What We Talk About When We Talk About Hepatitis C

Since 2007, more people have died every year from hepatitis C than from HIV. Fortunately, the latest hepatitis C medications can cure nearly everyone in a relatively quick, easy fashion. So, if it is so easy to cure hepatitis C, why haven't we?

Ostensibly, it is because of the cost. At $1125 a pill for Gilead Sciences' drug Harvoni, a 12-week course of hepatitis C treatment would amount to $94,500. Trying to manage these costs, many state Medicaid programs and insurance companies have severely restricted access to treatment. You save money if you deny treatment to people, and dead people cost nothing.

This means that although we can cure hepatitis C, we aren't. Under many insurance plans, patients have to prove that they have cirrhosis. In short, treatment is approved when liver damage has progressed to its worst stage. It is like refusing to pay for diabetes drugs until the patient is blind or minus a few toes.

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HealthWise: Hepatitis C and Pain—Part 1, by Lucinda K. Porter, RN

Hepatitis C or no hepatitis C, everyone experiences pain from time to time. However, if you have chronic hepatitis C virus (HCV) infection, you are likely to have pain. The Institute of Medicine (IOM) estimates that around 100 million Americans have pain. Compare this to the 3 million Americans living with HCV, how do you know if HCV or something else is causing your pain? This two-part series will explore hepatitis C and pain.

Hepatitis C is called the “silent killer,” because the liver is a non-complaining organ. Liver cells don’t have nerves, so there can be serious tissue damage, but no pain. However, lack of nerve cells doesn’t mean there can’t be liver pain (hepatalgia or hepatodynia). Located in the right upper part of the abdomen, hepatalgia is usually caused by stretching of the capsule surrounding the liver, as well as by complaints from nearby organs. Liver pain does not mean that hepatitis C is worsening. The discomfort may be dull, sharp, mild, severe, constant or intermittent. For me it felt like my liver was fluttering. The only way I can describe it was it felt like when I was pregnant and the baby moved.

Even if there isn’t discomfort in the area of the liver, HCV may cause pain in other parts of the body. These are known as extrahepatic manifestations, and the complaints most associated with pain other than hepatalgia are:

• Musculoskeletal (myalgia)
• Joint pain (arthralgia)
• Stomach pain 

Since pain is a common symptom of many medical conditions, the first order of business is to get a medical diagnosis to determine the cause of your discomfort. Is HCV the cause, or is there something else? It doesn’t have to be either/or, as some people have more than one cause of pain. If HCV is the cause, the next order of business is to find out if the pain is a direct result of the virus, or has HCV caused a secondary problem, such as cryoglobulinemia or an autoimmune disorder.

In the case of cryoglobulinemia, hepatitis C causes the body to produce proteins called cryoglobulins. Cryoglobulins clump together in the blood when they are cold; this causes joint pain. Various studies have shown that successful HCV treatment also improves cryoglobulinemia. The American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) HCV Guidelines highly recommend HCV treatment for people with cryoglobulinemia.

Treatment may also help HCV-positive people with autoimmune disorders such as lupus and rheumatoid arthritis. If the pain is primarily from HCV, then eradicating the virus usually eliminates the aches and pains that are caused by the virus.

Pain Medication
Acute pain, meaning that it is short-lived, is the easiest to manage. There is a wide selection of pain medications or analgesics, ranging from over-the-counter (OTC) aspirin to prescription narcotics. These drugs generally work well for acute pain because patients don’t take them for long periods of time, since the problem that caused the pain usually heals. 

That is not to say that there aren’t risks and downsides to taking painkillers—there are, especially from a liver standpoint. This risk increases if the liver is severely damaged by HCV. However, if someone with hepatitis C has a well-functioning liver, most physicians are comfortable prescribing a short-course of narcotics for conditions that warrant it, such as injuries or surgery. The risk to the liver is low, and it’s inhumane and medically unwise to withhold pain relief.

A much bigger problem is chronic pain, or pain that lasts for more than three months (some experts say six months). Chronic pain affects body, mind, and spirit, and it can change your life. The more severe the pain, the greater the transformation. Not the good transformation, like from a caterpillar to a butterfly; more like from a butterfly to an ogre.  

