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Alan Franciscus

Editor-in-Chief

HCV Advocate



Tuesday, August 4, 2015

Ireland: The psychological effects of hepatitis C: 'It was a dirty and uneasy feeling and it began to haunt me'

It was in the early noughties when I first got my bloods tested. I wasn't even thinking about hepatitis C at that time, that wasn't on my radar at all. To be honest, I only got tested because a number of other people in the methadone clinic I attended at that time were getting tested. I had no idea that test would turn out to be the turning point in my life and the reality check that I needed.

At this point, my lifestyle was chaotic. This was down to my misuse of drugs and the type of life that comes with taking that path.

My issues with addiction started very early on, when I was 14. Like many others from my area at the time, peer pressure to do drugs was a big issue - like many teenagers I suffered from low self-esteem and drugs were an appealing way to 'fit in'.

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A Brief Overview: Outbreaks of Acute HCV Infections in the U. S., by Alan Franciscus, Editor-in-Chief

In this review, I will discuss the outbreaks of acute infections of hepatitis C across the United States in urban and rural centers. 

Before I start discussing this very important issue, I would like to set the stage by going over the case definition of hepatitis C (HCV) acute infection as defined by the Centers for Disease Control and Prevention (CDC): 
“Laboratory-confirmed infection with infection with acute illness of discreet onsite.  An acute illness is considered as the presence of any sign or symptom of acute viral hepatitis plus either jaundice or elevated alanine aminotransferase >400 IU/L. In 2012, the surveillance case definition was expanded to include cases with negative HCV antibody followed by positive antibody within six months.”
To me there are problems with the CDC case definition.  Regarding the first part of the definition—an estimated two-thirds of people acutely infected have few or no symptoms.  This means that they are missing the majority of people who are acutely infected with HCV.  The new case definition regarding prior antibody testing is better, but it does not accurately capture people who are new to injecting drugs or people who have never been tested for hepatitis C.  However, it is understandable how difficult it is to set the criteria to define an acute infection.   Note:  In “Snapshots” this month there is a recap of a study that may provide a test to identify acute cases of HCV.

In the July 2015 HCV Advocate Mid-Monthly Edition, I wrote about an article published in the Annals of Internal Medicine titled “Underascertainment of Acute Hepatitis C Virus Infections in the U.S. Surveillance System: A Case Series and Chart Review,” by S Onofrey, MPH et. al.  The authors concluded that only 1% of acute infections has been reported to the CDC based on their case definition.  Keep the 1% in mind when reading the information below. 

Massachusetts
In July 2011 I wrote about the Massachusetts outbreak of acute HCV among young people who inject drugs.  In the CDC report Massachusetts initiated a comprehensive surveillance system and identified 1,925 new cases of HCV infections among people aged 15-24 years during 2007 to 2009.  Of these cases, 1026 were confirmed new hepatitis C infections and the remaining cases were classified as probable.  It was also interesting that the new hepatitis C infections were not just confined to the major metropolitan and suburban areas of Boston, but high rates were also found in smaller cities and rural areas.  It was also reported that the incidence of new HCV infections were similar in women and men and were seen mostly among non-Hispanic whites.  In the analysis, 72% of the people reported current or past injection drug use.  Among the people who self-disclosed that they injected drugs—85% used heroin, 29% cocaine, 1% methamphetamine and 4% had used other drugs.  Some of the characteristics seen in the Massachusetts outbreaks —rural, young, mostly White using heroin—were the beginning of a trend seen throughout the country. 

Massachusetts has an extensive network of needle exchanges.  One can only imagine what the number of acute infections would be without a needle exchange network.

Wisconsin
In “Notes from the Field:  Hepatitis C Virus Infections Among Young Adults—Rural Wisconsin, 2010,” a report from the CDC issued on May 18, 2012 /61(19);358-358 a number of outbreaks in rural counties of Wisconsin were discussed.  It was reported that in 6 contiguous rural counties of Wisconsin that in persons under 30 yo that the number of HCV infections had increased from an average of 8 cases per year during 2004 – 2008 to an average of 24 cases per year during 2009 – 2010. 

