1. HEPATITIS B AND
HEPATITIS C
Brenna Simons PhD
Lisa Townshend-Bulson, MSN, FNP-C Screening Guidelines, Understanding Tests &
Patient Management.
Alaska Native Tribal Health Consortium
Liver Disease and Hepatitis Program

2. What We Will be Discussing
 Hepatitis B Virus
 Background & Epidemiology
 Screening Guidelines
 Understanding Tests
 Patient Management
 Hepatitis C Virus
 Background & Epidemiology
 HIV-HCV Co-Infection
 Screening Guidelines
 Understanding Tests
 Patient Management

3. HEPATITIS B
CHRONIC VIRAL INFECTION
SEXUALLY TRANSMITTED DISEASE
HIGHLY INFECTIOUS VIRUS
LIVER DISEASE

4. Hepatitis B Virus – Background
and Epidemiology

5. Thank Goodness for Vaccines!
Hepatitis B Virus One Nasty Virus
HBeAg  Highly infectious and
stable virus
 Acute Hepatitis
HBcAg
 Chronic Hepatitis
 Cirrhosis/fibrosis
 Hepatocellular
Carcinoma
http://pathmicro.med.sc.edu

6. Hepatitis B Infection in the U.S.
HBV Universal
Vaccination http://www.cdc.gov/hepatitis/Statistics/
Nationwide

7. Hepatitis B Infection in the U.S. by
Race
http://www.cdc.gov/hepatitis/Statistics
U.S. State of Alaska
220
200 Yukon Kuskokwim Delta
180 Statewide
160
Rate per 100,000
140
120
100
80
60
40
20
0
81
83
85
87
89
91
93
95
97
99
01
03
05
07
19
19
19
19
19
19
19
19
19
19
20
20
20
20
Year
Statewide Vaccine Program Dr. Brian McMahon

8. Although Hep B Vaccine Effective
there are Other Factors to
Consider…
• Without intervention, up to 25% of chronically
infected individuals with HBV die of
complications
• 3,000-5,000 U.S.-acquired cases of chronic
HBV/year since 2001
• ~53,800 new cases of chronic HBV imported to
the U.S. between 2004 and 2008
• Vaccine longitudinal research ongoing
• Healthcare Workers - Increased risk of needle
stick
So Make Sure Your Patient is
• Vaccination History sometimes difficult to and Mitchell et. al. 201
Covered !!
http://www.cdc.gov/hepatitis/Statistics/

9. HBV Screening Guidelines

10. Antigens and Antibodies
Antigen (Ag) Antibody (Ab)
 Detection of the „Bug‟  Patient Immune Response to the
 Virus,bacteria,parasite… specific „Bug‟ Antigen
 Ag+ : bug is present  Ab+ : Patient Immune Response
to „Bug‟
 Ag- : too little of bug to detect –
OR- bug is not there  Ab- : No Patient Immune
Response to specific „bug‟
antigen
Viral Load (DNA or RNA)
Genetic Material of „Bug‟
(detected) : bug is present
(below limit of detection) : bug may be present, too low to detect
(not detected): bug is not there

11. Testing Specificity and
Sensitivity
Specificity Sensitivity
 False-Positives  Limit of Detection
Low(er) Limit of Detection
More Sensitive
High(er) Limit of Detection
Less Sensitive

12. Hepatitis B (HBV) Screening
Tests
TEST WHAT IS IT?
SAG Hepatitis B Surface Antigen
HbsAg
Hep B Surface Ag
HBeAg
Anti-HbS Hepatitis B S Antibody
SAB
HbsAb
HBcAg
HepB Surface Ab
Anti-HBc Hepatitis B Core Antibody
HBc Ab, IgM/Total
IgM
Total (IgM + IgG)

13. Hepatitis B Screening
Guidelines
SCREENING ALGORITHM
www.hepb.org Hepatitis B

14. Indications for HepB Screening
and Vaccination
& recipient
•HCV-positive patients
•Individuals incarcerated
•Health Care Worker
Hepatitis B Foundation www.hepb.org

