anandmedicos.com
- 8. HEPATITIS C - EPIDEMIOLOGY Before 1985 1999 Illegal Drug Use Transfusion Sexual Other Unknown anandmedicos.com
- 9. HEPATITIS C INFECTION - NATURAL HISTORY Resolve 15% Stable 80% Stable 75% Mortality 25% Cirrhosis 20% Chronic infection 85% Acute infection anandmedicos.com
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- 11. WHAT HAPPENS TO PEOPLE WITH HEPATITIS C VIRUS? anandmedicos.com Infected With Hepatitis C 100 15 No Chronic Disease Chronic Disease 85 Cirrhosis 17 2 Liver Cancer
- 12. CHRONIC HEPATITIS C FACTORS PROMOTING PROGRESSION OR SEVERITY • Increased alcohol intake • Age > 40 years at time of infection • HIV co-infection ? Other • Male gender • Other co-infections (e.g., HBV) anandmedicos.com
- 13. ALCOHOL MAJOR CONTRIBUTOR FOR PROGRESS OF DISEASE Drinker Without Hepatitis C Drinker With Hepatitis C Hepatitis C Non-Drinker Chance Of Getting Cirrhosis Non-Drinker anandmedicos.com
- 14. HEPATITIS C CAN PRESENT AS ACUTE OR CHRONIC INFECTION • Hepatitis C can be either “acute” or “chronic.” Acute Hepatitis C virus infection is a short-term illness that occurs within the first 6 months after someone is exposed to the Hepatitis C virus. For most people, acute infection leads to chronic infection. Chronic Hepatitis C is a serious disease than can result in long-term health problems, or even death. anandmedicos.com
- 15. TRANSMISSION / EXPOSURE • Hepatitis C is spread when blood from a person infected with the Hepatitis C virus enters the body of someone who is not infected. Today, most people become infected with the Hepatitis C virus by sharing needles or other equipment to inject drugs. Before 1992, when widespread screening of the blood supply began in the United States, Hepatitis C was also commonly spread through blood transfusions and organ transplants. • People can become infected with the Hepatitis C virus during such activities as Sharing needles, syringes, or other equipment to inject drugs Needle stick injuries in health care settings • Being born to a mother who has Hepatitis C anandmedicos.com
- 16. LESS COMMONLY TRANSMITTED THROUGH … • Less commonly, a person can also get Hepatitis C virus infection through Sharing personal care items that may have come in contact with another person’s blood, such as razors or toothbrushes • Having sexual contact with a person infected with the Hepatitis C virus anandmedicos.com
- 17. WHO SHOULD BE TESTED FOR HEPATITIS C ? ▪ People with risk factors for hepatitis C ▪ Those who wish to be tested anandmedicos.com
- 18. • You are a current or former injection drug user, even if you injected only one time or many years ago. • You were treated for a blood clotting problem before 1987. • You received a blood transfusion or organ transplant before July 1992. • You are on long-term hemodialysis treatment. • You have abnormal liver tests or liver disease. • You work in health care or public safety and were exposed to blood through a needle stick or other sharp object injury. • You are infected with HIV. WHO SHOULD BE TESTED FOR HEPATITIS C ? anandmedicos.com
- 19. HCV TESTING ROUTINELY RECOMMENDED Based on increased risk for infection • Ever injected illegal drugs • Received clotting factors made before 1987 • Received blood/organs before July 1992 • Ever on chronic hemodialysis • Evidence of liver disease • Healthcare, emergency, public safety workers after needle stick/mucosal exposures to HCV-positive blood • Children born to HCV-positive women anandmedicos.com
- 20. ROUTINE HCV TESTING NOT RECOMMENDED (UNLESS RISK FACTOR IDENTIFIED) • Health-care, emergency medical, and public safety workers • Pregnant women • Household (non-sexual) contacts of HCV-positive persons • General population anandmedicos.com
- 21. HCV INFECTION TESTING ALGORITHM FOR DIAGNOSIS OF ASYMPTOMATIC PERSONS EIA for Anti-HCV Negative (non-reactive) STOP Positive (repeat reactive) OR RIBA for Anti-HCV RT-PCR for HCV RNA Negative STOP Additional Laboratory Evaluation (e.g. PCR, ALT) Negative PositiveIndeterminate Medical Evaluation Positive Negative PCR, Normal ALT Positive PCR, Abnormal ALT anandmedicos.com
- 22. HOW IS HEPATITIS C DIAGNOSED? • Blood testing 1. Hepatitis C antibody test 2. Hepatitis C PCR test to find virus in blood • Liver function tests anandmedicos.com
- 23. LABORATORY DIAGNOSIS • Serologic tests to detect HCV antibodies: - enzyme immunoassay (EIA). False negative in pts on HD, immunodeficiency; false positive in autoimmune disorder. - recombinant immunoblot assay (RIBA) • Target amplification technique to detect HCV RNA (molecular assay) - polymerase chain reaction (PCR). A positive test confirms HCV infection. anandmedicos.com
- 24. CURRENTLY PERFORMED TESTES FOR HEPATITIS C INFECTION • Currently, the second-generation enzyme immunoassay (EIA-2) for antibodies to HCV (anti-HCV) is the most practical screening test for HCV infection. The diagnosis of HCV infection can be supported or confirmed by the recombinant immunoblots assay (RIBA) or tests for HCV RNA. RIBA detects antibodies to individual HCV antigens and confers increased specificity compared to EIA-2. anandmedicos.com
- 25. MOLECULAR METHODS IN DIAGNOSIS OF HEPATITIS C INFECTION • Qualitative reverse transcription- polymerase chain reaction (RT-PCR) assays for HCV RNA are simpler than quantitative tests and sufficient for confirmation of the diagnosis of HCV infection. anandmedicos.com
- 26. ALANINE AMINOTRANSFERASE • Serum ALT testing is inexpensive and noninvasive. • Insensitive means of monitoring disease activity. • A single determination gives limited information, and serial measurements recommended. • Weak association between the degree of ALT elevation and severity of histopathological findings on liver biopsy. • Resolution of ALT elevation with antiviral therapy appears to indicate disease response.
