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Dip GUM > Hepatitis C > Flashcards

Hepatitis C Flashcards

1
Q

What is the sexual transmission rate of HCV in heterosexual couples

A

Sexual transmission is extremely unlikely in heterosexual relationships
<0.1% /10years
rate increased if the index patient is HIV +ve

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2
Q

What factors are associated with an increased risk of sexual transmission of HCV

A 
HIV +ve source
presence of other STIs including syphilis and LGV
traumatic anal sex
fisting
sharing sex toys
communal lubricant
group sex
sero-sorting
 use of recreational drugs
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3
Q

Which asymptomatic patients should be screened for Hep C in the sexual health setting

A

Current or past injected drug users
HIV-positive individuals
MSM eligible for three monthly HIV testing
Blood product recipient pre-1991
Needlestick injury if donor HCV + or unknown
Sexual partners of HCV positive patients
Sex workers
Tattoo / piercing / acupuncture - where infection control inadequate
Migrants from high endemic countries (SE Asia, E Europe)
Alcoholics
Ex-prisoners

Patients with persistently abnormal LFTs for >3m

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4
Q

What test should be used to screen for HCV

A

anti-HCV antibody

or combined antibody/antigen test

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5
Q

window period for a positive HCV test after exposure

A

3 months + for anti-HCV test to become positive

the HCV antigen test has a much shorter window period

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6
Q

How often should hepatitis C testing be offered to patients eligible for it?

A

at least annually

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7
Q

Advice for reduction of risk of Hep C

A 
Safer sex (although low risk of transmission from sex) 
Safer injecting practices - incl not sharing any paraphernalia
Needle exchange schemes
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8
Q

How often should HIV+ patients be screened for Hep C

A

at HIV diagnosis

and every year thereafter

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9
Q

How often should patients be screened for Hep C who have self-cleared or been successfully treated for Hep C

A

annually

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10
Q

Management of a patient found to have acute hepatitis C?

A

Reassure it is treatable
Refer to a specialist centre for assessment, monitoring
and treatment
Four-weekly HCV RNA quantitation
Consider treatment if viral load does NOT reduce by at least 2 log10 by week 4 or those who remain positive at week 12
avoid UPSI
Avoid donating blood, semen or organs
PN
Contact tracing of needle sharing partners
Contact tracing of sexual contacts if patient is also HIV+
Notifiable disease

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11
Q

What % of patients diagnosed with HCV clear the virus in 2 - 6 months

A

20% clear the virus in 2-6 months

45% of all young healthy patients will clear the virus

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12
Q

Of the 80% of patients who do not spontaneously clear HCV infection, what % never develop liver damage or symptoms

A

20%

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13
Q

What % of patients diagnosed with HCV will develop long term symptoms /signs of liver inflammation

A

up to 60%

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14
Q

What % of patients with HCV will develop liver cirrhosis

A

16% develop cirrhosis - over 20 years

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15
Q

What % of patients with HCV will develop liver hepatocellular carcinoma?

A

1 - 2 %

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16
Q

What factors influence HCV progression

A

􏰀 Increased alcohol consumption
Older age
Gender - male􏰀
Co-infection with HIV or hepatitis B

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17
Q

Management of a patient with chronic hepatitis C?

A

Refer to hepatology for:

  • disease monitoring
  • liver cancer screening
  • consideration of treatment with Directly Acting Antivirals

Contact tracing = 2 weeks before jaundice / 2 weeks before suspected time of acquisition
Advise to disclose to new sexual partners
Arrange hep C screening for children born to HCV+ women
Screen for Hep A + B + vaccinate

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18
Q

How does HIV infection affect response to treatment for Hep C

A

HIV positive patients respond to treatment with DAAs as well as HIV- negative patients

bear in mind drug-drug interactions between DAAs and antiretroviral therapy

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19
Q

Advice for patients with chronic Hep C regarding sexual transmission risks

A

Advise condom use for patients with chronic HVC

very low rates of transmission outside of HIV co- infection = HIV -ve monogamous partners may choose not to use condoms

Advise sexual contacts with HIV of the risk of sexual transmission + regular testing + encourage condom use

Advise all MSM to use condoms / gloves for fisting / single person sex toys / not share lube + avoid group sex

20
Q

Management of a patient presenting as a contact of Hepatitis C

A

Screen for evidence of past / current HCV infection

Discuss sexual transmission - low rates of transmission outside of HIV co-infection, reduce risk with condom use

No available vaccine
No immunoglobulin preparation

21
Q

What is the aetiology of Hep C

A 
Single stranded
Enveloped
RNA virus 
in the flaviviridae family
Endemic worldwide

Most (90%) due to infection with genotypes 1 and 3

22
Q

Prevalence of Hep C in the UK

A

~1%

23
Q

Prevalence of Hep C in N. Africa / Middle East

A

~4%

24
Q

Mode of transmission of HCV in UK

A

Most = Parenteral

  • shared needles/syringes
  • transfusion of blood or blood products (pre1 990s),
  • re-use of needles in healthcare / tattoos / acupuncture
  • renal dialysis
  • needlestick injury
  • sharing a razor
  • sharing straws and notes for snorting recreational drugs

Sexual transmission extremely unlikely in heterosexual relationships (<0.1% /10years)
rate increases if HIV co-infected

