Date: Event: The Basics of Hepatitis C

Transcription

1 Date: Event: The Basics of Hepatitis C THIS TEXT IS BEING PROVIDED IN A ROUGH DRAFT FORMAT. COMMUNICATION ACCESS REALTIME TRANSLATION (CART) IS PROVIDED IN ORDER TO FACILITATE COMMUNICATION ACCESSIBILITY AND MAY NOT BE TOTALLY VERBATIM. THE CONSUMER SHOULD CHECK WITH THE MODERATOR FOR ANY CLARIFICATIONS OF THE MATERIAL. >> Hi, everyone. Welcome to the basics of hepatitis C webinar. It will be presented by Barb Panter. This webinar is part of our building block series. I'll be moderating this webinar. Before we move into the presentation, I would like to quickly review a few tips regarding the webinar technology that we'll be using today. First if you can't hear the audio, then hopefully you can see the slide and dial into the audio portion using a telephone. Please use the number listed on the slide. Second, if you called in and are using a speakerphone to listen to the audio, if you have any difficulties hearing, please try muting microphone. And lastly, if you have any technical difficulties you can always call the WebEx customer support number listed on the bottom right-hand side of the slide. The number is For purposes of accessibility, this webinar will be transcribed in real-time through a process called Communication Access

2 Realtime Translation. This is shown on the bottom right-hand side of your screen in a panel called media viewer. To resize the media viewer, move your curser to the top of the title bar until it changes shape and then drag up or down. Before we begin the presentation, I just want to remind everyone that this webinar will be recorded and made available on CATIE's website after the webinar has been concluded. So I would like to present Barb Panter. >> Barb: Welcome to the CATIE Building Blocks Webinar Series. Today we will be presenting on the basics of hepatitis C. My name is Barb Panter and I m the Regional Health Education Coordinator for Ontario. This webinar was developed in response to the growing need of HIV servicing agencies to also be providing Hep C services. This presentation has been designed to outline some basic information on hepatitis C. The information presented today can be grouped into five sections. We will be looking at transmission, prevention, disease progression, testing and treatment. Hepatitis is the word we use to describe the swelling of the liver. This can be caused by many things toxins, medication, alcohol, or a virus. Viral hepatitis is always given a letter name. There are many kind of viral hepatitis from Hep A to G. Hepatitis A, B and C are the most common in Canada. Before 1989, Hep C was simply called non-a and non-b hepatitis. In the intervening 20 plus years we have discovered much about this virus. We know that it is a virus that attacks the liver. It is divided into six different

3 subtypes that we call genotypes. These are numbered from 1-6. Genotype 1, 2 and 3 are the most common in Canada, although recently we have been seeing more of genotype 4 in federal prisons. Genotype 1 is the most common genotype in Canada and unfortunately it is also the hardest to treat. We know that Hep C is only transmitted from blood-to-blood contact. Infected blood needs to get inside the new host and into their blood stream. This makes injection drug use a particularly effective way of transmitting the virus. Over 60% of new Hep C infections in Canada are attributable to intravenous drug use although this varies somewhat from province to province. Sharing any used works or drug paraphernalia, even up to two weeks later, is a risk for Hep C infection. We also know that even after much research, we still do not have a vaccine for Hep C; however, there is treatment. To get an idea of the scope of Hep C infection, we turn to numbers. About 170 million people around the world are infected with Hep C. In Canada, an estimated 250,000 people are living with Hep C. Of those, approximately 140,000 people are current or previous intravenous drug users. But it is estimated that 20% of people living with Hep C don't know they have the virus. So these numbers could be higher. Just a little bit of information about the liver. We know Hep C attacks the liver so it is important to understand why this is a big deal. The liver is very important to us. We can't live without it. It is our largest internal organ and has over 500 functions. A few of the major ones are: as a blood

