Risk Factors for Hepatitis C Infection Among Vietnam Era Veterans Versus Nonveterans: Results from the Chronic Hepatitis Cohort Study (CHeCS)

Journal of Community Health
March 2014

Joseph A. Boscarino, Alexandra Sitarik, Stuart C. Gordon, Loralee B. Rupp, David R. Nerenz, Vinutha Vijayadeva, Mark A. Schmidt, Emily Henkle, Mei Lu

Abstract

Research suggests that Vietnam era veterans have a higher prevalence of hepatitis C virus (HCV) than other veterans and nonveterans. However, the reasons for this are unclear, since this research has been conducted among Department of Veterans Affairs (VA) patients and most veterans do not use the VA. The current study compares HCV risk factors between the Vietnam era veterans and nonveterans seen in 4 large non-VA systems to explain this disparity. A total of 4,636 HCV patients completed surveys in 2011–2012. Vietnam era veterans were defined as those who served in the military any time between 1964 and 1975. Bivariate tests followed by logistic regressions, and multivariable modeling were conducted to study risk factors among Vietnam era veterans and nonveterans. Since few veterans were female (~2 %), they were excluded. Among male respondents (N = 2,638), 22.5 % were classified as Vietnam era veterans. Compared to nonveterans, these patients were older (p < 0.001), more educated (p < 0.001), less often foreign born (p = 0.009), more often married (p < 0.001), less often employed, and less likely to have a history of drug abuse treatment (p < 0.001). Comparison of specific risk factor differences for HCV infection by veteran status suggested that while injection drug use approached statistical significance (nonveterans = 46.1 % vs. Vietnam era veterans = 41.4 %, p = 0.06), only reported sex with men was significant (nonveterans = 2.4 % vs. Vietnam era veterans = 0.6 %, p = 0.013). In multivariate logistic regression controlling for age, education, country of birth, marital status and study site, no HCV risk factor was associated with Vietnam era veteran status. However, veterans were more likely to report “other” exposures were the source of infection than nonveterans (p < 0.001). While Vietnam era veterans seen in non-VA facilities do not report a higher prevalence of common HCV risk factors, such as injection drug use, they are more likely to report “other” exposures, typically associated with military service, as the source of HCV infection.

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The Changing Epidemiology of Hepatitis C Virus Infection in the United States: National Health and Nutrition Examination Survey 2001 through 2010

Journal of Hepatology

Article in Press

Ivo Ditah, Fausta Ditah, Pardha Devaki, Oforbuike Ewelukwa, Chobufo Ditah, Basile Njei, Henry N. Luma, Michael Charlton

Received 17 July 2013; received in revised form 9 November 2013; accepted 19 November 2013. published online 02 December 2013.
Accepted Manuscript

Abstract

Background

In light of dramatically changing hepatitis C therapeutic landscape, knowledge of the current burden of HCV infection in the general population of the United States is critical.

Methods and Participants

The National Health and Nutrition Examination survey collects nationally representative data on HCV infection in the civilian population of the United States. Data from 2001 to 2010 were combined for this study. HCV testing was completed in 38,025 participants.

Results

The prevalence of anti-HCV in the United Sates decreased from 1.9% (95% CI1.5%-2.5%) in 2001-2002 to 1.3% (95% CI 0.9%-1.8%) in 2005-2006, and remained stable up to 2010. About 67% of all infected persons were positive for HCV RNA, indicating 2.3 million people with chronic HCV infection, of whom 68% have genotype 1. Seventy percent of infected persons were born between 1945 and 1965, with prevalence of 3.5% (95% CI 2.2%-4.8%). The stable rate since 2006 is mostly related to prevalent cases and foreign born persons migrating into US. Other important risk factors include less education and low economic status. Race, HIV status, number of sexual partners and blood transfusions are no longer associated with HCV infection.

Conclusions

As of 2010, approximately 2.3 million persons were chronically infected with Hepatitis C in the US. Most of those infected are prevalent, rather than incident cases. The prevalence of HCV was on the decline, but has stabilized since 2006. Future studies should explore reasons for no decline in HCV prevalence since 2006.

Keywords: NHANES, Hepatitis C infection, Prevalence, Trends, Risk factors

No full text is available. To read the body of this article, please view the PDF online.

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Reminder stickers can boost screening for hepatitis C virus in primary care clinics

Primary Care

Affixing a reminder sticker that lists risk factors for hepatitis C virus (HCV) infection onto patients’ medical charts can be effective in increasing the number of patients sent for HCV testing by their primary care physicians. It also boosts the number of patients found HCV-positive, according to a new study. 

HCV is the leading cause of liver failure in the United States, accounting for 15,000 deaths in 2007 and 3.2 million Americans with chronic HCV infection. Although new antiviral treatments promise to greatly reduce the burden of HCV-related disease, a majority of HCV-positive patients (45–85 percent) are unaware that they are infected.

To increase screening, the researchers developed a 2-ply (carbon copy) sticker with a list of 12 HCV infection-related risk factors (with yes and no check boxes) and 2 items about HCV testing (Was patient tested recently? Was an HCV test ordered?). The stickers, affixed to each patient’s chart, reminded the physician to ask about HCV risk factors. The top sheet could be detached for later data analysis, while the bottom sheet remained in the patient’s chart. The physicians saw 8,891 patients over the 15-week study period who had not undergone a recent anti-HCV antibody test. Screener pages were completed for 3,250 (36.2 percent of patients), with significant racial and gender-related differences in screening rates.

Overall, 27.8 percent of those screened had at least one risk factor. More than half (55.4 percent) of patients with any risk factors—and 13.7 percent of those with no identified risk—underwent HCV testing, yielding infection rates of 6.8 percent and 2.2 percent, respectively. Seven of the risk factors, including ever use of injected or snorted drugs, accounted for 82.9 percent of the 41 HCV-positive patients, but another 7 HCV-positive patients had no risk factors when screened. The researchers collected data from three urban clinics that instituted the use of the stickers with all adult patients and HCV testing based primarily on the presence of HCV risk factors as part of the Hepatitis C Assessment and Testing project.

The study was funded by AHRQ (Contract No. 290-06-0012). More details are in "Effectiveness of a risk screener in identifying hepatitis C virus in a primary care setting," by Mari-Lynn Drainoni, Ph.D., Alain H. Litwin, M.D., Bryce D. Smith, Ph.D., and others in the November 2012 American Journal of Public Health 102(11), pp. e115-e121.

— DIL

Current as of June 2013

Internet Citation: Reminder stickers can boost screening for hepatitis C virus in primary care clinics: Primary Care. June 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsletters/research-activities/13jun/0613RA23.html

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Pennsylvania General Assembly, Health Department Asked to Step Up Regulation of Tattoo Parlors

Provided by Infection Control Today

Pennsylvania auditor general Jack Wagner today called on the General Assembly and the state department of health to step up the state's role in regulating the tattoo parlor industry because of potential health risks to the general public, including hepatitis C.

