Treatment and Prevention of Hepatitis C in Adult Population - Essay Example

Community Assessment for Treatment and Prevention of Hepatitis C in Adult Population Inserts His/Her Inserts Grade Course Customer Inserts Tutor's Name 14 July 2008 Community Assessment for Treatment and Prevention of Hepatitis C in Adult Population Hepatitis C is the most common blood-borne viral illness in the United States and Hepatitis C virus (HCV), first identified in 1989, is a leading cause of chronic liver disease, and ultimately death from cirrhosis, and hepatocellular carcinoma. It is most prevalent among injection drug users, particularly homeless adults, and further spread of infection occurs through new injection drug users who share infected injection equipments, because HCV is more transmissible by blood. With the increased awareness and advancement in research, involving human immunodeficiency virus (HIV) epidemic, clinical expertise exists for the prevention and management of chronic viral disease like HCV among injection drug users, since mode of infection and behaviour of vulnerable population for both HIV and HCV contagion are identical. Since the transmission of HCV is similar to HIV and IDU is the primary risk factor for HCV infection, and coinfection of these two blood borne diseases cause morbidity and mortality, harm reduction approach and the strategies that addresses the social and economic harms that impact an individual, community, or society are paramount in preventing the epidemic. Prevalence of Hepatitis C Hepatitis C is the major cause of chronic hepatitis, cirrhosis, and liver cancer in the United States and the identification of Hepacivirus of the family Flaviviridae in 1989 led to an explosion of research and development of specific tests for detecting anti-HCV and HCV RNA as well as recognizing it as a common cause of chronic liver disease. (Chapter 5: Viral Hepatitis, p. 61). According to WHO estimates there are "about 180 million people, some 3% of the world's population, are infected with hepatitis C virus (HCV), 130 million of whom are chronic HCV carriers at risk of developing liver cirrhosis and/or liver cancer" and three to four million persons are newly infected each year, making HCV a "viral time bomb". It is also estimated that 3.9 million Americans are infected with HCV, with 'prevalence rates as high as 8-10% in African Americans'. The route of HCV transmission is mainly through injectable drug use that account for nearly 90% of new infection, as well as through blood transfusion and perinatal infection. (WHO2). (Initiative for vaccine Research (IVR). 2008). It is estimated that there are 1-2 million homeless youth in the United States and a national study of homeless youths found that "68% are 15-17 years old; 57% are Caucasians; 17% African American; 15% Hispanic; and 12% from other ethnic origins" (Nyamathi et al, 2005). It is found that approximately 16-25% of those infected with HCV are co-infected with HIV, and due to shared risk factors HIV/HCV co-infection is common among homeless and urban poor. Edlin & Carden (2006) argue that though HCV is four times more prevalent than HIV infection and viral transmission is uncontrolled among IDUs with 'incidence rates ranging from 16% to 42% per year' the efforts of the US government to "control this pandemic have largely ignored the population in whom its biology and epidemiology are being played out with the most devastating effects." (Edlin & Carden, 2008). The Disease: Its detection and symptoms Hepatitis is an inflammation of the liver and its symptoms include jaundice, dark urine, extreme fatigue, nausea, vomiting, and pain. There are five major types of hepatitis viruses, named A, B,C, D, and E type, of which A and E are caused by ingestion of contaminated food or water, and "hepatitis B, C, and D usually occur as a result of parenteral contact with infected blood fluids." (Hepatitis. 2008). HCV infection is categorized into acute and chronic and specific symptoms in the acute stage are nausea and vomiting, fatigue, loss of appetite, fever, head ache, and abdominal pain and may not present jaundice, although jaundice can sometimes occur along with dark urine. The incubation period of HCV varies from '2-26 weeks' and the infected person may lead normal life in the absence of specific symptoms. (Diagnosing and treating hepatitis, 2003). HCV infection can be determined by specific blood tests, which is not a part of routine physical, to detect HCV antibodies and liver enzyme measure. As HCV antibodies may not be detected for 5-12 months in some individuals, and "over 80% of HCV infection become chronic" an "HCV-RNA and RT-PCR tests" shall be more appropriate to determine HCV presence within 1-2 weeks of contact with an HCV suspected person or equipment. A liver biopsy should be used to identify type and degree of liver damage in chronic cases, because the presence of elevated enzymes "alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels may appear and disappear throughout the course of infection and they do not reliably predict the severity of the liver injury." (Diagnosing and treating hepatitis, 2003). Major outcomes of HCV infection are: (1) infection may spontaneously resolve during the acute phase and never progress to chronic infection; (2) infection may become chronic without medical complications or end-organ disease; or (3) infection may become