Hepatitis C H i i C Addi ti Addictions perspective ti Stewart Campbell Gastroenterologist Hairmyres Hospital March 2014 Predicted HCVHCV-Related Mortality through 2019 Non HCC liver-related 30,000 HCC 20,000 10,000 5,000 0 1992 1995 1998 2001 2004 2007 Year Wong et al. Am J Public Health. 2000;90(10):1562-1569. 2010 2013 2016 2019 Risk Factors Risk Factors ( g ( High Risk ) ) HCV transmission is blood to blood       Injection & intranasal drug use Blood transfusion prior to 1992 Clotting factors prior to 1987 Hemodialysis 3‐5% babies born to infected mothers % b bi b t i f t d th Persons from high risk countries Source: NIH Consensus Statement 2002 Source: Centers for Disease Control & Prevention Injecting Drug Use j g g & HCV Transmission  HCV transmission is highly efficient among injection drug users.  Transmission of HCV via IDU is at least 4‐times more common than with HIV. with HIV  HCV infection is rapidly acquired after initiation of IDU. p y q  Prevalence HCV is >80% after 5 years of IDU Source: Centers for Disease Control & Prevention Nosocomial Transmission of HCV  recognized primarily in context of outbreaks  reported in hemodialysis* units, hospital inpatient wards, home therapy, and private practice  contaminated equipment  unsafe injection practices with cross‐contamination  plasmapheresis,* phlebotomy  multiple dose medication vials  therapeutic injections – reused needles and syringes  NB Medical treatment/ vaccination abroad *Reported in US Source: Centers for Disease Control and Prevention Perinatal Transmission of HCV  transmission only from women HCV‐RNA positive at delivery  average rate of infection 6% g  higher (17%) if mother is coinfected with HIV  no association with delivery method or breast feeding i ti ith d li th d b t f di  infected infants do well; severe hepatitis is rare Source: Centers for Disease Control and Prevention Sexual Transmission of HCV  data from case‐control, cross sectional studies  infected partner, multiple partners, early sex, non‐use of condoms, other STDs, sex with trauma have variably non‐use of condoms other STDs sex with trauma have variably been associated with increased risk  MSM no higher risk than heterosexuals  data from partner studies  low prevalence (1.5%) among long‐term partners • infections might be due to common percutaneous exposures (e g unsafe injections drug use) (e.g., unsafe injections, drug use)  male to female transmission more efficient • more indicative of sexual transmission Source: Centers for Disease Control and Prevention Household Transmission of HCV Household Transmission of HCV  rare but not absent  could occur through percutaneous/mucosal exposures to blood g p p  theoretically through sharing of contaminated personal articles (razors, toothbrushes)  contaminated equipment used for home therapies • • • Injections IV therapies p Folk remedies *Reported in US Source: Centers for Disease Control and Prevention Natural History of HCV Cirrhosis Natural History of HCV Cirrhosis Risk of Decompensation Risk of Decompensation 40% 30% 20% Ascites A it (18%) Variceal bleed (22%) Encephalopathy (8%) HCC (7%) Any complications (26%) 10% 0% 0 1 2 3 4 5 6 7 Years After Diagnosis Fattovich - EuroHep, Gastroenterology 1997; 112:463. 8 9 10 What to tell them  Tell them you’d like to do a test  Matter of fact M f f  Treatable  Pregnancy Test Interpretation p Wh t Who to refer f  All RNA positives  All diagnostic uncertainties  Regardless of LFT Regardless of LFT’ss  Regardless of lifestyle Where to refer  Geographical Convenience  Monklands or Hairmyres y  Outreach  HIV positivity Common Symptoms of Hepatitis C Common Symptoms of Hepatitis C in the Absence of Cirrhosis in the Absence of Cirrhosis  NOTHING AT ALL  fatigue  impaired cognitive functions  low grade fevers l d f  abdominal discomfort  appetite disturbances  abdominal pain  digestive disturbances d d b  migratory arthralgia or myalgia  depression  anxiety  many others Treatment and Outcomes  Treatment  Is often tough I ft t h  Can usually be deferred  Requires close monitoring and support R i l i i d  Will improve survival overall  Will reduce infectious pool Will d i f i l J Viral Hepat. p 2013 Oct 10. doi: 10.1111/jvh.12185. j The number needed to treat to prevent mortality and cirrhosis‐related complications among patients with cirrhosis and HCV genotype 1 infection. van der Meer AJ et al van der Meer AJ, et al Genotype 1 chronic HCV: NNT to prevent Death within 5 years Disease progression within 5 years M Mono therapy h 1052 302 PEG + riba 61 18 PEG + riba + DAAV 43 133 Immune based therapies Direct- acting antivirals Immune based therapies Direct- acting antivirals Immune based therapies Direct- acting antivirals Now Immune based therapies Direct- acting antivirals Now 20% Interferon (INF) 1991 Immune based therapies Direct- acting antivirals Now 20% Interferon (INF) 1991 40% INF & ribavirin 1998 Immune based therapies Direct- acting antivirals Now 20% Interferon (INF) 1991 40% INF & ribavirin 1998 40% PEGINF 2001 Immune based therapies Direct- acting antivirals Now 20% Interferon (INF) 1991 40% INF & ribavirin 1998 40% PEGINF 2001 60% PEGINF & ribavirin 2002 Direct- acting antivirals Immune based therapies Now 20% Interferon (INF) 1991 40% INF & ribavirin 1998 40% PEGINF 2001 60% PEGINF & ribavirin 2002 80% PEG-INF Ribavirin + PI PI’ss 2011 Direct- acting antivirals Immune based therapies Now 20% Interferon (INF) 1991 40% INF & ribavirin 1998 40% PEGINF 2001 60% PEGINF & ribavirin 2002 80% PEG-INF Ribavirin + PI PI’ss 2011 ? 90% PEG- INF Ribavirin + newer DAAV 2014 N D New Drugs‐ 2014  Sofosbuvir  Simepravir Si i  Daclatasvir Direct- acting antivirals Immune based therapies Now 20% Interferon (INF) 1991 40% INF & ribavirin 1998 40% PEGINF 2001 60% PEGINF & ribavirin 2002 80% PEG-INF Ribavirin + PI PI’ss 2011 ? 90% ? 100% PEG- INF Ribavirin + newer DAAV 2014 Interferon free DAAV ? when Summaryy  Current treatment can offer many people a cure  Treatment is about to get a whole lot better  So please test and refer But don t wait But don’t wait