People with hepatitis C who are in pain, are confronted with the issue of finding pain relief that doesn’t further damage the liver. Fortunately, there is a wide selection of medications and pain management tools. Let’s explore pain medication this month; next month I’ll delve into medication-free pain management.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Acetaminophen (Tylenol) is one of the most commonly used non-prescription analgesics. Known as paracetamol in Europe, acetaminophen is great for headaches, fever and mild pain. Technically, acetaminophen is an NSAID, but it’s anti-inflammatory effects are not as good as drugs such as ibuprofen.

cetaminophen is one of the safest drugs there is, even if you have liver disease. It is harmless at low doses. However, acetaminophen can cause acute liver injury and death from acute liver failure at amounts just twice the maximum recommended dose of acetaminophen. The big problem with acetaminophen is that it is added to many medications. Remedies for colds, headaches, pain, sleep, sinus problems, cough and PMS often contain acetaminophen. Lose track of this fact, and you may take toxic amounts. For more information, read Acetaminophen: Safe or Harmless?(HCV Advocate,February 2014)

In the U.S., approximately 50 million people take acetaminophen every week, and more than 25 billion doses are sold yearly. Slightly more than 300 people die annually from it. Nearly all of these are from overdose; half are from intentional overdose (suicide attempts). Acetaminophen hepatotoxicity most commonly arises after a suicide attempt using more than 7.5 grams, but more often at more than 15 grams as a single overdose.

Aspirin is perhaps the most commonly used analgesic and fever-reducing medication in the world. At low daily doses (81 mg), aspirin is used to decrease the risk of stroke, and may prevent a second heart attack. Daily aspirin is no longer recommended to prevent heart disease unless there is a pre-existing condition.

At high doses, aspirin can injure the liver. However, this damage is not from toxicity, such as what may occur with high doses of acetaminophen. The biggest risk with aspirin is a gastrointestinal (GI) bleed. Far more people are injured every year from aspirin use than from acetaminophen. Mortality and morbidity studies are scant, but it appears that there are 10 times more deaths and hospitalizations from NSAID use than from acetaminophen. Complications may occur even at low doses, and the risk increases with age.

Rounding out OTC NSAIDs are drugs such as ibuprofen (Advil, Motrin) and naproxen (Alleve). These drugs are used for mild-to-moderate pain and inflammation. Around 30 million Americans take NSAIDs every year. These drugs rarely cause liver problems, but have other risks, such as injury to the kidneys and GI tract. In addition to OTC NSAIDs, there are many prescription NSAIDs.

Opioids
Opioids are medications related in structure to the natural plant alkaloids found in opium. There are natural and synthetic opioids, and many medications in this category. The most commonly prescribed opioids for pain are codeine, hydrocodone (Vicodin), and oxycodone (Oxycontin). Unlike NSAIDs, opioids have a high potential for dependency and abuse.

According to the CDC, more than 16,000 people in the United States die every year from overdose of prescription painkillers. This is approximately 44 people every day. On their own, opioids rarely injury the liver. However, opioids are sometimes formulated with acetaminophen, and excessive amounts can injure the liver. The FDA has recommended that physicians not use opioid combinations in which the dose of acetaminophen is greater than 325 mg per dose.

Opioid use is making the news these days. Hepatitis C infections rates are increasing at alarming rates in young people, most notably in Kentucky, Tennessee, Virginia and West Virginia. Sharing needles through opioid abuse is fueling this rise.

Another reason that opioids are making the news has to do with how it is prescribed. In some cases, opioids are over-prescribed. Just as bad, is that in some cases opioids are under-prescribed, leaving patients in misery. I am not going to dive in to this debate, but for those looking for well-written information on this, I highly recommend Judy Foreman’s book, “A Nation in Pain.”

What’s Ahead
When it comes to managing pain, there are more choices than just prescription and OTC medications. Next month, I will present information on effective alternatives, such as medical marijuana and drug-free pain management techniques including an effective technique that may surprise you. 

