Hep b and c powerpoint final
- 1. Hepatitis B and C A tale of two viruses Andrew Catanzaro, MD Unity Health Care, Inc Infectious Diseases
- 2. Objectives Understand screening and confirmation Indications for vaccination Awareness of the prognosis of chronic hepatitis Awareness of the therapy
- 3. Case 1: CE 36 Year old female, sexually active. Heavy use of crack cocaine, involved in an abusive relationship with the father of her 2 children Pmed Hx: s/p medical abortion May 2008 July 2008: fever, myalgia, extreme fatigue, anorexia. Mid-July 2008: presents with above symptoms plus jaundice. No n/v/diarrhea.
- 4. Case 1: CE Exam Jaundice, ill appearing Mild hepatic tenderness, hepatomegaly, no splenomegaly Labwork: AST 1,958 ALT 2,560, Bili 10.1 Hep A Ab IgM negative Hep C Ab negative Hep B profile Hep B Surface Ab (-) Hep B Surface Ag (+) Hep B core IgM (+) Hepatitis B e Ag (+) Hepatitis B viral load 1,400 copies/ml
- 5. Clinical Questions What is her diagnosis What is her risk for Chronic infection Cirrhosis Hepatocellular carcinoma What is important to tell her about Sexual partners Household contacts Future pregnancies
- 6. Hepatitis B and C: common features Acute Infection Chronic Infection Fibrosis Cirrhosis (compensated/decompensated) Death from End Stage Liver Disease (portal hypertension, varices, bleeding, hepatic failure) Hepatocellular Carcinoma
- 8. Hepatitis C: The rising wave
- 10. Risk Factors for Primary Hepatocellular Carcinoma
- 11. Hepatitis B and C Clinical Course: Springfield Mixing bowl vs I-95 Hepatitis B: Non-linear Springfield, VA Hepatitis C: Linear I-95 Chronic Infection Fibrosis Cirrhosis Hepatocellular Carcinoma Chronic Infection Fibrosis Cirrhosis Hepatocellular Carcinoma
- 12. Hepatitis B Virus Surface Antigen (HBS Ag) Core Antigen (HBc) Surface Ab (HBsAb) Core Ab (HbsAb) IgM Recent IgG Past
- 13. Hepatitis B Testing (see handout)
- 14. Hepatitis B Epidemiology 1.25 million US Cases 3,000 US deaths per year High risk groups Immigrants: SE Asia, China, Korea, India, Africa and Micronesia Men who have Sex with Men Drug use: Injection, inhalation Healthcare workers
- 15. Hepatitis B: Clinical Course Resolution of infection: 85% Time frame: 6 months Resolution = development of antibody to surface antigens Hepatitis B surface Antibody >0.99 Prognosis for cure No risk of cirrhosis, cancer or transmission to others ? risk of reactivation if treated with chemotherapy, transplantation
- 16. Case 1: Acute Hepatitis B Labwork: AST 1,958 ALT 2,560, Bili 10.1 Hep B profile Hep B Surface Ab (-) <= not resolved Hep B Surface Ag (+) <= infected Hep B core IgM positive <= Acute infection Hepatitis B e antigen positive <= highly infectious Hepatitis B viral load 1,400 copies/ml Plan: Supportive care, no alcohol, minimize acetaminophen, follow labs monthly x 6 months await clinical resolution
- 17. Hepatitis B clinical questions What is her diagnosis? Acute Hepatitis B What is her risk for chronic infection 15% Cirrhosis 0% if resolved hepatocellular cancer 0% if resolved What is important to tell her about her current and future sexual contacts? Condoms – 10% risk of transmission per sexual contact Household contacts? vaccinate Future pregnancies? Avoid pregnancy until 6 months
- 18. Hepatitis B: Chronic Infection Case 45 year old Vietnamese Woman In US for 20 years 16 Year old daughter Shopkeeper in Mount Pleasant Married, monogamous relationship Drink no alcohol, no h/o drug abuse, no tattoos No family history of liver cancer Tested 15 years ago and told she had “a little” Hepatitis B
- 19. Hepatitis B: Chronic Infection Hep B Surface Ab (-) Hep B Surface Ag (+) Hep B e Ag (-) Hep B DNA viral load 20,000 copies/ml CMP: AST normal, ALT normal, Albumin normal, PT/PTT normal
- 20. Hepatitis B: Chronic What is her diagnosis? What is her risk for cirrhosis? hepatocellular cancer? What is important to tell her about Her sexual contacts? Household contacts? Future pregnancies? Treatment options? Outlook on treatment Chronic Hepatitis B
- 21. Chronic Hepatitis B Greater than 6 months of Hepatitis B infection Hep B Viral Load Determines risk for cirrhosis Determines risk for Hepatocellular carcinoma High viral load indication for therapy Viral load suppression is the goal of therapy
- 22. Chronic Hepatitis B: Viral load predicts cirrhosis risk Baseline HBV DNA Level, copies/mL >1 Million 100000-999999 10000-99999 300-9999 <300 Viral Load 20,000 7%-10% risk of cirrhosis at 5 years
- 23. Chronic Hepatitis B: Carcinoma without cirrhosis Hepatocellular Carcinoma Cirrhosis 30-50% Liver cancer Without cirrhosis
- 24. Hepatitis B: Viral load predicts carcinoma risk 14 12 10 8 6 4 2 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Year of Follow-up Cumulative Incidence of HCC, % Chen CJ et al. JAMA 2006;295(1):65-73. Viral Load 20,000 5% risk of carcinoma at 10 years Baseline HBV DNA Level, copies/mL >1 Million 100000-999999 10000-99999 300-9999 <300
