1. 1
It’s Time: Integrate Viral
Hepatitis Into your Work
Tamara Brickham, MPH
Adult Viral Hepatitis
Prevention Coordinator
Houston Department of Health
and Human Services
tamara.brickham@cityofhouston.net
823-393-4706
Larry Cuellar
Adult Viral Hepatitis
Prevention Coordinator
Texas Department of State
Health Services
Larry.cuellar@dshs.state.tx.us
512-533-3124

2. 2
Housekeeping
 We will take short, frequent breaks, please return
on time.
 Please sign the participant list.
 If you want a certificate, please write your name
clearly and include your mailing address.
 We encourage you to ask questions and have
fun.

3. 3
Tell us……
 Your name
 Experience providing hepatitis or HIV
counseling and/or education
 A challenge you have experienced or anticipate
doing hepatitis education and/or counseling
 What you expect from this course?

4. 4
Goal of this course
To enhance the counseling skills of health
educators, outreach workers, HIV
counselors, STD workers, etc. that will
create opportunities to integrate viral
hepatitis prevention and control messages
into counseling sessions.

5. 5
Course Objectives
Participants will:
 Define the functions of the liver and different
types of viral hepatitis
 Identify recommendations for hepatitis testing
and vaccination
 Demonstrate skill in discussing viral hepatitis
and supporting risk reduction

6. 6
Course Overview
 Section 1: Overview of the Liver and Viral
Hepatitis
 Section 2: Focus on Hepatitis C
 Section 3: Guidelines for Viral Hepatitis Testing
& Vaccination
 Section 4: Client-Centered Risk Reduction
Planning
 Course Conclusion and Evaluation

7. 7
The Liver

8. 8
Liver
 Largest internal organ
 Weighs about 3lbs
 Located on right side under ribcage
 Ability to regenerate
 Has over 500 vital functions
 Involved in many digestive, vascular and
metabolic activities

9. 9
The Golden Fleece and the Heroes
Who Lived before Achilles Prometheus Bound
For Prometheus to be set free:
•An Immortal would have to give up his life for Prometheus – Chiron (centaur)
•A mortal would have to slay the liver-eating eagle - Hercules
Zeus’s
punishment
of
Prometheus

10. 10
Liver Functions
 Stores: iron, vitamins, minerals, sugars
 Produces: bile, cholesterol and lymph
 Regulates: blood clotting, glucose, and
hormone levels
 Cleans: the blood of bacteria and toxins

11. 11
Liver Functions Cont’d
 Processes: food, alcohol and other drugs
 Converts: food and drink into forms the body
can use
 Oxidizes: triglycerides to produce energy
Basically, the liver processes everything we eat,
drink, swallow, breathe and/or absorb!

12. 12
Liver Damage
 Inflammation – immune response
 Fibrosis – development of scar tissue
 Cirrhosis – a process where liver cells are
destroyed and replaced with scar tissue
 Hepatocellular Carcinoma – type of liver cancer

13. 13
Defining Viral Hepatitis

14. 14
What is Hepatitis?
 Inflammation of the liver
 Caused by viruses, alcohol, medications, and other
toxins
 This training will focus on viral hepatitis

15. 15

16. 16
ABCs… of Viral Hepatitis
 Hepatitis A Virus (HAV)
 Hepatitis B Virus (HBV)
 Hepatitis C Virus (HCV)
 Hepatitis D Virus (HDV)
 Hepatitis E Virus (HEV)
These viruses all affect the liver but otherwise are unique

17. 17
Viral Hepatitis Language
 Acute infection is when the infection is newly acquired,
and is less than 6 months
 Chronic infection lasts 6 months or more and is usually
life-long unless treated
 Resolved or cleared infection is the body getting rid of
the hepatitis infection – usually in the acute stage

18. 18
Hepatitis A Overview
 In 2006, ~32,000 newly infected people in the US
 Acute disease -- no chronic infection
 Primarily transmitted fecal- oral route
 Vaccine is available to prevent infection

19. 19
Reported Cases of Hepatitis A
in Texas 1990-2007
Hepatitis A vaccine licensed in 1995
Hepatitis A vaccine requirements