Lucinda K. Porter, RN, is a long-time contributor to the HCV Advocate and author of Free from Hepatitis C and Hepatitis C One Step at a Time. Her blog is www.LucindaPorterRN.com

Resources

• LiverTox: Clinical and Research Information on Drug-Induced Liver Injury
• U.S. Veterans Administration’s: Viral Hepatitis and Managing Pain

http://hcvadvocate.org/news/newsLetter/2015/advocate0615.html#2

Snapshots Lucinda K. Porter, RN

Article: Utility of Hepatitis C Viral Load Monitoring on Directly Acting Antiviral Therapy - S Sreetha Sidharthan, et al
  Source: Clinical Infectious Diseases first published online March 2, 2015

The National Institutes of Health (NIH) funded this small study. Researchers enrolled 114 subjects with chronic hepatitis C virus infection (HCV) who had genotype 1 and no prior treatment. The goal was to see if HCV RNA levels (viral load) at the end of treatment (EOT) negatively or positively predicted sustained virologic response (SVR12). Two viral load tests were used: The Roche COBAS TaqMan HCV test and the Abbott RealTime HCV assay.

To understand the results, it may help to define a couple of terms:

• LLOQ is lower limit of quantification, which is the lowest amount of virus that can be precisely counted.
• PPV is positive predictive value, which predicts the probability that the test will be positive. For instance, if there are 100 people and the PPV is 90%, this means that it is likely that 90 will test positive.
• NPV is negative predictive value, which predicts the probability that the test will be negative. If there are 100 people and the NPV is 2%, this means that it is likely that two will test negative.

Here are the various treatment arms and the results:

• Sofosbuvir and ribavirin for 24 weeks (n=55):
  All patients treated with sofosbuvir and ribavirin (55/55) had HCV RNA <LLOQ at EOT by the Roche and Abbott tests, but only 38 achieved SVR12 (PPV: 69%). Simply put, this means that if your viral load at EOT is less than the LLOQ, you have a 69% chance of having an SVR12.
• Harvoni (sofosbuvir and ledipasvir) for 12 weeks (n=20); Harvoni and GS-9669 for 6 weeks (n=20); Harvoni and GS-9451 for 6 weeks (n=19):
  In the Harvoni-based regimens +/- GS-9669 or GS-9451, 100% of the subjects (59/59) had HCV RNA <LLOQ at EOT, with one relapse (PPV: 98%). The Abbott assay had 90% (53/59) with HCV RNA <LLOQ with one relapse (PPV: 98%).

Here is the most important part: Six patients with HCV RNA ≥LLOQ at EOT achieved SVR12 (NPV: 0%).

The Bottom Line: In the past when using interferon-based treatments, a detectable viral load at EOT meant that treatment wouldn’t be successful. With Harvoni-based HCV treatment, this rule no longer applies—a detectable viral load at EOT DOES NOT mean that treatment will not be successful.

Editorial Comment: This research leads me to two points. First, don‘t despair if you have detectable virus during or at the end of HCV treatment. Second, be sure your doctor doesn’t stop treatment just because you have detectable HCV RNA. The HCV guidelines recommend viral load testing after 4 weeks of therapy and at 12 weeks following treatment completion.  If quantitative HCV viral load is detectable at week 4 of treatment, repeat viral load testing at treatment week 6. If viral load has increased by greater than 10-fold on repeat testing at week 6 (or thereafter), then discontinuation of HCV treatment is recommended. There are no other recommendations to stop or extend therapy based on viral load results.

Article: Treating HCV Infection in Children - Christine K. Lee and Maureen M. Jonas
  Source: Clinical Liver Disease January 2015; Volume 5, Issue 1, pages 14–16

Noting the successful treatment rate of adults with HCV, this study assessed treatment options in children with HCV. However, the newer, more effective, easier to tolerate HCV medications have not been approved for children.

The Bottom Line: Children don’t usually progress to advanced liver disease, so the researchers recommend deferring HCV treatment for children until interferon-free regimens are approved, or until children become adults. If treatment cannot be deferred, therapies using peginterferon and ribavirin can be given to children with compensated liver disease.

Editorial Comment: In last month’s HCV Advocate, I wrote about children with hepatitis C, chronicling the lack of safe HCV treatment options for kids. This new research supports my opinion that children need better options, and soon.

Article: Cost-Effectiveness and Budget Impact of Hepatitis C Virus Treatment with Sofosbuvir and Ledipasvir in the United States - Jagpreet Chhatwal, et al.
  Source: Annals of Internal Medicine March 17, 2015; 162(6):397-406

HCV treatment using Harvoni (sofosbuvir and ledipasvir) is safer and has higher cure rates than the old interferon-based treatments, but Harvoni is substantially more expensive. This NIH-funded study evaluated the cost-effectiveness and budget impact of Harvoni.

The Bottom Line: This research found that HCV treatment using Harvoni is cost-effective in most patients, but noted limitations of their research.