Wagner said that requiring Pennsylvania's more than 750 known tattoo parlors and artists to obtain a state license would protect public health while helping state officials monitor one of the fastest-growing segments of the local economy.

"We license cosmetologists, hair salons and nail salons; it's time we join the growing number of states that also regulate tattoo parlors," Wagner says. "If we do not, the potential health risk to Pennsylvanians increases with every needle puncture."

In a letter sent today to the Pennsylvania Department of Health, Wagner pointed out that 21 percent of U.S. adults have at least one tattoo, according to a recent Harris poll. Reflecting the national popularity, Pennsylvania has upwards of 750 tattoo parlors or artists, including 84 in Philadelphia, 83 in Pittsburgh, 54 in Allentown, 51 in Scranton, 31 in Harrisburg and 15 in State College.

A tattoo is a permanent design created by using a needle to inject indelible ink under the skin, altering the skin's pigmentation. It is an invasive procedure which presents a risk of infection with bloodborne pathogens and other infections, especially if the tattoo equipment is not properly sterilized.

The Centers for Disease Control and Prevention (CDC) has cited the use of non-sterile equipment and suboptimal infection control as causes for skin infections in people receiving tattoos. It has also warned that the risk of contracting the hepatitis C virus is also possible with poor infection control practices. Hepatitis C primarily infects the liver, and is spread by blood-to-blood contact that may occur through the sharing of unsterilized needles or contaminated dyes. An estimated 130 million people are thought to be infected with the hepatitis C virus, according to the World Health Organization. The Pennsylvania Department of Health estimates that almost 4 million persons in the U.S., and 120,000 to 170,000 in Pennsylvania, are infected with the Hepatitis C virus.

The estimated 750 tattooists in Pennsylvania is based on known advertising and does not include those operating out of homes, mobile units or other non-sterile environments. These underground operators may employ dangerous practices such as reusing ink or using contaminated needles.

The only regulation now on the books in Pennsylvania makes it unlawful to tattoo a person under the age of 18 without parental consent. In 2009, the General Assembly considered regulating the tattooing industry, but legislation was not enacted.

Of the 10 most populous states, all but Pennsylvania have approved tattoo regulations or have legislation pending. California enacted one of the most comprehensive bills regulating its tattoo industry in July. Known as "The Safe Body Art Act," it requires consent forms signed by the client acknowledging that he or she understands the procedure and post-procedure instructions. It also requires tattoo owners to register with local health agencies and to obtain a permit certifying that it meets federal Occupational Safety and Health Administration health and safety guidelines.

Several local Pennsylvania communities have regulations in place for tattoo parlors, including Philadelphia, State College and Erie County.

Wagner's letter recommended several legislative and enforcement steps, including:
- The licensing of all tattoo parlors by the Department of Health, requiring regular safety and sanitation inspections.
- Requiring training for tattoo artists, which may include apprenticeships with a professional tattoo artist, certification of blood-borne pathogens, first aid and CPR training.
- Requiring tattoo establishment owners to purchase adequate liability insurance to cover clients and the premises.
- Imposing monetary fines for artists who operate illegally.

Wagner said that any approved legislation should help limit problem practitioners who operate under unsanitary conditions and also help to eliminate unqualified artists from applying tattoos.

Source: Pennsylvania Department of the Auditor General

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What to do with a positive hep C test

Lynn Rapsilber, MSN, ANP-BC, APRN

September 13, 2012

According to the CDC, there are approximately 180 million hepatitis C antibody-positive individuals worldwide, 4.1 million of which reside in the United States. With 3 to 4 million new cases diagnosed per year, hepatitis C is among the fastest growing illnesses.

There are more than 7 million carriers of the hepatitis C virus (HCV) and 2.7 million chronically infected individuals. Approximately 12,000 people die from hepatitis C every year. The highest prevalence of the disease is among those aged 30 to 54 years.

Hepatitis C is often not recognized until asymptomatic persons are identified as HCV-positive. Blood testing, first made available in 1992, is the only way to determine that an individual has hepatitis C. The treatment goal is viral eradication. If eradication cannot be accomplished, clinicians must slow disease progression, improve histology, decrease the risk of hepatocelluar carcinoma and improve quality of life.

Who is at risk?

Hepatitis C (Flaviviridae hepacivirus) is a small, enveloped, single-stranded RNA virus. This virus mutates rapidly, so changes in the envelope proteins may help it invade the immune system. The virus does not incorporate itself into the host DNA, resulting in the ability to cure the infection indefinitely.

Acute hepatitis C refers to the first six months after infection. Between 60% and 70% of individuals infected with HCV develop no symptoms during this acute phase. In the minority of patients, acute-phase symptoms may be mild and nonspecific. Approximately 55% to 85% of acute hepatitis C patients will remain infected. Signs and symptoms of acute hepatitis C infection include fatigue, fever, dark urine, clay-colored stools, abdominal pain, loss of appetite, nausea, vomiting, joint pain and jaundice.

Hepatitis C can also be chronic and cause chronic liver disease that ranges from mild to severe, including cirrhosis and liver cancer. Liver disease associated with chronic hepatitis C is usually insidious and progresses slowly without any signs or symptoms for several decades.

HCV can be transmitted through a variety of ways, including:

• Transfusions and organ transplants before 1992
• IV drug use
• Intranasal cocaine use
• Sharing personal items with an infected person (e.g., razors, shavers, and toothbrushes)
• Tattooing and body piercing
• High-risk sexual activity
• Clotting factors before 1987
• Occupational exposures (health-care professionals)
• Mother-to-infant transmission (rare but still considered a risk).

Testing and screening

HCV antibody testing is sensitive and inexpensive. Anti-HCV screening assays include the enzyme immunoassay (EIA) or the enhanced chemiluminescence immunoassay (CIA). Positive results are reportable and should be confirmed with a repeat test. The recombinant immnunoblot assay (RIBA), a more specific serologic anti-HCV assay, is no longer used. Once the antibody test is positive, HCV-polymerase chain reaction (PCR) RNA test measures how much HCV is in the bloodstream.

The American Association for the Study of Liver Disease (AASLD) recommends that all persons be screened for behaviors that place them at risk for hepatitis C infection as part of comprehensive health screening. Universal testing is not required at this time. The groups that are most strongly recommended for testing include:

• Recent and current injection drug users (even if they have only used once)
• HIV-infected individuals
• Hemodialysis recipients
• Hemophilia patients who received clotting factor concentrates before 1987
• Patients with unexplained elevated liver abnormalities
• Recipients of organ transplant or transplantation before July 1992
• Children born to women infected with hepatitis C
• Health-care workers who have had a needle exposure
• Current sexual partners of individuals with hepatitis C
• Persons who have used illicit noninjectible drugs (e.g., intranasal cocaine).

