Hep B and C Screening & Management Simons Towns
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Transcript of Hep B and C Screening & Management Simons Towns
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
e p
er 1
00,0
00
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
Lisa Townshend MSN, FNP-C
Thank You!
The ANTHC Liver Disease and Hepatitis ProgramANTHC LiverConnect
www.anthc.org/chs/crs/hep