Editorial Comment: While I understand the value of measuring the financial impact of new HCV medications compared to the older drugs, I am reminded by words purportedly said by former U.S. Surgeon General, Julius Richmond, “Statistics are people with their tears wiped dry.”

Article: Predictors of poor mental and physical health status among patients with chronic hepatitis C infection: The Chronic Hepatitis Cohort Study - Joseph A. Boscarino
  Source: Hepatology March 2015; Volume 61, Issue 3, pages 802–811

The purpose of this study was to evaluate the extent and risk factors for depression and poor physical health among HCV patients. They collected survey data from 4,781 participants, averaging 57 years old, 71% White, and 57% male. Slightly more than half reported past injection drug use, a third were current smokers, and nearly 18% had abused alcohol in the previous year. Around, 47% had been previously treated for HCV and 15% had an SVR.

The Bottom Line: Nearly 30% of HCV patients met criteria for current depression and 25% were in poor physical health. These risks increased among men, Blacks, less educated, unemployed, stress, and little social support. These risks were lower in those who achieved an SVR.

Editorial Comment: Over the years, similar studies to this one have been done, yielding similar results. Depression scores tend to be higher even among HCV-positive people who are unaware that they have HCV. Reading this study on the heels of the previous one about the cost-effectiveness of HCV treatment, I can only shake my head, and ask, “When are we going to treat all HCV patients?”

http://hcvadvocate.org/news/newsLetter/2015/advocate0415.html#4

HealthWise: Hepatitis C: Giving a Liver, Getting a Liver Lucinda K. Porter, RN

Years of living with chronic hepatitis C virus infection (HCV) destroyed my friend Rick’s liver. Last year, a liver transplant saved his life. A motor vehicle accident killed a 19-year-old man, and now Rick is healthy. Not a day passes, that Rick doesn’t say thank you for the life of the man whose liver restored Rick’s health.

The same year Rick received his liver, I lost three friends who would have lived had hepatitis C been diagnosed earlier and they could have had a chance at liver transplantation. Rick was incredibly fortunate to have received a liver, because there is a major organ shortage in the U.S. According to the American Liver Foundation, approximately 17,000 people are on the liver transplant list. Of these, 6000 people were transplanted; 1500 to 1700 people died before they could receive a liver.

Chronic liver failure caused by complications from HCV is the most common reason for adult liver transplantation in the United States. Cirrhosis caused by long-term alcohol abuse is the second leading cause. The majority of people living with HCV will never progress to the point where transplantation will be necessary. Liver transplantation is a complicated surgery, requiring lifelong follow-up care. Liver transplant patients have an approximately 86% one-year and 78% three-year survival rate.

Most liver transplants use deceased donors. However, the liver’s remarkable ability to regenerate allows us to use partial livers from living donors. A living donor doesn’t have to be a blood relative, but must have a compatible blood type. About 40% to 60% of the donor’s liver is removed. Within eight weeks, the livers of both the donor and the recipient are usually completely regenerated. The average donor recovers in about two months; recipients recover in roughly six to 12 months.

Although living liver transplantation sounds like the perfect way to address the organ shortage, it isn’t.  The potential risk to the donor is so high that live liver donations are done only when the potential risk to the donor is small and the potential benefit to the recipient is unquestionable. It is difficult to find current data on live liver transplantation, but it appears that there are 250 to 400 liver donor transplants a year. One in 300 donors die and about 30% suffer a complication. Many living donors who die are relatives of the recipients. One can only imagine how difficult it might be to live with the knowledge that you are alive, but your otherwise healthy donor is not. 

Although increasing the donor organ pool is important, a better plan is to reduce the organ demand. Screening, linkage to care, and treating hepatitis C patients will reduce the number of liver transplant procedures needed. When I began working in this field, hepatitis C patients who were transplanted would still have HCV. This meant the transplanted liver was reinfected, and in some cases, it too would progress to cirrhosis. Now we can cure hepatitis C, which greatly cuts down on the stress to the transplanted organ and diverts the need for a second transplant.