The CDC investigated 25 cases during 2010 of the adults under 30 years old who resided in the 6 counties.  Of these patients 7 had jaundice (a rare symptom of acute HCV).  All 21 had positive antibody tests.  Twenty-one had positive EIA with signal-to-cutoff ratio or had a test to confirm the presence of HCV RNA (viral load test).  Additionally, seventeen patients were interviewed. Of the patients who were interviewed (17 pts) 94% had either injected drugs, snorted drugs or both.
The age group that had the highest prevalence was those 20-29 yo, which is a national trend of people who inject drugs in rural areas. No information about the sex of the patients was given in the report.  

Ohio
In Ohio, the number of confirmed cases of acute cases HCV was 112 in 2013 and 105 in 2014.  The demographics are similar to the demographics in other outbreaks across the U.S. —mostly white, equally divided among gender and many of the acute cases occurred in rural settings. 

Indiana
The May 1st issue of the Morbidity and Mortality Weekly Report (MMWR), contained “Community Outbreak of HIV Infection Linked to Injection Drug Use of Oxymorphone—Indiana, 2015, by C Conrad,” which describes a recent outbreak of HIV and HCV in a rural community of Indiana.  On January 23, 2015 the Indiana State Department of Health began an investigation on an outbreak of HIV after 11 cases were reported and confirmed.  Although little attention was given to HCV there was a confirmed HIV/HCV coinfection rate of 84.4%!  All of the people who injected drugs reported crushing, dissolving and injecting oxymorphone tablets as well using other drugs including methamphetamine and heroin.  The total number of people who tested positive for HIV was 135.  The community in rural southeastern Indiana had a population of 4,200.  The age range was 18 to 57 yo (median 35 yo), 54.8% were male.  

The response to the outbreak is best summed up by a statement in the MMWR: “A public health emergency was declared on March 26 by executive order.  The response has included a public education campaign, establishment of an incident command center and a community outreach center, short-term authorization of syringe exchange, and support of comprehensive medical care including HIV and hepatitis C virus care and treatment as well as substance abuse counseling and treatment.”  Hopefully, the ‘short-term’ will be changed to ‘permanent.’

Maine
On July 6, 2015 the Portland Press Herald reported on a surge of hepatitis C cases: during 2013 to 2014 the incidence of acute HCV increased from 9 to 31 cases and there were 14 cases in the first 6 months of 2015.   The users who were interviewed stated that they had started with opiates like Oxycontin and switched to heroin. This is a recurring theme.   Maine has 5 needle exchange programs.  

Kentucky, Tennessee, Virginia and West Virginia (2006-2012)
The CDC released an MMWR report on May 8, 2015 titled “Increases in Hepatitis C Virus Infection Related to Injection Drug Use Among Persons Aged ≤ 30 Years –Kentucky, Tennessee, Virginia, and West Virginia, 2006—2012,” by J E Zibbell and Colleagues detailing the outbreaks in the Appalachia region of the U.S.   

A total of 1,377 cases of acute HCV were reported to the CDC during the period 2006-2012 from Kentucky, Tennessee, Virginia and West Virginia.  There were 1,374 cases reported where the age was available—616 (44.8%) were ≤ 30 yo (median age 25 yo—range in urban and non-urban 6-30 yo).

The number of persons who were non-Hispanic whites in non urban settings was 247 (78.4%); males, 156 (49.5%); in urban counties, 249 (82.7%) cases were non-Hispanic whites, and 155 (51.5%) were males. See Figure 1 below.   

