The Five: The Flu —Alan Franciscus, Editor-in-Chief

This year’s strains of influenza are particularly virulent, and unfortunately the vaccine developed this year does not provide protection against all of the strains.  The flu is a nasty virus that causes 36,000 deaths and 200,000 hospitalizations each year in the United States. The largest and deadliest flu outbreak was the Spanish flu pandemic of 1918-1919 that caused 20 to 40 million deaths.  Now we are lucky to have a healthcare system that prevents most deaths, and vaccines that provide protection against most strains of the flu. 

1. Symptoms:  Many people confuse the symptoms of flu with the cold, but the flu has definite symptoms, such as: 

• A fever of 100 degrees or higher (but not everyone gets a fever)
• A cough and/or sore throat
• A runny or stuffy throat
• Headache and/or body aches
• Chills
• Fatigue or feeling tired
• Nausea (feeling sick to your stomach), vomiting, and/or diarrhea

2. People who are at risk for severe complications:

• Children younger than 5, especially those younger than 2 years old
• Adults 65 years and older
• People who have medical conditions including liver disease (such as hepatitis B and C)

3. Prevention:

• The best prevention is the flu vaccination.  It is safe and is usually effective; but this year’s flu has mutated so the vaccine is not protective against this year’s most virulent flu strain.  Even so, it is protective against 50% of the strains infecting people this year.
• Basic hand washing can help to protect people from the cold, flu and other infections—wash the hands for at least 20 seconds with soap and water. 
• Watch what you touch, especially other people’s items—phones, iPads, remote controls, etc.

4. The Flu:

• If you get the flu, the best advice is to get bed rest, and monitor your temperature and drink lots of fluids.
• There are many over-the-counter medicines that can help lessen some of the symptoms
• Your medical provider can prescribe antiviral medications to reduce the symptoms and shorten the duration of the flu
• Seek medical attention if you experience any of the following:
• Difficulty breathing or shortness of breath
• Purple or blue discoloration of the lips
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Seizures
• Flu-like symptoms that improve but then return with fever and worse cough

5. The Bottom Line:

• There is still time to get the flu vaccine, but if you don’t get vaccinated, be prepared to take precautions to protect yourself against getting the flu. 

New Viral Hepatitis Numbers from the CDC, by Alan Franciscus, Editor-in-Chief

The Centers for Disease Control and Prevention (CDC) released new estimates on the acute and chronic cases of hepatitis A, B and C: 

Hepatitis A (HAV):

2013: Estimated acute cases and deaths from hepatitis A

• Acute:  3,500–range:  2,500 to 3,900
• Deaths:  80 (underlying contributing cause of death in most recent year available (2013))

Hepatitis B (HBV):

2013: Estimated acute, chronic and deaths from hepatitis B

• Acute:  19,800—range: 11,300 to 48,500
• Chronic:  700,000 to 1.4 million
• Deaths:  1,873

Hepatitis C (HCV):

2013:  Estimated acute, chronic and deaths from hepatitis C

• Acute:  29,700—range: 23,500 to 101,400
• Chronic: 2.7 to 3.9 million
• Deaths:  19,368*

NOTE: Current information indicates these represent a fraction of deaths attributable in whole or in part to chronic hepatitis C.”  

Editorial Comments:  The good news is that vaccination against hepatitis A and B and education efforts are working to keep new infections, chronic infections and deaths consistent with previous years.  Hepatitis A and B are in line with what have been previously reported and rates of new infections have leveled off.  I personally believe that hepatitis B may be under reported especially in some larger populations of immigrants who may be infected with hepatitis B.  Furthermore, we may not know the extent of chronic hepatitis B in the undocumented immigrant population. 

HCV however, seems be getting worse. The range of acute HCV population is much likely higher since we really don’t have an effective surveillance system in our country.  We have had large outbreaks of acute HCV in Wisconsin, Kentucky, Massachusetts, Indiana and elsewhere. I also believe the number of people with chronic hepatitis C is much higher and the deaths caused by hepatitis C is certainly higher.  The CDC has a * (see note) that captures the deaths which are most likely under reported.  Many times a death reported on a death certificate is listed as another cause when HCV or cirrhosis, liver cancer or a consequence of HCV may be listed instead.   

On a sad note, the age group that had the highest  rate of death was the 55 to 64 year old group with 51% of the total number of deaths—this is very young age for such a high death rate.


http://hcvadvocate.org/news/newsLetter/2015/advocate0615.html#4

Snapshots, by Alan Franciscus, Editor-in-Chief

Article: Prevalence and risk factors for patient-reported joint pain among patients with HIV/Hepatitis C coinfection, Hepatitis C monoinfection, and HIV monoinfection—A Ogdie et al.
   Source:  BMC Musculoskeletal Disorders 2015, 16:93  doi:10.1186/s12891-015-0552-z

A common symptom that people with hepatitis C report is pain—liver pain, muscle and joint pain, fibromyalgia, headaches and the list goes on and on.  The aim of the current study was to determine the prevalence of patient reported joint pain among 3 groups (a total of 202 patients, mostly males): HCV mono-infection (93 patients); HIV-mono-infection (30 patients); and HIV/HCV co-infection (79 patients).  The ages and genders were similar across all three groups.  More than half were Black. 

The Multi-Dimensional Health Assessment Questionnaire was used to determine joint pain and any related symptoms. The patients were also interviewed and their charts were reviewed. 