Other strategies that will reduce the demand for livers are:

• Immunizing all children against hepatitis B
• Implementing awareness programs to reduce liver-injury risk, such as from alcohol, drug, and dietary supplement use
• Raise awareness of the impact of diet on the liver. Fatty liver disease is on the rise in the U.S., which in turn causes a decrease in the number of viable livers.
• Increase the organ donor pool. For instance, countries that use an “opt-out” strategy have much higher donor rates. “Opt-out” means that everyone is a potential donor unless otherwise indicated. For instance, Germany uses an opt-in system and 12% of its population consents to donate. Neighboring Austria uses an opt-out system, and has a consent rate of nearly 100%. The U.S. uses an “opt-in” strategy.

In some cases, patients whose hepatitis C is cured, may be potential organ donors. This situation is considered if the organ is in good shape, and the recipient would otherwise die. The recipient is given the option to decline the HCV antibody-positive organ. Compared to HCV antibody-negative organs, the long-term survival rate in patients who received an HCV antibody-positive/viral load-negative organ are similar. So, if you are cured of HCV, celebrate by filling out your organ donor card. Ask family and friends to fill theirs out too.

Lucinda K. Porter, RN, is a long-time contributor to them HCV Advocate and author of Free from Hepatitis C and Hepatitis C One Step at a Time. Her blog is www.LucindaPorterRN.com

Additional Resources

• Donate Life America
  http://donatelife.net
• National Living
  Donor Assistance
  www.livingdonorassistance.org
• OrganDonor.gov
  www.organdonor.gov
• Organ Procurement and Transplant Network
  http://optn.transplant.hrsa.gov
• Transplant Living
  www.transplantliving.org
• United Network for Organ Sharing
  www.unos.org

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Hepatitis on the Hill —Lucinda K. Porter, RN

I have been doing hepatitis C advocacy for nearly 18 years. My hope and fury have never been greater. We can cure hepatitis C, but people are having a hard time getting the medications. The Centers for Disease Control and Prevention (CDC) recommends HCV testing for baby boomers, but we aren’t doing it. This is the sort of stuff that drives me wild.

HCV Advocate Editor-in-Chief Alan Franciscus asked me if I would attend “Hepatitis on the Hill,” held in Washington, DC on March 9 and 10. After years of complaining about the government’s anemic response to the hepatitis C epidemic, I automatically said “yes.”

Approximately 75 hepatitis advocates met in Washington, DC, for Hepatitis on the Hill. Hosted by the Hepatitis Appropriations Partnership, Hep B United and the National Viral Hepatitis Roundtable, and supported by the National Alliance of State and Territorial AIDS Directors, the event focused on increasing the federal response to the viral hepatitis epidemic in the United States.

Hepatitis C virus (HCV) is killing more Americans every year than HIV is, but dollar for dollar, hep C funding is pennies compared to HIV’s. State health departments’ Viral Hepatitis Prevention Coordinator programs receive less than $1 in federal funding for every person living with viral hepatitis. In the meantime, hep C infection and death rates continue to rise. Immunizing all children against hepatitis B virus (HBV) also continues to be a problem.

Advocates from hep B and C groups attended Hepatitis on the Hill. The first day focused on core issues, particularly why now is the time for this level of advocacy. President Obama’s budgetary request for viral hepatitis programs is double that of previous budgets, and the advocates learned how to ask for support from their senators and congressional representatives.

The next day, advocates visited the offices of their senators and representatives on Capitol Hill, educating their staff on the experiences of people living with hep B and C. At each office, the advocates requested the following:

• Signature of House/Senate letter in support of the president’s proposed FY2016 budget to increase funding of the CDC’s Division of Viral Hepatitis to $62.8 million, and include the request in the member appropriations submissions
• Support the repeal of the federal funding ban on syringe services programs
• That their elected official would join the Congressional Hepatitis Caucus

Senator Bill Cassidy (R-LA), MD, spoke during lunch on Capitol Hill. Cassidy is a hepatologist, committed to issues surrounding viral hepatitis. Ronald Valdiserri, MD (deputy assistant secretary for health, infectious diseases, at the Department of Health and Human Services), and John Ward, MD (director of the CDC’s division of viral hepatitis), also spoke at Hepatitis on the Hill. Ward emphasized the urgent nature of acting now, saying we can prevent approximately 300,000 deaths.

Presentations by Reps. Brett Guthrie (R-KY), Mike Honda (D-CA), Charlie Dent (R-PA) and Hank Johnson (D-GA) were televised at the event. These congressional representatives introduced the Viral Hepatitis Testing Act of 2015 (HR 1101). In addition to being an ally in Congress, Johnson has been public about his hepatitis C status, treatment and eventual cure.