4 cleanser. The liver metabolizes alcohol, drugs, chemicals really everything that we put into our body through eating or breathing. The liver then filters everything and neutralizes toxins. The liver is also a chemical regulator. It monitors body fuels through glucose production, storage and supply. It regulates hormones for sexual development, and thyroid and adrenal function. It controls the supply of iron, copper and other vitamins and minerals. And it monitors levels of cholesterol and other fats. It is also a protein manufacturer. The liver makes essential proteins for blood transporting systems, blood clotting, and immune functions. But one of the very cool things about the liver is that it can regrow. In fact, often a liver transplant is just part of the liver that will then regrow to normal size. This also means that some liver damage can be repaired by the liver itself. This slide is to demonstrate what liver damage can look like. The portion of the liver towards the left of your screen is a healthy liver. It looks a lot like the liver you might buy in the grocery store, shiny and spongy. The middle section shows what the liver can look like what it starts to get fibrotic. Fibrosis is what we call the scarring that can occur on the liver in reaction to an infection or toxin. The scar tissue is harder, not spongy, and starts to impair the liver's ability to function. The last section of the liver on the right of your screen is a liver with cirrhosis. Cirrhosis is widespread scarring throughout the liver. A cirrhotic liver is no longer spongy and shiny. It is shrunken and hard and can no longer do many of the functions we need

5 it to do. So now that we have an idea of what Hep C is and why our liver is so important we'll switch gears and talk about transmission. As mentioned earlier transmission of Hep C can only happen through blood-to-blood contact. The most common way this happens in Canada is through injection drug use. The risk of transmission comes not only through sharing needles but also through sharing any works; cookers, ties, tourniquets, filters, et cetera. The virus can survive outside the body for days and even longer in favorable conditions and can survive in microscopic amounts of blood. We also know that it is not only injection drug use that poses a risk. Transmission can happen through other kinds of drug use like sharing crack or crystal meth pipes or sharing snorting straws. Most of you probably have some knowledge of the tainted blood scandal in Canada in the 1990s. Many people became infected with Hep C through blood and blood products that had not been screened for Hep C; however, all blood products in Canada have been thoroughly screened since 1992 and only people that received blood products before 1992 in Canada are at risk. That may not be true of people coming from countries with less well-resourced health care systems. Unsterilized or reused tattooing and piercing equipment also possess a risk of transmission. Tattoos done in prison in particular are much less likely to be done in conditions that would prevent the spread of Hep C. Many young people arrest tending piercing or tattooing parties where a number of people use the same equipment for their piercing or tattoos.

6 It is a good idea when thinking of getting a tattoo or piercing to get it done by an expert in a professional setting and ensure that new equipment is being used for the procedure including new tattoo ink. Unsterilized or shared hygiene and grooming equipment like nail clippers and razors may also present a risk of transmission. Although it is very rare in Canada, reused or unsterilized medical equipment is sometimes used in under-resourced countries. People coming to Canada from these countries may think about getting tested for Hep C if they have had any medical procedures in their country of origin. People often ask about the sexual transmission of Hep C, especially when they have been working in the field of HIV. Hep C is not considered a sexually transmitted infection and sexual transmission is rare; however, there can be a risk if blood is present or if either partner has a sexually transmitted infection. Remember, the blood doesn't have to be visible to contain the Hep C virus. Research has shown that the sexual transmission of Hep C is more common in men who have sex with men who are also co-infected with HIV. In this next section we will talk about prevention. Since we've talked about how Hep C is transmitted we can have a good idea about how to prevent transmission. We know that the majority of Canadians living with Hep C acquired it through injection drug use so prevention messages must include harm reduction. Without wanting to get into too much detail harm reduction is a model of working with people who use drugs that is nonjudgmental and meets people with they're at, not

7 requiring abstinence in order for them to receive services. Some practical applications of harm reductions are NEP or needle exchange program which ensures that people who use drugs have access to unused equipment so they don't have to share or reuse their work. MMT, methadone method treatment which can act as a stabilizing influence in people's lives allowing them to live without worrying about overdosing or getting arrested for drug possession. Safe consumption services like Insight in Vancouver create a safe base for people who might otherwise be using on the street or other unsafe places. Safe consumption services prevent overdose deaths and connect people who use drugs to needed services. Ideally harm reduction programs should involve people with lived experience of drug use, either people currently using drugs or former drug users, and they should be practical and meet the needs of the people that use the services. This means that harm reduction services always look a little bit different from community to community. I'll talk a bit more about some harm reduction specifics in the next slide. Blood screening is now in place in Canada and is an important tool to prevent Hep C transmission. Although Hep C isn't a sexually transmitted infection we need to encourage safe sex practices especially in people that are HIV-positive as they are at higher risk of acquiring Hep C through sex. We need to continue routine practices, a.k.a. universal precautions. Universal precautions assumes that any body fluid you might come into contact with is potentially infectious.

