Hepatitis Specialist Nurse Practitioner

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Hepatitis B and C in Injecting Drug Users
Simon Joseph BSc (hons) Psych Health, RMN, BSc
(hons) Substance Misuse

• Hepatitis Specialist Nurse Practitioner
• Bristol Specialist Drug Service
• simon.joseph_at_awp.nhs.uk
• 0117 3784500 / 07887 636 901

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• Hepatitis B Prevalence, Causes and Prevention.
• Acute Hepatitis B.
• Chronic Hepatitis B.
• Hepatitis C Causes, tests and Treatments.
• Drug related deaths
• Overcoming obstacles

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Ganem, D. et al. N Engl J Med 20043501118-1129
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Trends

• Blood borne virus rates, comparing Bristol to
  England and Wales 1999-2004 (data Unlinked
  anonymous Prevalence Surveys)

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• Case control study (Acute Hep B outbreak)
• IDUs, general characteristics
• Snowball (injected heroin and crack) 9/15 (60)
  in last four weeks (cases CCS)
• Groin injecting 9/15 (60) in last four weeks,
  (cases CCS)
• Immunised 10/28 (36), (cases CCS)
• Injecting, more than twice day 55/88 (63), more
  than five times 19/88 (22), (controls CCS)
• Shared injecting equipment in Bristol 28/28
  (100), (cases-CCS)
• Shared equipment with someone, jaundiced in last
  year, 8/18 (40) (cases-CCS)
• Source Charles Irish HPA

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Hep B Prevention

• Universal infection control in healthcare.
• Safer sex.
• Harm reduction in drug users.
• Vaccination.
• Identifying carriers.

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Why vaccinate?

• A liver transplant costs 50-60,000
• A full course of hepatitis B vaccines and blood
  tests costs less than 50
• 30-56 of injecting drug users test positive to
  hep B antibodies - Noone et al 1993

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Adult Vaccine Schedules

• Normal 0 / 1 / 6 Months
• Accelerated 0 / 1 / 2 / 12 Months
• Super-accelerated 0 / 7 / 21 Days 12
  Months
• For High risk groups more doses more quickly and
  opportunistic vaccines.
• Post vaccine blood tests Anti HBs.

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The liver is in the upper right quadrant of the
Abdomen
Functions Detoxification, Manufacture of
proteins, clotting factors, bile (fat
emulsification), breakdown of sugars and
carbohydrates Temperature homeostasis
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Acute Symptoms

• Half have few or no symptoms
• Tiredness lethargy
• Vomiting diarrhea
• Weight loss
• dark urine / pale feaces
• Pain
• Alcohol intolerance
• Jaundice
• lasts a couple of months

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Chronic Hepatitis B

• Defined as lasting more than 6 months.
• Two types (sort of)
• High Viral load (eAg Positive)
• Low viral load (eAg negative)
• High risk of cirrhosis and cancer

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• Chronic infection
• Perinatal 90
• Childhood 30
• Adult 5
• gt300 million carriers worldwide
• 5 worlds population
• 0.5 - 1 million deaths/year
• 9th leading cause of death worldwide

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High viral load

• eAg pos
• May become eAg neg (1-5)
• 8-10 develop cirrhosis per year

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5 year mortality

• 0-2 without cirrhosis
• 14-20 with compensated cirrhosis
• 70-86 following decompensation

Hepatocellular Carcinoma

• Without cirrhosis
• 0.2-0.6 per year
• With cirrhosis
• 2 per year
• Predictors
• Older, male, alcohol, co-infection,
  decompensation

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Treatments

• Acute symptom management.
• Fulminant - transplant.
• Inactive carrier / mild chronic observe
• Moderate / severe Lamivudine, Interferon, /-
  Adefovir or Tenofovir
• End of hep B presentation

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Hepatitis C Transmission

• Both Hep B and C are much more resiliant than
  HIV, bleach resistant, time resilient.
• Hep C affects anywhere between 40 - 70 of
  injecting drug users.
• Sex risk extremely low.
• Cannot be vaccinated against.
• Transfusions before 1991.

