Canada: Hep C at colonoscopy clinic: Taking measures to prevent a second outbreak

On Dec. 24, 2013, four patients at a Kitchener colonoscopy clinic became infected with hepatitis C.

It was several months before any of them realized it – and nearly a year before a second diagnosis allowed public health officials to link the cases to Tri-City Colonoscopy Clinic.

While nobody knows what happened to transmit the virus with complete certainty, it’s believed shared equipment is to blame.

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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

Southern Illinois sees shocking rise of Hepatitis C

Cases of Hepatitis C -- a blood borne virus that attacks the liver and is spread via shared drug needles, unsterile tattoos and other means -- are on the rise. It's a "silent epidemic" waiting to strike many unsuspecting Baby Boomers and young adults, health officials warn, because the liver has a long memory. Even if you have forgotten what you did this past weekend, or in the freewheeling 1970s, your liver did not.  

Hoping to stem the tide of premature deaths from liver-related complications, lawmakers narrowly passed a bill in recent days that would require doctors to offer screening tests for patients considered high-risk for Hepatitis C.

It is curable in most cases, but left undetected can lead to cirrhosis of the liver and death.

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Public Health Hepatitis C map by county: Illinois

This map from the Illinois Department of Public Health shows Hepatitis C case numbers, confirmed and suspected, by county as of May 19, 2015.

http://thesouthern.com/public-health-hepatitis-c-map-by-county/pdf_12d9703a-d9d7-56ba-9c8b-223e1c269cf6.html 

Note: You may need to answer a quiz to gain access to this article 

FDA addresses concerns on approval of drugs to treat chronic hepatitis C

Public Release:1-Jun-2015 

Wiley 

Treatment options for chronic hepatitis C, a serious and life-threatening infection, have improved substantially and several new regimens with shorter durations and improved efficacy and safety profiles are now available.

Groups have raised concerns about the evidence used to support the approval of some newer drugs, however, and the issue has been used to cast doubt on their efficacy and even to question treatment or deny reimbursement.

To address these concerns, the US Food and Drug Administration's Division of Antiviral Products in the Center for Drug Evaluation and Research (CDER) has published a paper that highlights the agency's scientific approaches and regulatory processes that support the development and approval of promising drugs to treat hepatitis C.

"FDA's approach to evaluation of recent hepatitis C drugs underscores the Agency's flexibility in considering innovative or alternative trial designs for drugs that have demonstrated highly promising outcomes in early phase development," said Dr. Poonam Mishra, deputy director for Safety, Division of Antiviral Products/Office of Antimicrobial Products in the FDA's Center for Drug Evaluation and Research and lead author of the Hepatology paper. "Expedited approaches can be used without compromising efficacy standards for drugs that demonstrate breakthrough therapy potential."

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Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.

Source: http://www.eurekalert.org/pub_releases/2015-06/w-fac060115.php

Hep C drug tourism has begun as patients seek Harvoni, Sovaldi overseas

When Gilead Sciences ($GILD) struck its hepatitis C supply deal with Indian generics makers, the terms were tight, with provisions designed to keep the knockoff pills in countries where Gilead allows cut-rate pricing. Some state health systems overseas require patients to show IDs to get their meds and present empty pill bottles for refills.

And this is why.

As Bloomberg reports, everyone from individual patients on up to pharmacy benefits managers has been scheming about how to get Gilead's Harvoni and Sovaldi at the lower prices available in other countries--as low as 1% of the U.S. sticker price, the news service notes.

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Almost three quarters of HIV/HCV group may have DDA-ARV interactions

Among 125 HIV/HCV-coinfected people taking antiretrovirals in a Denver group, 70% could have moderate or severe interactions with one of four common direct-acting antiviral (DAA) regimens for HCV [1]. Researchers calculated that 20% of patients who needed to switch antiretrovirals because of certain DAA interactions could not switch because of antiretroviral resistance.
 
This retrospective study involved 125 HIV/HCV-coinfected adults with antiretrovirals prescribed within the last year. All participants were in care at an academic medical center in Denver. Researchers assessed potential interactions between each person's antiretroviral regimen and four possible DAA combinations: simeprevir and sofosbuvir (SIM/SOF), sofosbuvir and ledipasvir (SOF/LDV), sofosbuvir and daclatasvir (SOF/DCV), and ritonavir-boosted paritaprevir plus dasabuvir and ombitasvir (3D). The analysis did not explore potential interactions between non-HIV drugs and DAAs.

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