8 So, wearing latex gloves in situations where you might be in contact with someone's blood and having diluted bleach spray to wipe up spills are ways to implement universal precautions. Note that while bleach is considered ineffective for cleaning syringes it is much more effective on nonporous surfaces. Education, counseling and ensuring people have solid information about Hep C are also really important so people can make choices to keep themselves and their communities safer. It is also important for us to keep an eye on the social determinants of health like poverty, housing, access to care, social isolation and nutrition as these things all impact our health and our ability to keep ourselves well. So just a bit more detail about some harm reduction practices. I just wanted to show what kinds of things are included in a Safer Injection Kit. Any one of these items can be possible transmission route if shared by someone who has Hep C by someone who does not so it is important to offer all the items to people who are injecting drugs. Most kits will also include information on Hep C, places where people can get support and where they can return their used supplies for safe disposal. People that are smoking rather than injecting it is still important they have access to unused supplies. You can see at the top left of the screen a pipe for smoking crack with electrical tape at one end to act as a mouthpiece, and some brass screens tamped down into the other end where the crack sits when it is being smoked. Some alternate mouthpieces, sections of rubber tubing, are in the photo below

9 it, along with some brass screens beside that. The full kit again will usually provide people with some information about the health and safety and services. On to disease progression. This chart illustrates untreated Hep C disease progression. There are two phases of Hep C; acute and chronic. The initial infection is what we call acute hepatitis. The acute phase lasts for about 6 months. Interestingly, about 20 to 25% of those infected with Hep C will completely get rid of the virus without receiving treatment. We call this spontaneous clearance or spontaneous recovery. People who have spontaneously cleared the virus will have Hep C antibodies for life. But this does not mean that they are immune and can therefore be infected with Hep C again. The majority of people, 75 to 80%, will go on to have chronic hepatitis. Of those, 40 to 60% will develop fibrosis, 20% will develop cirrhosis, and one to 4% will develop liver cancer and possibly die. Cirrhosis and cancer are more likely in people co-infected with HIV or Hep B. However, as you can see from the chart, it can take many decades for the disease to progress to significant liver damage. Disease progression varies from person to person once they move into the chronic phase of Hep C. But we do know that progression can be significantly speeded up by heavy alcohol use and by HIV. The majority of people with Hep C will experience no symptoms. This is why so many people can live with the virus for so many years without knowing they're infected. For the remaining 20 to 30%, they may experience some of the

10 symptoms you can see on the slide. Depression, fatigue, nausea and flu-like symptoms can be symptoms of so many things it is hard to use them for diagnostic purposes. However, jaundice, dark urine and abdominal pain often could be the liver. Interestingly, people that do show symptoms seem to be more likely to spontaneously clear the virus. Testing for Hep C is a bit complicated so we'll go through it in some detail. Two separate tests are needed to determine current active Hep C infection. The first is an antibody test. The second is a diagnostic test called a Hep C PCR RNA test. The hep C Antibody test looks for Hep C antibodies in the blood. It indicates exposure from blood-to-blood contact. But as was discussed earlier, people who have spontaneously cleared the virus will have antibodies for life even though they no longer have the virus. That is why a second diagnostic test is required. And we'll discuss that in a minute. The window period is what we call the amount of time someone has to wait before a Hep C test will pick up antibodies in the blood. The literature has variable window periods from five weeks to 12 weeks. Generally we say the window period is between six to eight weeks. However, in rare cases, it can be up to 6 months before antibodies are detectable. The antibody tests are sometimes referred to by other names as you can see from the slide. The RNA PCR test looks for the Hep C virus itself. Therefore, someone who tested antibody positive must always get the second confirmatory test to determine if they actually have Hep C. The PCR RNA test

11 also measures the person's viral load and finds out what genotype the virus is. This becomes important when we talk about treatment. This test has a shorter window period of one to three weeks; however, most people will not be tested so soon as they will be tested after their antibody test. In reality, many people getting tested for Hep C in Canada have been living with the virus for many years before they get tested so the window period are not so important. These tests listed below are not specific for Hep C but they are generalized tests that tell us about liver health. Sometimes the blood tests can indicate to a clinician that there is something wrong with someone's liver and that s what leads to a Hep C test. However, liver damage must be assessed before treatment starts. Although it is better to start before there is significant liver damage, many provinces health care systems require METAVIR score of F2 or higher before paying for someone's treatment and we'll discuss the Metavir scale on another slide. However, treatment may be denied if there is decompensated liver disease or other serious complications. Liver enzyme tests measure liver enzyme levels in the blood. Liver damage can lead to higher blood levels of liver enzymes such as ALT and AST. These enzymes are normally contained within liver cells but if the liver is injured or damaged they spill these enzymes into the blood. This can be caused by any number of factors including hepatitis viruses, chemicals, alcohol, medicines, or toxins. Sometimes liver enzyme tests can flag that something