Vertical occurs at a low rate (about 5%)
but higher rates (7%+) if woman HIV co-infected

25
Q

Risk factors for HCV

A

Associated factors

  • presence of STIs
  • HIV +ve
  • traumatic anal sex
  • fisting
  • sharing sex toys
  • communal lubricant
  • group sex
  • sero-sorting
  • use of recreational drugs
  • sex workers
  • current / former prisoners
  • people from highly endemic countries
  • tattoo recipients
  • people who inject steroids
  • people who snort cocaine
  • alcoholics
26
Q

Incubation period for HCV

A

4 to 20 weeks

27
Q

How long does HCV serology take to become +ve after exposure

A

3 months after exposure in 90% - for antibody test
can take as long as 9 months

2 weeks for HCV- RNA

28
Q

Impact of HIV on the appearance of HCV antibodies

A

may be significantly delayed

29
Q

What proportion of patients with HCV are asymptomatic

A

> 60%

30
Q

Complications of Acute Hepatitis C

A

<1% - acute fulminant hepatitis

50-85% become chronic carriers

31
Q

What % of patients spontaneously clear acute Hep C

What % spontatnouesly clear chronic Hep C

A

Spontaneous clearance = 15% of acute Hep C

Spontaneous clearance = 0.02% per year for chronic Hep C

32
Q

What makes symptoms / signs of Hep C worse?

A

high alcohol intake

other liver disease

33
Q

Complications of chronic Hepatitis C

A

cirrhosis (5-20% after 20 years)
hepato-cellular carcinoma (after 30 years)
acute liver failure - requiring liver transplantation
death

treatment-related hepatitis B reactivation
rheumatological complications
skin lesions include porphyria, cutanea tarda and lichen planus
cryoglobulinaemia
glomerulonephritis
keratoconjunctivitis sicca (dry eyes)
Mooren ulcer (a rapidly progressive, painful ulceration of the cornea)

34
Q

Diagnosis of Acute Hep C infection

A

HCV- RNA positive

Anti-HCV negative

35
Q

Diagnosis of chronic Hep C infection

A

HCV RNA assay is positive 6 months after the first positive test

36
Q

Further investigations for patients diagnosed with Hep C

A

Screen for STIs
Assess liver fibrosis - Hepatic elastography (e.g. fibroScan)
+/- liver biopsy
Liver ultrasound

37
Q

Goals of HCV treatment

A

cure HCV infection
reduce the progression of liver fibrosis / decompensation of cirrhosis / hepatocellular carcinoma and
extrahepatic manifestations

38
Q

How is HCV cure defined

A

negative HCV RNA in blood 12 weeks after completion of

HCV treatment

39
Q

When should treatment be considered in acute Hep C

A

do 4- weekly HCV RNA quantitation

Treat if there is:
< 2 log10 decline in HCV RNA at week 4
or HCV RNA remains positive at week 12,

• Patients should be referred to a specialist centre for monitoring and treatment and access to clinical trials (1A) [183, 184]. See algorithm below for the management of Acute HCV (NEAT algorithm) (1A) [184].

40
Q

Effect of treatment given in acute Hep C

A

Treatment given during the acute phase of Hep C reduces progression and will reduce the rate of chronicity

acute phase treatment has significantly higher success rates than treatment in the chronic phase

41
Q

How do direct acting antivirals work>

A

DAAs target HCV non-structural proteins to prevent viral replication

Current DAAs target

  • NS3/4A protease inhibitors (simiprevir / ritonavir boosted ombitasvir / grazoprevir / glecaprevir)
  • NS5A (ledipasvir, daclatasvir, ombitasvir, velpatasvir, elbasvir, pibrentasvir)
  • NS5B inhibitors (sofosbuvir, dasabuvir).
42
Q

How can vertical transmission be reduced from a HCV +ve mother

A

No clearly demonstrated intervention to reduce HCV transmission from mother-to-child

Ribavirin is teratogenic

Treatment of HCV in pregnancy is not recommended

Inform women of small risk of transmission in pregnancy

Breast feeding - is no firm evidence of additional risk of transmission

43
Q

Advice for patients treated with ribavirin for HCV

A

Strict use of contraception - by both men and women
during treatment and for 6 months after

Avoid any alcohol - as little as 140 g weekly can triple the rate of cirrhosis

Paracetamol is not restricted, except in people with cirrhosis, where a maximum 2 g/day is safe

Caution when taking new drugs including OTC - may interact with antiviral therapy

44
Q

Why are Interferon based regimens no longer advised for treatment of HCV

A

oral DAAs are now considered first-line therapy.

Up to 30% of hepatitis C-infected patients receiving interferon therapy develop major depression.

45
Q

Management of a neonate born to a mother with confirmed HCV

A

Test baby for HCV RNA NAAT at 2-3 months of age
If reactive - reported as “Evidence of HCV infection.”
- Repeat HCV RNA NAAT at 6 months of age

If non-reactive - reported as “Infection with HCV unlikely.”
- Advise anti-HCV testing at 12-18 months of age

+ Hep B vaccination
+/- HIV testing

46
Q

Factors increasing HCV vertical transmission rate

A

HIV-HCV co-infection = increased 3 to 4 fold

prolonged rupture of membranes

47
Q

Risk of HCV transmission via breastfeeding

A

Rare

Dip GUM (27 decks)

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