Tattoos drawing attention

Note:  the article discusses the risk of tattoos and hepatitis C, but as this articles points out that it is a transmission route in unsafe settings--NOT in commercial settings were safety is being carefully followed.

Tattooing, once a fringe, minority pursuit, is going mainstream in Dunedin, local tattoo artists say, with everyone from law students to nurses inking their skin.

But, the council says as legitimate operations flourish, there has been a spike in tattooing of the underground, backyard variety, too.

There were eight registered tattoo studios in Dunedin, but many more illegal operators were working out of private homes, with no training, risky hygiene practices and cheap tools and ink, Dunedin City Council Environmental Health and Animal Services manager Ros MacGill said.

Read more...

Visit our Tattoo Blog HERE

Cherokee Nation Working to Eliminate Hepatitis C

The Cherokee Nation is on a mission to eliminate Hepatitis C, which officials call an epidemic.

According to the Centers for Disease Control and Prevention, the highest increase in Hepatitis C incidence from 2000 to 2013 was among Native Americans.

Dr. Jorge Mera oversees Cherokee Nation Health Services’ infectious diseases division. He said the first step is screening everyone age 20–69 for Hepatitis C, even though two out of three Americans with the disease were born between 1945 and 1965.

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Article: Hepatitis B Virus Reactivation During Successful Treatment of Hepatitis C Virus with Sofosbuvir and Simeprevi

This article is being re-posted from a previous newsletter.  I have been hearing from patients who have been inquiring about treatment with a DAA and who are also co-infected with chronic hepatitis B.  People co-infected with HCV and HBV should make their medical providers aware that their chronic hepatitis B should be monitored on a regular basis.  The article below recommends that people being treated with a DAA should be monitored every 2 weeks.  -Alan

Snapshots - Alan Franciscus

Article:  Hepatitis B Virus Reactivation During Successful Treatment of Hepatitis C Virus with Sofosbuvir and Simeprevir—J. M. Collins et. Al
  Source:  Clinical Infectious Diseases Advance Access

Results and Conclusions: This was a case report of two individuals with hepatitis C. 

The first case was a 55 yo man who was coinfected with hepatitis B and hepatitis C genotype 1a.  He had been previously treated with pegylated interferon plus ribavirin but did not achieve a cure.  He was started on sofosbuvir and simeprevir.  After week 4 he was HCV undetectable, but at week 7 he started to have severe liver symptoms (AST of 1792 IU/L, ALT of 1495 IU/L, total bilirubin of 12.2 mg/dl and INR of 1.96) and his hepatitis B viral load rose to 22 million.  His other tests (antinuclear antibody, ferritin, a-fetoprotein, etc.) were also abnormal.

The HCV treatment was discontinued, and hepatitis B treatment (tenofovir/emtricitabine) was started and the hepatitis B viral load subsequently decreased to less than 20 IU/mL.  The hepatitis B treatment was continued for ongoing hepatitis B suppression.

The second case was a 57 yo man with HCV genotype 1a.  He had been treated for HCV with pegylated interferon plus ribavirin but had not been cured. He was positive for the hepatitis B virus, but the hepatitis B viral load was below the level of detection (20 IU/mL).  He was started on HCV treatment—sofosbuvir and simeprevir and his HCV and hepatitis B viral loads were monitored every two weeks.  After two weeks, his HCV viral load was undetectable and his hepatitis B viral load increased to 353 IU/mL.  After four weeks of HCV treatment, HCV was still undetectable, but the hepatitis B viral load increased to 11,255 IU/mL.  The liver function tests were normal, and there were no other signs of liver disease.  The patient remained on sofosbuvir/simeprevir treatment.  Tenofovir was added to the HCV treatment regime to treat hepatitis B. 

The Bottom Line:  The reactivation of HBV in people who were coinfected with HBV and HCV was rare in the days of pegylated interferon based therapies.  This was most likely because PEG works against HBV whereas the new HCV direct acting antivirals do not have antiviral properties that will suppress hepatitis B while treating HCV.   