In addition to the viral load measurement or the PCR RNA testing, genotyping should also be performed. Of the six genotypes, genotypes 1, 2 and 3 are the most common in the United States.

Consequences of hepatitis C

Some of the consequences of chronic hepatitis C include hepatic fibrosis, cirrhosis, hepatocellular carcinoma, end-stage liver disease requiring transplantation and various extra-hepatic manifestations.

Hepatitis C causes inflammation of the tissue, resulting in fibrosis, which leads to scarring. This affects liver function, which further progresses the scarring to cirrhosis, eventually leading to liver failure and ultimately transplant. About 30% of those with hepatitis C will experience liver scarring leading to potential cirrhosis. Hepatocellular carcinoma occurs in about 3% of the population infected with hepatitis C. This incidence has increased over the past two decades and is identified through imaging studies or jaundice and in elevated alpha-fetoprotein levels in the blood. Surgical resection or ablative procedures increase the chance for cure.

Extra-hepatic manifestations of hepatitis C include:

• Hematologic (anemia, and lymphoma)
• Dermatologic (lichen planus and vasculitis)
• Renal (glomular nephritis and nephritic syndrome)
• Endocrine (hypothyroidism and diabetes)
• Neuropsychiatric disease
• Ocular (corneal ulcer and uveitis)
• Vascular (polyarteritis nodosa and necrotizing vasculitis)
• Neuromuscular (arthralgias and arthritis)
• Autoimmune (CREST syndrome).

Transmission

Avoiding transmission to others is one of the best ways to contain the spread of the infection. Advise individuals with hepatitis C to: avoid sharing toothbrushes, shaving equipment, razors, nail files, and clippers; avoid tattoos and body piercings; do not donate blood, organ tissue or semen; cover bleeding wounds to prevent contact with others; discontinue illicit drug use; do not share needles. Because of the low sexual transmission rate, barrier protection is not needed in monogamous relationships; otherwise, safe sex practices are warranted.

Alcohol and hepatitis C

The effects in alcohol and hepatitis C are well documented. Alcohol consumption of greater than 50 g per day clearly increases the progression of hepatitis C fibrosis. Daily consumption of less than 50 g appears to increase hepatitis C PCR RNA viral load levels.

Treatment eligibility

The AASLD recommends that all patients with chronic hepatitis C be considered candidates for treatment. Review all risks and benefits with the patient. Treatment is based on histology, symptoms, probability of viral eradication, and progression of disease -- not just the alanine aminotransferase levels. Treatment is contraindicated in patients with:

• Major uncontrolled depression
• Solid organ transplant (e.g., renal, heart, or lung)
• Autoimmune hepatitis and other autoimmune conditions that could be worsened by treatment
• Undiagnosed and untreated thyroid disease
• Pregnancy unwillingness to comply with contraception
• Severe hypertension, congestive heart failure, coronary artery disease, diabetes, and chronic obstructive pulmonary disease that is not well controlled

Hypersensitivity to any of the treatment medications (i.e., peginterferon alfa-2a [Pegasys] and alfa-2b [PEG-Intron], ribavirin [Copegus, Rebetol, RibaTab, Ribasphere], telaprevir [Incivek], Boceprevir [Victrelis]).

Work-up

The initial work-up of hepatitis C should include a complete medical, family, and social history; depression scale; and laboratory testing (Table 1). With the advent of the protease inhibitors (PIs), liver biopsy is not required; however, if a patient is considering treatment and unsure whether or to proceed, a biopsy can document what liver damage has occurred and determine the grade of inflammation and the stage of liver fibrosis.

Dental work must be completed prior to treatment. Vaccination for hepatitis A and B should be initiated and should not delay the start of treatment.

Predictors of treatment response include age (younger individuals have greater likelihood of response), sex (both males and females are at the same rate of treatment response), race (blacks respond less favorably to treatment than whites), and weight (higher BMI, insulin resistance, and fatty liver can hinder the ability to process medications that can help treatment response). Severe depression and anxiety and continued drug and alcohol use will impact the ability of the medications to be effective in cure. HIV-positive individuals who are co-infected with hepatitis C respond less favorably to treatment.

Treatment response

Treatment response for hepatitis C is measured by viral response. Rapid viral responders have no measurable virus at four weeks. Early viral responders have a >2 log drop at four weeks and no measureable virus at 12 weeks. Slow viral responders are not negative at week 12 but turn negative at week 24. Null responders have <2 log drop in viral load. Sustained viral response is no measurable virus six months after treatment and is considered a cure.

Genotype used to be a factor in treatment response, but with the development of the new PIs, genotype 1 responses are equal to or comparable to genotype 2 and 3. The higher the viral load the greater the virus to be killed, which can impede response.

Adherence to treatment is favorable when there is a good patient/provider relationship; adequate support systems in place; compliance with follow-up instructions, appointments, and lab draws; belief on the part of the patient that treatment will be beneficial; completion of the treatment; and a thorough explanation of the costs associated with treatment (i.e., insurance co-payments, medications, prior authorization).

Treatment recommendations

The current treatment recommendations for hepatitis C are based on genotype. Individuals with genotype 2 HCV receive peginterferon and ribavirin. Peginterferon helps fight the virus in two ways: (1) it helps healthy cells defend themselves against the virus; and (2) it strengthens the immune response, which helps the T and B cells fight off the virus. Peginterferon alfa-2a and alfa-2b are administered as subcutaneous weekly injections.

Side effects of treatment include flulike symptoms, fatigue, headache, arthralgias and myalgias, fever and chills. Other potential symptoms include anemia, diarrhea, nausea, worsening depression, mood instability, injection-site reaction, weight change, alopecia and increased susceptibility to infections and insomnia.

Ribavirin is an antiviral that interferes with RNA metabolism and slows the growth of the virus when used together with peginterferon. Ribavirin is administered orally b.i.d. Side effects include nausea; hemolytic anemia; MI with anemia; and such pulmonary symptoms as dyspnea, infiltrate and pneumonitis. Ribavirin is teratogenic and can cause birth defects or death of an unborn child. Female partners and female partners of individuals being treated with ribavirin should not become pregnant during treatment or for six months after treatment has stopped.

Protease inhibitors

PIs represent the new class of hepatitis C treatment and give new hope for individuals infected with genotype 1 HCV. Eligibility includes those who are treatment-naïve, partial responders, relapsers and null responders. PIs are given in conjunction with peginterferon and ribavirin. The response rates are quite phenomenal: 80% in treatment-naïve individuals; 75%-85% in relapsers; 50% in partial responders; and even 30% in null responders. There are two PIs available at this time.

Boceprevir. This medication is given orally 800 mg (four 200-mg tablets) t.i.d., every eight hours with food. Treatment is initiated with a four-week lead-in period of peginterferon and ribavirin alone; the triple therapy with boceprivir begins at week 5.

