July 3, 2010

Self-Management Program for Veterans with Hepatitis C Virus Improves Health

July 1, 2010

This study looked at the effects of being involved in a self-management program on the quality of life of Veterans with Hepatitis C virus (HCV). Self-management programs are more complete or thorough than traditional patient education, and they focus on teaching problem-solving skills and helping patients manage their illness. In this study, 132 VA patients with HCV infection were randomly assigned to either a 6-week self-management workshop or an information-only program between 5/07 and 11/08. Researchers then looked at what, if any, changes occurred in health-related quality of life, knowledge of HCV, the ability to manage one's health condition, depression, energy, and health distress at the beginning of the study and, again, six weeks later.

Findings show that when compared to the information-only group, Veterans who attended the self-management workshop knew more about their disease and were better able to manage their condition, and they had more energy and vitality. Increased energy and vitality is important because fatigue is the most commonly reported symptom of chronic HCV infection. The study researchers suggest that this intervention can improve the health of Veterans with HCV infection, independent of medication therapy.

Groessl E, Weingart K, Stepnowsky C, Gifford A, Asch S, and Ho S. The Hepatitis C Self-Management Program: A randomized controlled trial. Journal of Viral Hepatitis May 31, 2010;e-pub ahead of print.

This study was funded by HSR&D (IAC 05-067). Drs. Groessl, Weingart, and Stepnowsky are part of the VA San Diego Healthcare System. Drs. Gifford and Asch are part of VA/HSR&D's HIV/Hepatitis Quality Enhancement Research Initiative (QUERI).


For Family and Friends: Caring for Someone with Hepatitis C

• Introduction

In a presentation to the American Association for the Study of Liver Diseases (AASLD), Brian Edlin from Cornell University’s Weill Medical College reported that 5 million people in the United States have chronic hepatitis C virus infection (HCV). HCV primarily affects the liver. Usually it takes a long time to do any damage, especially if the person who has it does not drink alcohol and lives a healthy lifestyle. Sometimes the damage is so minimal that people will go through their entire lives without knowing they have HCV. However, HCV may cause extensive damage to the liver and health of an individual. A small percentage of people will experience liver cancer, liver failure and death resulting from HCV.

Important note: Most people will die with HCV and not of HCV. Unfortunately, it is not known who will and who will not have serious disease progression. Also, the number of patients expected to have HCV-related cirrhosis will dramatically increase between 2010 and 2030. For this reason, everyone with hepatitis C needs to be regularly monitored by a medical provider.

HCV symptoms are vague because they are similar to many other medical conditions. Some people have little or no symptoms. The most commonly reported one is fatigue. Body aches, flu-like symptoms, depression, and abdominal discomfort are also symptoms of HCV. Some patients report difficulty concentrating or that their thinking feels cloudy. Although not an official medical term, many refer to this as “brain fog.”

You may have a loved one or friend who tested positive for the hepatitis C virus (HCV). Whether this person is asymptomatic or struggling with multiple HCV symptoms, their disease may affect you. Since HCV is not passed casually, it is unlikely that you will acquire HCV.

Caregivers are at high risk for health problems. According to the Family Caregiver Alliance, caregivers have a higher risk of mental and physical health problems than non-caregivers do. They experience depression, pain, loneliness, isolation, abandonment, loss, and grief. They experience fear – of the unknown, of death and of change. Caregivers may feel insecure about their ability to give adequate support. They may worry about the security of their future, the risk of acquiring HCV, or of being a single parent or sole financial provider. The likelihood of any of this happening is low. However, it is normal to feel and think about these possibilities.

Lucinda K. Porter, RN
Writer, Hepatitis C Support Project and HCV Advocate

Common Reactions of Caregivers

Guilt is a common feeling among caregivers. If you find yourself saying the word “should,” this is associated with guilt. Examples are “I should do more,” “be more understanding,” “be more loving.” Guilt helps no one. It robs us of our self-esteem. Try to let go of guilt.

Anger is another emotion reported by caregivers. The HCV patient may be getting sympathy and attention, while you are striving to keep your family afloat. You may feel resentful that no one notices how overworked and exhausted you are.

Many caregivers feel afraid. You may fear what the future holds for you and your loved one. You may wonder if you are going to be strong enough to handle the future.

Grief is common. Your life has changed. You may feel that your dreams are gone. Your loved one may be wrapped up in his or her illness and you may feel lonely because of this. You may need to mourn the loss of the person you once knew and the dreams you once held.