Editorial Comment:  A couple of important points:

• Everyone with hepatitis C should be tested for hepatitis B (and A), and if not previously infected should be vaccinated.
• People who are chronically infected with HBV and HCV who are being treated with the direct-acting antiviral medications (Harvoni or Viekira Pak) and monitored very closely—every two weeks as listed in the second study—for HBV flares and treated for chronic HBV as needed. 

[HAP] NASTAD Releases White Paper on Drug User Health and ACA Opportunities‏

With generous support from the Elton John AIDS Foundation, NASTAD is pleased to announce the release of a new white paper: Modernizing Public Health to Meet the Needs of People Who Use Drugs: Affordable Care Act Opportunities. The paper assesses new financing and delivery models for drug user health services. Working with the O’Neill Institute for National & Global Health Law, the project team focused on coverage and financing opportunities for community-based drug user health and harm reduction services typically not covered by insurance. Research focused on eight states, assessing how health departments, community-based organizations, Medicaid programs and plans and hospitals are working together to better address the needs of people who use drugs.

The need to find creative solutions to ensure that broader health care systems and payers are providing prevention, care, and treatment services for people who use drugs comes in the midst of a public health crisis for this population. Rates of HIV infection and viral hepatitis are substantially higher among persons who use drugs than among persons who do not. Opioid use in particular in the United States is at epidemic proportions. This crisis – coupled with limited federal and state resources for drug user health programs and services – has made leveraging the ACA and partnerships with broader health systems and payers even more critical.

NASTAD has been awarded another year of Elton John AIDS Foundation funding to support a learning collaborative that builds off of the findings of the white paper and supports health departments to partner with broader health care systems and payers to increase access to drug user health services. To see more of NASTAD’s drug user health work, including our Statement of Urgency: Addressing the Opioid Epidemic in the United States and Minimizing Harm, Maximizing Health: The Role of Public Health Programs in Drug User Health, please visit our website.

 For questions, please contact Amy Killelea at akillelea@nastad.org

For more information, visit the NASAD Website.....

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. 

Nursing Home Blamed for Hep C Outbreak

MINOT, N.D. (CN) - An "unprecedented outbreak" of hepatitis C at a North Dakota nursing home made at least 44 people sick, at least four of whom died, 13 people, including representatives of the estates, claim in court.
   
Lead plaintiff Richard Kerzman claims he was one of the elderly patients who contracted hepatitis C from 2003 through 2013 due to the negligence of ManorCare Nursing Home and Trinity Health.
   
Kerzman et al. say at least 52 people in and around Minot contracted hepatitis C during the outbreak. The lawsuit says that state investigators traced 44 of the infections to the ManorCare Nursing Home.

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Medicare spending for hepatitis C cures surges

Medicare’s prescription drug program spent nearly $4.6 billion in the first half of this year on expensive new cures for the liver disease hepatitis C — almost as much as it paid for all of 2014.

Rebates from pharmaceutical companies — the amounts of which are confidential — will reduce Medicare’s final tab for the drugs, by up to half. Even so, the program’s spending will likely continue to rise, in part because of strong demand.

Medicare’s stunning outlays, spelled out in data requested from the government by ProPublica, raise troubling questions about how the taxpayer-funded program can afford not only these pricey medications but a slew of others coming on the market

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Nurse used same syringe on 67 people at N.J. flu clinic, state says

A nurse who administered flu vaccines to employees of a West Windsor company has been reported to health officials because she re-used a single syringe for the shots.

At an employer-sponsored flu clinic at Otsuka Pharmaceuticals last week, the unnamed nurse committed an "infection control breach," according to a spokeswoman for the N.J. Department of Health.

"Full infection control practices that prevent transmission of blood-borne diseases were not used by a contracted health care agency, Total Wellness," said Donna Leusner, the spokeswoman.

Read more....

THE FIVE: Cirrhosis —Alan Franciscus, Editor-in-Chief

This month’s column is about cirrhosis—the causes, how it develops, the symptoms and
consequences and issues about HCV treatment related to cirrhosis.
 