chronic, with progressive medical complications, such as cirrhosis, hepatocellular carcinoma, or end-stage liver disease. It is pointed out that "the long period of clinical latency before chronic HCV infection causes severe liver disease and the low but variable proportion of infected persons who will develop severe liver disease make it impossible to predict the clinical sequelae of untreated HCV infection in any particular individual", which complicates the assessments of the benefits of treatment ((Edlin et al, 2005). It is alarming to note that the "projected costs of the current HCV epidemic will be over $85 billion for the year 2010 through 2019" and "HCV related deaths in the U.S. is expected to triple by 2019." For achieving the goal for a reduction of hepatitis cases among high-risk adults by 75 percent, set under Healthy People 2010, concerted effort to identify risk factors and check the prevalence of HCV epidemic is indispensable. (US department of health and human services, 2007). Injecting drug use and HCV transmission Injecting drug use and blood-borne viral infections, like HIV, HBV, and HCV, are interlinked as viral infection is transmitted to uninfected IDUs through the use of injection equipment that has been used by an infected person. The transmission of HCV is similar to HIV and IDU is the primary risk for HCV infection. In addition to IDUs, using razors, needles, barber's scissors, tattooing and body piercing equipment, etc., that are contaminated by blood of infected person may transmit HCV to unsuspecting population. It is also evidenced that "health care workers have a 2% risk of acquiring HCV after a needle stick contaminated with HCV-positive blood. The increased awareness of HIV epidemic and research evidence establishing the risks of disease transmission through sharing of injection syringes and equipments have prompted new initiatives and prevention programs aimed at reducing needle sharing, which indirectly assisted in containing the HCV transmission The change in blood supply policy, for thorough virus screening before blood transfusion, has checked the mode of blood transfusion associated HCV transmission, but the mode of transmission has now shifted to shared unsterilized IDU equipments. The introduction of needle exchange and other HIV prevention interventions for IDUs have shown that the "prevalence and incidence of HCV infection among young IDUs and recent initiatives have declined substantially" (Edlin et al, 2005). However, researchers point out that compared to HIV infection prevention among IDUs very little advances has been made in preventing HCV, through implementation of harm reduction programmes. The policies and programs that aim to reduce the harms associated with non-prescription drug use, such as HIV and HCV transmission, is known as harm reduction approach and the strategies addresses the social and economic harms that impact an individual, community, or society. Harm reduction initiatives like needle exchanges, community based outreach, and methadone programs aims to prevention of drug related harm, which expose people to risk of HCV infection. HCV-HIV coinfection Though debate on relation between HCV infection and unprotected sexual contact still abound and 'sexual transmission of HCV is uncommon', hepatitis C in the HIV infested population is a significant cause of morbidity and mortality. According to Hahn (2007) "Sexual transmission of HCV may occur more readily in the presence of biological cofactors, such as high risk sexual contacts of STIs that traumatize the anal or genital mucosa or behaviours that lead to blood-blood contact." (Hahn, 2007). McNelis (2006) opine that "because of the shared routes of transmission, hepatitis C virus (HCV) coinfection in HIV-infected individuals has emerged as a significant and somewhat common opportunistic infection." (McNelis, 2006). The immune system of a patient infected with HIV will naturally get breached and coinfection of HCV aggravates the situation. There is increased risk for faster development of liver damage in patients with HCV- HIV coinfection as the presence of HIV infection accelerates the HCV RNA levels when 'cell mediated immunity decreases with HIV infection'. Coinfected patients who contract hepatitis A, B, or both infections are also at risk for developing 'fulminant hepatitis' and they should be tested for immunity and vaccinated against hepatitis A and B, if necessary. Until recently treatment strategies aimed at patients with coinfection was based on established clinical data in HCV monoinfection, due to shortage of clinical data. Recent research findings by "Chung and colleagues; Torrani and colleagues; Laguno and colleagues; and Carrat and Colleagues" brought important breakthrough in coinfection treatment, yet the complexity and toxicity of treatment of patient population with coinfection still pause challenge to the medical world (McNelis, 2006, p. 41-44) Through non-pharmacologic interventions like psychological counselling for promoting discontinuation of alcohol and drug intake, adopting healthy eating habits, and engaging in regular exercise further liver damage could be checked. Educating the people coinfected with HIV-HCV on needle exchange program, refraining from sharing contaminated injecting drug equipments and personal dental and shaving kits, the use of methadone treatment, and offering opportunities to decrease