- 25. Hepatitis B: Screening for Hepatocellular Carcinoma Risk factors Family history of HCC Male Age >40 Hep B e Ag (+) Hepatitis B viral load* Viral load >100,000 10% at 10 years Viral load <20,000 1% at 10 years Viral load <1,000 <1% at 10 years Note: antivirals lower HCC risk *Summarized from JAMA: Chen CJ Vol. 295 No. 1, January 4, 2006
- 26. Approved Oral Antivirals for Hepatitis B Highly potent, resistance uncommon Entecavir Tenofovir Potent, less resistance Adefovir Less potent, resistance common Telbivudine Lamivudine Interferon-alpha, potent, no resistance Curative in 25% Medicaid covered, Alliance/Health Right non-formulary
- 27. Chronic Hepatitis B What is her diagnosis?Chronic Hepatitis B What is her risk for Cirrhosis: 7-10% at 5 years Hepatocellular Carcinoma: 5% at 10 years What do you tell her about sexual contacts and household contacts? Treatment options? Prognosis on Therapy No cure Reduced risk of cirrhosis and carcinoma
- 28. Hepatitis B Vaccination All infants, catch up for adolescents Adults Same day test and vaccinate: MSM, homeless Screening for infection Foreign born (esp Asian, African, Latin American) Day care workers, Pregnancy: 1 st and 3 rd trimester Vaccine 0, 30, 180 days 70% effective after first dose Off schedule: revaccinate, test HBS Ab in 30 days
- 29. Hepatitis C
- 30. Hepatitis C Infection Natalie Cole Greg Altman Ken Watabe Evel Kneivel Gene Weingarten Pamela Anderson Naomi Judd
- 31. Hepatitis C: Mr. J 55 year old African American Male Former IV drug user in the 1970's No diabetes, hypertension Smoker Drinks daily: 2-4 cans of beer per day Labs AST 256 ALT 141 Platelet count 70,000 Albumin, PT/PTT normal HCV Ab positive, HCV VL 668,000 HCV genotype 1A AFP 7.1 (normal)
- 32. Hepatitis C: Clinical Questions What is his diagnosis? What is his prognosis? How can you evaluate his liver disease? Is there treatment/cure? How should he modify his habits? What should you do before referral to ID?
- 33. Hepatitis C: Route of infection
- 34. Hepatitis C: Disease Progression Liver Cancer Cirrhosis (Stage 4) Normal (Stage 0) Fibrosis (Stage 1) Fibrosis (Stage 2) Fibrosis (Stage 3)
- 35. Hepatitis C: Risk of Cirrhosis
- 36. Hepatitis C: Risk of Carcinoma Carincoma patients have cirrhosis first After cirrhosis: 1% annual risk each year
- 37. Hepatitis C Treatment Peginterferon combined with Ribavirin Weekly injections BID Ribavirin (weight adjusted) Duration of therapy HIV positive or Genotype 1: 48 weeks Genotype 2,3: 24 weeks
- 38. HCV Treatment Response: Interferon weekly and Ribavirin twice daily
- 39. Hepatitis C: Sustained Response Rates 48 weeks 24 weeks
- 40. Hepatitis C: Non-viral Treatment effects AST/ALT normalization Improvement in fibrosis scores Reduction in liver related death Reduction in Hepatocellular carcinoma death Compensated cirrhotics: lower response, but improved fibrosis scores
- 41. Hepatitis C: Clinical Questions for Mr. J What is his diagnosis? Cirrhosis What is his prognosis? HCC 1%/year, decompensation, varices How can you evaluate his liver disease? Liver biopsy Is there treatment/cure? PegIFN - gently How should he modify his habits? Stop drinking What should you do before referral to ID? Consider U/S of liver Age appropriate preventive health AST 256 ALT 141 Platelet count 70,000 Albumin, PT/PTT normal HCV Ab positive, HCV VL 668,000 HCV genotype 1A AFP 7.1 (normal)
- 42. HCV Protease Inhibitors: Trials done by 2014
- 43. Hepatitis: Needle exposure Hepatitis B Transmission 30% Baseline test for Hep B S Ab Consider Immunoglobulin Hepatitis C Transmission 3% Consider HCV Viral load at 2-4 weeks
- 44. Hepatitis: Pregnancy Hepatitis B Screen via Hep B Ag Transmission: 95% C-Section not indicated Immunoglobulin at delivery, vaccinate newborn Breastfeeding not contraindicated if infant vaccinated Hepatitis C Screening not routine Transmission: 0-8% C-Section not indicated Consider HCV VL for infant Breastfeeding not contraindicated
- 45. Hepatitis: Sexual Transmission Hepatitis B Transmission 30% Vaccinate sexual partners Hepatitis C Transmission Low Condoms effective Monagamous: test and consider no condoms
- 46. Hepatitis: Testing patients Hepatitis B Screening: Hep Bs Ag Confirmation: Hep Bs Ag Monitor Sn/LFTs abnl Staging: Hep B Viral load, e Antigen Liver biopsy – rarely useful Cancer screening: >45, alcohol, Fam Hx, Hepatitis C Screening: HCV Ab Confirmation: HCV VL Monitor for sn cirrhosis Staging: Liver biopsy Cancer screening: >55, alcohol, cirrhosis
- 47. Hepatitis B: Advice to patients Avoid sharing razors, tooth brushes, clippers Proper use and disposal of needles Sexual transmission: low, but does occur Follow up liver function tests, HCV viral load every 6 months Avoid heavy alcohol consumption Resources: ORGANIZATION TO ACHIEVE SOLUTIONS IN SUBSTANCE-ABUSE http://www.oasiscliniconline.org/