20. 20
Hepatitis A
 Found in the stool (feces) of persons infected with
hepatitis A virus
 HAV is usually spread by “fecal-oral transmission”
 Putting something in the mouth (food, water, hands) that
has been contaminated with the stool of a person with
hepatitis A
 Most infections come from contact with a household
member or sex partner who has hepatitis A
 Highly infectious and stable in environment for
months

21. 21
Signs and Symptoms of HAV
 jaundice
 fatigue
 abdominal pain
 loss of appetite
 nausea
 diarrhea
 fever
Adults have signs and symptoms more
often than children
Incubation Period: 15-50 days (average 28 days)

22. 22
Persons at Risk for HAV
 Household contacts of infected persons
 Sex contacts of infected persons
 Persons traveling to countries where hepatitis
A is common
 Men who have sex with men
 Injecting and non-injecting drug users

23. 23
Preventing HAV Infection
 Get vaccinated for hepatitis A
 Always wash your hands with soap and
water after using the bathroom, changing a
diaper, and before preparing and eating
food

24. 24
Summary of Hepatitis A
 HAV is spread the fecal-oral route through
contaminated food or water
 There is no long-term infection and you
cannot get it again
 The best way to protect against HAV is
vaccination and hand washing

25. 25
Hepatitis B Overview
 In 2006 ~ 46,000 new infections in US
 ~1.4 million in US living with chronic HBV
 Primarily transmitted through blood and bodily
fluids
 Vaccine is available to prevent infection

26. 26
Reported Cases of Acute Hepatitis B in
Texas, 1980-2008
Hepatitis B recombinant vaccine
licensed in 1986
Universal infant vaccination
Universal adolescent vaccination
Adult recommendation

27. 27
Hepatitis B
 Inflammation of the liver caused by the hepatitis B
virus (HBV)
 Can cause lifelong infection, cirrhosis (scarring) of
the liver, liver cancer, liver failure, and death
 Highly infectious, stable in environment for at least
7 days

28. 28
Transmission of HBV
 Being in contact with infected blood or
body fluids while you are not immune
 Having sex with an infected person
without using a condom
 Sharing needles to inject drugs or works
(e.g., spoons, cotton, water)

29. 29
Persons at Risk for HBV

Persons with multiple sex
partners or diagnosis of a
sexually transmitted
disease (STD)

Men who have sex with
men

Sex contacts of infected
persons

Injection drug users

Hemodialysis patients

Household contacts of
chronically infected
persons

Infants born to infected
mothers

Infants/children of
immigrants from areas
with high rates of HBV
infection

Health care and public
safety workers

30. 30
Symptoms of HBV
 jaundice
 fatigue
 abdominal pain
 loss of appetite
 nausea, vomiting
 joint pain
About 30% of persons have no signs
or symptoms
Incubation Period: 45-160 days (average 120 days)

31. 31
Preventing HBV Infection
 Get vaccinated with Hepatitis B vaccine
 Use latex condoms correctly and every time you
have sex
 If you are pregnant, you should get a blood test
for hepatitis B
 Do not share personal care items that might
have blood on them (razors, toothbrushes)

32. 32
Preventing HBV Infection
 Do not shoot drugs; never share drugs, needles,
syringes, water, or "works"
 Consider the risks if you are thinking about
getting a tattoo or body piercing
 If you are a health care or public safety worker,
always follow routine barrier precautions and
safely handle needles and other sharps

33. 33
Summary of HBV
 HBV is spread through
unprotected sex with an infected person
by sharing drugs, needles, or "works" when using
drugs
through needlesticks or sharps exposures on the
job
from an infected mother to her baby during
birth
 The best way to protect against HBV is
vaccination

34. 34
HCV Overview
 An estimated 4 million Americans have been
infected with HCV, of whom 3 million are
chronically infected
 Most infections are due to illegal injection and
drug use
 55%-85% of adults have chronic infection
 If resolved, no protective antibodies
 No vaccine available

35. 35
Hepatitis C
 Inflammation of the liver caused by the hepatitis C
virus (HCV)
 HCV can be found in the blood of a person with
hepatitis C
 People with hepatitis C may carry the HCV in their
blood for the rest of their lives, and could pass the virus
on to others
 Highly infectious, stable in environment for at least 16
hours but not longer than 4 days

