# Presentation: 040750

## Welcome To The Hepatitis C Education Class

## Topics Of The Class

- Your liver
- Types of hepatitis
- How hepatitis C is spread
- How to protect your liver
- Treatment for hepatitis C

## Common Feelings When Learning About Hepatitis C

- Sadness
- Guilt
- Anger
- Fear
- Anxiety

**Notes:**
Sadness or Depression:
Get involved with a support group
Spend time with supportive people
Talk with your doctor about medicine for depression

Anger:
Talk about your feelings with others
Try to get some exercise to relieve some of the tension
Avoid situations or triggers that cause you to feel angry or stressed. 

Fear and Anxiety:
Learn as much as you can about hepatitis C
Join a support group
Talk with your doctor about medicines for anxiety

## What Is The Liver?

- Makes chemicals that your body needs to stay healthy
- Removes waste products and other harmful substances from your blood
- Guards against infection

**Notes:**
One of the largest and most important organs in the body.  

Right side of the body behind the lower right part of the rib cage

Size of a “football”

Acts as a filter to clean blood

The liver is a toxic waste station.  It breaks down what we take in.

Most of the substances in our bodies have been through the liver at some point 

## The Liver Is A Factory

- Builds and converts proteins and sugars
- Stores vitamins, hormones, minerals
- Releases chemicals and nutrients into the body when needed.

## What Is Hepatitis?

- “Hepatitis” means swelling of the liver
- Can be caused by:
- Genetic diseases
- Medications (including over-the-counter)
- Alcohol
- Hepatitis Viruses (A,B,C,D,E)

**Notes:**
Many things can cause hepatitis.  

With hepatitis C you need to be careful not to do anything that will irritate your liver

With hepatitis the liver enzymes are usually elevated and the liver can become enlarged

## What Are Liver Enzymes?

- Chemicals that your liver uses to do its work
- Healthy liver:
- the number of enzymes in your blood is normal
- Unhealthy Liver:
- the number of enzymes can be higher than normal

**Notes:**
AST (SGOT) and ALT (SGPT) are sensitive indicators of liver damage.But it must be emphasized that higher-than-normal levels of these liver enzymes should not be automatically equated with liver disease. They may mean liver problems or they may not. 

A patient may have normal liver enzymes levels but have liver damage.  

Liver enzyme levels do not tell us what is going on in the liver.  

## Hepatitis A

- Spread through contaminated food and water
- Vaccine available to prevent hepatitis A

*A*

**Notes:**
Most people infected with the hepatitis A virus get well within six months.  

Does not result in long-term (chronic) infection

Can be very serious for older people and people who already have liver disease.  

If someone is hepatitis C positive and gets hepatitis A there is a larger chance of making their hepatitis C worse.  

Those with hepatitis C should be vaccinated against hepatitis A.  The vaccine is given in two shots.  The first shot should be followed by a second shot 6 months to a year later.  The vaccine is good for 20 years. 

A common question is, "If I've got hepatitis C, can I get either hepatitis A or B?"  The answer is, "yes".  That is because they are spread in different ways and affect your liver in different ways.  But all types of hepatitis can harm your liver. 

## Hepatitis B

- Spread through blood-blood contact
- Also transmitted through sex.
- Vaccine available to prevent hepatitis B.

*B*

**Notes:**
Most people who get hepatitis B can get rid of the virus on their own, but others can develop chronic hepatitis B.  

Usually does not result in long-term (chronic) infection.

May not have any symptoms.

Those at risk for getting hepatitis B should get vaccinated.  The vaccine is given in 3 shots.  A single shot followed by a second shot one month later, and then a third shot six months later.  The vaccine will protect you for about 13 years. 

## Hepatitis C

- Identified in 1989; Blood test became available in 1992
- Used to be known as “non-A, non-B” hepatitis
- Spread through contaminated blood
- No vaccine available to prevent hepatitis C.

*C*

**Notes:**
Important to stress the fact that HCV does not always have symptoms.  Can feel healthy for 10-20 or more years before developing symptoms.  Patient can be asymptomatic but have hepatitis C.

Symptoms are often very mild, but liver damage can occur without symptoms

No vaccine is available for hepatitis C, but researchers are working hard.  The virus mutates quickly making it difficult to make a vaccine.  

## Hepatitis C

- About 3 million Americans infected
- About 170 million infected worldwide
- Many do not experience symptoms

**Notes:**
4 times more common than HIV

Fewer people are transmitting HCV now compared to 20-30 years ago.  

