Management of Viral Hepatitis: A Canadian Consensus Conference 2003/2004

PDF Version
Cat. Number: H39-4/39-2004
ISBN: 0-662-68145-2
Publication Number: 4409

Funding for this publication/multimedia project was provided by

Funding for this publication/multimedia project was provided by Health Canada and Correctional Service Canada.

The opinions expressed in this publication are those of the authors/researchers and do not necessarily reflect the official views of Health Canada or of Correctional Service Canada.

Address for Correspondence:

Morris Sherman
Toronto General Hospital
200 Elizabeth Street Toronto,
ON M5G 2C4

Tel: (416) 340-4756
Fax: (416) 591-2107

Email: morris.sherman@uhn.on.ca

© Morris Sherman MB BCH PhD, FRCP(C), University of Toronto; Vincent Bain MD FRCP(C), University of Alberta; Jean-Pierre Villeneuve MD FRCP(C), University of Montreal; Robert P. Myers MD FRCP(C), University of Calgary; Curtis Cooper MD FRCP(C), University of Ottawa; Steven Martin MD FRCP(C), University of Montreal; Catherine Lowe MD FRCP(C), Queen's University.

In collaboration with:

• Association of medical Microbiology and Infectious Disease Canada
• Canadian Association for the Study of the Liver
• Canadian Association of Hepatology Nurses
• Canadian Viral Hepatitis Network
• Health Canada
• Correctional Service Canada

Prepared by: Morris Sherman MB BCH PhD, FRCP(C), University of Toronto, Vincent Bain MD FRCP(C), University of Alberta, Jean-Pierre Villeneuve MD FRCP(C), University of Montreal, Robert P. Myers MD FRCP(C), University of Calgary, Curtis Cooper MD FRCP(C), University of Ottawa, Steven Martin MD FRCP(C), University of Montreal, Catherine Lowe MD FRCP(C), Queen's University.

Table of Contents

• Acknowledgements
• Members of the conference organizing committee
• Conference program
• Preamble
• Introduction
• HEPATITIS B
• Prevention of hepatitis B virus infection
• Treatment of chronic hepatitis
  • Initial assessment
  • Hepatitis B and hepatocellular carcinoma
• Who should be treated?
• How to assess response to treatment?
• What treatment should be used?
  • Interferon in HBeAg-positive patients
  • Interferon in HBeAg-negative patients
  • Lamivudine in HBeAg-positive patients
  • Lamivudine in HBeAg-negative patients
  • Adefovir dipivoxil
  • Pegylated interferon
• Special situations
  • Hepatitis B in children
  • Pregnant women
  • Decompensated cirrhosis
  • HBV-HCV co-infection
  • Renal transplant candidates
  • Chemotherapy and bone marrow transplant (BMT)
  • HIV-HBV co-infection
• HEPATITIS C
• Initial assessment
• Choosing patients for antiviral therapy
• Drug treatment
  • Early virological response (EVR)
• Evaluation and monitoring during treatment
• Special situations
  • Normal ALT
  • Cytopenias
  • Acute hepatitis C
  • Cirrhosis
  • Extrahepatic manifestations of hepatitis C
  • Re-treatment of patients
  • Renal impairment and renal transplantation
  • Children with chronic hepatitis C
  • HIV-HCV co-infection
    • Screening and investigations
    • Treatment environment
    • Hepatitis C drug therapy
    • Use of antiretrovirals
    • Which therapy first
    • Adjuvant therapy
    • Transplantation
    • Vaccination
• Conclusions
• References
• Tables
  • Table 1 Grading system for ranking recommendations and clinical guidelines
  • Table 2 Contraindications to antiviral treatment

Acknowledgements

The authors would like to thank Dr. David Wong, Dr. Steve Shafran, and Dr. Marina Klein, who provided the very latest information about the efficacy of anti-HCV therapy in HIV co-infected patients after the conference and as soon as it was available.

Members of the conference organizing committee

Canadian Association for the Study of the Liver
Dr. Winnie Wong
Dr. Vince Bain
Dr. Marc Deschênes
Dr. Sam Lee

Association of Medical Microbiology and Infectious Disease Canada
Dr. Stephen Shafran

Canadian Viral Hepatitis Network
Dr. Morris Sherman Warren Hill PhD

British Columbia Centre for Disease Control
Dr. Mel Krajden

Canadian Association of Hepatology Nurses
Vera Simon

Correctional Service Canada
Dr. Francoise Bouchard
Josephine Muxlow

Health Canada
Dr. Tom Wong
Gregory Zaneiwski
Tracey Donaldson
Cathy Sevigny
Annie J. Lacoursière

Preamble

Presently in Canada, an estimated 250,000 individuals are infected with the hepatitis C virus (HCV) and probably a similar number are infected with hepatitis B. The HCV-infected population is heterogeneous and includes those infected through the blood supply, through contaminated injection drug use equipment, and through use of unsterile medical equipment in foreign countries. A significant proportion of the current infections are in vulnerable populations, including persons with low incomes and unstable housing. In the future, it is anticipated that 60% to 70% of new cases will be related to substance use with 10% to 20% of these cases being co-infected with HIV and other infections. Hepatitis B in Canada, in contrast, is largely a disease of immigrant populations with up to 70% of infected individuals born in foreign countries.

There is a new appreciation of the complexities involved in managing viral hepatitis in some patient subgroups, including vulnerable populations, such as Aboriginal people, street youth, incarcerated populations, and immigrants. It is recognised that the disproportionate number of new infections anticipated in these populations in the future requires special attention to ensure adequate care. This is particularly true for patients whose health care falls under federal jurisdiction, such as Aboriginal people and inmates in the federal correctional system.

In addition to meeting the need for updated treatment information for health care professionals, this consensus conference also provided an opportunity to identify gaps in the overall management of viral hepatitis in Canada and to set the stage for future strategic direction. The effective management of individuals undergoing screening, counselling or treatment for hepatitis requires the development of a broad partnership approach. Medical treatment is an important component of the management of viral hepatitis but it represents only one element of what needs to be a comprehensive approach. In order to maximize the chances of successful therapy and minimise the long-term consequences of the disease, the root determinants of health need to be considered. The management of the patient with viral hepatitis includes, in addition to drug therapy measures, help in dealing with alcohol and other addictions, dietary management and weight reduction, and in some cases, the provision of adequate housing and nutrition. These factors provide the patient with a variety of possible treatment settings and support issues. The model of service delivery is important for some populations and can impact on health status and outcomes.

Treatment, especially for hepatitis C, is "labour intensive". This limits the number of patients an individual physician can manage. The provision of specialized nursing care will allow a larger number of patients to be treated. For this to occur, effective physician and nursing educational programs need to be developed to provide primary care providers with a basic knowledge and understanding of the wide spectrum of management issues.

In addition to addressing patient care issues, the conference also identified the importance of monitoring outcomes of prevention and care programs. There is the need for a national database to track prevention/care and hepatitis-targeted research, including social and behavioural factors that influence risky behaviour. This could be used to inform the development of comprehensive counselling guidelines and innovative models of service delivery. Analysis of the data could be used to define program and support needs for hepatitis virus-infected individuals; to guide best prevention and comprehensive care practices; and to determine the cost-effectiveness of treatment.

There is also a need for targeted social and behavioural research to determine the most effective strategies to prevent risk behaviour. Primary and secondary prevention best practices and models of care for chronic disease "self" management are required. In developing these models, the diverse and vulnerable populations affected by hepatitis need to be engaged to articulate their healthcare needs across the continuum of prevention, care and treatment.