dr. aabha nagral management and prevention of hepatitis c

WORLD HEPATITIS DAY28TH JULY 2014

Prevention and Management of Hepatitis C

Aabha NagralJaslok and Fortis HospitalChildren’s Liver foundation

What is hepatitis C?

Hepatitis C is the disease of the liver caused due to infection by hepatitis C virus (HCV). It is one of the common causes of chronic liver disease and may to progressive liver disease. It is also the leading indication for liver transplantation in the world

6 types of hepatitis C virus – India type 1 and 3

Hepatitis C

• Average carrier rate of HCV in general population- in India is 1- 3%.

• Estimated number of HCV positive patients 12 million• Thalassemia major patients is a high risk group on account of

being multi-transfused• Mandatory testing of HCV was only implemented in 2001

What is the natural course of the disease?

• Only 20% of patients who gets infected with HCV develop symptoms of acute infection. In others the disease remains asymptomatic.

• 80% will develop chronic infection • Without treatment 20% in 15-20 years will

develop permanent liver damage (cirrhosis) and its manifestations.

• 1-3% of these patients will have the risk of developing liver cancer every year.

How does Hepatitis C spread?

• Blood transfusion• Mother to child• Infected needles and syringes• Tattooing• Hemodialysis• Dental work• Sexual

Can HCV be transmitted in spite of blood being screened before a transfusion?

YesWindow periodLess sensitive tests

What are the symptoms of hepatitis C?

• Acute phase - asymptomatic• Chronic - > 6 months

present after 15-20 yearswith complications of cirrhosis

• Thalassemia patients also have iron overloading in the liver which adds to liver damage

How is Hepatitis C infection diagnosed?• Blood test – anti HCV• Needs to be done yearly in thalassemia

patients• In window period, the test may be negative• Test with higher sensitivity need to be used• Liver function tests• Ultrasonography of the abdomen give degree

of damage

How can Hepatitis C be prevented ?

• No vaccine available for HCV infection • Screen high risk individuals for the presence of HCV infection• Avoid direct contact with blood and other body fluids• Do not share razor blades and tattooing needles. • Dentists need to use disposable or well sterilized instruments

and wear sterile gloves. • Avoid IV drug abuse. • Blood transfusions should be given only if truly indicated. • Tests with high sensitivity• NAT testing

How is Hepatitis C treated?

• Presently by injectable drugs – pegylated interferon given weekly and oral ribavirin caps

• 6 – 12 months • Side effects

Flu like symptomsThyroid problemslow countsDepressionHair fall etc

• Cost about 2- 4 lakhs

Are there any safer, more effective drugs to treat HCV infection?

• Newer oral drugs like sofosbuvir and simepravir are available in the Western markets.

• These drugs have a 90% success rate and are much better tolerated than the currently available drugs.

• Only orally, have lesser side effects and can be even given in patients with fairly advanced disease.

• potential to improve the liver disease and prevent liver transplantation.

• cost of these drugs – over Rs 1 crore urgent need for the Government to make these drugs available at affordable cost at the earliest possible

Thalassemia and Hepatitis C

In collaboration with Children’s Liver foundation (Sukhbir Kaur)THINK foundation (Vinay Shetty)Thalassemia and Sickle society, Hyderabad (Suman Singh )DMC Hospital, Ludhiana (Ajit Sood)SGPGI, Lucknow (Shubha Phadke, Anjurani)Thalassemia Welfare Association, Chennai (Revathi Raj)

Anti HCV Positive (%)in current survey

CENTERS THALASSEMIA MAJOR PTS ANTI HCV POSITIVE (%)

MUMBAI (12 DAY CARE) 953 118 (12.4)

CHENNAI 206 31 (15)

HYDERABAD 1500 8 (0.5)

LUCKNOW 308 28/242 (11.6)

LUDHIANA 192 58 (30.2)

TOTAL 3159 243 (7.7)

PUBLISHED DATAAuthor Year of Publication Geographic

Location% anti HCV positive

Bhattacharya DK 1991 Calcutta 14.3

Amrapurkar D 1992 Mumbai 17.5

Williams TN 1992 Delhi 11.1

Aggarwal MB 1993 Mumbai 16.7

Chopra K 1994 Delhi 62

Choudhry UP 1998 Lucknow 30

Mohammed I 2002 Delhi 30

Marwaha RK 2003 Chandigarh 54.4

Mishra D 2004 Delhi 27

All data prior to mandatory HCV screening of blood, which started in June 2001

Pre and post mandatory testing

Prior to 2001 Now

West India 17.5 (Mumbai)

12.4(Mumbai)

North India 35.75(Chandigarh, Delhi, Lucknow)

21(Ludhiana/Lucknow)

South India NA 7.5(Chennai, Hyderabad)

East India 14.3(Calcutta)

NA

Overall 22.5 13.6

MODE OF DETECTIONMUMBAI CHENNAI HYDERABAD LUCKNOW LUDHIANA

Routine Screening 42 (91.2) 27 (90) 8 (100) 22 (78.6) NA

Abnormal LFT 1 (2.2) 3(10)

Decompensated liver disease

1 (2.2)

Pre op check 1 (2.2)

Not available 1 (2.2) 6 (11.4)

How many patients with thalassemia have been treated?

• Poor documentation of treatment data • Few were tested for HCV RNA • Fewer were started with the treatment• From the data available significant drop in Hb,

requiring increased transfusion rate and volume

TREATMENT OF HCV INFECTIONMUMBAI CHENNAI HYDERABAD LUCKNOW LUDHIANA

TOTAL TREATED

6/46 10/27 1/8 3/27 40/58

% TREATED 13 37 12.5 11.1 69

SVR 2/6 NA NA NA 26/40

TREATMENT Peg-Inf α 2a with Ribavirin

Peg-Inf α 2a + Rib – 7/10, Peg-Inf α 2b + rib -3/10

Inf α 2b Interferon α 2a with or without Ribavirin

Peg-Inf α 2b alone v/s with Ribavirin

RIBAVARIN MINIMUM mg/day

200 200 mg alternate day

0 0

RIBAVARIN MAXIMUMmg/day

600 600 800 800

*Sood A et al., Indian J Gastroenterol. 2010 Mar;29(2):62-5

Chelation statusS. Ferritinng/mL

MUMBAI CHENNAI HYDERABAD LUCKNOW LUDHIANA

Minimum 283 935 2898 900 NA

Maximum 7500 71671 6000 8000 NA

Mean 4078 6201 5489 3017 NA

Median 4147 2216 5578 2560 NA

Summarising…Thalassemia major and HCV infection

• Overall reduction in HCV prevalence compared to a decade back

• However, continuing infection despite mandatory testing• Higher incidence in North India compared to the rest of the

country• Small proportion of patients receive treatment• Most patients are not adequately chelated • Need for overall focused care of thalassemic children

including growth, iron overload related heart problems, infections and psychological problems

• Need for affordable and more effective treatment

How can we prevent Hepatitis C

• Avoid blood transfusions• Voluntary blood donors• Sensitive kits for testing• NAT testing• Avoid sharing shaving blades, tooth brushes,

tattooing, use of sterile dental equipment