How to Cope

The best way you can help your loved one is to take care of yourself first. In the event of a pressure drop on an airplane, we are advised to put on our own oxygen mask first before assisting others. This concept applies to caregivers. If you put the needs of your loved one before your own, you serve no one.

• Make a commitment to your own health. Do not neglect your sleep, diet, exercise and other health-promoting habits. Get a flu shot and regular health care.

• Do not throw away inner peace by reacting to everything you hear. Get the facts first. That way, if you are going to be upset about something, at least it is about something accurate.

• Take time to process new information. You may hear “bad news” or be bombarded by data. This is not a good position from which to make decisions. Take a break. Give yourself time to digest new details.

• Accept your feelings and talk about them.

• Get support. Find out if there is a caregiver’s support group in your community.

• Every day, do something you enjoy.

• Maintain social contacts. Ask a friend out for coffee, a movie or a walk. Use the phone or email to stay in touch.

• Ask for help. You aren’t Superman or Superwoman. Be specific about the help you need.

• Take a break from care giving. See a friend, go for a walk, read, go to a movie, take a nap – anything that revitalizes you. It is all right to go away for a day, a weekend, or longer if this is what you need.

• Set limits for yourself. Remember the word “no” is a complete sentence.

• Focus on the positive.

• Find ways to laugh. Laughter can relieve all sorts of complaints and has no side effects.

Caregiver Stress Danger Signs

Caregiver stress must be taken seriously. If left unmanaged, caregiver stress can be life threatening. Some danger signs are:

• Uncontrollable anger or resentment

• Depression or suicidal thoughts

• Thoughts of harming another or physical abuse

• Misuse of alcohol or drugs

• Sleep problems

• Overeating or loss of appetite

• Physical complaints, such as headaches or stomach problems. Some of these may be serious and may affect your blood pressure or heart.

Protect Yourself from HCV Infection

HCV transmission between household members is rare. HCV is contagious, but mostly only through blood-to-blood contact. HCV is not transmitted by hugging, kissing, sneezing, coughing, sharing eating utensils or glasses, or by casual contact. Although the risks are low, it is recommended that family members be tested, especially children of women who may have had HCV at the same time they were pregnant.

In the August 2006 issue of Hepatology, Hwang and associates reported findings of a large study indicating no increased risk of HCV transmission based solely on history of body piercing, tattooing, or intranasal drug use. Although the risk of acquiring HCV is low, we recommend that you do not share razors, toothbrushes and other tools that may be exposed to blood. A common source of infection is through the sharing of contaminated injection drug utensils. If you use drugs with an HCV-positive person, learn how to do this safely.

Sexual Transmission

The risk of sexual transmission between monogamous heterosexual partners is low. The Centers for Disease Control (CDC) does not recommend any changes in sexual practices between monogamous, long-term partners. Sexual transmission rates increase with multiple sexual partners. It is important to get accurate information about sexual transmission of HCV.

Sex is a basic part of life. If your partner is HCV-positive and you have any concerns about transmission, talk to your partner about this. Honesty and openness are important. Be honest with yourself and your partner(s). If you are uncomfortable with the current sexual practices in your relationship, it is your right to express and change this. If you want to practice safer sex, it is your right to do so.

The HCV Patient during Treatment

The HCV patient in your life may be symptom-free or have symptoms of the disease. The decision to undergo treatment is a complicated one and not based solely on the presence of symptoms. Current HCV treatment uses a combination of medications. Peginterferon is an injection, usually given once weekly. Ribavirin is a pill, usually taken twice daily.

HCV medications may cause many side effects. Some common ones are fatigue, irritability, depression, anxiety, difficulty concentrating, insomnia, itching, rashes, stomach upsets, headaches, fevers, and body aches. Patients sometimes report decreased sex drive (libido) during treatment. The social and psychological side effects are usually harder to deal with than the physical ones, especially for family and friends of HCV patients. These side effects are temporary and they will reverse with time after HCV treatment is stopped.

Patients often “look good” during treatment. This can create problems, especially if the patient feels awful and assumes everyone around her can see this. Open communication is the best way to find out how your loved one feels. However, do not expect too much from the person undergoing HCV therapy, especially if he was not a good communicaton before treatment. Some patients do not want to talk about their experiences. Others want to talk about them a great deal. The two best things you can do for your loved one are to encourage him or her to join a support group and to take care of your own health.