12 is damaging the liver and alert a health care provider to do more testing. The more the liver sustains the less able it is to complete its 500 plus functions. There is a range of tests that health care providers can use to check how well the liver is working. These are called liver function tests. They include prothrombin time or INR. Prothrombin is a protein that is responsible for helping the blood to clot. Bilirubin is a substance that produces the yellow color of jaundice and is produced when the liver breaks down old red blood cells. Albumin is a major blood protein produced by the liver and used in transporting some molecules through the body and maintaining fluid levels in the blood. These tests may read as abnormal when the liver is damaged. Other conditions can affect these blood tests such as diet or other viruses but a physician can interpret what the results mean. An ultrasound can also be done to indicate liver health. An ultrasound uses sound waves to take a picture of the liver. It can show the difference between a healthy liver and one with a lot of damage. And ultrasound can also screen for liver cancer. A biopsy is the standard test done in Canada to measure liver damage. You can see from the illustration on the slide a pretty good representation of a liver biopsy. A large needle is inserted through the side and into the liver. A small piece of liver is removed and examined under a microscope. A biopsy can measure the level of cirrhosis and/or fibrosis in the liver. There are also fibrotests and fibroscans that can be used but they're not as common. Fibrotests are non-invasive tests

13 using a blood sample and an algorithm. The test results correspond to the metavir scoring system. Fibroscan is type of ultrascan machine that measures liver stiffness. It s a non-invasive process and unlike the biopsy, but it is not covered in Canada and so not used as often as a biopsy. This is the METAVIR scale. People who have had their liver tests done will be given a METAVIR score to indicate the level of damage their liver has sustained. F0 at the top of the chart, represents no fibrosis or liver damage. F4, down at the bottom, is cirrhosis where the liver is severely damaged and it is no longer able to function properly. There are other scales such as the Child-Pugh Score that Metavir is simpler. This graphic is from the website of Victrelis which is the brand name for boceprevir. Now moving on to treatment. The goal of Hep C treatment is to clear the virus from the body. This is known as SVR, sustained virological response. Someone who has achieved SVR which involves being virus-free 6 months after the last treatment date will be considered cured of Hep C. There used to be some reluctance to use the word cure as it seems like the virus reemerged for some people after treatment. So it was theorized that people remained carriers even after treatment; however, new research indicated it is more likely that those people are re-infected after their treatment. More and more health professionals are becoming comfortable using the word cure with Hep C. Currently treatment is between 60 and 80% effective. It involves four medications, pegylated or peg-interferon,

14 ribavirin, boceprevir, which is under the brand name Victrelis or telaprevir which is known as Incivik. Interferon is a drug that boosts the immune system. Pegylated interferon is improved version that only needs to be taken once a week. Scientists are not clear why or how ribavirin works. It seems to be both an antiviral agent and immune booster. It is also used for some respiratory illnesses and some other viral infections. Boceprevir and telaprevir are protease inhibitors or PIs and they interfere with viral replication in the liver cell itself. These are called direct acting antivirals or DAAs. Currently the last two medications are only approved to treat genotype 1. This information is based on the current guidelines from the Canadian Association of the Study of the Liver, otherwise known as CASL. Dual therapy includes a weekly peg-interferon injection and a daily ribavirin pill. Until a year ago this was the standard of care for all genotypes and still is for genotype 2 and 3. The pegylated interferon is the medication that seems to cause the most side effects. Many people report feeling overwhelmingly fatigued and sometimes nauseated by the interferon. For those with genotype 1, telaprevir or boceprevir is also prescribed. This triple therapy is now the standard of care for genotype 1 in Canada and has been shown to have improved results over dual therapy; however, this comes at a cost. There is a higher pill burden with these medications. Telaprevir is prescribed as two pills every eight hours. Patients taking boceprevir need to take four pills every eight hours. Unlike interferon and ribavirin