For information about how to support efforts to improve viral hepatitis funding and services, visit Lucinda Porter’s blog (blogs.hepmag.com/lucindakporter). The National Viral Hepatitis Roundtable and Caring Ambassadors Hepatitis C provide ongoing coverage of the latest news and advocacy alerts related to viral hepatitis in the U.S.

Portions of this article by Lucinda K. Porter first appeared in Hep Magazine, March 16, 2015.

http://hcvadvocate.org/news/newsLetter/2015/advocate0415.html#1

Snapshots—Lucinda K. Porter, RN

Article: Systematic Review: Patient-Reported Outcomes in Chronic Hepatitis C - The Impact of Liver Disease and New Treatment Regimens - Z. Younossi and L. Henry
  Source: Alimentary Pharmacology and Therapeutics January 23, 2015

How do we measure successful hepatitis C (HCV) treatment? Is it strictly by clinical trial data showing how safe and effective a treatment is? Alternatively, is it by patients’ experiences, outcomes, and overall quality of life? This ambitious study examined patients’ experiences of living with hepatitis C and its treatment. 

They found that current data support the fact that HCV patients suffer substantially. This burden was much worse during interferon/ribavirin treatment and worse yet if that treatment used telaprevir or boceprevir. The newer interferon-free treatments showed that patients reported improvements in quality of life and productivity; and even bigger improvements with ribavirin-free regimens. Patients who reported easier treatment were more likely to complete therapy and respond to it.

This study also looked at fibrosis stage, finding significant fatigue and impairment among those with early stage liver disease. Patients with early fibrosis reported significant benefits, similar to the gains achieved by those with advanced fibrosis.

 

The Bottom Line: Using fibrosis stage to limit the cost of HCV treatment does not take in to account the other costs of HCV, such as its effect on work productivity, quality of life, etc.

 

Editorial Comment: This study validates what patients have been reporting for decades—that having hepatitis C is hard, and that the newer treatments offer hope for improved quality of life. Denying access to treatment violates human rights.

Article: Seven Years of Chronic Hepatitis C Virus Infection in an HIV-Infected Man without Detectable Antibodies – Joost Vanhommerig, et al.
  Source: AIDS 2015, Vol 29 No 3

After an HCV exposure, about half of those exposed will form antibodies in 5 to 10 weeks.

It averages 10 to 13 weeks for HCV antibodies to be detectable in HCV/HIV-coinfected men who have sex with men (MSM). There have been reports of some HIV-infected individuals for whom HCV antibodies didn’t show up for more than 3 years. In this case study, an HIV-positive man had positive HCV viral load results for 7 years but never had a positive HCV-antibody test result. 

The Bottom Line: These researchers recommend HCV viral load testing rather than relying solely on antibody testing for HIV-infected MSM.

 

Editorial Comment: I am both fascinated and irritated when there are rare exceptions in medical science, but they do exist. 

Article: Hepatitis C Virus Infection: A Risk Factor for Parkinson’s Disease – Wendy Wu, et al.
  Source: Journal of Viral Hepatitis January 21, 2015

Recent evidence indicates that HCV may invade the central nervous system.  In rat studies, researchers observed that HCV and Parkinson’s disease both overexpress inflammatory biomarkers. Analyzing data from 62,276 subjects, researchers found similarities between HCV and Parkinson’s.

 

The Bottom Line: This study demonstrated an association between HCV infection and Parkinson’s and confirms the observation of dopaminergic toxicity of HCV similar to that found in rats.

 

Editorial Comment: As horrifying as these results are, perhaps this research will shed light on the nature of “brain fog,” which is experienced by so many HCV patients. 

Article: Hepatitis A hospitalizations in the United States, 2002-2011 – Melissa Collier, et al.
  Source: Hepatology February 2015

This study reviewed hospitalization rates for hepatitis A from 2002-2011. The number of hepatitis A-related hospitalizations hasdeclined significantly, but patients who are hospitalized for hepatitis A are older and more likely to have liver diseases and other comorbid medical conditions.

 

The Bottom Line: Immunization could prevent hepatitis A infection and ensuing hospitalizations.

 
Editorial Comment: Hepatitis A vaccination is recommended for hepatitis C patients.

http://hcvadvocate.org/news/newsLetter/2015/advocate0315.html#4