OUR HEPCBC "Meet and Greet", 2007
Transcript of OUR HEPCBC "Meet and Greet", 2007
Working TogetherAgainst HCV
HepCBC March 31, 2007
Natalie Rock RN, BSN
Hepatology Nurse
Clinic Director LAIR Centre
www.laircentre.com
THE LIVER
• The Largest Organ
• Weighs 1200-1500 grams
• Metabolically the most active organ
THE LIVER
• Sheltered by Ribs in RUQ
• Two Major Lobes
• Has a Double Blood Supply• portal vein• hepatic artery
FUNCTIONS OF THE LIVER
• Manufacture
• Filtration
• Metabolism
• Excretion
• Regulation
• Secretion
carbohydrates
proteins/fat
clotting factors
cholesterol/bile
bacteria
drugs/toxins/hormones
WHAT IS HEPATITIS ?
• HEPAR = LIVER
• ITIS = INFLAMMATION
• HEPATITIS = INFLAMMATION OF THE LIVER
WHAT ARE SOME CAUSES OF HEPATITIS?
• Alcohol
• Drugs
• Toxins
• Metabolic Diseases
• Autoimmune Diseases
• Fatty Liver Disease
WHAT ARE SOME CAUSES OF HEPATITIS?
• Viruses• A
• B
• C
• D
• E
• G
• GB
• TT
Signs and Symptoms
• Jaundice-yellow skin and eyes
• dark urine• pale or bloody stools• abdominal swelling• prolonged itching of
skin• chronic fatigue
• Nausea or loss of appetite
• vomiting of blood• severe, prolonged
abdominal pain • bruising, inability to
heal minor cuts and injuries
TRANSMISSION OF HEPATITIS
RareModerateRareOccupational
RareModerateRareHousehold
UncommonCommonNoMother – Child
UncommonYesNoSexual
RareYesNoBlood – Oral
NoNoYesFecal – Oral
RareNoNoBlood Products
YesYesPossiblyBlood to Blood
HEP CHEP BHEP AMODE
Family: Flaviviridae
Enveloped, +ve strand RNA virus
50 nm particles contain:
E1 and E2 proteins on surface
C protein inside
Hepatitis C Virus (HCV)
HCV Genome
HCV in Canada vs BC
• ~ 60,000 (1.5%) British Columbians
• May 2005, 55,000 identified as anti-HCV reactive
~ 25% clear infection, therefore about 41,000 people are chronic
~ 20,000 undiagnosed, projecting 3,000 newly identified cases in 2005
Hepatitis C Rates by Year, 1995-2004
0.0
50.0
100.0
150.0
200.0
250.0Rate per 100,000 population
Note: Canadian rates are based on reporting provinces and territories only
BC Hepatitis C Reports 4650 6140 7720 6266 5011 4396 4379 4536 3617 3074
BC Hepatitis C Rate 123.1 158.5 195.5 157.3 124.9 108.8 107.4 110.2 87.2 73.5
Canadian Hepatitis C Rate 64.4 53.5 60.7 67.8 62.0 58.0 54.3 50.9 43.3 41.3
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
PHIS Reported HCV Rates - BC 1995 to 2004
0
50
100
150
200
250
300
350
Acute_F 0 0 0 0 6 13 11 10 7 4 3 1 1 0 0 0
Acute_M 1 0 0 0 2 13 18 14 13 8 5 3 1 1 1 0
Probable chronic-F 47 2 1 4 22 61 97 125 146 152 106 57 39 33 35 25
Probable chronic-M 62 2 2 4 13 67 155 223 282 324 270 151 77 53 46 43
<1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 >70
Rate of anti-HCV reactivity/100,000 BC residents/yearby age and gender including acute HCV infections
BCCDC 1992 – 2002, n = 45,661 (2,168 acute)
45,661
alcoholobesity
HIVolder age
males
poorlytoleratedsupport
hard toidentify
IDU!
Alter 99, Jaeckel 01, Freeman 01, Hofer 03
HCVinfections
~ 25%symptomatic
75%
Chronic
25 %
Clear
Do nothing15% to 25%
cirrhosis, ESLD, HCC, transplant
early treatment feasible
pegylated INF/Rib cure 50% to 60%
decades
Prevent infections? Prevent complications?
