1	"Ass" Ass Booty Cooker The ABCs of Viral Hepatitis Heather Lusk 2^nd National Conference on Methamphetamine, HIV and Hepatitis February 2, 2007
2	Hepatitis A Virus (HAV) Overview In 2005, ~42,000 people infected in the US 31.3% of U.S. population have been infected Acute disease -- no chronic infection Symptoms common in adults Once resolved, protective antibodies develop and give lifelong immunity
3	HAV Transmission Primarily transmitted via fecal-oral route and rarely through blood exposure Highly infectious and stable in environment for months Most common transmission through close personal contact with an infected person Vaccine is available to prevent infection
4	Hepatitis B Virus (HBV) Overview In 2005 ~51,000 new infections in US ~1.25 million in US living with chronic HBV 4.9% of U.S. population have been infected 6% of infected adults develop chronic HBV 90% of infants develop chronic HBV Often no symptoms in acute stage If resolved, protective antibodies develop and give lifelong immunity
5	HBV Transmission Transmitted by blood, semen, vaginal fluids Highly infectious, stable in environment for at least 7 days Most common transmission through: Þ perinatal (mom to baby) Þ unprotected sex Þ percutaneous (through opening in skin) Vaccine is available to prevent infection
6	Hepatitis C Virus (HCV) Overview In 2005, ~20,000 new infections in US ~4 million* in US have been infected 1.6% of U.S. population have been infected 55%-85% of adults have chronic infection Often no symptoms in acute stage If resolved, no protective antibodies *Recent analysis indicates closer to 5 million since NHANES didn’t include homeless, incarcerated etc.
7	HCV Transmission Transmitted by direct blood-to-blood contact Highly infectious, stable in environment for at least 16 hours but not longer than 4 days Most common transmission through sharing of injection drug use paraphernalia Also blood transfusions & products before 1992 Perinatal transmission (4% chance, 19% HIV/HCV+) Needle stick/healthcare exposure (1.8%) Sexual transmission Other blood risks low/unknown risk: tattooing/piercing intranasal cocaine use, shared personal items
8	HCV Transmission Sharing Injection Equipment Studies have found high rates of HCV in IDUs who didn’t share syringe, but shared cooker, cotton, water or other paraphernalia People who inject other things (steroids, vitamins, silicone and hormones) may also be at risk IDUs should use new, sterile equipment every time (clean hands, injection site and surface too) It is unknown if bleach kills HCV
9	HCV Transmission Sexual Transmission Seven US studies of long-term discordant partners found 1.5 - 3% seroprevalence of HCV Other studies of MSM, sex workers, and those with history of STD found prevalence of 4-6% Risk may be increased when trauma is present Other factors related with sexual transmission include # of partners, the presence of other STDs, and use of condoms
10	HCV Transmission Low/Unknown Risks Non-professional tattooing (prisons tattoos etc): some studies find higher rates of HCV in persons with tattoos Intranasal cocaine/meth use: Some studies have found link to HCV transmission by blood getting into nasal membrane from shared snorting items Crack use: at least one study (Schaefer) found higher rate of HCV in non-injecting crack users who indicated cracked, bleeding or burned lips Personal items with blood on them: anything that cuts/breaks the skin or membrane (razor, clippers)
11	Sources of Infection for Persons with Hepatitis C
12
13	Hepatitis D and Hepatitis E HDV: Coined “Delta Hepatitis” Rarely seen in the United States Found only in persons infected with HBV and has similar routes of transmission as HBV Prevention is vaccination for HBV
14	Meth and Viral Hepatitis Little research on meth/viral hepatitis. PubMed search: HIV/meth = 213 abstracts and HCV/meth = 26 abstracts Documented outbreaks of HAV and HBV in meth users Hepatitis A - feces can be on pipes etc. Hepatitis B - transmitted like HIV so similar links Hepatitis C - IDU but what about bloodier sex? Blood into open wounds (incl. Nose/mouth)? Scheinmann, R. et al., Non-injection drug use and Hepatitis C Virus: A systematic review, Drug and Alcohol Dependence (2006)
15	Prevention of Viral Hepatitis Vaccinate against hepatitis A and hepatitis B If no access to vaccine: Wash hands! Prevent fecal matter from entering mouth Use barriers for oral/anal sex Clean sex toys between use Prevent blood, semen and vaginal fluids from entering body Avoid blood exposure: New syringe, cooker, cotton etc. every time for injection Use universal precautions Don’t share personal items that may contain blood (toothbrush/razor) Hydration and lubricants Cover open cuts/wounds Ensure instruments used for tattoos, piercing, acupuncture are new or sterilized
16	Hepatitis A and Hepatitis B Vaccines Hepatitis A vaccine began usage in 1995 Two dose series at 0 and 6-18 months Hepatitis B vaccine began usage in 1982 Usually three dose series at 0, 1 and 6 months No severe adverse reactions. Most common side effects include site of injection soreness, headache, malaise Combination vaccine available called TWINRIX
17	Recommendations for Hepatitis A Vaccine Injection and non-injection drug users Men who have sex with men (MSM) Travelers to HAV endemic countries Persons with chronic liver disease Persons with clotting-factor disorders Children living in communities with historically increased rates of hepatitis A Household and sex contacts of HAV+ persons (People living with HIV – not a formal rec. but should be!)
