Hep b and c powerpoint final

Hepatitis B Hepatitis C

Hepatitis B and CA tale of two viruses

Andrew Catanzaro, MDUnity Health Care, Inc

Infectious Diseases


Objectives

Understand screening and confirmation Indications for vaccination Awareness of the prognosis of chronic hepatitis Awareness of the therapy


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.


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


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


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


Hepatitis Epidemiology

Chronic Infection Deaths Annual Acute Infection1,000

10,000

100,000

1,000,000

10,000,000

1250000

3000

78000

3,200,000

9,000

24,000

Hepatitis BHepatitis C


Hepatitis C: The rising wave


Liver Transplantation


Risk Factors for PrimaryHepatocellular Carcinoma

Other3%

Hepatitis C43%

Alcohol31%

Hepatitis B15%

Tobbacco8%


Hepatitis B and C Clinical Course: Springfield Mixing bowl vs I-95

Hepatitis B: Non-linearSpringfield, VA

Hepatitis C: LinearI-95

Chronic Infection

Fibrosis

Cirrhosis

Hepatocellular CarcinomaChronic Infection

Fibrosis

Cirrhosis

Hepatocellular Carcinoma


Hepatitis B Virus

Surface Antigen (HBS Ag)

Core Antigen (HBc)

Surface Ab (HBsAb) Core Ab (HbsAb)

IgM RecentIgG Past


Hepatitis B Testing (see handout)

Result Interpretation ActionHepatitis B S Ab (+)Hepatitis B S Ag (-)

Immune None

Hepatitis B S Ab (-)Hepatitis B S Ag (-)

Unprotected Need Vaccination

Hepatitis B S Ab (-)Hepatitis B S Ag (+)

Hepatitis B infected Check Hep B DNAMonitor x 6 months to establishresolution (85%)

Hepatitis B S Ab (-)Hepatitis B S Ag (-)Hepatitis B c Ab (+)

1. Remotely infected 2. Recently infected3. False positive

Vaccinate x 1 and check in a monthNote: Hep B DNA or Hep Bc IgMif suspicious of recent infection


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


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


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


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


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


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


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

Hepatitis B: Chronic

Chronic Hepatitis B


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


Chronic Hepatitis B: Viral load predicts cirrhosis risk

Cirrhosis Risk by HBV DNA levels

0%

10%

20%

0 1 2 3 4 5 6 7 8 9 10

Year of Follow-up

Cu

mu

lati

ve

In

cid

en

ce

of

Liv

er

Cir

rho

sis

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


Chronic Hepatitis B: Carcinoma without cirrhosis

Hepatocellular

Carcinoma

Cirrhosis

30-50% Liver cancer Without cirrhosis


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

Cu

mu

lati

ve I

nci

de

nce

of

HC

C,

%

Baseline HBV DNA Level, copies/mL

>1 Million

100000-999999

10000-99999

300-9999

<300

Chen CJ et al. JAMA 2006;295(1):65-73.

Viral Load 20,000 5% risk of carcinoma

at 10 years


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 CJVol. 295 No. 1, January 4, 2006


Approved Oral Antivirals for Hepatitis B

Highly potent, resistance uncommonEntecavirTenofovir

Potent, less resistanceAdefovir

Less potent, resistance commonTelbivudineLamivudine

Interferon-alpha, potent, no resistanceCurative in 25%

Medicaid covered,Alliance/Health Right non-formulary


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


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: 1st and 3rd trimester

Vaccine 0, 30, 180 days 70% effective after first dose Off schedule: revaccinate, test HBS Ab in 30 days


Hepatitis C


Hepatitis C Infection

NatalieCole

Greg Altman

KenWatabe

Evel Kneivel

GeneWeingarten

PamelaAnderson

NaomiJudd


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)


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?


Hepatitis C: Route of infection

Injection Drug Use60%

Sexual15%

Transfusion (before screening)10%

Other5%

Unknown10%


Liver Cancer

Cirrhosis (Stage 4)

Normal (Stage 0)

Fibrosis (Stage 1)

Fibrosis (Stage 2)

Fibrosis (Stage 3)

Hepatitis C: Disease Progression


Hepatitis C: Risk of Cirrhosis


Hepatitis C: Risk of Carcinoma

Carincoma patients have cirrhosis first After cirrhosis: 1% annual risk each year


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


HCV Treatment Response: Interferon weekly and Ribavirin twice daily


Hepatitis C: Sustained Response Rates

0%

20%

40%

60%

80%

Genotype 1

Genotype 2/3

48weeks

24weeks


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


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)


HCV Protease Inhibitors: Trials done by 2014


Hepatitis: Needle exposure

Hepatitis BTransmission 30%

Baseline test for Hep B S AbConsider

Immunoglobulin

Hepatitis CTransmission 3%

Consider HCV Viral load at 2-4 weeks


Hepatitis: Pregnancy

Hepatitis BScreen via Hep B AgTransmission: 95%C-Section not indicated

Immunoglobulin at delivery, vaccinate newborn

Breastfeeding not contraindicated if infant vaccinated

Hepatitis CScreening not routineTransmission: 0-8%C-Section not indicated

Consider HCV VL for infant

Breastfeeding not contraindicated


Hepatitis: Sexual Transmission

Hepatitis BTransmission 30%

Vaccinate sexual partners

Hepatitis CTransmission Low

Condoms effectiveMonagamous: test and

consider no condoms


Hepatitis: Testing patients

Hepatitis BScreening: Hep Bs Ag Confirmation: Hep Bs AgMonitor Sn/LFTs abnlStaging: Hep B Viral load,

e AntigenLiver biopsy – rarely usefulCancer screening: >45,

alcohol, Fam Hx,

Hepatitis CScreening: HCV AbConfirmation: HCV VLMonitor for sn cirrhosisStaging: Liver biopsy

Cancer screening: >55, alcohol, cirrhosis


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-ABUSEhttp://www.oasiscliniconline.org/

Health & Medicine

Hep b and c powerpoint final