15 therapy, the new PIs are highly susceptible to viral resistance. This means that people taking these medications must be adherent to the dosing schedules so that their virus doesn't become resistant to the medication. More research is being done in the field to tweak these recommendations. For example, there is some indication that telaprevir could be as affective taken two times a day. People on Hep C need to be monitored often to ensure that the treatment is working. There are often co morbid -- often co morbid conditions experienced by people with Hep C such as mental health issues, drug using issues, unstable housing and poverty. The CASL guidelines recommend a multidisciplinary approach that includes experienced physicians, nurses and allied health professionals like psychologists, psychiatrists, addiction specialist like harm reduction workers and social workers. People who have gone through treatment have often talked about the support they derived from others going through treatment. Support groups and peer mentors can be useful. Treatment duration depend on a number of factors including genotype, the type of treatment, liver health, co-morbidity such as HIV, et cetera. But very generally treatment for genotype 1 lasts for 24 to 28 weeks for triple therapy or a year for dual therapy. For genotype 2 and 3, it is generally 24 weeks. People with the option to start treatment will often ask about the efficacy of the treatment. The research that was done on boceprevir and telaprevir used study participants who were quite healthy. Clinical trials exclude people who may be

16 unlikely to be successful on treatment one) because they want their drug to be approved and two) because they want to exclude confounding factors like HIV or Hepatitis B or diabetes. On-going research in the field better reflects what real world outcomes as clinicians try to treat people with cirrhosis and other co-morbidities. This means that our data is still very new. These data come from a review in the Annals of Internal Medicine from January Triple therapy with boceprevir has a 66 to 75% chance of SVR or sustained virological response. Triple therapy with telaprevir has a 60 to 73% chance of SVR. Dual therapy for all genotypes has a 38 to 62% chance of SVR. The low end of that range is likely due to the difficulty treating genotype 1 with dual therapy. Dual therapy for genotypes 2 and 3 have between a 67 and 78% of SVR. It should be noted that clinicians are starting to realize that genotype 2 and 3 should not be linked together as we have been doing, as genotype 3 is significantly harder to treat. There is only one absolute contraindication for treatment according to the CASL guidelines and that is pregnancy. This is because ribavirin is toxic to a fetus. Therefore, people with childbearing years will have to take extra precautions to make sure they cannot get pregnant while on treatment. Both parties must be vigilant to prevent pregnancy. All patients are encouraged to prevent pregnancy for 6 months after treatment as well. There are also some strong contraindications including alcohol abuse, coronary artery disease, and organ transplantation except for

17 liver transplantation. Unfortunately there is not a commonly accepted definition of alcohol abuse, which leaves much of the decision-making in the hands of the prescribing physician and can cause much confusion for patients trying to access Hep C treatment. Also note that alcohol use is no longer a contraindication. Nor is intravenous drug use or methadone maintenance. This is because there is good research that shows that with appropriate supports people who use alcohol or other drugs can be successful on Hep C treatment. Preparation work is generally done with people before they start their Hep C treatment to ensure that they know what to expect with the side effects and how to deal with them. For example, people with history of depression may be put on anti-depressants prior to initiating Hep C treatment. Side effects can make treatment tough, especially depression and fatigue. We also know that interferon can trigger depression in some people. Most side effects disappear after treatment is completed but some, including depression, can linger. Some minor side effects can fade after a few weeks. And many side effects can be managed. Some other potential side effects include flu-like symptoms, nausea, diarrhea, loss of appetite, weight loss, itchy skin (and telaprevir has been known to cause a severe rash in some people), hair loss, taste changes, mood swings, insomnia, anemia, blood disorders, which can lead to immune problems, dry mouth and mouth sores are other potential side effects. People who have been through treatment have come up with many strategies to

18 manage treatment side effects. Some of them are listed on the slide. Because interferon is the medication that seems to hit people the hardest, it can be a good idea to ensure that you have a lot of time to rest after you get your injection. Another strategy is to do household chores and errands and schedule appoints when your energy is the highest and look out for windows of energy. Drinking lots of water to help flush the toxins out of the body is another strategy, as well as avoiding dehydrating drinks like alcohol or caffeine. People need to think about pain management like meditation or massage. For some people connecting to their spiritual side through sweats or church services can be helpful. Gentle exercise when possible is necessary. This can be something as simple as lifting your legs while you sit in a comfy chair. The fatigue induced by both the virus and the medication can make this especially difficult for people to manage but any little bit of exercise helps. We also encourage people to have a look at the CATIE guide called Hepatitis C: Managing common symptoms and side effects for further tips how to manage side effects. >> Thank you, Barb. This ends our presentation on Hep C basics. Open the line to questions. Please feel free to type your questions or comments in the chat window on the left side of your screen. I would like people to note that we may not be able to address all questions and comments especially if they're not directly related to the topic. We ll give people a few minutes to type in their questions.