The Bottom Line:  Joint pain was more commonly reported in HCV-monoinfected patients than in HIV/HCV-coinfected patients—71% vs. 56.  Joint paint was also more commonly reported in HCV mono-infected patients than in HIV-monoinfected patients—71% vs 50%.

The study found that a previous diagnosis of arthritis and current smoking were risk factors for joint pain among people who are infected with hepatitis C. 

Editorial Comment:  This is another reason why everyone with hepatitis C should be treated.  There are so many symptoms and conditions caused by hepatitis C.   

For more information see this month’s HealthWise.

Article: Liver-related death among HIV/hepatitis C virus-co-infected individuals: implications for the era of directly acting antivirals—D Grint et al. 
   Source: AIDS. 2015 Apr 13. [Epub ahead of print]

The new interferon-free therapies provide similar cure rates in people who are co-infected with HIV and hepatitis C as in people who are mono-infected with hepatitis C.  However, access is being restricted due the higher costs of the newer medications.  

In general, people who are co-infected with HIV and hepatitis C have a faster rate of HCV disease progression than someone with hepatitis C mono-infection.  Even so, treatment is being restricted to those with the greatest risk of liver-related death.  The current study sought to provide a degree of guidance on who should be prioritized for receiving the new direct acting antiviral medications (DAAs) or HCV inhibitor combination medications.  The study looked at the liver-related deaths of the people who were co-infected with HIV and hepatitis C.

In the current study 3,941 HCV antibody positive patients who were part of a European study (EuroSIDA) and who were followed-up after 1 January 2000 were included. 

Liver-related deaths accounted for 145 of 670 (21.6%) deaths in the study population. Liver-related death rates peaked in those aged 35-45 years, and occurred almost exclusively in those with at least F2 fibrosis at baseline.  Note: The Metavir scale is F0, no activity, F1 for inflammation, F2 for light scarring, F3 for moderate-severe scarring and F4 for cirrhosis. 

The Bottom Line: The authors reported that the 5- year probability of liver related death (LRD) was low for those with F0-F1, but substantial for those F2, F3 and F4. 

The authors also noted that “treatment with DAAs should be prioritized for those with at least a F2 fibrosis.  Early initiation of cART with the aim of avoiding low CD4 cell counts should be considered essential to decrease the risk of LRD and the need for HCV treatment.” 

Editorial Comment:  I wonder how many people coinfected with HIV/HCV are F0-F1, how quickly people progress from one stage to another, how often do you need to monitor people in stage F0/F1, how much does it cost to monitor, and would it be cheaper in the long run to treat everyone?  

Article: Hepatitis A and B among young persons who inject drugs—Vaccination, past, and present infection. MG Collier et al.
  Source:  Vaccine. 2015 Apr 15. pii: S0264-410X(15)00472-7. doi: 10.1016/j.vaccine.2015.04.019. [Epub ahead of print]

It is recommended that people who inject drugs (PWID) should be vaccinated against hepatitis A (HAV) and hepatitis B (HBV). There is some evidence that some young individuals who were vaccinated as children may have lost their immunity.  The current study sought to understand the current HAV and HBV immunity status among 519 persons who inject drugs.   The study group included 18 to 40 year olds who lived in San Diego—49% were non-Hispanic white, 7% were non-Hispanic Blank, 27% were White Hispanic, 4% were born outside of the U.S. 

The Bottom Line:  After being tested it was found that 47% were susceptible to HBV infection and 63% were susceptible to hepatitis A infection.  Additionally, 26% tested positive for HCV antibodies.  The authors reported that even though the participants believed that they had been vaccinated, many had not.  The authors commented that "Programs serving this population should vaccinate PWIDs against HAV and HBV and not rely on self-report of vaccination."

 
Editorial Comment:  This recommendation makes perfect sense. People forget about what vaccines they received as children or if they were vaccinated at all.  If you have hepatitis C it is even more important to be protected.  Becoming co-infected with another hepatitis virus such as HAV or HBV can lead to serious health consequences, even death.   The HAV vaccine can be given without serologic testing since it will do no actual harm.   It is important, however, to give the HBV serologic test to make sure that people are not already infected with the hepatitis B virus before giving the HBV vaccine.  The HBV vaccine doesn’t provide any benefit to people who have acute or chronic HBV and might just might give people a false sense of security and prevent much needed follow-up medical care.

http://hcvadvocate.org/news/newsLetter/2015/advocate0615.html#3

Variations in Liver Cancer Attributable to Hepatitis Virus Variations

Discovery that hepatitis B and C viruses generate markedly different clinical pathologies highlights potential change in treatment plans for newly diagnosed patients

Newswise — CHICAGO —Significant clinical variations exist among patients with the most common type of liver cancer called hepatocellular carcinoma (HCC), depending on the viral cause of the disease –hepatitis B virus (HBV) or hepatitis C virus (HCV). These differences suggest that hepatitis status should be considered when developing treatment plans for newly diagnosed patients, according to researchers at The University of Texas MD Anderson Cancer Center.

These findings, from the largest single-center studies of its kind will be presented on Sunday, May 31 in an oral presentation at the 2015 Annual Meeting of the American Society of Clinical Oncology (ASCO). The research builds on previous studies of differential effects of demographics, geographical distribution and risk factors, including hepatitis status, on treatment outcomes among patients with inoperable HCC. In these earlier studies, researchers observed different outcomes based on demographics and geographic patients distribution (Asia versus Europe and USA) among patients receiving the same local or systemic therapy approaches. They hypothesized that these differences might be attributed to variations with regard to hepatitis type, among other factors.

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