36. 36
Transmission of HCV
 Sharing needles or "works" when
"shooting" drugs
 Through needlesticks or sharps exposures
on the job
 From an infected mother to her baby
during birth

37. 37
Persons at Risk for HCV
 Injecting drug users
 Recipients of blood and/or solid organs
before 1992
 Recipients of clotting factors made before
1987
 Hemodialysis patients
 Infants born to infected mothers

38. 38
Symptoms of HCV
 jaundice
 fatigue
 dark urine
 abdominal pain
 loss of appetite
 nausea
80% of persons have no signs or symptoms
Incubation Period: 14-180 days (average 45 days)

39. 39
Preventing HCV Infection
 There is no vaccine
 Best prevention is behavior change
Do not shoot drugs
Do not share personal items such as razors or
toothbrushes
Avoid tattoos or body piercing

40. 40
Summary of HCV
 HCV is spread through blood contact with an
infected person
 HCV positive individuals should be evaluated by
a doctor for liver disease

41. 41
Hepatitis D Overview
 Caused by hepatitis D virus (HDV)
 Coined “Delta Hepatitis”
 Rarely seen in the United States
 Found only in persons infected with HBV and
has similar routes of transmission as HBV
 Prevention is vaccination for HBV

42. 42
Hepatitis E Overview
 Caused by hepatitis E virus
 Primarily a disease of import
 Very similar to hepatitis A with fecal-oral
transmission
 Transmitted like HAV with the same
symptoms
 No vaccination available

43. 43
Disease Burden
Deaths /yr
New infections /yr
Chronic infections
Outcome
4,000
46,000
1.4
(million)
HBV
10,000
19,000
3.2
(million)
HCV
14,000
56,000
1.1
(million)
HIV
HCV is the most common bloodborne viral infection.
*2006 CDC estimates for US

44. 44
Chronic Viral Hepatitis Disease
Burden = 409,400 cases
Hepatitis B Hepatitis C
Prevalence in General Population 5% or 1,115,000 1.6% or 368,000
% Chronic Hepatitis 10% or 115,000 80% or 294,400
Texas 2006 population est. 23 million

45. 45
Comparison of the big three
Virus Prevalence % of
Population
Unaware of
Infection
Status
Deaths in 2006
Related to
Infection
HBV 800,000 –1.4
million
About 65% 3,000
HCV 2.7–3.9 million About 75% 12,000
HIV 1.1 million About 21% 14,016

46. 46
Populations at increased risk
Asian/Pacific Islanders – in the US,
1 out of 10 API are chronically
infected with hepatitis B
Injecting Drug Users – 60% - 90%
of IDUs are infected with hepatitis C
What are some of the other populations
at high risk?

47. 47
Domestic HIV
69%
TB 14%
STD 15%
National Center for HIV/AIDS, Viral Hepatitis, Sexually
Transmitted Disease, and Tuberculosis Prevention Funding
$1 Billion Total
Hepatitis 2%Source: CDC
The Fiscal Issues

48. 48
Current Hepatitis Surveillance
Activities in Texas
 What does the state require to be reported
to the health department regarding
hepatitis infection?
Hepatitis A, B, C, D, E (acute)
Hepatitis B (acute and chronic)
identified prenatally or at delivery

49. 49
Focus on Hepatitis C
Transmission and
Prevention

50. 50
Sexual 15%
Other* 5%
Unknown 10%
Injecting drug use 60%
Transfusion 10%
(before screening)
*Nosocomial; Health-care work; Perinatal
Source: Centers for Disease Control and Prevention
HCV Transmission
Sources of Infection

51. 51
Sharing Injection Equipment
 Studies have found high rates of HCV in IDUs who didn’t share
syringe, but shared cooker, cotton, water or other paraphernalia
 People who inject other things (steroids, vitamins and hormones)
may also be at risk
 IDUs should use new, sterile equipment every time (clean hands,
injection site and surface too)
 CDC recommendation for blood spill clean up
 1 part bleach, 10 parts water