Duration of boceprevir for treatment-naïve individuals depends on response. If a negative HCV PCR RNA is achieved at week 4, week 8, and week 12, treatments can cease at 28 weeks. Response-guided treatment (RGT) continues depending on whether the patient is below 100 IUs of viral load measurement at specific intervals. A treatment-naive patient detected at eight weeks and negative at 12 weeks will complete boceprivir at week 36 but continue the peginterferon and ribavirin for a total of 48 weeks.

Previous partial responders and relapsers get the four-week lead in of peginterferon and ribavirin, followed by triple therapy for at least 36 weeks if negative viral-load measurements are found at four, eight, 12, 24 and 36 weeks. A patient who had measurable viral load at week 8 but was below 100 IU/mL would continue treatment for a total of 36 weeks and then dual therapy with peginterferon and ribavirin for 48 weeks.

Null responders and all cirrhotic patients get a four-week lead-in, followed by triple therapy with boceprivir, peginterferon and ribavirin for a total of 44 weeks. Any time the viral load measurement is above 100 IU/mL, the treatment is discontinued.

Telaprevir. This medication is given orally 750 mg (two 375-mg tablets) t.i.d. every eight hours with a high-fat 20-gram snack. RGT for telaprevir includes starting with triple therapy. Therapy for treatment-naïve and previous relapsers includes all three medications up front (telaprevir, peginterferon and ribavirin) for a period of 12 weeks. Depending on response, the treatment can end as early as 24 weeks or may continue for up to 36 weeks. Patients with cirrhosis may benefit from a full 48-week course.

For a previous partial responder or null responder, prescribe triple therapy (telaprevir, peginterferon and ribavirin) for 12 weeks, followed by 36 weeks of peginterferon and ribavirin alone. If viral load is nondetected at week 4 and week 12, discontinue the telaprevir and continue the peginterferon and ribavirin for a total response-week duration of 24 weeks. If the viral load is detectable but below 1,000 IU/mL at week 4 and week 12, continue the treatment to week 12, and then order an additional 36 weeks of dual therapy with peginterferon and ribavirin for a total treatment duration of 48 weeks. If at any time the viral load measurement goes above 1,000 IU/mL, at week 4, week 12, or detectable at week 24, the therapy is discontinued.

Managing side effects

Educate patients on the importance of adequate hydration and maximizing nutrition and energy-conservation strategies. If possible, clinicians should work with patient's employer to see about decreasing 12-hour shifts to eight hours to maximize energy conservation.

It is imperative that patients undergoing treatment for hepatitis C be able to continue to work, as this provide a distraction from the side effects of the medication. Counseling, patient support groups, or referral for professional help should also be considered.

Advise patients to use moisturizer to prevent rashes and dry skin. Alopecia can be minimized through less-frequent hair manipulation. Antiemetics for nausea, hematologic support for anemia and premedication with nonsteroidal anti-inflammatory drugs and alternating with acetaminophen for flulike symptoms is recommended.

During treatment monitoring, have patient visit every other week for side-effect management, counseling, and review of lab data. Viral load measurements throughout the course of treatment as described by the PI treatment algorithms are recommended and should be adhered to for the futility rules.

Above all, no PI should be stopped once it is started. The chance of developing resistance to these medications rapidly increases with the omission of even one dose. It is essential that all patients take peginterferon and ribavirin with these medications as well, and they are not interchangeable. Always stop the PI if the viral load measurement continues to increase.

Patient selection for antiviral therapy

For successful outcomes, it is imperative that clinicians spend the time up front to counsel and teach the patients and their families or supportive others. Explain that commitment requires the full duration of the treatment. Have patients sign a consent form agreeing to frequent blood testing, scheduled office visits, pregnancy prevention, and abstention from alcohol and drug use.

There is significant risk for medication reactions with PIs. A throughout medication review must be obtained before starting these drugs. Several medications are contraindicated, including simvastatin (Zocor), St. John's wort, and sildenafil (Viagra). Other medications require cautious use, including amlodipine (Norvasc), clarithromycin (Biaxin), methadone and zolpidem (Ambien). Please see the Victrelis and Incivek pagackage inserts for a complete list of potential drug interactions.

The goal with any of the treatments described is to support the patient through the process, foster a partnership in this unique opportunity to cure, and provide congratulations on the successes along the way.

Lynn Rapsilber, MSN, ANP-BC, APRN, is a nurse practitioner with Litchfield County Gastroenterology in Torrington, Conn.

References

1. Ghany MG, Strader DB, Thomas DL, et al. Diagnosis, management, and treatment of hepatitis C: an update. Hepatology. 2009;49:1335-1374.
2. Strader DB, Wright T, Thomas DL, et al. Diagnosis, management, and treatment of hepatitis C. Hepatology. 2004;39:1147-1171.
3. Victrelis (boceprevir) Package Insert. Merck & Co., Inc.; 2011.
4. Incivek (telaprevir) Package Insert. Vertex Pharmaceuticals; 2011.

   All electronic documents accessed September 13, 2012.

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Hepatitis C, a leading killer, is frequently undiagnosed but often curable

February 24, 2012 By Jeffrey Norris

(Click picture to enlarge)

(Medical Xpress) -- Hepatitis C virus — not AIDS-causing HIV — is the leading chronic virus infection leading to death in the United States, and its victims most often are baby boomers. More than half who are infected do not know it.

Researchers from the U.S. Centers for Disease Control and Prevention (CDC) found in a study published in the February 21 issue of the Annals of Internal Medicine that hepatitis C had overtaken HIV as a cause of death in the United States by 2007.

Deaths in the United States due to HIV infection have been steadily decreasing, and dropped below 13,000 in 2007, while deaths from hepatitis C infection have been steadily increasing, first surpassing 15,000 per year in 2007.

The good news, according to UCSF liver specialist Alex Monto, MD, is that there has been progress in fighting both diseases, and the kinds of drug combination strategies that have done so much to transform HIV infection from a death sentence to a manageable disease are poised to further boost cure rates for those infected with hepatitis C.

“We know that not enough people with risk factors get tested,” Monto says. “There are a lot of people walking around with hepatitis C who don’t know it.”

Monto directs the liver clinic at the UCSF-affiliated San Francisco Veteran’s Affairs Medical Center, one of four hepatitis C centers nationally within the VA system. Like boomers, veterans are disproportionately affected by hepatitis C. The VA cares for 165,000 patients who are chronically infected with the virus.

Three Million in U.S. Diagnosed with Hep C

Chronic Hepatitis C has been diagnosed in about three million people in the United States. It often causes no symptoms, and many who have been infected for years or even decades may remain unaware of it until symptoms finally appear. The ultimate cause of death attributable to chronic infection is cirrhosis or liver cancer, although the disease progresses to cirrhosis in fewer than half of cases. There is no vaccine.