risks are paramount in prevention of the spread of both viruses. Focus of prevention strategies Edlin & Carden (2006) observe that HCV prevention activities are focused on 'convenient populations-patients who come to our clinics and office of their own accord- rather than the more challenged and stigmatized populations in whom the epidemic continues to range out of control,' because number of HCV infected population projected by National Health and Nutrition Examination (NHNE) Survey does not capture the population most severely affected by HCV. It is contended that the NHNE Survey is far from reality for the reason that: (1) the sample design excluded people who are homeless, incarcerated, hospitalized, or institutionalized from the survey, which is the core vulnerable group known to have high prevalence of HCV infection; (2) IDUs may not divulge the truth from the fear of excommunication, because they are engaged in illegal activities; and (3) little is known about recent initiatives and young IDUs. Identifying risk factors for HCV infection among young and vulnerable IDUs may provide important prevention clues for tackling outbreaks of blood-borne infections. Vulnerable groups for HCV infection HCV infection occurs among persons of all ages, but the "highest incidence of acute hepatitis C is found among persons aged 20-39 years, "and persons of Hispanic ethnicity have higher rates of acute disease. (Recommendations and reports). Research findings indicate that underprivileged populations have strong exposure to HCV due to increased frequency of intravenous drug use. Among the vulnerable groups for HCV infection, homeless youth face unique challenges of unmet health needs because of the high risk of substance abuse, unprotected sex, blood-borne infections, and other environmental hazards compounded with lack of health coverage. Those having family conflict or dysfunction as well as release from foster care system or institutional confinement become homeless and get adapted with the street life. The strict shelter rules, crowded conditions, limited privacy, loss of autonomy may prevent homeless youth from residing in shelters and finding freedom of the street more attractive. They will be more prone to high risk of drug abuse, sexual risk behaviours, and depression exacerbated with poverty. Studies of homeless youth also revealed that there are higher rates of drug and alcohol use than their peers living at homes or residing at shelters. Considering the grave situation homeless youth are exposed to Nyamathi et al (2005) suggests that "the concept of 'one-stop shopping' with services provided at sites frequented by street, as well as sheltered or accompanied youth, may enhance access and care and facilitate a multidisciplinary approach to the complex and diverse mental, social and physical health needs of this vulnerable population." In addition, "Interventions that combine youth-centred, service-based care, street outreach, case management, and motivational interviewing with integrated health services, such as hepatitis A/B vaccination and mental health and substance abuse programmes, are presented as innovative approaches to address the healthcare needs of homeless youth" (Nyamathi et al, 2005) Healthcare workers handling needles such as hypodermic needles, blood collection needles, and intravenous stylets and needles are at increased risk of needle stick injury, which can lead to serious infections with blood borne pathogens like Hepatitis C, Since HCV is transmitted primarily through large of repeated direct percutaneous exposure to blood, healthcare providers and public safety workers have increased risk of exposure to blood in work places and being infected with blood borne pathogens and constitute vulnerable groups for HVC infection in the community. As such, healthcare providers and public safety workers also have to be evaluated at regular intervals for presence and severity of HCV infection. Reducing the burden of HCV infection and HCV-related diseases is paramount and primary prevention, surveillance, and evaluation activities should be implemented through comprehensive strategies. Treatment of HCV There is no vaccine for immunization against HCV or preventing infection in infants born to HCV infected women. Similarly, there are few treatment alternatives against chronic hepatitis C, and the most effective pharmacological therapy is with a combination of interferon and ribavirin, which has 'sustained viral remission rates'. As ribavirin used alone is ineffective, "combination therapy with pegylated interferon and ribavirin is the treatment of choice resulting in sustained response rates of 40%-80%" and "Interferon monotherapy is generally reserved for patients in whom ribavirin is contra-indicated." (Viral Hepatitis C, 2006). Hepatitis Foundation International project that "while 50-60% of patients respond to treatment initially, lasting clearance of the virus occurs in about 10-40% patients" and "combined therapy (Interferon and ribavirin) shows elimination of virus after 6 months of therapy" while "re-treatment with bioengineered consensus interferon alone results in elimination of virus in 58% of patients treated for one year." (Diagnosing and treating hepatitis, 2003). However, scientific evidence shows that treatment of chronic hepatitis C can be very difficult for patients, because "the neuropsychiatric complications of interferon