52. 52
Sexual Transmission
 Seven US studies of long-term discordant partners found
1.5 - 3% seroprevalence of HCV
 Other studies of MSM, sex workers, and those with
history of STD found prevalence of 4-6%
 Risk may be increased when trauma is present
 Other factors related with sexual transmission include #
of partners, the presence of other STDs, and use of
condoms

53. 53
 There is a risk with pregnancy (5-6%)
 Post-exposure prophylaxis not available
 Coinfection with HIV risk increases risk up to 17%
 Test infants born to HCV-positive women
 Consider testing any children born since woman became infected
 Evaluate infected children for chronic liver disease
 Breastfeeding ok unless nipples are cracked and/or
bleeding
Mother-to-Infant Transmission

54. 54
Tattooing and Body Piercing
 While some studies have found an association between
tattooing and HCV in select populations, (mostly
incarcerated) it is unknown if these can be generalized to
the whole population.
 Major concern is non-professional tattooing and/or
piercing
 Should use new separate ink containers and new and sterile
needles and other equipment

55. 55
Low/Unknown Risks
 Intranasal cocaine/meth use: Some studies have found link
to HCV transmission by blood getting into nasal
membrane from shared snorting items
 Crack use: at least one study (Schaefer) found higher rate of
HCV in non-injecting crack users who indicated cracked,
bleeding or burned lips
 Personal items with blood on them: anything that
cuts/breaks the skin or membrane (razor, clippers)

56. 56
HCV Survival Outside the Body
 One study has been done
 Study found HCV alive outside body at 16
hours, 4 days, and 7 days
 16 hour sample caused infection, 4 day sample
did not cause infection

57. 57
HIV vs. HCV
 Both HIV and HCV are blood-borne infections
 HCV is 10 times more infectious than HIV by
blood-to-blood contact
 Most co-infected drug users probably were infected
with HCV years before HIV
 HIV is more transmissible between sexual partners
and from mother to infant

58. 58
Video
HIV and HCV

59. 59
HCV and HIV Coinfection
 Up to 240,000 people in the U.S. are co-infected with
HIV/HCV
 Majority have chronic disease (85%)
 1/3 of HIV+ people are co-infected with HCV
 10% of HCV+ people are co-infected with HIV
 In urban areas, up to 90% of HIV+ IDUS are co-
infected with HCV

60. 60
Potential Co-infection Effect of HIV
on HCV Disease
 HIV infection may worsen HCV disease
Weakened immune system allows HCV to
replicate faster
More infectious because higher viral load
Accelerates and increases disease progression
 May not respond well to HCV treatment

61. 61
Potential Co-Infection Effect of HCV
on HIV Disease
 HCV disease does not appear to accelerate HIV
disease
 Higher toxicity from HAART
 As people live longer with HIV, many more HIV
deaths are caused by HCV-related end stage liver
disease
 There is still a lot of research to be done on these
effects

62. 62

63. 63
Guidelines for Viral Hepatitis Testing
and Vaccination

64. 64
Overview of HAV Vaccine
 Began usage in 1995
 Two manufacturers of inactivated vaccine:
 VAQTA®
(Merck) and HAVRIX®
(GSK)
 Two dose series at 0 and 6-18 months
 Also available in combination with hepatitis B vaccine
called TWINRIX ®

65. 65
Side Effects of HAV Vaccine
• No severe adverse reactions
• Most common side effects
− Soreness/ tenderness at injection site
− Headache
− Malaise
• Safety in pregnancy not known - likely ok
• Contraindications - Severe adverse reaction to
previous dose vaccine; allergy to vaccine
components

66. 66
Hepatitis A Vaccine Recommendations
Hepatitis A vaccine is recommended for:
• All children at age 1 year
• Travelers to HAV endemic countries
• Men who have sex with men (MSM)
• Injection and non-injection drug users
• Persons with chronic liver disease
• Persons with clotting-factor disorders

67. 67
Overview of HBV Vaccine
 Began usage in 1982
 Two manufacturers of recombinant vaccine:
Recombivax HB
®
(Merck) and Energix-B
®
(GSK)
 Usually three dose series at 0, 1 and 6 months
 Also available in combination with hepatitis A vaccine
called TWINRIX
®

