HEPATITIS B AND HEPATITIS CScreening Guidelines, Understanding Tests & Patient Management.

Brenna Simons PhD Lisa Townshend-Bulson, MSN, FNP-CAlaska Native Tribal Health ConsortiumLiver Disease and Hepatitis Program

What We Will be Discussing

Hepatitis B Virus Background & Epidemiology Screening Guidelines Understanding Tests Patient Management

Hepatitis C Virus Background & Epidemiology HIV-HCV Co-Infection Screening Guidelines Understanding Tests Patient Management

CHRONIC VIRAL INFECTIONSEXUALLY TRANSMITTED DISEASEHIGHLY INFECTIOUS VIRUSLIVER DISEASE

HEPATITIS B

Hepatitis B Virus – Background and Epidemiology

Thank Goodness for Vaccines!

Highly infectious and stable virus

Acute Hepatitis Chronic Hepatitis

Cirrhosis/fibrosis Hepatocellular

Carcinoma

Hepatitis B Virus One Nasty Virus

HBcAg

HBeAg

http://pathmicro.med.sc.edu

Hepatitis B Infection in the U.S.

http://www.cdc.gov/hepatitis/Statistics/HBV Universal

Vaccination Nationwide

Hepatitis B Infection in the U.S. by Race

020406080

100120140160180200220

Year

Rat

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er 1

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Yukon Kuskokwim Delta

Statewide

Statewide Vaccine Program Dr. Brian McMahon

State of AlaskaU.S.http://www.cdc.gov/hepatitis/Statistics/

Although Hep B Vaccine Effective there are Other Factors to Consider…

• Without intervention, up to 25% of chronically infected individuals with HBV die of complications

• 3,000-5,000 U.S.-acquired cases of chronic HBV/year since 2001

• ~53,800 new cases of chronic HBV imported to the U.S. between 2004 and 2008

• Vaccine longitudinal research ongoing• Healthcare Workers - Increased risk of

needle stick• Vaccination History sometimes difficult to

obtain

So Make Sure Your Patient is Covered !!http://www.cdc.gov/hepatitis/Statistics/ and Mitchell et. al. 2011

HBV Screening Guidelines

Antigens and Antibodies

Detection of the ‘Bug’ Virus,bacteria,parasite…

Ag+ : bug is present Ag- : too little of bug to

detect – OR- bug is not there

Patient Immune Response to the specific ‘Bug’ Antigen

Ab+ : Patient Immune Response to ‘Bug’

Ab- : No Patient Immune Response to specific ‘bug’ antigen

Antigen (Ag) Antibody (Ab)

Viral Load (DNA or RNA)

Genetic Material of ‘Bug’(detected) : bug is present(below limit of detection) : bug may be present, too low to detect(not detected): bug is not there

Testing Specificity and Sensitivity

False-Positives Limit of Detection

Specificity Sensitivity

Low(er) Limit of Detection

High(er) Limit of Detection

More Sensitive

Less Sensitive

Hepatitis B (HBV) Screening Tests

TEST WHAT IS IT?SAGHbsAgHep B Surface Ag

Anti-HbSSABHbsAbHepB Surface Ab

Hepatitis B Surface Antigen

Hepatitis B S Antibody

Anti-HBcHBc Ab, IgM/Total

Hepatitis B Core Antibody

IgMTotal (IgM + IgG)

HBcAg

HBeAg

Hepatitis B Screening Guidelines

SCREENING ALGORITHM

Hepatitis B Foundation

www.hepb.org

Indications for HepB Screening and Vaccination

•HCV-positive patients•Individuals incarcerated•Health Care Worker

Hepatitis B Foundation www.hepb.org

& recipient

Hepatitis B Patient Management

Four Main Phases of Chronic HBV Disease…. But it’s complicated

S Ag+E Ag+

S Ag+E Ag-Anti-HE+

S Ag-E Ag-

2009 Hepatology McMahon

HBV Treatment Dependent on Phase

Inactive

Active

Immune Tolerant

HBsAg Clearance Phase

• Maintain HBV Viral Load < 2,000 IU/mL• Normal ALT

• HBV Viral Load > 20,000 IU/mL• Elevated ALT

• HBV Viral Load generally undetected, but can be present and <2,000 IU/mL• HBsAg NEGATIVE• Normal ALT

• HBV Viral Load > 20,000 IU/mL• Normal ALT

Hepatitis B (HBV) Clinical Tests in Persons who are HBsAg-Positive

TEST NAME

WHAT IS IT?

Anti-HBE

HepB E AgHBeAg

Hepatitis B E-Antigen (Viral Protein)

Anti-Hepatitis B E-Antigen Antibody

ALT Alanine aminotransferaseLiver Enzyme

HBV DNA Hepatitis B Viral DNA (Viral Load)International Unit / mL (IU/mL)

HBcAg

HBeAg

The HBsAg+ Test is Positive…Now What?

Evaluating and Monitoring Chronic Hepatitis B

Hepatitis B Foundationwww.hepb.org

Chronic Viral InfectionHIV Co-InfectionInjection Drug UseCirrhosis Liver Failure

HEPATITIS C

Hepatitis C Risk FactorsHepatitis C Co-Infection with HIV

Hepatitis C Virus – Background and Epidemiology

No Vaccine for “Non-A, Non-B”

IV Drug Use (IDU), Incarceration, blood transfusion before 1992, tattoos, some sexual contact

Acute Infection Often asymptomatic

Chronic Infection Develops in 75-85% of those

infected Chronic liver disease Cirrhosis Liver Cancer

Hepatitis C Virus Distinctive Risk Factors

www.prn.org

Acute Hepatitis C in the U.S.

