HCV: Health Danger of Parties Past

HCV: Health Danger of Parties Past

Wall Street Journal
Sept 20 2010

Most people think their wild-child past is just that—in the past. But some former party animals may be carrying a harmful reminder of their youth and not know it.


People who used intravenous drugs, snorted cocaine with a shared straw, or had an unsterile tattoo or body piercing could be infected with hepatitis C and not realize it. The virus, which spreads via blood-to-blood contact, can cause no symptoms for decades while silently destroying the liver.


Some people may have innocently been infected if they had a blood transfusion before 1992, when the blood supply began to be screened for the virus. Others may have contracted the virus simply by sharing a toothbrush or a razor. More than three million Americans have been diagnosed with hep C, and health experts say at least that many more are unaware that they have it.


"There's a huge reservoir of people who made a few bad decisions many years ago. Now they're successful business people, lawyers, doctors, school principals, and they don't know they are carrying this," says Joseph Galati, medical director of the Center for Liver Disease and Transplantation at Houston's Methodist Hospital. In the meantime, he says, "they could be doing things like drinking alcohol that accelerate the disease or transmitting it to other people."


Hep C, first identified in 1989, is today the leading reason for liver transplants and causes about 12,000 deaths in the U.S. each year. In most cases, the infection becomes chronic, inflaming the liver for years, but often with no apparent symptoms unless the inflammation becomes severe. In about 20% of cases, it progresses to cirrhosis, a severe scarring that shuts down liver function. And about 20% of those cirrhosis cases become liver cancer.


About 20,000 people are diagnosed with hepatitis C each year, and some two-thirds of those are middle-aged, having contracted the disease 20 or 30 years ago.


There is no vaccine against hep C, unlike for hepatitis A and B, which are liver diseases caused by different viruses. Hep C can be cured with a year-long course of chemotherapy drugs, but only about 50% of patients respond to them. A host of new medications now in clinical trials could work faster, and raise the cure rate as high as 80%, according to early results.


Hep C can be diagnosed with an inexpensive blood test that checks for antibodies—if doctors think to look for it. If that test is positive, another test can determine if the virus is still active. (In about 15% of hep C cases, the virus goes away on its own, although the antibodies may still be present.)


A regular annual checkup may reveal elevated liver enzymes. But many people with hep C have normal enzyme levels, and only vague symptoms like fatigue or joint pain, until the damage is well advanced.


"I never had any symptoms. I've had major surgery twice and nobody picked up on this," says a Houston nurse who was diagnosed with hep C in December at age 59. She thinks she was exposed to the virus in 1980, when she was accidentally stuck with a needle while caring for a patient. Her hep C was only found because a new job required the test for hep C antibodies. By then, 35% of her liver was damaged from cirrhosis. She is currently undergoing treatment in a clinical trial with Dr. Galati.


Even minute blood drops—from borrowing a toothbrush or piercing several friends' ears with the same needle—can transmit the virus. "Any blood-to-blood transition route can spread it, no matter how microscopic," says Melissa Palmer, medical director at New York University's Hepatology Associates in Plainview, NY.


"People may have done something once and forgotten about it, like share a $1 or a $100 bill to snort cocaine. The blood vessels in the nose are very weak and could bleed a little, and then the blood gets passed to the next person," says Dr. Palmer.


For now, the standard course of treatment for hep C is two chemotherapy drugs—interferon in weekly injections and ribavirin as pills three times a day—for either 24 or 48 weeks, an arduous regime that can cost more than $50,000 a year. Side effects can include fatigue, weakness, muscle and joint pain, hair loss, nausea and depression. Some patients need additional drugs to boost their red and white blood cells, which the chemo drugs deplete. Some have to stop the treatment because it can be so debilitating.

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Hepatitis A Through E


Hepatitis is an inflammation of the liver, generally caused by viruses, with symptoms ranging from slight to severe. Versions A through C are the most common.


* Hep A: Transmitted via contaminated water or food, particularly in countries with poor hygiene. Symptoms include fatigue, fever, abdominal pain, depression and jaundice. Permanent liver damage is rare. Vaccine recommended for all children at 1 year.

* Hep B: Two billion people world-wide have been infected with hep B, mostly through infected blood or body fluids. It can become chronic and lead to cirrhosis and liver cancer, but most adults clear the virus without treatment and are then immune. Vaccination is now required for many college students and healthcare workers.

* Hep C: Spread by blood-to-blood transmission, with few symptoms either in early stages or for decades later. About 20% of chronic cases develop into cirrhosis or liver cancer. Curable in about 50% of cases by chemotherapy.

* Hep D: Caused by a small RNA virus that only propagates in the presence of hep B, greatly increasing the chance of cancer, cirrhosis and death. Hep B vaccine will prevent illness from D.

* Hep E: Transmitted by fecal-oral contamination in unsanitary conditions. Patients are generally very ill for the first few weeks of infection then the virus usually clears on it own. Vaccine is being tested.


Source: WSJ Reporting
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"I was really, really sick for a while—I had to hide under the wedding gowns so I could nap," says Sidney Merry, 53, who works for a bridal retailer in Houston. Routine blood tests spotted her hep C, which she thinks she got from a blood transfusion in the 1970s, and later started treatment with Dr. Galati. Ms. Merry stuck with the program and is now free of the virus. She helps counsel other patients undergoing treatment.


Ms. Merry says two of her friends died of hep C they declined to treat, and her own mother died of liver cancer at age 53, from what Ms. Merry suspects may also have been hep C. "This touches many lives—but it's so unspoken about and misunderstood," she says.


Two new drugs on the horizon—boceprevir by Merck & Co. and telaprevir by Vertex Pharmaceuticals Inc.—are protease inhibitors similar to those in AIDS drugs. They could win approval by the Food and Drug Administration next year. Other companies are studying different approaches to fight hep C.


In July, the FDA approved a synthetic form of interferon, called Infergen, by Three Rivers Pharmaceuticals LLC, for use in daily injections for patients who don't respond to the first course of treatment.


In some cases, doctors are advising hep C patients to postpone treatment until the new drugs come on the market. But Dr. Galati, who has been the principal investigator for several industry-sponsored clinical trials, notes that the new drugs will be in addition to the current ones, so waiting for the new regimes won't allow patients to avoid the side effects.


Unborn babies can acquire hep C from infected mothers. Kathryn Maloney had complained of fatigue for years before she was diagnosed with hep C in 2005. "Turns out I had it my whole life and didn't know," says Ms. Maloney, 29, an accountant in Houston.


Since there was no obvious source of her infection, Dr. Galati suggested that her mother, Pamela Grant, be tested too. She tested positive as well, though she has no idea when or where she was exposed. She and her daughter underwent treatment together. They also took part in a clinical trial for one of the new medications and are now free of the virus.


Some patients opt to forgo treatment, since only about 20% progress to cirrhosis. But doctors can't tell in advance which cases will progress. Meanwhile, drinking alcohol, smoking cigarettes and carrying excess weight make cirrhosis more likely.


Some health experts are urging that the general public be screened for hep C; the blood test for antibodies costs only about $12. Short of that, liver specialists urge anyone who might have been exposed, no matter how or how long ago or how well they feel now, to tell their doctors and be tested.


Since hep C can carry a lingering stigma of past drug use, even though there are many other ways to contract it, Dr. Galati says some primary-care physicians routinely hand patients a list of risk factors and say, "If you fit into any of these categories, you should get tested. You don't need to tell me which one."