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

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Hepatitis CFacts for today,Hope for
tomorrowSchool Nurses TrainingPresented by
Maggie Damron,RNCalifornia HCV Task Force
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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

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Functions of the liver

• Digestive enzymes
• Metabolism
• Immune system
• gt500 chemical functions
• Detoxifies
• Clotting factors
• Hormones
• Can regenerate itself!

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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.
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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.
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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

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Acute Hepatitis C

• Incubation period averages 6 7 weeks
• Only 2530 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

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HEPATITIS C THE MAJOR HEALTH CONCERN
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Risk Factors for the transmission ofHepatitis C
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Hepatitis C is spread through blood to blood
contact !

• Blood transfusion before 1992
• Blood products before 1987
• Injecting drug use
• History of multiple sex partners
• History of hemodialysis

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(Risk factors contd)

• Tattoo or repeated body piercing
• History of intranasal cocaine use
• Occupational eg. Needlestick injury
• Infants born to HCV infected moms
• Vietnam-era veterans

• 10 of unknown aetiology

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Occupational Transmission HCV

• No documented transmission from mucous membrane
  or non-intact skin exposure
• Two case reports from blood splash to eye

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Needlestick Injuries (NSIs)

• Estimated 600,000 - 800,000 per year
• Recent studies of underreporting found rates
  range 20-50

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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

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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

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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

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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
  

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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

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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

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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 ALTs are
  normal
• Can be used to measure progression of the
  disease

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Risk factors for Fibrosis/Cirrhosis

• Alcohol consumption
• Age at acquisition
• Male gender
• Longer duration of infection
• Coinfection with HBV or HIV
• Immunosupression
• Organ transplant

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Treatment of HCV
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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

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The goals of Treatment
Primary HCV RNA undetectable Secondary Inhibit
the progression of the disease
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Current Therapies Available

• Intron A monotherapy
• Rebetron Combination therapy
• PegIntron and Rebetol (Ribavirin)
• Pegasys and Copegus (Ribavirin)

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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

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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

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Potential side effects of Ribavirin

• Anemia
• Fatigue
• Irritability
• Itching
• Skin rash
• Dry, irritating cough
• Nasal stuffiness, sinusitis
• Teratogenicity

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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

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(Nursing considerations continued)

• 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!

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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

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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

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For more information on current blood borne
pathogen research, visit the CDCs web site at
www.cdc.gov/ or consult the latest version of
OSHAs blood borne pathogen standard.
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www.californiahcvtaskforce.org
A Community Response To A Major Health Concern
THE CALIFORNIA HEPATITIS C TASK FORCE