About 30,000 more become infected each year

## Who Should Be Tested For Hepatitis C

- People with risk factors for hepatitis C
- Those who wish to be tested
- Some VA hospitals test ALL veterans

## How Do People Become Infected With Hepatitis C?

- Blood Products
- Blood transfusions before 1992
- Other blood products before 1987
- Current transfusions no longer a major risk factor
- Injection (IV) Drug Use – 60% of all new infections

- High Risk:

## How Do People Become Infected With Hepatitis C?

*Snorting Cocaine or other drugs*
- Occupational Exposure
- Body Piercing & Acupuncture with unsterilized needle
- Tattooing

- Lower Risk:

## How Do People Become Infected With Hepatitis C?

- From pregnant mother to child (about  <5%)
- Non-sexual household contacts (rare)
- Sharing razors and/or toothbrushes
- Sexual Transmission
- Low risk in monogamous relationship (<5%)
- Unknown (10%)

- Lower Risk:

## What About Sex?

- Sexual transmission is not very likely, _BUT_ it is still possible* *
- If you have more than one sex partner, use latex condoms
- If you have one long-term sex partner, you do not necessarily need to change your sex habits
- Long-term is considered 5 years or longer

## Hepatitis C Is NOT Spread By:

- Sneezing
- Coughing
- Food or Water
- Sharing Drinking Glasses or Eating Utensils

- Handshakes
- Holding hands
- Hugging
- Kissing on the Cheek
- Playing with Children
- Donating Blood

**Notes:**
Emphasize:
Saliva, sweat and tears cannot spread the virus.  Remember blood-to-blood.

Do not need to sterilize household items such as kitchenware and utensils.  

HCV + person should not be restricted in work or home, or in social activities or settings.  

Donating blood:
Cannot get HCV from donating blood, but can get it from receiving blood that someone else donated. 

## How Can I Prevent The Spread Of Hepatitis C?

- Cover open wounds
- _Tell people not to touch your blood_
- Clean blood spills yourself or inform others to use latex gloves
- Dispose of needles/materials properly
- Do not inject drugs

**Notes:**
Around the house, cover cuts and sores; clean up blood spills with bleach solution; properly dispose of needles

Good idea to have latex gloves at home or in the car.  

How long can hepatitis C live outside of the body?
We don’t know.  We do know that hepatitis C can leave outside of the body longer than HIV. 

Will bleach, hot water, or alcohol kill the HCV on my needle or razor?
No, bleach, hot water, or alcohol cannot kill the HCV on a needle or razor.  

How do I sterilize my needle or razor?
A medical autoclave can sterilize a needle or razor.  

If I have HCV and I share my equipment or works with someone else who has HCV can my HCV be made worse?
We do not know, however, we have no reason to think that it would. 

## How Can I Prevent The Spread Of Hepatitis C?

- _Avoid sharing contaminated articles_
- Razors, toothbrushes, or other personal care items.
- Inform health care professionals/others
- Do not donate blood, body organs, tissues or semen.
- Practice safe sex

## How Will I Know If I Have Hepatitis C?

- Many people have _no symptoms_ of the virus
- If you do have symptoms:
- The only way to know if you have hepatitis c is to have a blood test

| • Fatigue | • Discomfort in the liver area |
| --- | --- |
| • Loss of appetite | • Aching joints |
| • Trouble sleeping | • Depression |

**Notes:**
You may be surprised to hear that you’re HCV + because you feel great or you might have mistaken your symptoms for something else. 

Symptoms may come in cycles

Some find out they’re HCV + by the results of a series of tests to determine why they’re so tired.  

Some may find out when they donate blood.  The Red Cross will contact them to inform them that they cannot use their blood because their blood tested positive for HCV.  

If I have an infection in my liver shouldn’t I be showing symptoms?
Not necessarily, the symptoms can sneak up on you.  

Can discomfort in the liver be sharp, shooting pains?
Yes.

## How Is Hepatitis C Diagnosed?

- Blood Testing
- Hepatitis C Antibody test
- Hepatitis C PCR test to find virus in blood
- Liver Function Tests

## What Is My Hepatitis C Genotype?

- 6 different genotypes of hepatitis C:
- Like different breeds of dog
- Genotype 1:
- most common in U.S.
- hardest to treat
- Genotypes 2 & 3:
- less common
- easier to get rid of

## Why Should I Be Concerned About Hepatitis C?

- Hepatitis C may cause serious problems in some patients
- Fibrosis
- Cirrhosis
- Advanced liver disease
- Hepatocellular carcinoma

## Fibrosis

- The beginning of scarring
- Caused by infection, swelling, or injury
- Can prevent the liver from working well
- Can lead to cirrhosis

**Notes:**
“The progression of fibrosis in chronic hepatitis C determines the ultimate prognosis and thus the need and urgency of therapy.”