“The main risk factor in the United States is past injection-drug use,” Monto says. “The others most at risk are those who received blood transfusions before 1992,” Monto says, referring to the year when high-quality screening of the blood supply was implemented.

Compared to HIV or hepatitis B, the risk of hepatitis C being transmitted by sex is low, Monto says, but among men who have sex with men there has been an increase in reports of the virus being sexually transmitted, more so among those who are infected with HIV.

“Anybody with a history of ever being exposed to injection drugs or who received a transfusion before the blood supply was screened should be tested,” Monto says. “That’s not controversial at all. What has been controversial is whether or not all baby boomers should be screened.”

Another study in this week’s edition of the journal suggests that a one-time blood test ordered by primary care providers to screen for antibodies to hepatitis C in those born between 1945 and 1965 would be cost effective — costing $2,874 for each chronically infected patient identified — and would lead to the identification of more than 800,000 previously undiagnosed cases.

Those who are chronically infected may be able to reduce the likelihood of disease progression by avoiding alcohol, by maintaining a healthy weight, and by being vaccinated against hepatitis A and hepatitis B, Monto says.

Treatment Often Cures Hepatitis C

About four out of five who are infected do not rid themselves of the virus without treatment. For about a decade the standard treatment was a combination of two drugs — pegylated interferon given once per week by subcutaneous injection, and daily ribavirin pills, with treatment lasting from six to 11 months. This treatment represented a vast improvement — offering cure rates of 40 percent to 50 percent in most patients, according to Monto.

Within the past year two new drugs of a type known as protease inhibitors have become available. These are valuable for the 75 percent of U.S. hepatitis C patients infected with a form of the virus called genotype 1. With the protease inhibitors added to the mix, the duration of treatment may be shorter, and the cure rate has increased to about 70 percent in patients who have not previously been treated, Monto says. A cure may be less likely for those who have been previously treated, depending on how they responded to earlier treatment.

“New therapies are clearly getting better, and there are probably 25 to 30 new drugs in the pipeline, with many coming out in the next few years,” Monto says. “There are going to be drugs that are better than the ones we have so far.” Several UCSF researchers, including Monto, are helping to evaluate new drugs in clinical trials. UCSF researchers also are investigating the role of the immune system in hepatitis C and hepatitis B infection.

Not to Be Confused with Hepatitis B

Hepatitis B chronically infects about half as many as hepatitis C in the United States, and hits those of Asian descent especially hard — they account for half of hepatitis B infections. Hepatitis B is responsible for about 1,800 deaths yearly in the United States.

Despite the similar names, the two viruses are not closely related. Hepatitis B is spread much more easily through sexual intercourse, and passes from mother to newborn child much more easily. In most adults who become infected the immune system successfully controls infection. Only about five percent of adults exposed to hepatitis B become chronically infected, according to Monto.

There are vaccines for hepatitis B. A UCSF laboratory team led by William Rutter, PhD, now professor emeritus, first demonstrated that an uncontaminated source of material for a hepatitis B vaccine could be obtained by mass-producing viral proteins in genetically engineered, laboratory-grown yeast. This was the groundwork leading to the first marketed genetically engineered vaccine, made by Chiron, a company co-founded by Rutter.

Provided by University of California, San Francisco (news : web)

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Examining Hepatitis C Virus Testing Practices in Primary Care Clinics

From Journal of Viral Hepatitis

C. V. Almario; M. Vega; S. B. Trooskin; V. J. Navarro

Posted: 02/14/2012; J Viral Hepat. 2012;19(2):e163-e169. © 2012 Blackwell Publishing

Abstract and Introduction

Abstract

Prior studies found that hepatitis C virus (HCV) risk assessment and testing in primary care clinics were suboptimal. We aimed to determine the actual HCV testing rate among patients with HCV risk factors and to identify variables predictive of testing. In order to do so, we performed a prospective cohort study among patients seen in four urban primary care clinics. At the initial visit, patients were given a questionnaire that listed HCV risk factors and they were instructed to check 'yes' or 'no' if they did or did not have a risk factor, respectively. Patients then handed this questionnaire to their physician during their initial visit. Among those who acknowledged having a HCV risk factor via the questionnaire, we determined the subsequent HCV testing rate and calculated adjusted odds ratios (aOR) with 95% confidence intervals (CI) to identify variables predictive of testing. Of the 578 individuals who acknowledged having a HCV risk factor via the questionnaire, only 8% (46/578) were tested for HCV within 2 months of their initial visit. Among those tested, 11% (5/46) had a positive HCV antibody test result. The only variable predictive of HCV testing after adjusting for confounders was having a specific HCV risk factor identified and documented in the chart by physicians [16% (26/159) vs 5% (20/419); aOR 4.5, 95% CI 2.1–9.5]. In summary, 92% of patients with a HCV risk factor were not tested for HCV in the primary care setting, and efforts to improve such rates are clearly warranted.

Introduction

Hepatitis C virus (HCV) is the most common bloodborne infection in the United States, as 3.2 million individuals are chronically infected nationwide.^[1] Furthermore, 40% of chronic liver disease is related to HCV, and HCV-associated end-stage liver disease is the most frequent indication for liver transplantation.^[2] Given the significant morbidity and mortality associated with HCV, the Centers for Disease Control and Prevention (CDC),^[2] National Institutes of Health (NIH),^[3] and American Association for the Study of Liver Diseases (AASLD)^[4] all recommend HCV testing for persons at high risk. However, previous studies, most of which were survey based, showed that HCV risk assessment and testing in primary care settings were suboptimal.^[5–11] Shehab et al.^[5] noted that among primary care physicians (PCPs) surveyed nationwide, only 59% asked all patients about HCV risk factors. A retrospective chart review by Trooskin et al.^[11] revealed that PCPs documented a history (positive or negative) of intravenous drug use and blood transfusion prior to 1992 for 12% and 2% of patients, respectively. Furthermore, they also found that of those who admitted intravenous drug use, only 55% were subsequently tested for HCV.^[11]

Patient care in primary care settings has become increasingly complex. While the time physicians spent with patients has increased over the years,^[12,13] the number of clinical items addressed per visit also increased.^[13] Yet, the increase in the number of addressed clinical diagnoses outpaced the increase in visit duration, thereby leading to a decrease in the amount of time devoted to each clinical item.^[13] Given the increased demands placed on PCPs along with the fact that most prior studies that examined HCV testing practices were survey based, we aimed to perform a prospective cohort study to determine the actual rate of HCV testing among primary care patients with a HCV risk factor and to identify factors predictive of testing.