15. Hepatitis B Patient
Management

16. Four Main Phases of Chronic HBV
Disease…. But it‟s complicated
S Ag+
E Ag+
S Ag+
E Ag-
Anti-HE+
S Ag-
E Ag-
2009 Hepatology McMahon

17. HBV Treatment Dependent on
Phase
Inactive
• Maintain HBV Viral Load < 2,000 IU/mL
• Normal ALT
Active
• HBV Viral Load > 20,000 IU/mL
• Elevated ALT
Immune
Tolerant
• HBV Viral Load > 20,000 IU/mL
• Normal ALT
HBsAg Clearance Phase
• HBV Viral Load generally undetected, but can be present and <2,000 IU
• HBsAg NEGATIVE
• Normal ALT

18. Hepatitis B (HBV) Clinical Tests in
Persons who are HBsAg-Positive
TEST
WHAT IS IT?
NAME
Anti-HBE Anti-Hepatitis B E-Antigen
Antibody
HBeAg
HepB E Ag Hepatitis B E-Antigen (Viral Protein)
HBeAg
HBcAg
HBV DNA Hepatitis B Viral DNA (Viral Load)
International Unit / mL (IU/mL)
ALT Alanine aminotransferase
Liver Enzyme

19. The HBsAg+ Test is Positive…Now
What?
Evaluating and Monitoring Chronic
Hepatitis B
www.hepb.org Hepatitis B Foundatio

20. HEPATITIS C
Chronic Viral Infection
HIV Co-Infection
Injection Drug Use
Cirrhosis
Liver Failure

21. Hepatitis C Virus – Background
and Epidemiology
Hepatitis C Risk Factors
Hepatitis C Co-Infection with HIV

22. No Vaccine for “Non-A, Non-B”
Hepatitis C Virus Distinctive Risk Factors
 IV Drug Use
(IDU), Incarceration, blood
transfusion before
1992, tattoos, some sexual
contact
 Acute Infection
 Often asymptomatic
 Chronic Infection
 Develops in 75-85% of those
infected
 Chronic liver disease
 Cirrhosis
www.prn.org  Liver Cancer

23. Acute Hepatitis C in the U.S.
• Urban
populations
affected more
prevalently
• In Alaska, our
program has
identified over
2,300 anti-HCV
positive
AN/AI, approxima
tely equivalent to
US prevalence.
• Some programs
report up to 11-
12% prevalence
in urban
communities.
http://www.cdc.gov/hepatitis/Statistics

24. Prevalence of HIV-HCV Co-
infection
 Estimated 25% of individuals infected with HIV
in the US are also infected with Hepatitis C
 Approximately 80% (50-90%) of IDUs with HIV
infection also have Hepatitis C
 Hepatitis C infection progresses more rapidly
to liver damage in HIV-infected persons
 HCV infection also impacts the course and
management of HIV infection
 U.S. guidelines recommend that all HIV-
infected persons be screened for HCV
infection
http://www.cdc.gov/hepatitis/

25. HCV Screening Guidelines

26. Hepatitis C Clinical Tests
TEST WHAT IS IT?
Anti-HCV Ab Anti-HCV Antibody
HCV RNA Quant HCV Viral Load RNA Te
QUANTITATIVE

27. Hepatitis C Screening
Guidelines
SCREENING ALGORITHM
• Screen for HIV
Patient is HCV Positive • Collect HepA and HepB Vaccination History
Consult with Specialist • Screen for HepA and B
• HepC Viral Genotyping
AASLD AND CDC GUIDELINES and the ANTHC Liver Disease and Hepatitis Program

28. Hepatitis C Genotyping
TEST WHAT IS IT? INTERPRETATION
HCV Genotype There are 6 major
Genotype 1
genotypes of HCV.
Genotype 2
This test will give you
Genotype 3
dominant HCV
genotype the patient
Genotype-Specific
is infected with. This
Treatment Eligibility and
will affect treatment
Options
options.
Uncommon in the U.S.
Genotype 4
Genotype 5
Genotype 6
Consult with Specialist