There are four stages: 1 – 4.  4 being more severe

“The rate at which fibrosis progresses varies markedly between patients. The major factors known to be associated with fibrosis progression are older age at infection, male gender, and excessive alcohol consumption. “

 22. P Marcellin and others. Fibrosis and disease progression in hepatitis C Hepatology 36(5): S47-S56. November 2003, part 2. 

## Cirrhosis

- Pronounced “sir-o-sis”
- Means “scarring of the liver”
- At risk for liver failure and liver cancer
- Requires close medical follow-up

## Advanced Liver Disease

- Fatigue
- Difficulty thinking clearly or concentrating
- Yellow jaundice
- Swelling
- Fluid in the abdomen
- Gastrointestinal bleeding
- Poor blood clotting

**Notes:**
Results from long-term advanced liver disease

Does not occur in every patient and does not develop over night 

Swelling (edema)

Fluid in the abdomen (Ascites)

## Hepatocellular Carcinoma

- Most common type of liver cancer
- Chronic hepatitis C increases the risk
- Treated with surgery, medications or liver transplant

## Liver Transplant

- May be needed for patients who develop liver failure or liver cancer
- About 50% of all U.S. liver transplants result from liver damage caused by hepatitis C
*Most patients with hepatitis C will *_*never*_* need a liver transplant*

**Notes:**
Patients with cirrhosis or liver cancer may have liver failure and will need a liver transplant.

The transplant is very stressful on the body.  Only considered when the patient might die from liver disease.  Does not mean the patient is in danger of dying right away. 

For more information refer to reference 13

## What Happens To People With Hepatitis C Virus?

**Notes:**
Chronic disease means that the person will carry the virus in their blood long-term.

No chronic disease means that the person will not carry the virus in their blood long-term, but will still have the antibodies in their blood. 

## How Will I Know If I have Problems from Hepatitis C?

- Ultrasound and CT Scan
- Useful for finding masses or tumors in the liver (but not fibrosis)

**ULTRASOUND**

**CT SCAN**

**Notes:**
Can reliably detect cirrhosis, fatty infiltration and enlargement associated with inflammation.  

Can detect fluid, cysts, tumors or abscess in the abdomen or liver. 

Can determine if the liver is shrunken or swollen.

## How Will I Know If I have Problems from Hepatitis C?

- Liver Biopsy
- Only way to determine the amount of scarring
- Small risk of complications and very few side effects
_***Need to be free of alcohol and street drugs***_

**Notes:**
A liver biopsy will help you and your doctor find out more about the health of 
your liver and can help you decide when to start treatment. 

Patients who are interested in treatment need to have a liver biopsy.  

Why do I need to be off alcohol and street drugs?
If we get a liver biopsy of somebody who has been drinking recently, it is going to be hard to tell how much of the inflammation or irritation in the liver is really hepatitis C, and how much is from the alcohol. 
Can I be tested for liver scarring without having a liver biopsy?
The only sure way to tell how much scarring your liver has is to have a liver biopsy.
Can I begin treatment without having a liver biopsy done?
We prefer to have a liver biopsy performed before we start treatment, but there are exceptions.  	
Does the liver biopsy hurt?
Generally no.  Patients describe it as a sharp pinch.  
Can I have a liver biopsy done without being sober?
We prefer that the patient be off drugs and alcohol for six months before we perform a liver biopsy. 

For more information refer to reference 10

## What About Alcohol?

**Chance of Getting Cirrhosis**

## Those With Hepatitis C Should.....

_*Avoid All Alcohol*_
- Be careful with all medications, including over the counter and herbal medications
- Tell all health care providers that you have hepatitis C

**Notes:**
We don’t know what a “safe” amount of alcohol is for patients with hepatitis C. 

Remember, even “non-alcoholic” drinks have a certain amount of alcohol in them (i.e. Near Beer)

Can alcohol and/or smoking cause or transmit HCV?
No, drinking alcohol and/or smoking cannot cause or transmit HCV.  Remember blood-to-blood contact.  However, we do see a lot of HCV patients who are heavy drinkers, but do not have other risk factors.  We cannot explain this yet.  We rely on people telling us their current and past behavior.  As for smoking, a patient with HCV can develop more scar tissue and advance to cirrhosis faster than a non-smoking patient with HCV. 

