Dr. Huma HCV Presentation

7/28/2019 Dr. Huma HCV Presentation

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Prevention & control of

Hepatitis B&C

Dr Huma Qureshi (TI)

Executive Director

Pakistan Medical Research Council,

Islamabad


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Hepatitis

Two types of hepatitis:

Waterborne (Hepatitis A & E)

Blood borne (Hepatitis B, D & C)

Acute illness: Irrespective of the virus type:clinical and other manifestations areidentical.


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Water borne Hepatitis A &E Both are transmitted by consuming sewage

contaminated water/food

Hepatitis A is a disease of children inPakistan, over 90% have been exposed andrecovered by the age of 12 years

Produces flu like symptoms in over 50%without jaundice, rest have jaundice

Recovery is 100% in 2-3months


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Hepatitis E It is seen all the year the round but more so

after rains and in summer

It is a disease of children and adults both

Mostly presents with jaundice and itching

Takes 2-3 months to recover with 100%recovery in all cases except 6% mortality in

pregnant cases


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Treatment of A & E Viruses Vaccine is available for hepatitis A but not

recommended as routine in Pakistan

No vaccine for hepatitis E is available

Both recover fully

Give normal diet with full fats, proteinsand CHO, allow normal work and avoid

drips,glucose and liver supporting drugs


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Prevalence data of B&C(2007-8) 50,000 subjects selected from 7000 houses

all over Pakistan by FBS sampling unit

Rapid test used (ELISA verified)

2.5% were HBsAg positive (4 million)

5% were HCV positive (8 million) Total positive 7.5% (12 million)


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Major risk factors for spread of

hepatitis B & C Therapeutic injections for various reasons

with reused syringe (14/person/year)

Improperly sterilized medical devices

Blood transfusion

Shaving by barbers, body piercing Rituals


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Who need screening for B&C Operated

Blood transfused/thalessemia etc

Frequent therapeutic injections

Dental treatment

Dialysis

Health care providers

HBV/HCV cases

Others


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How do u diagnose hepatitis C Anti HCV is a permanent stamp that identifies

exposure

Whether virus is there or not is based on LFTs(ALT)

Raised ALT means virus is there and patient mayneed treatment

Normal ALT means virus is expelled out, notreatment is required

PCR (HCV RNA) indicates viral presence


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What is chronic hepatitis B&C Any hepatitis infection that lasts over 6

months is chronic hepatitis

Most of the times it is difficult to tell how

old is the exposure

Need 2 reports of HBsAg and ALT 6

months apart

For HCV 2 raised ALTs and 1 ELISA


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Inclusion criteria for HCV for the

program Nave patient (non responders have poor

response)

No co-infection with HBV Age 10-60 years

Non pregnant

No cirrhosis (albumin, spleen. PV)

No decompensation HCV reactive by ELISA

ALT raised by 1.5 to 2 times the upper limit on 2occasions 6 months apart


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Baseline tests for HCV after

induction CP

ALT

Serum albumin

Ultrasound abdomen (PV,spleen, ascites)

Sugar

Creatinine

Optional- Thyroid functions

- liver biopsy in normal ALT


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When to do PCR Patient is HCV+ve

ALT is raised at 2 occasions 6 months

apart

Patient fulfills inclusion criteria

Willing to take treatment Can afford PCR

No need to do qualitiative PCR or

genotyping


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HCV treatment planHCV +ve ELISA

ALT raised> 2 times at 2

Occasions 6 months apart

HCV RNA+ve

Start 6 months

IFN therapy

CP,ALT every month

HCV RNA at 3 or 6 months

Inclusion criteria


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What treatment IFN 3 Miu 3 times/wk for 6 months

Patient should take injection

subcutaneously himself, those who inject

get infected

Take ribavarin daily

Normal diet, normal activity

Check PCR at end of treatment


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Side effects of IFN Fever

Bodyaches

Temporary hair fall

Anorexia

FatiguePanadol, B complex and good food will

reduce these effects


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Side effects of Ribavarin Produces hemolysis

In most cases Hb will drop by 3 grams

Always start therapy when Hb is over 11 grams,

else give iron and folate to bring Hb up

With ribazole, anemia is macrocytic as heme goes

back in circulation Add folic acid when ever more drastic Hb drop is

seen

Reduce ribazole dose or stop if Hb


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How to follow CP, ALT every month (Hb, TLC, platelets)

ALT should reach baseline in a month (if

no check, site of injection/compliance)

HCV RNA at 3 or 6 months (should

become non detected by 3 months)

HCVRNA at 12 months (sustained

response)

Tailor drugs when CP shows side effects


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Response/ relapse About 60-70% will recover completely

30% will relapse

Disease shall not aggravate in relapsers, so

dont panic yourself and the patient

Do not give Peg.IFN as chances are only10% response

Wait as new drugs are in pipeline


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Interventions during therapy

Ribazole: Hemolysis-add folic acid

Add iron if microcytosis

Acetaminophen oral for pains and fever

Vitamin B complex to keep going

Fever to be appreciated as a response andnot reaction

Good food intake


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When to reduce therapy Hb drops around 8 grams

Reduce Ribazole

TLC /platelets are around 2500 and 40,000

Reduce IFN


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When to stop treatment in between

therapy Stop treatment if ALT does not touch

baseline by 3 months

HCV RNA is still positive at 3 or 6 months

Hb drops below 6 gms

Platelets go below 30,000 TLC goes below 1200-1500


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Treatment urgency No urgency, virus takes 15-20 years to go into

cirrhosis- a stage where only supportive treatmentis done

Wait for 4-6 months to follow the disease

Avoid treatment in aged, non responders,relapsers,non affording cases

Virus is not passed from mother to child duringpregnancy or feeding

Breast feeding should be continued for at least ayear before starting mothers treatment


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Whom to observe but not treat Pregnant and lactating cases

Low Hemoglobin

Uncontrolled diabetes

All above cases can be treated once they are fit

HCV is a chronic slow growing disease so no harm

in waiting and observing.If someone goes in decompensation in 1-2 years then

it is already an advanced disease


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Do not treat Relapsed cases

Non responders

Non compliant

Low platelets (< 70.000)

Advanced cirrhosis

Decompensated liver disease

Dialysis (CRF), cardiac cases

Pregnant


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Prevention of HCV No vaccine available globally

Avoid un necessary injections

Always destroy a syringe after use

Always sterilize invasive medical devices

Rationalize blood transfusion

Avoid shaving outside

Public awareness to demand good clinical

practices


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Our duty! We all have a role in health sector

Follow SOPs in our fields, make SOPs where

required At least adhere to minimum standards

Justify all transfusions, injections andpractices/treatments that we prescribe

Should feel proud in avoiding transfusion,injection and reuse of devices- would meansaving at least 1life/ procedure

Dr. Huma HCV Presentation

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