Materials and Methods

We performed a prospective cohort study among patients seen at four urban primary care clinics in Philadelphia, Pennsylvania, from October 2004 to June 2005. Two clinics were university-based primary care practices (an internal medicine practice and a family medicine practice) at Thomas Jefferson University Hospital, while the other two clinics were federally qualified community health clinics. Each of the four primary care clinics served a unique population. The internal medicine university-based practice provided care for a population of which 45% were African American. A majority of the internal medicine patients had private insurance. For the family medicine university-based practice, 60% of the patients were African American and approximately 50% had private insurance. Regarding the community clinics, one served a predominantly Latino population (85%), of which approximately 25% were undocumented immigrants. The second community clinic served a predominantly African American population (70%). The majority of patients receiving care at the two community health clinics were either uninsured or covered by a Medicaid Health Maintenance Organization.

Our group previously performed a retrospective chart review among patients seen in the four clinics described previously. The aim of the prior study was to examine HCV risk factor ascertainment, testing and referral for treatment, with particular attention to the role of race and ethnicity.^[11] For our current prospective study, we focused on examining HCV testing practices and determining factors predictive of testing. Participants in our current study included patients, 18 years of age or older, who had not been seen in the clinic for 5 years or more. Individuals were asked to participate in the study while they were in the waiting room, and those who agreed to participate were given a HCV risk factor questionnaire that listed risk factors for HCV. The questionnaire asked patients whether they ever had any of the following: a blood transfusion before 1992, an organ transplant before 1992, long-term dialysis, a spouse or significant other who was diagnosed with HCV, been in prison or jail for more than 24 h, worked as a healthcare worker and accidentally been stuck with a needle, injected recreational drugs even if it was just one time or a tattoo or body piercing (ear piercing not included). At the bottom of the questionnaire, participants were instructed to check 'yes' or 'no' if they did or did not have any of the above HCV risk factors, respectively. Those who had a HCV risk factor were told to simply check 'yes' and to not identify their specific HCV risk factor on the questionnaire. The questionnaire was made in duplicate with one copy given to the study's personnel. Patients were instructed to hand the other copy of the questionnaire to their PCP during their initial visit. Of note, the HCV risk factor questionnaire did not include any language prompting the PCP to order HCV testing if the patient acknowledged having a HCV risk factor via the questionnaire.

The charts of all patients who identified themselves as having a HCV risk factor on the questionnaire were reviewed 2 months after their initial visit by a team of trained chart reviewers. Demographics collected included age, sex, race/ethnicity, primary care clinic setting (university-based vs community), total number of clinic visits within a 2-month period after the initial visit, insurance status, highest level of education and annual income. All pre-existing medical comorbidities documented in the chart were recorded. Anyone with a known prior diagnosis of HCV was excluded from the study. We checked to see whether the HCV risk factor questionnaire was present in the chart and determined whether physicians identified and documented in the chart the specific HCV risk factor that each patient possessed. We also determined whether a HCV antibody test was subsequently performed by searching the chart for a HCV antibody test result or documentation from the physician clearly stating that the patient was referred for HCV antibody testing.

Statistical tests were performed using SPSS 17.0 (SPSS Inc., Chicago, IL, USA). Student's t-test and the chi-square test were used to analyse continuous and categorical variables, respectively. When sample sizes for categorical variables were small, the Fisher's exact test was used in place of the chi-square test. A P value <0.05 was considered statistically significant. A binary logistic regression model was used to calculate adjusted odds ratios (aOR) with 95% confidence intervals (CI) to find variables predictive of HCV testing. Variables from univariate analysis with a P < 0.20 were included as covariates in the regression model. This cut-off value was chosen so that we could liberally include variables in the model and therefore assess confounding by more variables. This study was approved by the Institutional Review Board of Thomas Jefferson University Hospital

Results

Overall, 1848 individuals from four urban primary care clinics agreed to complete the HCV risk factor questionnaire during their initial primary care visit. Of the 1848 individuals who participated, 658 (36%) acknowledged on the questionnaire that they had a risk factor for HCV. On the subsequent chart review 2 months after their initial visit, 58 individuals either had charts with incomplete data or charts that could not be located. We excluded 22 individuals because they had a known prior diagnosis of HCV. Therefore, our study population included 578 patients with a HCV risk factor.

Demographic characteristics of the study population are presented in Table 1. Only 46 of 578 (8%) individuals with a HCV risk factor were tested for HCV within 2 months after their initial visit. Among those tested, five of 46 (11%) had a positive HCV antibody test result, 39 of 46 (85%) were negative, and two of 46 (4%) had pending results at the time of chart review.

When comparing those who were tested for HCV vs those who were not, we found that those tested had a higher proportion of Latinos, were more often seen in the community primary care clinic setting, had more clinic visits during the 2 months after their initial visit and were less educated. They were also more likely to have the HCV risk factor questionnaire present in their chart and to have a physician who identified and documented a specific HCV risk factor in the chart. No statistically significant differences were found in regard to age, sex, insurance status, annual income and number of comorbidities.

Of the 578 individuals who acknowledged having a HCV risk factor via the questionnaire, only 159 of 578 (28%) had physicians who identified and documented a specific HCV risk factor in the chart. Twenty-one of 159 (13%) patients had two documented risk factors while 138 of 159 (87%) only had one. Table 2 lists the specific risk factors documented in the chart by physicians and their associated rates of HCV testing. No association was found between HCV testing and the number of identified HCV risk factors, as one of 21 (5%) individuals with two risk factors were tested vs 25 of 138 (18%) of those with one risk factor (P = 0.20).

Table 3 presents the rate of HCV testing associated with each medical comorbidity. The only comorbidity with a statistically significant association with HCV testing was hyperlipidemia. All other medical comorbidities were not predictive of HCV testing. Among individuals with 0, 1, 2 or ≥3 medical comorbidities, the rate of HCV testing was 22 of 343 (6%), 12 of 135 (9%), six of 64 (9%) and six of 36 (17%), respectively (P = 0.16).

Table 4 shows the unadjusted and aOR for variables predictive of HCV testing. In our unadjusted analysis, we noted that patients with ≥3 medical comorbidities were more likely to undergo HCV testing when compared to those without medical comorbidities. However, after adjusting for confounders with a binary logistic regression, no statistically significant difference was seen in HCV testing rates between patients with 0, 1, 2 or ≥3 medical comorbidities. The only variable that remained predictive of HCV testing after adjusting for confounders was having a physician who identified and documented a specific HCV risk factor in the chart.

Discussion

The rate of HCV testing among primary care patients with a HCV risk factor was very low, as only 8% underwent HCV testing. We found that having a specific HCV risk factor identified and documented in the chart by physicians predicted HCV testing.