Comments:  The trend of acute HCV outbreaks that started in Massachusetts is continuing across the United States.  This includes more adolescents and young adults injecting, infecting as many women as men and in rural more than urban settings.   What is even more disturbing is the reaction of the local and state governments—needle exchange being started post-outbreak rather than establishing needle exchange as prevention.  Almost every outbreak has resulted in the establishment of a needle exchange program after an outbreak.  If needle exchange programs had been in place before an outbreak many of the HIV and HCV infections could have been prevented. 

Figure 1
Figure 1.  Incidence of acute hepatitis C among persons ≤ 30, by urbanicity and year –Kentucky, Virginia, Tennessee, and West Virginia, 2006 –2012.

Source:  http://hcvadvocate.org/news/newsLetter/2015/advocate0815.html#1

Monday, August 3, 2015

Highway Bill Gives $500 Million to Veterans’ Hepatitis Drugs

The U.S. Department of Veterans Affairs was authorized to spend as much as $500 million for hepatitis C treatments through Oct. 1 as part of the emergency highway funding bill signed into law on Friday.

The spending could provide a short-term sales boost for Gilead Sciences Inc., which makes the hepatitis C treatments Harvoni and Sovaldi, and for AbbVie Inc., which makes a similar drug, Viekira Pak. Gilead sold $4.9 billion of its hepatitis C pills in the second quarter, while AbbVie sold $385 million of its treatment in the same period.

While the drugs provide a cure for the disease, which can cause liver damage to the point of needing a transplant, their prices have attracted a firestorm of criticism from politicians and insurers. List prices for the treatments are more than $83,000 for a 12-week course.

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Hepatitis C numbers up in Maine, Androscoggin County

Hepatitis C numbers are up in Maine, with Androscoggin County seeing some of the highest rates of acute cases in the state.

Experts say there are a variety of reasons for the increase, including a spike in heroin use — the hepatitis C virus is transmitted by blood and shared needles commonly spread it — and a new, dramatically more effective treatment that's made patients more willing to be tested.

"We are seeing people coming out of the woodwork to seek treatment for hepatitis C," Imad Durra, infectious disease specialist with Central Maine Infectious Diseases in Lewiston, said.

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HealthWise: Hepatitis C and Nonalcoholic Fatty Liver Disease —Lucinda K. Porter, RN

Recently I saw a post from a patient who was cured of hepatitis C, only to find out that he had fatty liver disease. I felt bad for him, since now he has another liver disease to contend with, but then I thought it over. Fatty liver disease can be fixed, and the cure may help more than his liver—it may help him live longer and feel better.

Nonalcoholic fatty liver disease (NAFLD) is a metabolic disease that generally occurs in overweight patients. It may also occur in patients whose weight is normal, but because of prior excess weight, they developed insulin resistance, diabetes, or fat in the liver area, called visceral fat. NAFLD may also arise in people who eat a high fat, low-nutrition diet.

NAFLD is the most common liver disease, and it is increasing in prevalence and severity. Since fat impairs liver regeneration, NAFLD can lead to fibrosis and cirrhosis. NAFLD is the third most common risk factor for primary hepatocellular carcinoma. The American diet is so harmful, that children are developing NAFLD. If we keep on this course, NAFLD may overtake hepatitis C as the single most common reason for liver transplantation. Tragically, the prevalence of NAFLD is so great, that there has been a decrease in the number of viable livers that can be used for transplantation.

Hepatitis C appears to increase the risk of NAFLD. However, before blaming hepatitis C for fatty liver disease, keep in mind that the prevalence of hepatitis C in the U.S. is less than 2 percent, whereas the prevalence of NAFLD is 30 percent. This makes it hard for hepatitis C to be the sole link to NAFLD. An exception is in genotype 3, where there is clearly a higher risk for NAFLD.

As I stated, fatty liver disease can be fixed. You probably already figured out that good nutrition and maintaining a healthy weight is important, but did you know that physical activity could improve NAFLD? Exercise also improves insulin resistance as well as cardiovascular health. A few studies bear this out, but the question some of us have is, “What kind of exercise, how much, and how often?”