DIAGNOSIS OF CHRONIC HEPATITIS C
1. Anti-HCVELISA, RIBA
3 To 6 Months Delay
2. PCR: (HCV RNA)Measures Presence of the Virus
Qualitative
Quantitative
DIAGNOSIS OF CHRONIC HEPATITIS C
3. Liver EnzymesAST, ALT
Levels Fluctuate
Elevated 1.5 times Normal
Over 3 Months
4. GenotypeMapping of the Virus
Type Determines Length of Treatment
Acute HCV Infection Progressing to Chronic Infection
Symptoms +/-
Time after Exposure
Tit
reanti-HCV
ALT
Normal
0 1 2 3 4 5 6 1 2 3 4YearsMonths
HCV RNA
Progression to Chronic Hepatitis
• Disease activity varies• Progression rate varies
– Older persons progress more quickly– Route of infection may affect progression– Males progress more rapidly– Alcohol enhances progression– Jaundice at acute attack progresses more
rapidly
Chronic Hepatitis C Progression
• Time to Chronic Hepatitis: 10 years
• Time to Cirrhosis: 18 - 20 years
• Time to Liver Cell Cancer: 28 years
EXPOSURE 1-3 WKS 7 WKS 3 MO 6 MO 10 YRS 20 YRS 30 YRS
HCV-RNA ALT ANTI-HCV CHRONIC OVERT CIRRHOSIS LIVER DETECTED ELEVATED INFECTION HEPATITIS CANCER
Chronic Hepatitis C
• Cirrhosis: 25%
•End stage liver disease: 5%
–Liver cell cancer: 5%
»Transplant: 3%
Pathology of Hepatitis
Liver Biopsy:
GRADE
Inflammation
STAGE
Fibrosis
Cirrhosis
NORMAL LIVER LOBULE
BRIDGING FIBROSIS
CIRRHOSIS
TREATMENT
• PEGYLATED INTERFERON– natural human protein– produced in response
to viruses– inhibits viruses– increases production of
antibodies– stimulates immune
system
• RIBAVIRIN– oral antiviral
– potentiates the effects of interferon
LENGTH OF TREATMENT• Dependent on Genotype and Response
– Genotype 1,4,5,6 – Treatment is up to 1 year – Cure rate approximately 50%
– Genotype 2 – Treatment is 6 months– Cure rate approximately 88%
– Genotype 3– Treatment is 6 months– Cure rate approximately 65%
Possibly longer
Possibly shorter
Possibly longer
GOALS OF TREATMENT
• Normal AST and ALT
• HCV RNA by PCR Negative
• Liver Biopsy Inactive/Improvement
• Quality of Life, Stopping Complications
TREATMENT
• Pharmacare• Fair Pharmacare
• Extended Health
• Peg-Care and PegAssist
Cost of Treatment $1,800/ month!
SIDE EFFECTS
SIDE EFFECTS
• Flu-Like Symptoms– Fever – Chills – Muscle Aches– Fatigue
SIDE EFFECTS
• Weight Loss• nausea, abnormal taste in mouth
• loss of appetite
• Skin Changes• dry, itchy, rash, psoriasis
• Hair Loss• comes back!
• Decreased Libido• comes back!
SIDE EFFECTS
• Anemia (decrease in hemoglobin)• shortness of breath
• cough
• Neutropenia (decrease in white blood cells)• risk of infection
• fever
• Thrombocytopenia (decrease in platelets)• possible risk of bruising
• possible risk of bleeding
SIDE EFFECTS
• Exacerbation/Precipitation of:• Autoimmune Diseases
» diabetes
» arthritis
» thyroid
• Mood Alterations» anxiety
» irritability
» depression
Prevention
• Get Vaccinated for Hepatitis A and B
• Abstain from Alcohol
• Smoking (??)
• Nutrition
• Exercise
• Do not share personal care items
FUTURE THERAPIES
• Interferon Variants
• Vaccines
• Antisense Oligonucleotides
• Proteases
• Helicases
• Polymerase Inhibitors
• Traditional Chinese Medicine
BC Hepatitis Strategy
• The goal is to
– Support
– Counsel
– Educate
– Assist
• Directed to:
– Patient
– Caregiver
– General public
InformationManagement
Integrated Hepatitis Program
Care Surveillance &
Management Prevention
Education & Research &
Support Evaluation
Significance of the Infection
• Impacts on individual, families and society– Physical– Social-Emotional– FinancialThese impacts may be associated with the disease
itself, the reactions of and implication for others, and the effects and costs of treatment.
Physical
• Liver disease can affect every aspect of an individual’s physical well-being, including the ability to eat and maintain adequate nutrition, obtain comfort and rest, have intact skin, work, and carry out activities of daily living and may be unable to care for their families or continue in their jobs.
Social Emotional
• A diagnosis of a chronic illness has a tremendous emotional impact.
– reactions that commonly follow a diagnosis:
• denial, fear, anger, guilt, grief, depression, and a sense of hopelessness
Social Emotional
• The uncertainty of living with a disease whose course and effects differ for each person
• concern over the health and safety of family members
• uncertainty and fear related to treatments and the risks associated with a possible liver transplant
• side effects of treatment
Social Emotional
• Fear of isolation and social exclusion if relatives, friends, and people at work find out about the diagnosis
• misinformation from physicians, nurses, and other care providers
• family members may be affected in ways similar to the person receiving the diagnosis; they may also experience distress arising from the revelation that a loved one may have contracted HCV by engaging in risky behavior (unprotected sex, intravenous drug use, etc.)
Societal
• Potential costs in terms of morbidity, quality of life, mortality
• the direct economic costs associated with Liver Disease for individuals, families and communities
• the burden on the medical and social care systems--est. 4,000 new cases identified annually of (HCV)
• lives lost prematurely
Financial
• The financial impact on the individual and family can be devastating. The individual may be unable to work consistently. The treatments may be expensive, ranging in the thousands of dollars. Pharmacare will cover some of the costs of for those who meet criteria.
Factors that interfere or assist with prevention
• Attitudes
• knowledge and skills
• social context of health and illness (ie poverty, education and social support)
• resources and tools (how and where to access clean equipment)
Attitudes
• Attitudes--your own and those of others--can interfere with education, making wise choices, and applying knowledge and skills.
• Attitudes arise from the ideas, beliefs, and values you hold.
Web Sites
• Canadian Liver Foundation: www.liver.ca
• Health Canada: www.sc-hc.gc.ca
• Hepatitis C Society of Canada: http://web-idirect,com/~hepc
• HepCBC: www.hepcbc.ca
• Hepatitis Foundation International: www.hepfi.org
• The Canadian Medical Association: www.cma.ca
• Hepatitis Information Network: www.hepnet.com