1.  What are the Causes of Cirrhosis?  

Cirrhosis is caused by many substances (alcohol), viruses (hepatitis B, C and D), and even by metabolic disorders (diabetes). Currently, the most common reason for liver transplantation in the United States is from complications from the hepatitis C virus.  Cirrhosis caused by hepatitis C is responsible for  more than 19,000 deaths every year.  Prior to the emergence of hepatitis C, the most common cause of cirrhosis was alcohol consumption. Fatty liver is also a common cause of cirrhosis, and it is expected to surpass the hepatitis C virus as the most common cause of cirrhosis and liver transplantation in the next two decades.

2.   How Does Cirrhosis Develop?

In the case of hepatitis C, the development of cirrhosis is a complex process of liver cells becoming damaged or destroyed by the hepatitis C virus.  Furthermore, the body’s immune system seeks out and identifies the hepatitis C virus (and the destroyed liver cell) as a foreign pathogen—attacks it and kills it.  As a result, scar tissue develops.  Usually, the liver can repair itself, but as the hepatitis C virus causes more and more damage, it overwhelms the body and the damage builds and builds.  As more scar tissue develops the damaged cells start to connect, and fibrosis develops. Over time, the scar tissue can be so extensive that it can interfere with the functioning of the liver.  This is called cirrhosis. Cirrhosis is classified into two types: compensated and decompensated. Compensated means that the liver is extensively scarred but can still perform most of its functions; decompensated means that the liver is extensively scarred and unable to perform many of the functions that keep the body healthy.  

3.  What are the Tests to Identify Cirrhosis?

There are many types of tests to find out if someone has cirrhosis.  In the past, the most common test was a liver biopsy.  The procedure requires a medical person to  insert a needle through the skin to extract a piece of liver tissue and examine it under a microscope.  The liver biopsy is still being used, but it is also being replaced by other procedures such as a Fibroscan (an imaging test), Fibrometer (combination of blood tests), and other blood tests to gauge the degree of liver damage.

There are many models used to grade and stage the degree of liver damage.  The most common is the Metavir. The Metavir has an inflammation and fibrosis scoring stage—in this article I am just listing the fibrosis stages:

• Stage F0 = no fibrosis
• Stage F1 = mild fibrosis
• Stage 2 = moderate fibrosis
• Stage 3 = bridging fibrosis
• Stage 4 = cirrhosis 

Note:  This is important to know because many insurance companies are using this system to approve or deny insurance for HCV treatment claims.

4.  What are the Symptoms and Consequences of Cirrhosis? 

In the early stages of extensive scarring—called compensated cirrhosis—the symptoms may be similar to hepatitis C—fatigue, loss of appetite, muscle and joint pain, flu-like symptoms, nausea, indigestion, headaches and many other symptoms.  As cirrhosis develops and reaches the later stages—called decompensated cirrhosis—the symptoms become more pronounced and can become life-threatening.  In addition to the symptoms described above I have listed some of the more common serious conditions below:

• Portal Hypertension: blood cannot flow through the liver because of the extensive scarring. 
• Encephalopathy: the liver is not able to remove toxins such as ammonia, and the result is that these toxins invade the brain.  Symptoms include personality changes, and changes in sleep patterns (sleep reversal—awake all night, sleep all day).
• Ascites:  accumulation of fluids in the abdominal cavity.  
• Edema: accumulation of fluid in the extremities—usually in the feet and legs.  
• Coagulopathy: the liver is not able to produce clotting factors that stop the blood from bleeding.
• Male and Female Hormone Regulation:  the liver may not be able to regulate female and male hormones.
• Severe Itching: the impairment of bile flow that can cause severe and at times debilitating itching.
• Wasting Syndrome: the liver is not able to process nutrients so people can have severe muscle wasting and weight loss.  

Most of these conditions can be managed effectively with lifestyle changes, medications and medical procedures—at least in the short term. The most important step is to be medically monitored and managed on a regular basis.  At this point, a person should be evaluated for a liver transplant.  The problem is that there are only an estimated 6,000 available livers for the estimated 15,000 livers needed every year for transplantation in the U.S.