68. 68
Side Effects of HBV Vaccine
• No severe adverse reactions
• Most common side effects
− Soreness/ tenderness at injection site
− Headache
− Malaise
• Safe in pregnancy
• Contraindications - Severe adverse reaction to
previous dose vaccine or bakers yeast

69. 69
Hepatitis B Vaccine Recommendations
Hepatitis B vaccine is recommended for:
 All infants within 12 hours of birth
 Older children not previously vaccinated
 Sex contacts of infected persons
 Persons with more than one sex partner in a six month period
 Persons diagnosed recently with an STD
 Men who have sex with men
 Injection drug users
 Household contacts of chronically infected persons
 Health care and public safety workers
 People with chronic liver disease, including those with HCV
 People living with HIV
 Travelers to areas with high rates of HBV
 Hemodialysis patients

70. 70
What is the recommendation in Texas
for vaccinating infants for hepatitis B?
The dosing schedule for infants whose
mothers have not been infected with
hepatitis B is as follows:
- Birth
- 1 to 4 months of age (must be at least
one month after the first dose)
- 6 to 18 months of age
The dosing schedule for infants whose
mothers have been infected with
hepatitis B is as follows:
- Within 12 hours at birth
- 1 to 2 months of age
- 6 months of age

71. 71
Adult Hepatitis B Vaccination Initiative

72. 72
Fun with Hepatitis B Tests
 HBV Antibody Test
 Appears 1-3 months after HBsAG is
detected.
 Immunity to hepatitis B.
 Not able to tell whether this is because
of vaccination or previous exposure.
 Anti-HBc Total
 Used as a marker for past infection.
 Never appears in those vaccinated,
almost always present in previous
infections.
 HBsAg
 First marker of infection.
 May appear as early as 1 -2 weeks after
infection.
 High levels = chronic or acute infection.

73. 73
Fun with Hepatitis B Tests
 Anti HBcIgM Test
 May be present in the absence of anti-HB or HBsAg.
 Positivity indicates recent infection (< 6 months)
 Rarely occurs in chronic infection.
 Negative with positive HBsAg means chronic HBV infection
 Anti HBeAb
 Present in patients with a resolved infection
 Anti HBeAg
 Found in acute and chronic.
 Presence indicates viral replication.
 Generally associated with a high degree of infectivity.
 Undetectable, if resolved.

74. 74
Acute infection
with resolution
Chronic Carrier

75. 75
Hepatitis B Serology Interpretation
Exercise
Review the six blood test results to determine which ones
are:
Susceptible
Immune through a previous infection
Immune through vaccination
Acute HBV
Chronic HBV
Other

76. 76
Describing HBV Test Results

77. 77
Immune due to Vaccination
PH Follow up & counseling:
 Seize the opportunity to educate on Hepatitis and other STIs.
Acute HBV
PH Follow up & counseling:
 Get a list of contacts both in the home and outside the home.
 Screen the contact for HBV and educate on the stages of the
disease, signs and symptoms and have them retest after incubation
period is over.
 Seize the opportunity to educate on Hepatitis and other STIs.

78. 78
Chronic Active HBV
PH follow up & counseling:
 Screen the contact for HBV and educate on the stages of the
disease, signs and symptoms and health issues associated with
being a chronic carrier.
 Seize the opportunity to educate on Hepatitis and other STIs.
Immune (Previous infection)
PH follow up & counseling
 Seize the opportunity to educate on Hepatitis and other
STIs.
Susceptible
PH follow up & counseling:
 Vaccinate and seize the opportunity to educate on
Hepatitis and other STIs.