Let me state this in a way that I can relate to, “What is the least amount of exercise in both time and intensity that I can get away with, and still look my doctor in the eye and say I am a regular exerciser?”

In a retrospective analysis of obese middle-aged men (Hepatology April 2015), Sechang Oh and colleagues reported that moderate to vigorous physical activity had a dramatic effect. Those who engaged in ≥ 250 minutes a week of moderate to vigorous physical activity had the most improvement of NAFLD.

That is more than four hours of exercise weekly. Surprisingly, the exercise seemed to improve liver health, regardless of weight loss. Other research shows similar benefits. When it came to liver health, aerobic activity showed more improvement than resistance training.

What is moderate to vigorous physical activity?
There are various was to measure intensity. I prefer the concept of relative intensity. Using this method, people pay attention to how physical activity affects their heart rate and breathing. Intensity level is subjective. What may be intense for one person may be less intense for someone else. For instance, I don’t play tennis, but if I were to try, I would probably be huffing and puffing after the first serve. On the other hand, I do aerobic dance, and it takes me a bit of effort to raise my heart rate.

In general, if you are doing moderate-intensity activity you can talk, but not sing, during the activity. If you are engaged in vigorous-intensity activity, you will not be able to say more than a few words without pausing for a breath.

According to the Centers for Disease Control and Prevention, examples of moderate-intensity activity are:
  • Walking briskly (3 miles per hour or faster, but not race-walking)
  • Water aerobics
  • Bicycling slower than 10 miles per hour
  • Tennis (doubles)
  • Ballroom dancing
  • Gardening

Examples of vigorous-intensity activity are:
  • Race walking, jogging, or running
  • Swimming laps
  • Tennis (singles)
  • Aerobic dancing
  • Bicycling 10 miles per hour or faster
  • Jumping rope
  • Heavy gardening (continuous digging or hoeing)
  • Hiking uphill or with a heavy backpack

Then there is the concept of duration. Perhaps 250 minutes a week is too much for you. Before you throw in the towel, bear in mind that any exercise is better than none. I don’t care if you are walking once around the table, it is better than sitting all the time. In fact, prolonged sitting is very unhealthy.

Prolonged sitting (eight to 12+ hours per day) increases risk of developing type 2 diabetes by 90 percent. It is also associated with increased premature death from cardiovascular conditions and cancer. The World Health Organization lists physical inactivity as the fourth-leading risk factor for death for people all around the world. It ranks up there with smoking.

When I first heard this, I thought, “I am screwed.” Writers sit a lot. Yes, I exercise every day, but I also sit a lot. After I was done whining, I set about to solve my sitting problem. I bought a stand-up desk, and set a timer to remind me to walk every hour. In addition to my regular workout, I added in a longer walk after dinner. I set a goal to stand during phone calls and commercials.

There are many other benefits of adding more physical activity in to your life. Last month, I talked about hepatitis C and the value of exercise for reducing chronic pain. Exercise helped alleviate arthritic and inflammatory pain, fibromyalgia, migraine headaches and back pain. Being active improves our sleep and our moods. We live longer, and the quality of our lives is better.

If you are new to exercise, be sure to talk to your medical provider before starting. Start slow and only do what feels comfortable. Most of all, do it. Find ways to battle every excuse. Make exercise a non-negotiable part of your life. It may be hard, but it is worth it.

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 http://www.lucindaporterrn.com/

Resources


Source: http://hcvadvocate.org/news/newsLetter/2015/advocate0815.html#2

Thursday, July 30, 2015

Eradicate hepatitis

By Sen. Mazie Hirono (D-Hawaii) and Rep. Mike Honda (D-Calif.)

