1. Hepatitis C: Facts for today, Hope for tomorrow School Nurses Training Presented by: Maggie Damron,RN California HCV Task Force

2. Liver Disease 25 million Americans are or have been afflicted with hepatitis or other liver disease Over 4 million infected with hepatitis C in the USA HCV: leading cause of liver transplantation in the USA 600,000 infected with HCV in California Most people infected with the virus do not know they have it Currently over 18,000 people waiting for a liver transplant

3. Functions of the liver Digestive enzymes Metabolism Immune system >500 chemical functions Detoxifies Clotting factors Hormones Can regenerate itself!

4. This is the external surface of a normal liver. The color is brown and the surface is smooth. A normal liver is about 1200 to 1600 grams.

5. Here is another example of macronodular cirrhosis. Viral hepatitis (B or C) is the most common cause for macronodular cirrhosis. Wilson's disease and alpha-1- antitrypsin deficiency also can produce a macronodular cirrhosis.

6. What is Hepatitis C ? Natural history evolves over decades A small single stranded RNA virus Virus mutates rapidly – evades the immune system Six major genotypes Different geographic distribution of genotypes

7. Acute Hepatitis C Incubation period averages 6 – 7 weeks Only 25–30% infected manifest clinical symptoms Can be spontaneously cleared by the immune system Majority will go on to develop chronic hepatitis C Disease progresses to cirrhosis, hepatic failure and hepatocellular carcinoma

8. HEPATITIS C THE MAJOR HEALTH CONCERN

10. Risk Factors for the transmission of Hepatitis C

11. Blood transfusion before 1992 Blood products before 1987 Injecting drug use History of multiple sex partners History of hemodialysis Hepatitis C is spread through blood to blood contact !

12. Tattoo or repeated body piercing History of intranasal cocaine use Occupational eg. Needlestick injury Infants born to HCV infected mom’s Vietnam-era veterans 10% of unknown aetiology (Risk factors contd)

13. Occupational Transmission: HCV No documented transmission from mucous membrane or non-intact skin exposure Two case reports from blood splash to eye

14. Needlestick Injuries (NSI’s) Estimated 600,000 - 800,000 per year Recent studies of underreporting found rates range 20-50%

15. How is HCV not spread ?? According to the CDC, HCV is NOT spread by: Sneezing Coughing Hugging Food or water Sharing eating utensils Sharing drinking glasses Casual contact

16. Diagnosis of Hepatitis C Diagnosis can no longer be ignored Patients need to understand that HCV is a progressive disease Treatment is available Testing should be done if there are any known risk factors Testing should be done if there are possible risk factors Elevated liver enzymes should be evaluated further

17. Reasons to identify persons with HCV Infection Medical management Evaluate for chronic liver disease Treatment, if indicated Substance abuse treatment, if appropriate Immunization Counsel to prevent disease transmission Household contacts Sexual contacts Drug use contacts

18. Antibody Tests EIA – enzyme immunoassay Highly sensitive with 99% sensitivity In acute phase, may take up to 12 weeks to become positive Does not detect the presence of active infection Indicates exposure to the virus Result will be “positive” or “negative” False positive: - autoimmune hepatitis - hypergammaglobulinemia - normal liver enzymes/no risk facotrs False negative: - immunosuppressed patients - chronic dialysis patients RIBA (recombinant immunoblot assay) test Confirmatory May become obsolete with HCV RNA testing

19. Hepatitis C Virus RNA test Determines the presence of HCV virus present Helpful when antibody tests inconclusive Expensive and requires special handling Result in copies/ml or iu/ml Used to confirm active HCV infection Used to confirm medications are working once treatment has started Does not correlate with disease progression Possibly may effect transmission

20. HCV Genotype Six major genotypes Within genotypes, there are subtypes and quasispecies Valuable when making treatment decisions Genotype 1a and 1b most common in the USA Genotype 1a and 1b most difficult to treat Disease progression similar for all genotypes Determined by a blood test Genotype 2 and 3 respond well to current treatment

21. Liver Biopsy Can help determine the extent of liver damage Measures the degree of inflammation Measures the degree of fibrosis or cirrhosis Biopsy results can help guide decisions about treatment Can help gauge how well HCV treatment is working Four histological stages of liver damage Liver damage may be present even when ALT’s are normal Can be used to measure progression of the disease

22. Risk factors for Fibrosis/Cirrhosis Alcohol consumption Age at acquisition Male gender Longer duration of infection Coinfection with HBV or HIV Immunosupression Organ transplant

23. Treatment of HCV

24. Who should NOT be treated ? Clinically decompensated cirrhosis Persons with uncontrolled neuropsychiatric syndromes Active substance or alcohol abuse Autoimmune not well controlled Inability to practice birth control Anemia Pregnancy Thyroid abnormalities not controlled by therapy Deteriorated cardiac function Opthalmologic disorders esp in diabetes and hypertension

25. The goals of Treatment Primary: HCV RNA undetectable Secondary: Inhibit the progression of the disease

26. Current Therapies Available Intron A monotherapy Rebetron Combination therapy PegIntron and Rebetol (Ribavirin) Pegasys and Copegus (Ribavirin)

27. Factors predicting patient adherence to treatment Patient health beliefs Ease of access to health provider Familiarity of clinic setting Existence of social support system Perceived support from clinical staff Simplicity of medication regime

28. Potential side effects of Interferon Fatigue Flu-like symptoms Nausea, vomiting, diarrhea Skin irritation at injection site Appetite loss and taste changes Depression Insomnia Alopecia Skin sensitivity to the sun Changes in menstrual cycle Mild bone marrow suppression Low grade fever Headaches

29. Potential side effects of Ribavirin Anemia Fatigue Irritability Itching Skin rash Dry, irritating cough Nasal stuffiness, sinusitis Teratogenicity

30. Nursing Care and Considerations TLC! TLC! TLC ! … we need to reach out Educate… how the disease is and is not spread pregnancy and contraception guidelines the need to avoid alcohol skin sensitivity to the sun diet water consumption during treatment Side effect management

31. Lab monitoring Immunization against HAV and HBV Encourage healthy lifestyle TLC! TLC! TLC! to family and significant others supporting patient through treatment Most difficult task: keeping messages given to patient factually correct! (Nursing considerations continued)

32. Issues to consider regarding HCV infection and children Psychosocial impact on child if parent is the one infected Impact on child while parent is going through treatment Disclosure to school if child is infected Fear attached to the disease, treatment and possible discrimination - confidentiality Impact on school attendance if on treatment Medication use during school hours

33. Communication In the schools! Pass along facts about HCV - teachers - parents - children Teach about risk factors Teach prevention strategies Be a caring adult – you may be the only person a child feels he/she can safely talk to

34. For more information on current blood borne pathogen research, visit the CDC’s web site at or consult the latest version of OSHA’s blood borne pathogen standard. For more information on current blood borne pathogen research, visit the CDC’s web site at www.cdc.gov/ or consult the latest version of OSHA’s blood borne pathogen standard.www.cdc.gov/

35. www.californiahcvtaskforce.org THE CALIFORNIA HEPATITIS C TASK FORCE