• Urban populations affected more prevalently

• In Alaska, our program has identified over 2,300 anti-HCV positive AN/AI, approximately equivalent to US prevalence.

• Some programs report up to 11-12% prevalence in urban communities.

http://www.cdc.gov/hepatitis/Statistics/

Prevalence of HIV-HCV Co-infection

Estimated 25% of individuals infected with HIV in the US are also infected with Hepatitis C

Approximately 80% (50-90%) of IDUs with HIV infection also have Hepatitis C

Hepatitis C infection progresses more rapidly to liver damage in HIV-infected persons

HCV infection also impacts the course and management of HIV infection

U.S. guidelines recommend that all HIV-infected persons be screened for HCV infection

http://www.cdc.gov/hepatitis/

HCV Screening Guidelines

Hepatitis C Clinical Tests

TEST WHAT IS IT?Anti-HCV Ab

HCV RNA Quant

Anti-HCV Antibody

HCV Viral Load RNA TestQUANTITATIVE

Hepatitis C Screening GuidelinesSCREENING ALGORITHM

Patient is HCV PositiveConsult with Specialist

• Screen for HIV• Collect HepA and HepB Vaccination History• Screen for HepA and B• HepC Viral Genotyping

AASLD AND CDC GUIDELINES and the ANTHC Liver Disease and Hepatitis Program

Hepatitis C Genotyping

TEST WHAT IS IT? INTERPRETATION

HCV Genotype There are 6 major genotypes of HCV. This test will give you dominant HCV genotype the patient is infected with. This will affect treatment options.

Genotype 1Genotype 2Genotype 3

Genotype-SpecificTreatment Eligibility and Options

Uncommon in the U.S. Genotype 4Genotype 5Genotype 6

Consult with Specialist

Lisa Townshend-Bulson, MSN, FNP-CAlaska Native Tribal Health Consortium

Management of HEPATITIS C

New Diagnosis of Hepatitis C

Counsel patient about new diagnosis, review risk factors to estimate length of infection

Determine hepatitis A and B status; vaccinate Begin educating patient about hepatitis C Brief lifestyle interventions: alcohol and weight

loss Consider referral for liver biopsy

Genotype 1 patients Those who may have had the disease ≥10 years

Consider hepatitis C treatment Follow patient, liver labs every 6 – 12 months

AST to Platelet Ratio Index (APRI)

Poor man’s biopsy Calculation =

Patient’s AST/ULN AST (40) Platelet counts (109/L)

Interpretation

< 0.5 rule out significant fibrosis (Metavir F0-F1)

> 1.5 rules in significant fibrosis (Metavir F2-F4)

> 2.0 probable cirrhosis (Metavir F4) Repeat yearly, track APRI trend

x 100

Loaeza-del-Castillo, A., et al., Annals of Hepatology 2008; 7(4), 350-357

Key Messages for Patient About HCV Diagnosis

HCV does not make your liver sick over night

HCV is not spread by casual contact Low rate of sexual transmission (< 5%) Low rate of vertical transmission (< 5%) Follow up labs/evaluation every 6-12

months are important to prevent complications Reiterate lifestyle intervention at each visit Continue educating patients

Helpful Patient Tips After Hepatitis C Diagnosis

Avoid alcohol Do not share needles, toothbrushes or

razors Eat a healthy diet, maintain healthy weight Stop smoking Get plenty of rest/reduce stress Take in adequate vitamin D Coffee is good Do not combine alcohol and acetaminophen Milk thistle won’t get rid of hepatitis C Stay informed

Liver Disease Progression

Inflammation Fibrosis – Scar tissue forms Cirrhosis – Scar tissue replaces

healthy tissue and blocks blood flow through the liver and decreases its function (20-30 years)

Hepatocellular Carcinoma (HCC) – Occurs in hepatitis C after development of cirrhosis (20+ years)

Liver Disease Progression

Liver Cancer

Healthy Liver

Fibrotic Liver

Cirrhotic Liver

Who Should be Screened for Hepatocellular Carcinoma (HCC) with HCV ?

Those with cirrhosis or bridging fibrosis (advanced fibrosis)

Screen with liver ultrasound every 6 months, adding alpha-fetoprotein (AFP) blood test optional, may increase effectiveness of screening

In persons in whom stage of fibrosis is unknown, AFP can be used If AFP > 8ng/ml, US should be added

every 6 monthsBruix et al. Hepatology 2010; at aasld.org/practice guidelinesBruce et al. J Viral Hepatitis 2007; 25:6958-64

Effective Treatment Regimes for HCC

Surgical resection Tumor ablation

Radiofrequency Ablation Chemoembolization

Liver Transplantation: Almost all patients get reinfected

with HCV if not treated before transplant

Conclusions

Screening for hepatitis B infection and/or vaccine status is critical for protection

Assess patients completely to determine acute & chronic infection, immunity to hepatitis B

Screening for hepatitis C is a 2-step process

HCV genotype is important to patient management

Remember to screen for HIV co-infection

Hepatitis B Hepatitis C

Both infections require life-long monitoring

Alaska Native Tribal Health Consortium

Liver Disease and Hepatitis ProgramANTHC LiverConnectwww.anthc.org/chs/crs/hep

Brenna Simons PhD

bcsimons@anthc.org

Lisa Townshend MSN, FNP-C

ltownshend@anthc.org

Thank You!

The ANTHC Liver Disease and Hepatitis ProgramANTHC LiverConnect

www.anthc.org/chs/crs/hep