18	Recommendations for Hepatitis B Vaccine Men who have sex with men Persons with more than one sex partner in a six month period Persons diagnosed recently with an STD Sex contacts of infected persons Injection drug users Household contacts of chronically infected persons Infants born to infected mothers Infants/children of immigrants from areas with high HBV rates Health care and public safety workers Hemodialysis patients Developmentally disabled in long-term care settings People living with HIV
19	New Hepatitis B Immunization Recommendations “A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the U.S.” MMWR Dec. 8, 2006. Vol. 55 No. RR-16 Venue-based immunizations: all persons should be vaccinated in STD/HIV sites, drug treatment programs, correctional settings and clinics that see large amounts of IDU or MSM Recommends all unvaccinated adults at-risk should be vaccinated All adults who ask for vaccine should be immunized without having to self-disclose risk
20	Viral Hepatitis Testing
21	HCV Testing Recommendations from CDC Test routinely based on risk for infection: Ever injected drugs (even once) Transfusions/organ transplants before 1992 Selected medical conditions (chronic hemodialysis, elevated liver enzymes) Received clotting factors before 1987 Test routinely based on a recognized exposure: Healthcare or public safety workers after exposure to HCV-positive blood Children born to HCV-positive women
22	HCV Testing Recommendations from CDC Routine testing of uncertain need: Recipients of transplanted tissue History of tattooing or body piercing History of multiple sex partners or STDs Long-term steady sex partners of HCV-positive persons Users of intranasal cocaine or other non-injection drugs Routine testing is not recommended: Health care and public safety workers Pregnant women Household contacts of HCV-positive persons General population
23	Chronic Hepatitis B and C Top causes of liver cancer and liver transplant Symptoms include fatigue,depression,loss of appetite, nausea/indigestion,muscle/joint pain,mood swings, abdominal pain, fever, vomiting,jaundice,cognitive dysfunction,fluid retention,lack of concentration Slowly progresses over decades (sometimes slow, fast, or little progression) often leading to liver damage Monitoring important: liver, imaging, diagnostic tests Drug-based and complimentary therapies available for both hepatitis B and hepatitis C
24	Chronic Hepatitis C Factors promoting HCV progression: alcohol intake age >40 at time of infection HIV or HBV co-infection male gender Vaccinate for HAV/HBV when appropriate Not everyone needs drug-based therapies Liver and self-care essential Emotional support, empowerment and education
25	Drug-based Therapies for HCV Medications to treat HCV: Interferon (injected 3x week): an immune booster Pegylated Interferon (injected 1x week): interferon w/ protein Ribavirin (pill several times a day): an antiviral Standard of care is combination therapy for 24-48 weeks, depending on genotype (type 1=48 weeks) Effectiveness varies from about 40-80% (type 1 is hard to treat and ~40% of type 1 has sustained response) Treatment can have many side effects like fatigue, depression, aches, hair loss and nausea Treatment is expensive ($25,000 + a year) Many drug users are denied access despite federal guidance otherwise
26	HIV and Hepatitis C Liver disease is #1 cause of death and hospitalizations in people living with HIV Up to 1/3 of those living with HIV also have HCV (1/10 of those with HCV have HIV) HIV infection may promote HCV disease progression (and sometimes vice versa) Anti-HIV medications may cause hepatitis – especially in those with viral hepatitis HCV treatment in HIV+ becoming more effective HIV may impact HCV transmission (sex/perinatal)
27	Integrate Viral Hepatitis! If We Don’t, Who Will? Researchers: test for hepatitis B and C, ask about knowledge of serostatus, add hepatitis risks to surveys etc. Front line staff: comprehensive disease model approach based on identified risks Programs: include hepatitis questions on intake forms, risk assessments, case management forms, client surveys etc. Advocates: CDC DVH budget less than 20 million - we need a funded national response!
28	Do You Know Your Hepatitis C Coordinator? Most states and several major cities (NYC, Chicago, Philly, D.C.) have CDC-funded Hepatitis C Coordinators While HCV Coords may or may not have $$, they can provide data, presentations, brochures and other resources and want to collaborate with you! http://www.cdc.gov/ncidod/diseases/hepatitis/resource/coordinators.htm National Alliance of State and Territorial AIDS Directors (NASTAD) viral hepatitis working group, advocacy etc. www.nastad.org
29	Viral Hepatitis Resources Guidelines: NIH Consensus Statement on Hepatitis C, AASLD treatment guidelines, EASL and VA HIV/HCV treatment guidelines Strategic Plans: National Viral Hepatitis Roundtable “A Call to Action: Eliminating Viral Hepatitis” (many states also have plans) Websites: www.hcvadvocate.org, www.natap.org, www.hivandhepatitis.com, www.hepcnetwork.org, www.hepcproject.org
30	ABCs of Viral Hepatitis
31	Recommendations for Viral Hepatitis Testing and Vaccinations People who have injected drugs and other substances (hormones, steroids, vitamins): Test for hepatitis C Get vaccinated against hepatitis A and B People who use non-injection drugs: Get vaccinated against hepatitis A Maybe test for hepatitis C (depends on blood risk – with meth for example) Men who have sex with Men: Get vaccinated against hepatitis A and B People living with HIV: Get vaccinated against hepatitis A and B Test for hepatitis C People with multiple sex partners or recent STD: Get vaccinated against hepatitis B People born in countries in Asia, Africa or the Pacific: Get tested for hepatitis B Transgenders: Get vaccinated against hepatitis A and B Test for hepatitis C if injected hormones
32	"Mahalo!" Mahalo! For more information, contact Heather Lusk at heather.lusk@doh.hawaii.gov