19 You can also dial pound six to unmute your lines and ask the questions directly. We'll give you a few minutes to write your questions down. And note that your text messages can only be seen by moderator. So no one else will be able to see your question and read it out for everyone. So we have a question here. Someone would like a point of clarification around the transmission of Hep C. Through sexual activity. So he is asking if blood must be present for that to occur. >> As far as we know that is the case. As far as we know Hep C is only transmitted through blood-to-blood contact and so the people who have been infected through sexual activity there is the assumption that there has been some blood present again even if it is only microscopic amount [barb] >> Thank you. Any more questions, please type faster or just dial pound six. So we have another question. This person is wondering if we believe that one day there will be liver transplant for co-infected individuals. That is for individuals with both HIV and Hep C. >> Barb: It is a good question. And I'm -- unfortunately I'm not a specialist or a surgeon. I can say that I certainly hope so. And I do know that a lot of research is being done around liver transplantation particularly for people with Hep C and HIV. And it seems as though they're making really significant leaps forward in liver transplantation. So it is likely that at some point we will be able to see folks who are co-infected receive a liver

20 transplantation. When that will be I really can't say. >> Thanks, Barb. If anyone has more information on that please feel free to send us an or to share with the other participants. You can just type in the information or your contribution and we'll read it out for everyone to hear. Any more questions? Is Hep C higher in certain groups men who have sex with men? >> Barb: It is higher among certain groups. Among intravenous drug user in particular. Across Canada is 33 or more times higher in prison. For men who had sex with men I am uncertain about that. And I -- and I don't know if anyone else is able to comment on that many we're happy to read out your answer. >> There is another question. It says individuals with cirrhosis offered treatment. >> Barb: The answer to that is so often the case, it depends. People with cirrhosis can be offered treatment. It would depend on whether their liver is -- is decompensated. So there is compensated liver disease and decompensated liver disease and generally people with decompensated liver disease are not offered treatment. There is too much damage and real concern that the liver wouldn't be up to going through treatment. But it is -- you know, other factors would come into play there. >> Is it correct to say that the triple therapy is actually offered to people with cirrhosis compared to dual therapy?

21 >> Barb: Only for genotype one. >> Only for genotype one. Thank you. Any more questions? >> Barb: We have another question coming. So there is a question about what happens to a person with decompensated liver. When we get into -- I'm certainly not a liver specialist. When we get into really specific questions about -- about liver disease I'm not really the best person to ask. I do know though that it is very likely that somebody with a decompensated liver would be looking at liver transplant. I also know that the liver transplant lists are quite long in Canada. Liver transplant is not offered to everyone. And they can still live for quite some time with a decompensated liver but there is a real risk of death if somebody's liver is not doing what it needs to be doing. >> We don't see any more incoming questions. And so I would like to say thank you very much to Barb Panter for this wonderful presentation. Our next webinar we're looking at the viral cycle how they replicate and how drugs work to control it. It is going to be presented by Thomas who is one of our Regional Health Education Coordinators here at CATIE. So this webinar will be on Thursday January 16th. At 1:00 to 2:00 p.m. EST. So once this webinar has ended, your browser will automatically be directed to an evaluation page. We really appreciate your feedback. Use it to continue making our webinars even better. So with that, thank you very much. And we hope that you can join us for

22 our next webinar on the Building Blocks entitled viral replication cycle. Thank you very much and thanks, Barb. Bye. THIS TEXT IS BEING PROVIDED IN A ROUGH DRAFT FORMAT. COMMUNICATION ACCESS REALTIME TRANSLATION (CART) IS PROVIDED IN ORDER TO FACILITATE COMMUNICATION ACCESSIBILITY AND MAY NOT BE TOTALLY VERBATIM. THE CONSUMER SHOULD CHECK WITH THE MODERATOR FOR ANY CLARIFICATIONS OF THE MATERIAL.