Alcohol and smoking have been proven in scientific studies to absolutely cause further damage to your liver. 

For more information refer to reference 15 & 16

## Those With Hepatitis C Should.....

- _Take care not to spread hepatitis C to others_
- Be vaccinated for hepatitis A and hepatitis B
- Consider seeing a hepatitis C specialist to discuss treatment

**Notes:**
Get vaccinated for hepatitis A and B (having hepatitis C does not mean that you cannot get other kinds of hepatitis)

Avoid weight gain

## Which Medications Are Safe?

- Tylenol (acetaminophen):  No more than four extra strength or five regular strength per day
- 1⁄2 recommended dose on bottle
- Motrin (ibuprofen) and other non-steroid anti-inflammatory medications
- Hepatitis C patients _without_ cirrhosis may take the recommended dose on bottle
- Hepatitis C patients _with_ cirrhosis should _NOT_ take any

**Notes:**
What is it about ibuprofen that can cause liver problems?
In general, certain medications in the right doses, in the right person can cause severe problems.  In terms of ibuprofen, one of the chemical ends is toxic to the liver.

What about aspirin?

## Which Medications Are Safe?

***Iron supplements not recommended***
- They may increase the rate of liver scarring
- Milk thistle is safe, _BUT_ not shown to improve liver disease.
- Herbal Medicine

**Notes:**
Is iron in my vitamins and supplements okay?
Dietary iron is fine, however, try to take a multi-vitamin or supplements without iron. 

 For more information refer to references 17, 18, & 19

## Treatment Of Chronic Hepatitis C

## Goals Of Treatment

- Clear all the hepatitis C virus from the body
- Slow or stop damage to the liver
- Help someone who has hepatitis C to feel better

**Notes:**
Primary goal is to clear the virus.  You will still need to be followed your M.D.

You can relapse, or be a non-responder to treatment.

Throughout your treatment you will be monitored by labs that will screen your blood for hepatitis C viral load and serologies.  

## What Treatment Is Available?

- Interferon
- Given by shot, usually 3 times a week
- _NEW:  Pegylated Interferon_
- Long-acting, taken once a week
- Combination therapy
- Interferon (standard or pegylated) taken with Ribavirin
- Ribavirin is a pill taken twice daily

## Does It Work?

- Interferon Alone:
- 10 – 15% response
- Interferon & Ribavirin:
- About 40% response
- Pegylated Interferon alone:
- About the same as Interferon & Ribavirin 40%
- Pegylated Interferon & Ribavirin:
- About 50% chance of response* *

## During Treatment

- Medications taken for either 6 or 12 months
- Blood testing required 2 to 3 times the first month, then every 4 weeks
- Clinic visits every 1 month
- _Interferon must be refrigerated_
- We must have a way to contact you

**Notes:**
Length of treatment depends on genotype and response to medications during treatment.

## Side Effects OfInterferon & Ribavirin

- Flu-like symptoms
- Headache
- Fatigue
- Muscle & joint aches
- Fever, chills

- Psychiatric symptoms
- Depression
- Difficulty sleeping
- Difficulty concentrating
- Irritability

- Common Side Effects:

**Notes:**
Side effects are how most people with hepatitis C feel everyday but worse.  You may have several side effects from the medications used to treat HCV, but side effects can be dealt with effectively in many ways
.
IFN and ribavirin each have their own set of side effects.  We don’t know whose going to get which side effects.  It’s completely variable, on average you get 2-3 side effects

These are the common side effects seen, but these can vary between individuals.
Flu-like symptoms - These tend to occur in the first few weeks of therapy and many are manageable.

Mood changes can sometimes occur late in therapy and should be constantly monitored.

Depression and mood disorders must be under control before treatment. Your physician & health care provider will refer you to a professional if needed, and work closely with that person during your course of treatment.  On treatment, depression and other mood disorders can occur because of a direct response to the medication on your levels of serotonin in your brain.

To treat the side effects:
Fatigue - regular light exercise, get a good night sleep, manage stress
Mood changes/sleeplessness - relaxation exercises, support systems, discuss meditations with physician.

## Side Effects Of Interferon & Ribavirin

- May occur from the beginning:
- Upset stomach, diarrhea
- Decreased blood counts
- Skin irritation from shots

- Do not occur right away:
- Hair loss
- Weight loss
- Thyroid problems

- Less Common Side Effects:

**Notes:**
Nausea, vomiting, diarrhea, poor appetite
Try to eat small meals, choose nutritious foods, and drink plenty of fluids to help these symptoms.