- 27. Serologic Pattern of Acute HCV Infection with Recovery Symptoms +/- Time after Exposure Titer anti-HCV ALT Normal 0 1 2 3 4 5 6 1 2 3 4 YearsMonths HCV RNA anandmedicos.com
- 28. Serologic Pattern of Acute HCV Infection with Progression to Chronic Infection Symptoms +/- Time after Exposure Titer anti-HCV ALT Normal 0 1 2 3 4 5 6 1 2 3 4 YearsMonths HCV RNA anandmedicos.com
- 29. LIVER BIOPSY • Provides useful information about the degree of fibrosis in HCV infected patients. This information is important in management decisions. • Is not used for diagnosis of HCV infection. • Used for assessment of severity of inflammation, presence of fibrosis, evaluate possible concomitant disease processes, assess therapeutic intervention. anandmedicos.com
- 30. LIVER HISTOLOGY • Activity (necro-inflammation) – severity and progress. May fluctuate with disease activity or therapeutic intervention. • Fibrosis implies possible progression to cirrhosis. In mild cases, is limited to portal and periportal area. More advanced changes defined by ‘bridging fibrosis’. • Cirrhosis anandmedicos.com
- 31. DIAGNOSTIC ASSESSMENT OF INFECTED PATIENTS • In summary, the diagnostic algorithm of Hepatitis C depends on the clinical context. In asymptomatic, low-risk subjects, who are found to be anti-HCV- positive by EIA-2, the diagnosis of HCV infection needs to be confirmed, especially if the initial biochemical tests reveal normal ALT levels. anandmedicos.com
- 32. CAN WE PREVENT HEPATITIS C INFECTION • There is no vaccine for Hepatitis C. The best way to prevent Hepatitis C is by avoiding behaviors that can spread the disease, especially injection drug use. anandmedicos.com
Editor's Notes
- Many things can cause hepatitis. With hepatitis C you need to be careful not to do anything that will irritate your liver With hepatitis the liver enzymes are usually elevated and the liver can become enlarged
- Important to stress the fact that HCV does not always have symptoms. Can feel healthy for 10-20 or more years before developing symptoms. Patient can be asymptomatic but have hepatitis C. Symptoms are often very mild, but liver damage can occur without symptoms. No vaccine is available for hepatitis C, but researchers are working hard. The virus mutates quickly making it difficult to make a vaccine.
- 4 times more common than HIV Fewer people are transmitting HCV now compared to 20-30 years ago. About 30,000 more become infected each year
- Hepatitis C infection has major epidemic implications due to the natural history of the infection. Unlike Hepatitis B infections, where a small proportion of cases go on to chronic infection and thus, infectious states, the majority of Hepatitis C infections progress to chronic states. HCV viral loads do not correlate well with disease progression in the liver, however. Of those chronically infected, progression to liver disease (fibrosis) usually occurs in about 10 years, with progression to cirrhosis after about 20 years (hepatocellular carcinoma generally develops in a small percentage after about 30 years). REFERNCES Seeff LB. “Natural history of hepatitis C.” American Journal of Medicine 1999; 107(6B): 10S-15S. Tong MJ, El-Farra NS, Reikes AR, Co RL. “Clinical outcomes after transfusion-associated hepatitis C.” New England Journal of Medicine 1995; 332: 1463-1466.
- Chronic disease means that the person will carry the virus in their blood long-term. No chronic disease means that the person will not carry the virus in their blood long-term, but will still have the antibodies in their blood.
- To read the above graph in black and white: The first bullet ‘non-drinker’ corresponds to the smallest circle. As you go down the list of bullets the circles get bigger with ‘hepatitis C drinker’ being the largest circle. Alcohol is a direct poison to your liver. It prevents your body from absorbing certain vitamins that it needs to work properly. It can also make your hepatitis C medicine less effective. Alcohol damages your liver even when you are healthy. Drinking alcohol when you have hepatitis C make the damage much worse. 14. Department of Veteran Affairs, Hepatitis C Brochure Series, If You Have Hepatitis C Infection, http://www.va.gov/hepatitisC What about alcohol? How much is bad? 1-3 ounces? I’ve heard that a small amount of alcohol is good for you. At this time, we’re not sure. Is it okay to drink non-alcoholic wines? It’s not suggested. In the future when I clear the HCV can I drink alcohol? It depends on the amount of scarring in your liver. For more information refer to reference 15 at the end of the slide set