5.  HCV Treatment  

Hepatitis C treatment can now cure most people, the treatment duration is shorter, and treatment side effects are lower than ever.  However, once people develop cirrhosis, it becomes more difficult especially for those who are infected with genotype 3 and who have cirrhosis—the second most prevalent genotype in the United States.  Unfortunately, we also know that many insurance companies are denying coverage of hepatitis C medications to only those who are in the early stages of HCV infections (F0, F1, F2).  Many insurance companies are only covering F3 and F4 unless there are other severe complications.  Here’s the problem—if you wait until stage F3 or F4 and are cured you will have to be medically followed for the rest of your life since there is a possibility that you could still have liver disease progression. However, if you are treated early (F0, F1, F2), and cured you are free of future complications.  Does this scenario make any sense to you?  It does not make any sense to me either!

Managing Hepatitis C: Advances in treatment & evaluation

Improvements to the efficacy and side effects of hepatitis C medications have simplified the disease management calculus, tipping the scales towards treatment.

The availability of effective oral medication has also raised the bar for clinicians: is there a way to make similar progress in the evaluation side? What would it take to stage the disease quickly, safely, and without discomfort for the patient?

The stiffness of the patient's liver tissue, categorized at a certain stiffness as "fibrosis," provides hepatologists important diagnostic information about the extent and stage of hepatitis C. Liver biopsy has long been the gold standard for obtaining this information. However, biopsies are time-consuming invasive procedures that routinely cause patients pain and, in some rare instances, lead to greater complications such as internal bleeding. These procedures take up clinical staff time, necessitate bed space, and incur instrument and room sterilization costs. Lastly, they are subject to not insignificant sampling limitations, as each biopsy takes only a small sample from a large organ.

Read more...

Hepatitis C in Children

—Alan Franciscus, Editor-in-Chief

It is estimated that Hepatitis C (HCV) occurs in about 0.15% of 6-11 year-olds and 0.4% of 12-19 year-olds.  It is estimated that there are 23,000 to 46,000 children in the US with HCV.1  The actual number of children with HCV is unknown because children are not routinely tested for it.

Prior to 1992, the most common transmission route for HCV in children was through blood transfusion, blood products, and organ transplantation.  Now that blood products and organs are screened for hepatitis C the most frequent transmission of hepatitis C in infants is mother-to-child transmission.  The second most common transmission route in children and teenagers is in those who share equipment to inject drugs (needles, cookers, cotton, water, etc.)

Transmission of HCV from an HCV-infected mother-to-infant occurs about 6% of the time.  It can occur up to 10% of the time if a mother is coinfected with HIV and hepatitis C.  Also, a high viral load increases the risk of mother-to-infant transmission.   Unfortunately, there are no effective strategies or drugs to prevent the transmission of HCV from mother to child.  

When a baby is born to an HCV-infected mother, the child will acquire the mother’s HCV antibodies. For this reason, the child will not be tested for HCV antibodies for 18 months.  This is the period that it takes for the baby’s body to clear out the mother’s antibodies.
An HCV RNA or viral load test can be given as early as one month.  It might be too early since the HCV RNA, or viral load fluctuates during the acute infection phase.  Also, babies have a high rate of natural clearance.  Most medical providers prefer to wait out the 18-month period to test for HCV antibodies and the confirmatory HCV RNA (viral load test).

Table 1.  Children for whom screening is recommended.

• Children and adolescents with unexplained elevated aminotransferasesChildren at risk for vertically acquired HCV
• Children from regions with high prevalence of HCV (adoptees, refugees, immigrants)
• Children and adolescents with HIV
• Children or adolescents who are victims of sexual assault
• Adolescents with multiple sexual partners
• Adolescents who are or were intravenous drug users, even if only once in the past
• Children or adolescents who have ever been on dialysis
• Sexual partner of HCV-infected person
• Children or adolescent who have received needle stick (needles, piercing or tattooing)*

Source:  Mack CL1, Gonzalez-Peralta RP, Gupta N, et al. NASPGHAN practice guidelines:
Diagnosis and management of hepatitis C infection in infants, children, and adolescents Pediatric Gastroenterol, Nutr 2012;54:838-855

Baker R. Viral Hepatitis. In: Pohl JF, editor. Pediatric Gastroenterology. Baton Rougue, FL: CRC Press: 2014.  pp 313-327

*I read this recommendation with interest because we know that receiving a tattoo or piercing in a commercial parlor is safe.  .