Weight loss
Most patients are happy about this. 

Hair loss
Is reversible
Wear hats/scarves
Use mild hair products

## Disadvantages of Treatment 

- Side Effects
- Other medical conditions can be made worse
- Patients with severe mental health problems cannot be safely treated
- Ribavirin can cause severe birth defects if either parent is taking the medication
*Two forms of reliable birth control required*

**Notes:**
Interferon is not for everyone.  

Alpha interferons in treatment, cause or aggravate fatal or life-threatening neuropsychiatric, autoimmune, ischemic, and infectious disorders.  Patients should be monitored closely with periodic clinical and laboratory evaluations.  

The ribavirin pills can cause birth defects if either parent is taking the medicine.  Patients taking ribavirin need to use two forms of birth control if there is any chance of conceiving a child.  No attempts to conceive should be made during treatment or for six months after. 

Can I be treated if I’m already being treated for depression?
Yes, however, we may need to monitor you more closely during treatment. 

## Before Starting Treatment

- Be a good treatment candidate
- Have a financial plan and a social support network in place
- Avoid or plan for major life events during treatment
- Consider mental health issues

**Notes:**
Patients must be reliable in taking their medications every day.  Missed doses of either interferon or ribavirin decreases the effectiveness of treatment. 

Patients must be reliable in keeping their clinic appointments.  Your doctor needs to see you in clinic every month to closely monitor your condition and changes to your treatment plan as needed. 

Some patients may not be able to work their normal schedule during treatment so we prefer patients to be financially stable before they start treatment.  

The side effects of the medication can greatly worsen a person’s quality of life, or even make them a danger to themselves so it’s important to have a social support network in place to help the patient deal with the possible depressive side effects of the medication.  Also, a patient that already has mental health issues should be followed closely during treatment because the medication could worsen their condition. 

## Plan And CommitTo Your Therapy

- Individual treatment plan with provider and health care team
- _Must be reliable in taking medications and keeping appointments_
- Start a diary including problems and medications
- Write questions down

**Notes:**
It is very important to plan and commit to your therapy.  Remember to be proactive and discuss your individual treatment plan with your healthcare team

To help you remember to take your medications and keep track of things:
Use diaries, calendars and pillboxes
Organize your medication together in one place
Take your medicine at the same time each day
Take your medicine as directed by your physician

Committing to treatment includes:
Time and effort
Coming to all of your appointments
Getting all your blood tests
Never running out of your medicine
Routinely discussing the progress of your treatment with your physician & health care team

Maintaining a positive attitude is very important
Stay busy
Have fun
Don’t put your life on hold

## Alternative Therapies

- Herbal or Naturopathic remedies:
- WARNING:  Use herbal remedies, supplements, vitamins and other “natural” medicine carefully.
- Always check with your doctor
- See an expert
- Beware of false promises

**Notes:**
AVOID any alternative medicine that is not available in the United States or that costs a lot of money.  

Be sure to ask your health care provider before taking any herbs, supplements, or “mega” vitamins.  Just because a medicine says it is “natural” does not mean it is safe. 

## Complimentary Therapies

- Aromatherapy
- Massage therapy
- Meditation and visualization
- Yoga

**Notes:**
Aromatherapy is based on the idea that certain smells can change the way you feel. People use it to reduce stress or to help with fatigue.

Meditation and visualization are common tools people use to cope with pain and stress. 

Yoga is an ancient set of exercises that is often combined with meditation. It helps may people improve their fitness, reduce stress, and increase their flexibility. 

## Living With Hepatitis C

- Maintain a healthy life outlook
- Live your life!

## Education & Resources About Hepatitis C

- VA Hepatitis C Website
- www.va.gov/hepatitisC
- Centers for Disease Control & Prevention
- 1-888-4 HEPCDC
- www.cdc.gov/ncidod/diseases/hepatitis
- National Institutes of Health
- http://health.nih.gov
- Support Groups

**Notes:**
Getting educated is a very important part of learning to deal with side effects associated with HCV Treatment

There are several ways to get educated, including support groups, educational materials and the media.

## Acknowledgements

- The VA Hepatitis C Resource Center Program      and National Hepatitis C Program Office, Veterans Health Administration, U.S. Department of Veterans Affairs
- Creative Design by Meaghan Splan, MPH
- Editing by John Davison, MBA, PhD

## Thank You for Attending Class

## Slide 53