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Natural History of Hep C

• 20 year morbidity
• Incubation period 6 wk to 4 mth for reliable
  testing.
• Acute infection less common and minor.
• 15-20 clear the virus.
• one in 5 will progress to cirrhosis within 20
  years
• 20-25 will develp serious liver damage.
• Of this 20-25 around 10-15 remain stable but
  ill and 10 go on to develop liver cancer / liver
  failure 75 changeable /progressive.
• 2-5 risk of cancer or liver failure

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Hep C Symptoms mild/moderate

• 8-15 years asymptomatic (non drinkers).
• Fatigue is common and progressive and
  debilitating.
• Occasional upper right quadrant pain.

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Hep C Symptoms - severe

• Dominating fatigue.
• Liver pain ache and occasional sharp pain,
  backache.
• Gastric symptoms intolerance of alcohol, fat.
• Bloating, vomiting, diarrhoea.
• Ascites, palmar erythemia, clubbing, oesophageal
  varisces, carcinoma.

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Alcohol

• Virus reproduces faster, accellerating
  progression.
• Alcoholic liver damage.

Symptom management

• Diet fat, salt, caffeine
• Moderate exercise
• Acupuncture
• Herbs
• Emotional support

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Hepatitis C Treatment

• Pegylated Interferon 2 types.
• Ribavirin.
• Depends on genotype / viral load / weight.
• Usually 24 weeks (g2 or g3) or 48 weeks (g1 and
  rare types).
• Future treatments protease inhibitors

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4 aims of therapy

• Reduce the risk of progression to cirrhosis
• lessen risk of hepatocellular cancer
• Abolish infectivity
• Improve quality of life

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Liver Biopsy
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Common Treatment Side Effects

• flu like symptoms
• fatigue
• depression
• platelet and neutrophil suppression
• broken skin
• hair thinning

• loss of libido
• loss of appetite
• nausea
• diarrhoea
• disturbed sleep
• thyroid disease
• Mood swings
• Depression

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Rare Side Effects

• Severe mood swings.
• Severe depression.
• Psychosis.
• Stroke.
• Heart attack.

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Treatment effectiveness

• g2 / g3 up to 80
• g1,4,5,6 up to 60
• Dependant on compliance, side effects, age,
  gender, afro vs white.
• Rule of thumb over half are cured

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Drug Related Death

• Short Term
• Overdose
• Acute Infections
• DVT
• Poisoning
• Suicide
• Accidents
• Violence
• Heart attack / stroke

• Long Term
• Hepatitis B, C
• HIV
• Organ Damage

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Practical Solutions to Everyday Problems

• High DNA rate
• Be everywhere!
• Active follow up agreements
• Send out appointment 3 days before.
• Opportunism.
• Shorter first appointments, be flexible.
• Change to an accelerated schedule.
• HIV testing. Hep C testing.

• Blocks to change
• Early engagement - coming back for blood test
  results at 1 and 2 weeks.
• Respect.
• Accessibility.
• Small change is generative
• Humour
• Individualisation
• Honesty - even if this is scary.
• W questions

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• World Hepatitis Day 19 May 2008

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References

• www.addaction.org.uk/Drugsafeinject.htm
• Advisory Council on the Misuse of Drugs (2000)
  Reducing Drug Related deaths. London HMSO
• Bristol DAT 2003 Drugs Overview
  (www.swdrugstrategy.info/dats/Bristol)
• Christie 2003 conference presentation
  hepatitis B
• Department of Health (1999) NHS Executive Drug
  misuse special allocation 1999/2000 Funding and
  guidance of the Modernisation Fund element.
  Health Service Circular HSC 1999/036 London, DoH
• Derricott, Preston and Hunt (1999) The Safer
  Injecting Briefing Noone A., Durante, A J and
  Brady A R (1993) HIV infection in IDUs attending
  centres in England and Wales 1990-1991, AIDS 7,
  50-507
• Petersen, T (2002) Report on the BSDS Hepatitis B
  Vaccination Project and Survey of Risk Behaviours
  Amongst Bristol Based Injecting Drug users
  participating in a Hepatitis B Vaccination
  Programme.
• Petersen, T and Lllwellyn J (2001) Bristol
  Specialist Drug Service Hepatitis B Project
  Handbook
• Winstock A.R., Sheridan, J., Wansborough M, et al
  (2000) Observational study of the vaccine
  efficacy 14 years after trial of hepatitis B
  vaccination in Bambian children. British Medical
  Journal 325 (7364) 569-576
• Wilkipedia the free encyclopedia