79. 79
HCV Testing Recommendations
CDC recommendings testing the following for HCV:
 Current or former injection drug users (even once)
 Recipients of clotting factors before 1987
 Recipients of blood transfusions or donated organs before 1992
 Long-term hemodialysis patients
 Persons with known exposures to HCV
 HIV infected persons
 Children born to HCV infected mothers (do not test before age
18 months)
 Patients with signs or symptoms of liver disease (abnormal liver
enzyme tests)
 Donors of blood, plasma, organs, tissues, semen

80. 80
 EIA (Enzyme immunoassay)
 Detects antibodies to HCV (anti-HCV)
 97% of people have antibodies 6 months after infection
 RIBA (Recombinant immunoblot assay)
Confirms positive initial anti-HCV
 HCV RNA
Looks for actual virus in the blood
Testing & Diagnosis of HCV

81. 81
Reactive (Positive) EIA
 Reactive EIAs are considered confirmed by:
 RIBA
 Viral test that looks for the virus
 Signal-to-cut-off-ratio (S/CO)
 S/CO: Repeats EIA two more times. If all three are
reactive with high (>95%) S/CO then considered
confirmed. Samples with <95% S/CO require a
RIBA confirmation

82. 82

83. 83
Describing HCV Test Results

84. 84
Negative Antibody Test
 Client is NOT infected (unless recent infection
during window period, 4-10 weeks)
 If risk behavior occurred in the past 6 months
encourage to re-test
 If risk behavior is ongoing, explore risk
reduction

85. 85
Positive Antibody Test
Confirmed (w/RIBA or S/CO)
 Client has been infected with HCV in the past and
probably is still living with it
 Recommend further evaluation and testing:
determine if HCV is still in the blood
establish the health of the liver
discuss treatment options
 Discuss prevention and health messages

86. 86
Positive Antibody Test
Not Confirmed or Low/No Risk
 Client may have been infected with HCV
 Recommend further evaluation and testing to:
confirm positive result (RIBA or viral test)
determine if the HCV virus is in the blood
establish the health of the liver
discuss treatment options
 Discuss prevention and health messages

87. 87
Indeterminate Result
 Explain that test results are inconclusive
 May indicate recent infection if risk has
occurred in past few months
 Need to wait and retest

88. 88
Client Centered Counseling Skills
and Risk Reduction Planning

89. 89
ADDICTOPHOBIA
The fear of
persons
associated with, or
thought to be
associated with,
substance abuse
or illicit drug use.

90. 90
Goals of Viral Hepatitis
Risk Reduction Counseling
 Decrease risk for transmission and/or
acquisition of viral hepatitis
 Increase quality of life for those living with
chronic hepatitis
 Identify larger goal and small, reasonable steps
to get to goal
 Partner with client to identify options to reduce
harm

91. 91
How to Support Behavior Change
 Meet person where they are at
 Options, options, options
 Support any positive change
 Focus on the factors that influence behaviors
and behavior change
 Explore the pros and cons of changing behavior
(or not changing)

92. 92
Factors that Influence Behavior
 Access to resources
 Attitudes/Beliefs
 Consequences
 Discrimination
 Drug use
 Competing issues
 Emotions
 Intentions
 Knowledge
 Policy
 Priorities
 Self-efficacy
 Self-esteem
 Skills
 Social Norms
 Social Support

93. 93
Safer Goal Behavior
 Goal should be big
 A behavior that will reduce the risk of or
prevent transmission of disease
 Doesn’t need to be something client is ready to
do now
 Should be something client wants to move
towards in future

94. 94
Action Plan
 Composed of small, attainable action steps
 Explore potential barriers and supports needed
for each step
 Prioritize first step
 Explore “what ifs”
 Validation and support

95. 95
Skills Practice!!
 You will be counseling someone who is at
risk for or living with viral hepatitis
 Utilize the pre test / post test counseling
points
 Transition into viral hepatitis
 Conduct brief risk assessment
 Identify and give core health messages
 Negotiate risk reduction plan

96. 96

97. 97
Conclusion and Evaluation
 Evaluation and comments
 Please include your e-mail, phone number
and address if you need a certificate of
attendance.
Thank you for participating!

98. 98
It’s Time: Integrate Viral Hepatitis Into
your Work
 Tamara Brickham, MPH
Adult Viral Hepatitis Prevention Coordinator
Houston Department of Health and Human
Services
tamara.brickham@cityofhouston.net
823-393-4706
 Larry Cuellar
Adult Viral Hepatitis Prevention Coordinator
Texas Department of State Health Services
Larry.cuellar@dshs.state.tx.us
512-533-3124