29. Management of HEPATITIS C
Lisa Townshend-Bulson, MSN, FNP-C
Alaska Native Tribal Health Consortium

30. New Diagnosis of Hepatitis C
 Counsel patient about new diagnosis, review risk
factors to estimate length of infection
 Determine hepatitis A and B status; vaccinate
 Begin educating patient about hepatitis C
 Brief lifestyle interventions: alcohol and weight loss
 Consider referral for liver biopsy
 Genotype 1 patients
 Those who may have had the disease ≥10 years
 Consider hepatitis C treatment
 Follow patient, liver labs every 6 – 12 months

31. AST to Platelet Ratio Index
(APRI)
 Poor man‟s biopsy
 Calculation =
Patient‟s AST/ULN AST (40)
x 100
Platelet counts (109/L)
 Interpretation
< 0.5 rule out significant fibrosis (Metavir F0-F1)
> 1.5 rules in significant fibrosis (Metavir F2-F4)
> 2.0 probable cirrhosis (Metavir F4)
 Repeat yearly, track APRI trend
Loaeza-del-Castillo, A., et al., Annals of Hepatology 2008; 7(4), 350-357

32. Key Messages for Patient
About HCV Diagnosis
 HCV does not make your liver sick over night
 HCV is not spread by casual contact
 Low rate of sexual transmission (< 5%)
 Low rate of vertical transmission (< 5%)
 Follow up labs/evaluation every 6-12 months
are important to prevent complications
 Reiteratelifestyle intervention at each visit
 Continue educating patients

33. Helpful Patient Tips After
Hepatitis C Diagnosis
 Avoid alcohol
 Do not share needles, toothbrushes or razors
 Eat a healthy diet, maintain healthy weight
 Stop smoking
 Get plenty of rest/reduce stress
 Take in adequate vitamin D
 Coffee is good
 Do not combine alcohol and acetaminophen
 Milk thistle won‟t get rid of hepatitis C
 Stay informed

34. Liver Disease Progression
 Inflammation
 Fibrosis – Scar tissue forms
 Cirrhosis – Scar tissue replaces healthy
tissue and blocks blood flow through the
liver and decreases its function (20-30
years)
 Hepatocellular Carcinoma (HCC) –
Occurs in hepatitis C after development of
cirrhosis (20+ years)

35. Liver Disease Progression
Healthy Fibrotic Liver
Liver
Cirrhotic Liver Liver
Cancer

36. Who Should be Screened for
Hepatocellular Carcinoma (HCC) with HCV
?
 Those with cirrhosis or bridging fibrosis
(advanced fibrosis)
 Screen with liver ultrasound every 6
months, adding alpha-fetoprotein (AFP) blood
test optional, may increase effectiveness of
screening
 In persons in whom stage of fibrosis is
unknown, AFP can be used
 If AFP > 8ng/ml, US should be added every 6
months
Bruix et al. Hepatology 2010; at aasld.org/practice guidelines
Bruce et al. J Viral Hepatitis 2007; 25:6958-64

37. Effective Treatment Regimes for
HCC
 Surgical resection
 Tumor ablation
 Radiofrequency Ablation
 Chemoembolization
 Liver Transplantation:
 Almost all patients get reinfected with
HCV if not treated before transplant

38. Conclusions
Hepatitis B Hepatitis C
 Screening for  Screening for
hepatitis B infection hepatitis C is a 2-
and/or vaccine status
is critical for step process
protection  HCV genotype is
 Assess patients important to patient
completely to management
determine acute &
 Remember to
chronic infection,
immunity to hepatitis screen for HIV co-

B Both infections require life-long
infection
monitoring

39. Alaska Native Tribal Health Consortium
Liver Disease and Hepatitis Program
ANTHC LiverConnect
www.anthc.org/chs/crs/hep

40. Thank You!
Brenna Simons PhD
bcsimons@anthc.org
The ANTHC Liver Disease and Hepatitis Program
Lisa Townshend ANTHC LiverConnect
MSN, FNP-C www.anthc.org/chs/crs/hep