Chronic Infection
Approximately 75% of infants who are acutely infected with hepatitis C will continue to chronic infection.  In children, the rate of disease progression is slow.  There is, however, a small percentage (estimated at less than 2%) of children in whom there is a rapid rate of disease progression that could lead to fibrosis and cirrhosis.

Watch, Wait and Protect
A baby born to an HCV-infected mother should receive the hepatitis A and hepatitis B vaccines to protect the child from becoming infected with another liver disease.  As well the baby and child should receive other immunizations to protect the health of the child.

Hepatitis C is not spread by casual contact and infected children should not be restricted from attending daycare or school.  Children should be taught that they should not share toothbrushes, nail clippers, razors or any other items that have the potential to transmit hepatitis C.

Any drug, herb or supplement that the child is given should be screened to make sure that it is liver safe.  When the child is older, a discussion should take place about sex, drugs, and alcohol.

Most importantly, a child should be medically monitored on a regular basis.

When to Tell a Child
Telling a child that they have hepatitis C can be one of the most difficult decisions a parent can ever make.  The timing is the most important decision.  The best advice is never to lie to a child.  We have an excellent fact sheet that can provide plenty of advice to parents.  http://hcvadvocate.org/hepatitis/factsheets_pdf/TellChild_HCV.pdf

Treatment
As stated above most children have a slowly progressive disease.  For the small percentage that have severe fibrosis or cirrhosis, immediate treatment may be needed.   The decision to treat or not is never easy and in children it is even more difficult.  Some questions that are important to consider include:

• Can treatment be postponed until the interferon-free therapies are available?
• Is there an interferon-free clinical trial that your child can enroll in?
• Are you and your child ready to take on interferon treatment and the side effects?
• The new medications are very expensive—there is always the possibility that your insurance company may not cover the new medications.

Current treatment of pegylated interferon plus ribavirin is approved for children who are three years and older with compensated cirrhosis.

Again, most children have slowly progressive disease, and it takes decades before serious liver disease develops.  By this time, children will age to adults and be eligible for interferon- and ribavirin-free therapies that approach 100% effectiveness.

The Future
Hepatitis C infections are on the rise.  The so-called Second Epidemic of hepatitis C is affecting females equally as males.  As a result, there will be many women of child-bearing age that will become pregnant and have children who may also have hepatitis C.

For the first time, there is an opportunity to prevent mother-to-child transmission. Direct-acting antiviral medications without ribavirin that are pregnancy category B.

Pregnancy Category B: In humans, there are no well-controlled studies. However, in animal studies, pregnant animals received the medicine, and the babies did not show any problems related to the medicine.

However, there have not been any clinical studies using the interferon- and ribavirin-free medications in pregnant women.  As a result, studies are needed to evaluate the safety and effectiveness of these new drugs for the mother and the infant.

1American Liver Foundation
Source:  Hepatitis C in Children in Times of Changes, Robert D. Baker and Susan S. Baker Walters Kluwer Health, Inc.

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

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.

Read more....

Film Puts Hep C in the Spotlight

A film to raise awareness and increase knowledge of hepatitis C among GPs and other primary care practitioners has been launched today by the Royal College of GPs (RCGP),the Hepatitis C Trust and HCV Action.

Hepatitis C affects around 214,000 people in the UK and the virus can lead to liver disease and cancer, making it a significant public health issue.

With 90% of all patient contacts in the NHS conducted by GPs and their teams, it is likely that patients with hepatitis C will at some point be treated in general practice and wider primary care services, yet guidance from both the National Institute for Health and Care Excellence (NICE) and Public Health England suggests that more needs to be done to raise awareness levels among primary care professionals.

Editor's note:  The link to the film in the article is bad.  Please use this one instead: http://hcvaction.org.uk/resource/film-detecting-managing-hepatitis-c-primary-care

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The end of hepatitis C?

2014 will do down as a pivotal year in the fight against hepatitis C virus (HCV), a blood-borne infection that is thought to infect around 2.5% of the world's population - some 170 million people.

The availability of new, more effective therapies for hepatitis C virus have raised the tantalising prospect of being able to eliminate the infection on a global basis,  although there are still significant obstacles to overcome.