Across our country and around the world, hepatitis B and C have taken countless lives and the numbers continue to explode. Regrettably, this rise is partially tied to the heroin epidemic in our country—since the 1990s the medical use and subsequent abuse of highly addictive opioids like Oxycontin has risen tremendously

The overuse of medication has caused too many Americans to succumb to addiction, and many turn to heroin. The rise in heroin use means that individuals are sharing needles as their need for the drug outweighs safety concerns.

The Center for Disease Control (CDC) estimates there were nearly 30,000 new hepatitis C infections in 2013, a 150 percent increase since 2010. The CDC also found an alarming rise in new infections among people under the age of 30, especially in rural areas.

Tragically, hepatitis infection, driven by drug abuse, threatens an alarming portion of an entire generation of Americans. We must do everything we can to help address heroin and opioid addiction.

Hepatitis C and hepatitis B are life threatening yet preventable diseases. Look at the story of Rob, of Hawaii. He met his wife Mei over 30 years ago when they were students at the University of Hawaii.

She is Chinese from Hong Kong, and he is Caucasian. In the over 30 years since they first met they’ve built a life in Hawaii. They have two kids in their 20s—both college educated and looking to build families and lives of their own.

Their life was great—until Mei suddenly became ill. Only weeks after first taking ill, Mei passed away from liver failure.

To add to this incredible tragedy, shortly before Mei’s passing they learned that not only Mei - but both of their children - had been infected by hepatitis B since birth.

For over 30 years, they’d never known that they were infected by hepatitis.

Hepatitis is 100 times more infectious than the HIV virus, and in the U.S. perinatal transmission, or being passed from mother to child immediately before or after birth, is one of the primary ways that people contract the disease. It’s a silent killer that slowly destroys the liver, often displaying no symptoms in those infected with the virus until it is too late – the liver is diseased, riddled with cancer, cirrhosis, or end-stage failure.

Around the world, four hundred million people are living with hepatitis B or C. 1.4 million people die annually from complications due to viral hepatitis. In the United States, approximately 6 million individuals have hepatitis B or C, likely an underestimate. Both hepatitis B and C are the leading causes of liver cancer, and 65-75 percent of infected individuals do not know that they have either virus.

The difficulty with identifying the disease means that we do not have accurate data on infections. Without accurate data, we do not have a strong grasp of the scope of the problem. If we don’t take decisive action soon, our health care system will face a significant burden in decades to come.

We simply cannot handle the costs of the rampant spread of a disease whose complications are entirely preventable.

Stopping hepatitis has to be a three-step process.
First, people need to get tested, especially those in the Asian American and Pacific Islander communities, of which one in 10 will get hepatitis B.

Second, we need to make treatment options available to everyone regardless of income level.

And third, we must continue to invest in research on hepatitis to rid the world of the viruses once and for all.

This week, we recognized World Hepatitis Day, a day that President Obama declared by proclamation for the first time in the United States. This day was an opportunity to make a new commitment to educating people about the silent killers, helping prevent further infection rate spikes, identifying infected individuals, and providing them with proper medical care.

Working together, we can eradicate this preventable, treatable virus and save millions of lives.
Hirono is Hawaii’s junior senator, serving since 2013. She sits on the Armed Services; the Energy and Natural Resources; the Small Business and Entrepreneurship; and the Veterans’ Affairs committees. Honda represents California’s 17th Congressional District and has served in the House since 2001. He sits on the Appropriations Committee.

Source: The Hill

Following Spike in Hepatitis C Cases, Kentucky Considers Expanding Screenings for Virus

Officials at the state and local levels are in discussions about offering hepatitis C testing at all Kentucky county health departments.

Some local offices offered the tests last year as part of a pilot project, when Kentucky began to see a spike in hepatitis C cases related to intravenous drug use. The Centers for Disease Control and Prevention said in May that Kentucky’s rate of hepatitis C is seven times higher than the national average.

Deputy Commissioner Kraig Humbaugh, with the Kentucky Department of Public Health, says increased screening opportunities would be a way for health and addiction experts to reach out to those who need help.

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