1Hepatitis CPrepared byDivision of Viral HepatitisCenters for Disease Control and PreventionRevised by Jill Gallin, CPNPAssistant Professor of Clinical NursingColumbia University1/17/03Features of Hepatitis C Virus InfectionFeatures of Hepatitis C Virus InfectionIncubation periodIncubation periodAverage 6Average 6--7 weeks7 weeksRange 2Range 2--26 weeks26 weeksAcute illness (jaundice)Acute illness (jaundice)Mild (Mild (<<20%)20%)Case fatality rateCase fatality rateLowLowChronic infectionChronic infection60%60%--85%85%Chronic hepatitisChronic hepatitis10%10%--70% (most asx)70% (most asx)CirrhosisCirrhosis<5%<5%--20%20%Mortality from CLDMortality from CLD1%1%--5%5%Age-relatedChronic Hepatitis C Factors Promoting Progression or Severity n Increased alcohol intaken Age > 40 years at time of infectionn HIV co-infectionn Other– Male gender– Chronic HBV co-infectionSerologic Pattern of Acute HCV Infection with RecoverySymptoms +/-Time after ExposureTiteranti-HCVALTNormal01 2 3 4 561234YearsMonthsHCV RNASerologic Pattern of Acute HCV Infection with Progression to Chronic InfectionSymptoms +/-Time after ExposureTiteranti-HCVALTNormal01 2 3 4 561234YearsMonthsHCV RNAHepatitis C Virus Infection, United StatesHepatitis C Virus Infection, United StatesNew infections per year 1985-89 242,0002001 25,000Deaths from acute liver failure RarePersons ever infected (1.8%) 3.9 million (3.1-4.8)*Persons with chronic infection 2.7 million (2.4-3.0)*HCV-related chronic liver disease 40% - 60%Deaths from chronic disease/year 8,000-10,000*95% Confidence Interval2Estimated Incidence of Acute HCV InfectionUnited States, 1960-20010204060801001201401960 1965 1970 1975 1980 1985 1989 1992 1995 1998 2001YearNew Infections/100,000Decline intransfusion recipientsDecline in injection drug usersSource: Hepatology 2000;31:777-82; Hepatology 1997;26:62S-65S;CDC, unpublished dataPrevalence of HCV Infection by Prevalence of HCV Infection by Age and Gender, United States, 1988Age and Gender, United States, 1988--1994199401234566-11 12-19 20-29 30-39 40-49 50-59 60-69 70+Age in YearsPercent Anti-HCV PositiveMalesFemalesSource: CDC, NHANES III, NEJM 1999TotalExposures Known to Be Associated With HCV Infection in the United Statesn Injecting drug usen Transfusion, transplant from infected donor n Occupational exposure to blood– Mostly needle sticksn Iatrogenic (unsafe injections)n Birth to HCV-infected mothern Sex with infected partner– Multiple sex partnersReported Cases of Acute Hepatitis C by Reported Cases of Acute Hepatitis C by Selected Risk Factors, United States, Selected Risk Factors, United States, 19821982--2001*2001*010203040506070801982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2001YearPercentage of CasesInjecting drug useSexualHealth related workTransfusion* 1982-1990 based on non-A, non-B hepatitisSources of Infection forPersons With Hepatitis CSexual 15%Other 1%*Unknown 10%Injecting drug use 60%Transfusion 10%(before screening)* Nosocomial; iatrogenic; perinatalSource: Centers for Disease Control and PreventionOccupational 4%Reduce or Eliminate Risks for Acquiring HCV Infectionn Screen and test donorsn Virus inactivation of plasma-derived productsn Risk-reduction counseling and services– Obtain history of high-risk drug and sex behaviors– Provide information on minimizing risky behavior, including referral to other services– Vaccinate against hepatitis A and/or hepatitis Bn Safe injection and infection control practicesHCV Prevention and ControlMMWR 1998;47 (No. RR-19)3HCV Prevalence by Selected GroupsUnited States0 102030405060708090HemophiliaInjecting drug usersSurgeons, PSWsHemodialysisAverage Percent Anti-HCV PositiveGen population adultsMilitary personnelSTD clientsPregnant womenHCV Testing Routinely Recommendedn Ever injected illegal drugsn Received clotting factors made before 1987n Received blood/organs before July 1992 n Ever on chronic hemodialysisn Evidence of liver diseasen Healthcare, emergency, public safety workers after needle stick/mucosal exposures to HCV-positive bloodn Children born to HCV-positive women Based on increased risk for infectionBased on need for exposure managementPostexposure Management for HCVn IG, antivirals not recommended for prophylaxisn Follow-up after needlesticks, sharps, or mucosal exposures to HCV-positive blood– Test source for anti-HCV – Test worker if source anti-HCV positive• Anti-HCV and ALT at baseline and 4-6 months later• For earlier diagnosis, HCV RNA at 4-6 weeks– Confirm all anti-HCV results with RIBAn Refer infected worker to specialist for medical evaluation and managementHCV Counselingn Prevent transmission to others– Direct exposure to blood– Perinatal exposure– Sexual exposuren Refer to support groupPreventing HCV Transmission to Othersn Do not donate blood, body organs, other tissue or semenn Do not share items that might have blood on them– personal care (e.g., razor, toothbrush)– home therapy (e.g., needles)n Cover cuts and sores on the skinAvoid Direct Exposure to BloodHCV CounselingPersons Using Illegal Drugsn Provide risk reduction counseling, education– Stop using and injecting– Refer to substance abuse treatment program– If continuing to inject• Never reuse or share syringes, needles, or drug preparation equipment• Vaccinate against hepatitis B and hepatitis A• Refer to community-based risk reduction programsHCV Counseling4Mother-to-Infant Transmission of HCVn Postexposure prophylaxis not availablen No need to avoid pregnancy or breastfeeding– Consider bottle feeding if nipples cracked/bleedingn No need to determine mode of delivery based on HCV infection status n Test infants born to HCV-positive women– >15-18 months old– Consider testing any children born since woman became infected– Evaluate infected children for CLDHCV CounselingPersons with One Long-Term Steady Sex PartnerHCV CounselingSexual Transmission of HCVn Do not need to change their sexual practicesn Should discuss with their partner– Risk (low but not absent) of sexual transmission– Counseling and testing of partner should be individualized• May provide couple with reassurance• Some couples might decide to use barrier precautions to lower limited risk furtherPersons with High-Risk Sexual BehaviorsHCV CounselingSexual Transmission of HCVn At risk for sexually transmitted diseases, e.g., HIV, HBV, gonorrhea, chlamydia, etc. n Reduce risk– Limit number of partners– Use latex condoms– Get vaccinated against