Our study has a number of unique features that differentiate it from prior studies examining HCV testing in primary care settings. Most notable was the prospective design of our study and our focus on actual PCP practices, as we examined individual medical charts. Prior investigators primarily used surveys to study how PCPs identified and managed HCV,^[5–10] but surveys are prone to bias and may not reflect true practices. In fact, our HCV testing rate of 8% is in stark contrast to the 70% of surveyed PCPs who stated that they test all patients with risk factors.^[5] This strongly suggests that actual practices differ markedly from surveyed responses. The low rate of HCV testing among our study population was especially surprising given that all PCPs were handed a questionnaire from each patient at the initial visit identifying themselves as having a HCV risk factor. This strongly suggests that HCV testing was not a high priority for PCPs at the initial visit. The low rate may also reflect PCPs' unfamiliarity with HCV testing guidelines from national organizations. This is supported by our finding that only 47% and 7% of patients with a history of intravenous drug use and blood transfusion before 1992 were tested for HCV, respectively. These two risk factors are arguably the most important ones for HCV acquisition, and the CDC,^[2] NIH,^[3] and AASLD^[4] all recommend testing these two cohorts for HCV. Further supporting the idea that PCPs are unfamiliar with HCV testing guidelines was a prior survey that found that 42% of PCPs were unaware of the national guidelines regarding HCV testing.^[8] Other surveys administered among primary care residents^[9] and family physicians^[10] revealed their insufficient knowledge about HCV testing guidelines and that they often tested for HCV in inappropriate clinical situations.

Another unique aspect of our study was our examination of the impact of medical comorbidities on HCV testing rates. Originally, we hypothesized that patients with comorbidities would be less likely to undergo testing for HCV. Given the increasing demands placed on PCPs,^[12,13] we theorized that PCPs would prioritize the management of comorbidities they perceived as having a more immediate impact on the patient's health and be less concerned with testing for HCV, which is often asymptomatic for years. We also thought that PCPs would be more likely to manage or screen for medical conditions for which effective therapies are available. At the time of our study, the standard HCV treatment of peginterferon-α and ribavirin led to sustained virological response in only 41–52% of those with HCV genotype 1.^[14–16] However, our results showed that the presence of comorbidities did not negatively impact the HCV testing rate, thus disproving our original hypothesis. In fact, we found a trend, albeit not statistically significant, towards increased testing with increasing number of medical comorbidities. There are several possible explanations for this finding. PCPs may have given more attention to sicker patients in regard to assessing risk factors for other disease processes, including HCV. Also, patients with multiple medical conditions often receive frequent laboratory tests, and PCPs may have been more likely to order HCV serological testing for a patient already going for blood work.

Other interesting findings from our study included our examination of the rates of HCV testing associated with specific HCV risk factors. Notably, only 47% of patients with a history of intravenous drug use were tested for HCV. This rate is comparable to our prior retrospective study that discovered that 55% of intravenous drug users were tested.^[11] These findings are surprising given that 98% of surveyed family physicians stated that they offer HCV testing to this group.^[7] Such a low rate of testing among intravenous drug users is troubling because prior studies found that 35% to 57% were HCV antibody positive.^[17,18]

A limitation of our study included our data being limited to what was documented in the chart. We may have missed specific HCV risk factors and medical comorbidities that went undocumented. We also may have missed patient refusals for HCV testing that were not documented by the PCP. Another limitation relates to the fact that our study population only included patients new to each primary care clinic and that we only looked for HCV antibody test results within the 2 months after their initial visit. It is possible that HCV testing could have occurred at later visits. However, the initial visit is often the most comprehensive visit, and we would expect that most referrals for HCV testing would occur during the first visit. Our study was also limited by the fact that we were unable to determine why PCPs did not offer HCV testing to most individuals who admitted to having a HCV risk factor. Lastly, our study did not examine a realistic clinical situation, as patients were 'prelabelled' as being high risk for HCV via the HCV risk factor questionnaire. Yet, we should point out that despite 'prelabelling' patients as high risk for HCV, only 8% were tested and the true HCV testing rate is likely much lower.

In summary, we found that 92% of patients with a HCV risk factor were not tested for HCV. Testing those at high risk for HCV is critical, as it can lead to early identification of infection and find those who will benefit from antiviral therapy.^[19] This is especially important given the new and effective protease inhibitors that are now available.^[20,21] Aside from referring for antiviral treatment, PCPs can also immunize patients with the hepatitis A and B virus vaccines, recommend abstinence from alcohol and provide education regarding behaviours that transmit HCV to others.^[22–24] Given these benefits, PCPs should make every effort in increasing HCV testing rates among patients with a HCV risk factor. Future studies that further define the barriers associated with HCV testing in primary care settings as well as the development of novel strategies to improve HCV testing rates are clearly needed.

References

1. Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med 2006; 144: 705–714.
2. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related
3. chronic disease. Centers for Disease Control and Prevention. MMWRRecomm Rep 1998; 47: 1–39.
4. NIH consensus statement on management of hepatitis C. 2002. NIHConsens State Sci Statements 2002; 19: 1–46.
5. Strader DB, Wright T, Thomas DL et al. Diagnosis, management, and treatment of hepatitis C. Hepatology 2004; 39: 1147–1171.
6. Shehab TM, Sonnad SS, Lok AS. Management of hepatitis C patients by primary care physicians in the
7. USA: results of a national survey. JViral Hepat 2001; 8: 377–383.
8. Navarro VJ, St Louis TE, Bell BP. Identification of patients with hepatitis C virus infection in New Haven County primary care practices. J Clin Gastroenterol 2003; 36: 431–435.
9. Clark EC, Yawn BP, Galliher JM, Temte JL, Hickner J. Hepatitis C identification and management by family physicians. Fam Med 2005; 37: 644–649.
10. Kallman JB, Arsalla A, Park V et al. Screening for hepatitis B, C and nonalcoholic fatty liver disease: a survey of community-based physicians. AlimentPharmacol Ther 2009; 29: 1019–1024.
11. Coppola AG, Karakousis PC, Metz DC et al. Hepatitis C knowledge among primary care residents: is our teaching adequate for the times? Am JGastroenterol 2004; 99: 1720–1725.
12. Ferrante JM, Winston DG, Chen PH, de la Torre AN. Family physicians' knowledge and screening of chronic hepatitis and liver cancer. Fam Med 2008; 40: 345–351.
13. Trooskin SB, Navarro VJ, Winn RJ et al. Hepatitis C risk assessment, testing and referral for treatment in urban primary care: role of race and ethnicity. World J Gastroenterol 2007; 13: 1074–1078.
14. Mechanic D, McAlpine DD, Rosenthal M. Are patients' office visits with physicians getting shorter? N Engl JMed 2001; 344: 198–204.
15. Abbo ED, Zhang Q, Zelder M, Huang ES. The increasing number of clinical items addressed during the time of adult primary care visits. J Gen Intern Med 2008; 23: 2058–2065.
16. Manns MP, McHutchison JG, Gordon SC et al. Peginterferon alfa-2b plus ribavirin compared with interferon alfa-2b plus ribavirin for initial treatment of chronic hepatitis C: a randomised trial. Lancet 2001; 358: 958–965.
17. Fried MW, Shiffman ML, Reddy KR et al. Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection. N Engl J Med 2002; 347: 975–982.
18. Hadziyannis SJ, Sette H Jr, Morgan TR et al. Peginterferon-alpha2a and ribavirin combination therapy in chronic hepatitis C: a randomized study of treatment duration and ribavirin dose. Ann Intern Med 2004; 140: 346–355.
19. Judd A, Hutchinson S, Wadd S et al. Prevalence of, and risk factors for, hepatitis C virus infection among recent initiates to injecting in London and Glasgow: cross sectional analysis. J Viral Hepat 2005; 12: 655–662.
20. Miller CL, Johnston C, Spittal PM et al. Opportunities for prevention: hepatitis C prevalence and incidence in a cohort of young injection drug users. Hepatology 2002; 36: 737–742.
21. Mallette C, Flynn MA, Promrat K. Outcome of screening for hepatitis C virus infection based on risk factors. Am J Gastroenterol 2008; 103: 131–137.
22. McHutchison JG, Everson GT, Gordon SC et al. Telaprevir with peginterferon and ribavirin for chronic HCV genotype 1 infection. N Engl JMed 2009; 360: 1827–1838.
23. McHutchison JG, Manns MP, Muir AJ et al. Telaprevir for previously treated chronic HCV infection. NEngl J Med 2010; 362: 1292–1303.
24. Peters MG, Terrault NA. Alcohol use and hepatitis C. Hepatology 2002; 36: S220–S225.
25. Wiley TE, McCarthy M, Breidi L, McCarthy M, Layden TJ. Impact of alcohol on the histological and clinical progression of hepatitis C infection. Hepatology 1998; 28: 805–809.
26. Shehab TM, Orrego M, Chunduri R, Lok AS. Identification and management of hepatitis C patients in primary care clinics. Am J Gastroenterol 2003; 98: 639–644.