cause significant distress and morbidity and are among the most common reasons for treatment discontinuation." (Onyike, et al 2004). Even then, Onyike, et al (2004) recommend that 'all patients with chronic hepatitis C should be offered pegylated interferon and ribavirin treatment' since many cases will progress to liver cirrhosis, liver failure, and further complications in the absence of pharmaceutical intervention. Strategies for intervention Hepatitis C infection is "asymptomatic or paucisymptomatic in 90% of cases" making it a slow and silent killer, because many infected individuals are unaware of having chronic hepatitis B or C until they develop signs or symptoms of cirrhosis or liver cancer (WHO 2, 2008) Only by identifying and vaccinating high risk adults the goal set under Healthy People 2010 for a reduction of hepatitis case by at least 75% could be achieved. Integrating STD clinics, HIV counselling and testing sites, correctional facilities, and drug treatment clinics with vaccination of high-risk adults program is considered as the most effective approach. In addition, development of a hepatitis C vaccine is essential for public health protection. Though possibility of achieving sustained virological response has been well studied in various patient groups, whether the intervention will be effective in preventing cirrhosis, liver cancer, end-stage liver disease, or death is less confirmed. As such, before commencing the regimen, patients should be informed about their disease status and prognosis, the probable treatment effect, and known risks associated with the treatment. Effective treatment of active drug users may be even more challenging, because there may be chances of lesser adherence to the treatment, psychological side effects, and possibility of reinfection, and such patients should be considered case-by-case basis. This will be possible by designing specific programs for drug users and with the assistance of experienced groups having exposure with substance abuse patients, as well as adhering to treatment guidelines for human immunodeficiency virus infection. Physicians have an important role while making treatment decisions, and they should carefully assess, monitor, and support each patient's personal values. Educating the physicians and pharmacists in safe injection techniques and the ways to provide access to sterile syringes are better life saving interventions to reduce HCV infection. Considering the mode of transmission and prevalence of HCV among drug users its treatment require an interdisciplinary approach that brings together expertise in treating hepatitis and caring for drug users. Since majority of new HCV infections occur through Injecting Drug Users (IDUs) and considering the obstacles, such as characteristics of the disease, patients, providers, and health care system, for providing effective care all the strategies for developing, testing, and implementing HCV prevention should be IDU centred. References Chapter 5: Viral hepatitis. Retrieved July 14, 2008, from http://www2.niddk.nih.gov/NR/rdonlyres/D629F764-6A1F-43C9-8169-29F6F7FA7E53/0/ldrb_chapter5.pdf Diagnosing and treating hepatitis. (2003). Hepatitis Foundation International. Retrieved July 14, 2008, from http://www.hepfi.org/living/liv_diagnosis.html Edlin, Brian R.. & Carden, Michael R. (2008). Injection drug users: The overlooked core of the hepatitis c epidemic. PubMed Central Journal List. Retrieved July 14, 2008, from http://www.pubmedcentral.nih.gov/articlerender.fcgiartid=1611492 Edlin, Brian R et al. (2005, July 17). Overcoming Barriers to Prevention, Care, and Treatment of Hepatitis C in Illicit Drug Users. PubMed Central Journal List. Retrieved July 14, 2008, from http://www.pubmedcentral.nih.gov/articlerender.fcgitool=pmcentrez&artid=1510897 Hahn, Judith A. (2007, January 18). Sex, Drugs, and Hepatitis C Virus. The Journal of infectious diseases. Chicago Journals. Vol. 195. Retrieved July 14, 2008, from http://www.journals.uchicago.edu/doi/full/10.1086/516792prevSearch=%28Hepatitis+C+prevention%29+AND+%5Bjournal%3A+jid%5D&cookieSet=1 Hepatitis. (2008).World Health Organization. Retrieved July 14, 2008, from http://www.who.int/topics/hepatitis/en/ Initiative for vaccine research (IVR). (2008).World Health Organization. Retrieved July 14, 2008, from http://www.who.int/vaccine_research/diseases/viral_cancers/en/index2.html McNelis, Kelly. (2006). Management of hepatitis C infection in the HIV-infected patient. Journal of Pharmacy Practice. Vol. 19, No.1. Retrieved July 14, 2008, from http://jpp.sagepub.com/cgi/reprint/19/1/37 Onyike, Chiyadi U et al. (2004). Mania during treatment of chronic hepatitis C with pegylated interferon and ribavirin. The American Journal of Psychiatry. Retrieved July 14, 2008, from http://ajp.psychiatryonline.org/cgi/content/full/161/3/429 Recommendations and reports: Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. (1998, October 16). CDC. Retrieved July 14, 2008, from http://www.cdc.gov/mmwr/preview/mmwrhtml/00055154.htm US department of health and human services. (2007, June 15). Washington, DC. Retrieved July 14, 2008, from http://www.nastad.org/Docs/highlight/2007731_HHS_strategic_plan_signon.doc Viral Hepatitis C. (2006). National center for hiv/aids, viral hepatitis, STD and tb prevention. CDC. Retrieved July 14, 2008, from http://www.cdc.gov/ncidod/diseases/hepatitis/c/lbtinfo.htm Read More