Working TogetherAgainst HCV

HepCBC March 31, 2007

Natalie Rock RN, BSN

Hepatology Nurse

Clinic Director LAIR Centre

www.laircentre.com

THE LIVER

• The Largest Organ

• Weighs 1200-1500 grams

• Metabolically the most active organ

THE LIVER

• Sheltered by Ribs in RUQ

• Two Major Lobes

• Has a Double Blood Supply• portal vein• hepatic artery

FUNCTIONS OF THE LIVER

• Manufacture

• Filtration

• Metabolism

• Excretion

• Regulation

• Secretion

carbohydrates

proteins/fat

clotting factors

cholesterol/bile

bacteria

drugs/toxins/hormones

WHAT IS HEPATITIS ?

• HEPAR = LIVER

• ITIS = INFLAMMATION

• HEPATITIS = INFLAMMATION OF THE LIVER

WHAT ARE SOME CAUSES OF HEPATITIS?

• Alcohol

• Drugs

• Toxins

• Metabolic Diseases

• Autoimmune Diseases

• Fatty Liver Disease

WHAT ARE SOME CAUSES OF HEPATITIS?

• Viruses• A

• B

• C

• D

• E

• G

• GB

• TT

Signs and Symptoms

• Jaundice-yellow skin and eyes

• dark urine• pale or bloody stools• abdominal swelling• prolonged itching of

skin• chronic fatigue

• Nausea or loss of appetite

• vomiting of blood• severe, prolonged

abdominal pain • bruising, inability to

heal minor cuts and injuries

TRANSMISSION OF HEPATITIS

RareModerateRareOccupational

RareModerateRareHousehold

UncommonCommonNoMother – Child

UncommonYesNoSexual

RareYesNoBlood – Oral

NoNoYesFecal – Oral

RareNoNoBlood Products

YesYesPossiblyBlood to Blood

HEP CHEP BHEP AMODE

                                                                                   

        

Family: Flaviviridae

Enveloped, +ve strand RNA virus

50 nm particles contain:

E1 and E2 proteins on surface

C protein inside

Hepatitis C Virus (HCV)

HCV Genome

HCV in Canada vs BC

• ~ 60,000 (1.5%) British Columbians

• May 2005, 55,000 identified as anti-HCV reactive

~ 25% clear infection, therefore about 41,000 people are chronic

~ 20,000 undiagnosed, projecting 3,000 newly identified cases in 2005

Hepatitis C Rates by Year, 1995-2004

0.0

50.0

100.0

150.0

200.0

250.0Rate per 100,000 population

Note: Canadian rates are based on reporting provinces and territories only

BC Hepatitis C Reports 4650 6140 7720 6266 5011 4396 4379 4536 3617 3074

BC Hepatitis C Rate 123.1 158.5 195.5 157.3 124.9 108.8 107.4 110.2 87.2 73.5

Canadian Hepatitis C Rate 64.4 53.5 60.7 67.8 62.0 58.0 54.3 50.9 43.3 41.3

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

PHIS Reported HCV Rates - BC 1995 to 2004

0

50

100

150

200

250

300

350

Acute_F 0 0 0 0 6 13 11 10 7 4 3 1 1 0 0 0

Acute_M 1 0 0 0 2 13 18 14 13 8 5 3 1 1 1 0

Probable chronic-F 47 2 1 4 22 61 97 125 146 152 106 57 39 33 35 25

Probable chronic-M 62 2 2 4 13 67 155 223 282 324 270 151 77 53 46 43

<1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 >70

Rate of anti-HCV reactivity/100,000 BC residents/yearby age and gender including acute HCV infections

BCCDC 1992 – 2002, n = 45,661 (2,168 acute)

45,661

alcoholobesity

HIVolder age

males

poorlytoleratedsupport

hard toidentify

IDU!

Alter 99, Jaeckel 01, Freeman 01, Hofer 03

HCVinfections

~ 25%symptomatic

75%

Chronic

25 %

Clear

Do nothing15% to 25%

cirrhosis, ESLD, HCC, transplant

early treatment feasible

pegylated INF/Rib cure 50% to 60%

decades

Prevent infections? Prevent complications?

DIAGNOSIS OF CHRONIC HEPATITIS C

1. Anti-HCVELISA, RIBA

3 To 6 Months Delay

2. PCR: (HCV RNA)Measures Presence of the Virus

Qualitative

Quantitative

DIAGNOSIS OF CHRONIC HEPATITIS C

3. Liver EnzymesAST, ALT

Levels Fluctuate

Elevated 1.5 times Normal

Over 3 Months

4. GenotypeMapping of the Virus

Type Determines Length of Treatment

Acute HCV Infection Progressing to Chronic Infection

Symptoms +/-

Time after Exposure

Tit

reanti-HCV

ALT

Normal

0 1 2 3 4 5 6 1 2 3 4YearsMonths

HCV RNA

Progression to Chronic Hepatitis

• Disease activity varies• Progression rate varies

– Older persons progress more quickly– Route of infection may affect progression– Males progress more rapidly– Alcohol enhances progression– Jaundice at acute attack progresses more

rapidly

Chronic Hepatitis C Progression

• Time to Chronic Hepatitis: 10 years

• Time to Cirrhosis: 18 - 20 years

• Time to Liver Cell Cancer: 28 years

EXPOSURE 1-3 WKS 7 WKS 3 MO 6 MO 10 YRS 20 YRS 30 YRS

HCV-RNA ALT ANTI-HCV CHRONIC OVERT CIRRHOSIS LIVER DETECTED ELEVATED INFECTION HEPATITIS CANCER

Chronic Hepatitis C

• Cirrhosis: 25%

•End stage liver disease: 5%

–Liver cell cancer: 5%

»Transplant: 3%

Pathology of Hepatitis

Liver Biopsy:

GRADE

Inflammation

STAGE

Fibrosis

Cirrhosis

NORMAL LIVER LOBULE

BRIDGING FIBROSIS

CIRRHOSIS

TREATMENT

• PEGYLATED INTERFERON– natural human protein– produced in response

to viruses– inhibits viruses– increases production of

antibodies– stimulates immune

system

• RIBAVIRIN– oral antiviral

– potentiates the effects of interferon

LENGTH OF TREATMENT• Dependent on Genotype and Response

– Genotype 1,4,5,6 – Treatment is up to 1 year – Cure rate approximately 50%

– Genotype 2 – Treatment is 6 months– Cure rate approximately 88%

– Genotype 3– Treatment is 6 months– Cure rate approximately 65%

Possibly longer

Possibly shorter

Possibly longer

GOALS OF TREATMENT

• Normal AST and ALT

• HCV RNA by PCR Negative

• Liver Biopsy Inactive/Improvement

• Quality of Life, Stopping Complications

TREATMENT

• Pharmacare• Fair Pharmacare

• Extended Health

• Peg-Care and PegAssist

Cost of Treatment $1,800/ month!

SIDE EFFECTS

SIDE EFFECTS

• Flu-Like Symptoms– Fever – Chills – Muscle Aches– Fatigue

SIDE EFFECTS

• Weight Loss• nausea, abnormal taste in mouth

• loss of appetite

• Skin Changes• dry, itchy, rash, psoriasis

• Hair Loss• comes back!

• Decreased Libido• comes back!

SIDE EFFECTS

• Anemia (decrease in hemoglobin)• shortness of breath

• cough

• Neutropenia (decrease in white blood cells)• risk of infection

• fever

• Thrombocytopenia (decrease in platelets)• possible risk of bruising

• possible risk of bleeding

SIDE EFFECTS

• Exacerbation/Precipitation of:• Autoimmune Diseases

» diabetes

» arthritis

» thyroid

• Mood Alterations» anxiety

» irritability

» depression

Prevention

• Get Vaccinated for Hepatitis A and B

• Abstain from Alcohol

• Smoking (??)

• Nutrition

• Exercise

• Do not share personal care items

FUTURE THERAPIES

• Interferon Variants

• Vaccines

• Antisense Oligonucleotides

• Proteases

• Helicases

• Polymerase Inhibitors

• Traditional Chinese Medicine

BC Hepatitis Strategy

• The goal is to

– Support

– Counsel

– Educate

– Assist

• Directed to:

– Patient

– Caregiver

– General public

InformationManagement

Integrated Hepatitis Program

Care Surveillance &

Management Prevention

Education & Research &

Support Evaluation

Significance of the Infection

• Impacts on individual, families and society– Physical– Social-Emotional– FinancialThese impacts may be associated with the disease

itself, the reactions of and implication for others, and the effects and costs of treatment.

Physical

• Liver disease can affect every aspect of an individual’s physical well-being, including the ability to eat and maintain adequate nutrition, obtain comfort and rest, have intact skin, work, and carry out activities of daily living and may be unable to care for their families or continue in their jobs.

Social Emotional

• A diagnosis of a chronic illness has a tremendous emotional impact.

– reactions that commonly follow a diagnosis:

• denial, fear, anger, guilt, grief, depression, and a sense of hopelessness

Social Emotional

• The uncertainty of living with a disease whose course and effects differ for each person

• concern over the health and safety of family members

• uncertainty and fear related to treatments and the risks associated with a possible liver transplant

• side effects of treatment

Social Emotional

• Fear of isolation and social exclusion if relatives, friends, and people at work find out about the diagnosis

• misinformation from physicians, nurses, and other care providers

• family members may be affected in ways similar to the person receiving the diagnosis; they may also experience distress arising from the revelation that a loved one may have contracted HCV by engaging in risky behavior (unprotected sex, intravenous drug use, etc.)

Societal

• Potential costs in terms of morbidity, quality of life, mortality

• the direct economic costs associated with Liver Disease for individuals, families and communities

• the burden on the medical and social care systems--est. 4,000 new cases identified annually of (HCV)

• lives lost prematurely

Financial

• The financial impact on the individual and family can be devastating. The individual may be unable to work consistently. The treatments may be expensive, ranging in the thousands of dollars. Pharmacare will cover some of the costs of for those who meet criteria.

Factors that interfere or assist with prevention

• Attitudes

• knowledge and skills

• social context of health and illness (ie poverty, education and social support)

• resources and tools (how and where to access clean equipment)

Attitudes

• Attitudes--your own and those of others--can interfere with education, making wise choices, and applying knowledge and skills.

• Attitudes arise from the ideas, beliefs, and values you hold.

Web Sites

• Canadian Liver Foundation: www.liver.ca

• Health Canada: www.sc-hc.gc.ca

• Hepatitis C Society of Canada: http://web-idirect,com/~hepc

• HepCBC: www.hepcbc.ca

• Hepatitis Foundation International: www.hepfi.org

• The Canadian Medical Association: www.cma.ca

• Hepatitis Information Network: www.hepnet.com