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Amateur tattoos carry hepatitis C risk: CDC

By Amy Norton

NEW YORK | Tue Feb 7, 2012 3:27pm EST

NEW YORK (Reuters Health) - If you're planning on getting a tattoo, make sure it's from a professional and not your friend, says a new report from the Centers for Disease Control and Prevention (CDC).

In an analysis of several dozen past studies, CDC researchers found that tattoos from non-professionals appear to carry a risk of the blood-borne liver infection hepatitis C. That included tattoos done by friends or family, or ones done in prison.

On the other hand, there was no evidence that tattoos done by professionals carried a hepatitis C risk.

Hepatitis C is passed through contact with infected blood. In the U.S., there are roughly 18,000 new infections each year, most of which occur when people who inject heroin and similar drugs share tainted needles or syringes.

But in almost 20 percent of acute hepatitis C infections, the person has no known risk factor, said Dr. Rania A. Tohme, a medical epidemiologist at the CDC who led the new study.

Given that -- and the popularity of tattoos -- there have been concerns that the body art could be a risk factor for hepatitis C.

Based on these findings, it's the tattoos from non-pros that consumers should beware, according to Tohme.

"Tattoos and piercings can transmit hepatitis C and other infections if performed under non-sterile conditions," Tohme told Reuters Health in an email. "People should not have tattoos or piercings done by friends or by people who are not trained professionals."

The findings, published in the journal Clinical Infectious Diseases, are based on a collection of studies published since 1994.

In general, people who had tattoos done by non-professionals faced a hepatitis C risk that was two to four times higher than average.

Prison tattoos are a particular concern, Tohme's team writes, because tattooing is so common, and many prisoners may have other risk factors for hepatitis C. And outbreaks of the infection have been linked to tattooing among prisoners.

But no U.S. outbreaks have been tied to professional tattoo parlors.

"To this date, there has been no evidence that tattoos and piercings performed in professional parlors in the United States have been implicated in transmission of hepatitis C virus," Tohme said.

Still, you can take some precautions if you're thinking of inking up.

Tohme said to make sure the tattoo artist is using sterile equipment, including single-use needles and ink that has not been used on anyone else.

"Disposable piercing needles, tattoo needles and razors are used on one person and then thrown away. Reusing needles or razors is not safe," Tohme said.

In the U.S., new cases of hepatitis C infection have fallen sharply since the 1980s, according to the CDC.

But chronic hepatitis C infection remains a major public health problem, the agency says.

Between 75 percent and 85 percent of people infected with hepatitis C develop chronic infection, which can eventually cause serious liver diseases like cirrhosis (scarring of the liver) and liver cancer.

An estimated 3.2 million Americans have chronic hepatitis C, about half of whom are unaware of it. (The initial infection most often causes no symptoms.)

There are medications for treating chronic hepatitis C, though they are not effective for everyone and have side effects like fatigue, nausea, headache and sleep problems.

SOURCE: bit.ly/w6rw3u Clinical Infectious Diseases, online January 30, 2012.

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Is acupuncture a risk factor for hepatitis C in Asian patients?

4.08PM 07 February 2012

Several years ago, I was refused from donating blood because I had recently received acupuncture as a participant of a trial. Even today, the NHS is very clear on this point: the current leaflet handed out to all blood donors states, 'you must not give blood if you have had acupuncture, unless this was done in the NHS or by statutory registered health care professional'.

But is this wise?

A Californian team investigated 494 patients with hepatitis C in order to determine the risk factors for this infection.¹ Specifically they wanted to find out whether the risk factors differ between various ethnic groups. 55% of all patients were Caucasian, 20% Hispanic and 25% Asian.

The laboratory profiles of these sub-groups were similar. 94% and 86% of Caucasians and Hispanics had commonly known risk factors for hepatitis C such as blood transfusion, drug injection or tattooing. For Asian patients, the picture was significantly different: in this population, acupuncture was a prominent risk factor. Some 50% of this subgroup had had acupuncture prior to the infection (Caucasians = 31%, Hispanics = 20%).

Many British GPs regularly see Asian patients; these findings from the US therefore beg the question whether UK Asians might be at similar risks. Patients can, of course, only be infected, if the acupuncture needle is not sterile. Thus the chances of acquiring an infection via adequately handled disposable needles should be zero. All regulated acupuncturists are told to use proper and safe techniques. It follows that, in the UK, the risk of hepatitis C infection through acupuncture should be zero.

But what about the unregulated acupuncturists who Asian patients might consult? What about the TCM-outlets in our high streets? What about amateur Asian acupuncturists who are on no register at all? To the best of my knowledge, there is no research to answer these questions.

To be on the safe side, therefore, acupuncture should be considered as a potential source of hepatitis C, particularly in Asian patients. To prevent such infections, GPs should urge their Asian patients not to frequent unregistered acupuncturists. And to prevent infections via blood donors, the categorical statement by the NHS mentioned above seems correct.

References

1. Ho EY, Ha NB, Ahmed A, Ayoub W, Daugherty T, Barcia G et al. Prospective study of risk factors for hepatitis C acquisition by Caucasian, Hispanic, and Asian American patients. J Viral Hepatitis 2012; 19:e105-e111.

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