Depression, Anxiety, Iritability and Mania

Psychiatric problems commonly occur during HCV treatment. Watching a loved one experience these may leave you feeling frightened and helpless. Encourage him or her to speak to a doctor. Appropriate diagnosis and treatment are essential. Treatment for depression may take anywhere from two to eight weeks to become fully effective. Encourage your friend or family member to stick with it until the medications start to work, or to talk to his or her doctor about alternatives if there seems to be no improvement. If there are any hepatitis C support groups available in your area, encourage your loved one to attend. You may offer to drive her to the group. If the group is open to everyone, perhaps volunteer to attend together. Respect the wishes of your loved one if he does not want you to attend.

Encourage the depressed person to go for a walk, go to the movies, or engage in other activities that previously gave pleasure. However, if the offer is refused, do not push it. It may be enough to just sit and listen to the radio or watch TV together. Some patients have difficulty reading during treatment, so perhaps listening to an audio book might interest you both.

People with hepatitis C are sometimes irritable during treatment. Try not to take this personally. Keep your expectations to a minimum. Do not expect a depressed HCV patient to “snap out of it” or to be able to turn his or her mood around through positive thinking. Medication-induced depression is influenced by physical factors, and all the willpower in the world won’t make it go away.

Important Note: Do not ignore remarks about suicide or hurting oneself or others. Report these immediately to the patient’s doctor or other professional. If a suicide attempt is imminent, call 911. If you feel the patient could physically harm you, get immediate help. Do not put yourself in harm’s way.

HCV affects many people besides patients. Educating yourself about the disease and the side effects of HCV therapy may help you understand some of the issues your loved one is confronting. Above all else, get support for yourself. Remember the advice given on airplanes – put your oxygen mask on first before assisting others.


• Hepatitis C Support Project http://www.hcvadvocate.org/

• Caring.com http://www.caring.com/


Harold Amos Scholar Finds Many HCV-Infected Children Don’t Receive Treatment

Publication Date: Jun 21, 2010

If at first you don’t succeed, try, try again.

Physician scientist Aymin Delgado-Borrego re-learned this fundamental lesson while researching the Hepatitis C virus (HCV).

Four years ago, Delgado-Borrego, M.D., M.P.H., moved to Miami to begin research into insulin resistance in adults and children, a project that was funded by the Harold Amos Medical Faculty Development Program. Supported by the Robert Wood Johnson Foundation (RWJF), the Harold Amos Program aims to enhance the diversity of faculty at the nation’s medical schools. Delgado-Borrego became a Harold Amos Program scholar in 2006 and will complete the program in 2011.

Based on national survey data, Delgado-Borrego expected to find hundreds of children in the city and the surrounding areas who were infected with Hepatitis C. But, to her surprise, she could only identify a handful of HCV-infected children at local health clinics.

The lack of HCV-infected children was so puzzling that she decided to look into the matter further. While continuing her research into insulin resistance, she also began a search for the children infected with HCV who she had expected to find at local clinics.

Delgado-Borrego conducted a detailed review of the health data for all of Miami-Dade County and sent an online survey to all licensed pediatric gastroenterologists in the county inquiring about the number of pediatric HCV-infected patients. She then broadened her investigation to the state level.

What she found shocked her.

Of the 12,155 children estimated to have HCV in Florida, only 1,755—or 14.4 percent—had been identified. What’s more, only 1.2 percent of the estimated number of infected children were actually receiving medical care.

Delgado-Borrego says the proportion of children with HCV infection that have been identified is even lower in most other states. Florida, she notes, does a better job than most other states of keeping track of communicable diseases.

“There is a frightening lack of awareness among both the public and clinicians about Hepatitis C virus infection in pediatric patients,” she says.

Delgado-Borrego Asked to Present Findings at Conference of Physician Scientists

Her findings have since become the basis of a new study about the lack of awareness of HCV-infected children. Delgado-Borrego was one of four researchers—selected from a group of more than 5,000 physician scientists—who were asked to present their findings in a special telebriefing in advance of Digestive Disease Week, the world’s largest gathering of physicians and researchers in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery. The conference was held in New Orleans.

The news garnered nationwide media coverage in publications ranging from regional newspapers and health trade publications to U.S. News & World Report and the Discovery Channel online. It also sparked a discussion among health authorities about steps that can be taken to identify more HCV-infected children.

“We have identified a significant problem that needed attention,” she says. “Hopefully that means we can focus our energy on identifying barriers that are preventing children from being identified and treated for HCV infection and then do something about it.”