Viral hepatitis - which generally means hepatitis B and C - “kills more people every year than HIV, malaria and tuberculosis combined, but has not had the same level of resources committed to it,” according to Charles Gore, who is chief executive of the Hepatitis C Trust in the UK and president of the World Hepatitis Alliance (WHA).

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USA-Lack of Insurance Bars Some from Hepatitis C Treatment

Survey data from 2001 to 2010 show that lack of insurance kept some people with hepatitis C virus from getting treatment.

Recently, more effective and well-tolerated drugs have been developed to treat hepatitis C, removing many of the discouraging side effects of older drugs. The infection is curable and transmission can be prevented, researchers write in the American Journal of Gastroenterology.

But for the more than three million people in the U.S. who have chronic liver disease from hepatitis C, there are still two important barriers to getting treatment, said lead author Dr. Ivo Ditah from the Mayo Clinic in Rochester, Minnesota.

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Canada-Ontario decision to cover costly hepatitis C drug a lifesaver, doctor says

Ottawa liver specialist Dr. Curtis Cooper is calling Ontario’s decision to pay for new treatments that can cure hepatitis C a “landmark event” that will change the lives of thousands of people with the disease.

Cooper, director of The Ottawa Hospital and Regional Hepatitis Program, sees thousands of hepatitis C patients, many of whom will benefit from the new drug therapy now that it is covered by the province.

“This is going to mean the difference between health or illness and death,” for many patients, he said.

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Hepatitis Pills Contributed to 13 Percent Spike in Drug Spending

Costly new hepatitis pills helped drove a 13 percent increase in drug spending last year among insurer-managed plans in the United States, a rate not seen in more than a decade, according to a report from the pharmacy benefit manager Express Scripts.

A course of therapy to treat the liver-damaging hepatitis C virus could cost as much as $150,000 with the approvals of medicines such as Gilead Sciences Inc.’s Sovaldi and Harvoni and Johnson & Johnson’s Olysio, Express Scripts said in the report, released Tuesday. Driven as well by higher costs of specialty and compounded medicines, the estimated drug spend in general for each person in commercial-insured plans was $980 in 2014.

The new hepatitis C medicines are particularly challenging for government health plans and programs.

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Re-infection due to ongoing risk probably the cause of HCV recurrence after SVR

Rates of hepatitis C virus (HCV) reoccurrence after successful therapy differ markedly between risk groups, according to the results of a meta-analysis presented at the recent Conference on Retroviruses and Opportunistic Infections. 

At one end of the spectrum, over a fifth of patients with HIV co-infection who cleared HCV infection with treatment experienced a recurrence of the infection. This compared to a rate just 1% in patients with no HCV risk factors. The UK investigators leading the study believe these large differences point to re-infection rather than relapse being the cause of the re-emergence of HCV after treatment response.

HCV infection is an increasingly important cause of liver-related illness and death around the world. Diagnosing and treating HCV is therefore a global health priority, especially as therapy with combinations of new direct-acting anti-HCV drugs can achieve a cure or sustained virological response (SVR) – absence of HCV RNA 24 weeks after the completion of therapy – in up to 90% of patients.    

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Sydney-Benitec Biopharma Doses Fourth Patient In Hepatitis C Trial

Benitec Biopharma (ASX: BLT; OTCPK: BTEBY), a biopharmaceutical company focused on providing potentially curative therapies with its proprietary gene-silencing technology called ddRNAi or "expressed RNAi," today announced that the fourth patient in the company's Phase I/IIa dose escalation clinical trial of its lead program TT-034 for treating hepatitis C was dosed at the Duke Clinical Research Unit.  This is the second patient to be dosed in Cohort Two, with the third and final patient in Cohort Two well advanced in their preparation for dosing. 

As previously announced, the parallel dosing of these patients follows a positive recommendation from the DSMB's review of the safety data from the first patient in this cohort.

All three patients in Cohort Two receive a dose of 1.25 x 10^11 vg/kg of TT-034, a concentration that is a half-log higher than the dose administered in Cohort One.  This dose level is still below the concentration expected to inhibit hepatitis C viral replication and therefore data from Cohort Two are expected to serve primarily as a further safety assessment.

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