Early identification and treatment of HCV could save countless lives, she says.

HCV infection, she said, is like a time bomb: There are often no discernable symptoms until the very late stages of the disease. At that point, patients may begin to experience enlarged abdomens, profuse bleeding and bruising. But when patients are diagnosed at this late stage, the virus is often too advanced to treat. Patients who cannot get a liver transplant are faced with death.

Early treatment, however, can prevent liver failure, liver cancer and death, especially among children, she says.

More than half of the children who are currently infected with the virus could be cured, Delgado-Borrego says. Advances in antiviral therapy could boost that rate and save even more lives in the future, she notes. Treatment and prevention programs could also ease the social and financial burdens of the disease and prevent its spread.

Children are excellent candidates for medical treatment because most have had the disease for a shorter period of time than adults, they are less likely to have co-existing conditions that could complicate treatment, and they are less likely to have extensive liver damage. Early identification and treatment would have a disproportionate benefit for Blacks and Latinos, who are more likely than other groups to carry the virus.

The good news is that the solutions to the problem are simple, Delgado-Borrego says.

To start, physicians should screen all children born to women who are infected with the virus, Delgado-Borrego says. Physicians should also screen all pregnant women at risk for the infection, because children are most likely to acquire the infection in the womb. Physicians should also screen teenagers who use drugs or other illegal substances.

“If we started with these simple steps, we would be much better off,” she says.


Hepatitis C Virus Infections from Unsafe Injection Practices at an Endoscopy Clinic in Las Vegas, Nevada, 2007–2008

Clinical Infectious Diseases 2010;51:267–273
© 2010 by the Infectious Diseases Society of America.
All rights reserved.
DOI: 10.1086/653937

Gayle E. Fischer, Melissa K. Schaefer, Brian J. Labus, Lawrence Sands, Patricia Rowley, Ihsan A. Azzam, Patricia Armour, Yury E. Khudyakov, Yulin Lin, Guoliang Xia, Priti R. Patel, Joseph F. Perz, and Scott D. Holmberg

Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD and TB Prevention, and Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; and Southern Nevada Health District and Southern Nevada Public Health Laboratory, Las Vegas, and Nevada State Health Division, Carson City

Background. In January 2008, 3 persons with acute hepatitis C who all underwent endoscopy at a single facility in Nevada were identified.

Method. We reviewed clinical and laboratory data from initially detected cases of acute hepatitis C and reviewed infection control practices at the clinic where case patients underwent endoscopy. Persons who underwent procedures on days when the case patients underwent endoscopy were tested for hepatitis C virus (HCV) infection and other bloodborne pathogens. Quasispecies analysis determined the relatedness of HCV in persons infected.

Results. In addition to the 3 initial cases, 5 additional cases of clinic‐acquired HCV infection were identified from 2 procedure dates included in this initial field investigation. Quasispecies analysis revealed 2 distinct clusters of clinic‐acquired HCV infections and a source patient related to each cluster, suggesting separate transmission events. Of 49 HCV‐susceptible persons whose procedures followed that of the source patient on 25 July 2007, 1 (2%) was HCV infected. Among 38 HCV‐susceptible persons whose procedures followed that of another source patient on 21 September 2007, 7 (18%) were HCV infected. Reuse of syringes on single patients in conjunction with use of single‐use propofol vials for multiple patients was observed during normal clinic operations.

Conclusions. Patient–to‐patient transmission of HCV likely resulted from contamination of single‐use medication vials that were used for multiple patients during anesthesia administration. The resulting public health notification of 50,000 persons was the largest of its kind in United States health care. This investigation highlighted breaches in aseptic technique, deficiencies in oversight of outpatient settings, and difficulties in detecting and investigating such outbreaks.

Received 17 December 2009; accepted 31 March 2010; electronically published 24 June 2010.

Reprints or correspondence: Dr Gayle E. Fischer, Div of Viral Diseases, Mailstop A34, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Atlanta, GA 30333 (fez7@cdc.gov).

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.


Hepatitis C virus enters human peripheral neuroblastoma cells – evidence for extra-hepatic cells sustaining hepatitis C virus penetration

Journal of Viral Hepatitis

B. Bürgel , M. Friesland 1 , A. Koch , M. P. Manns , H. Wedemeyer , K. Weissenborn , W. J. Schulz-Schaeffer , T. Pietschmann 1 , E. Steinmann  and S. Ciesek

Division of Experimental Virology, TWINCORE, Centre for Experimental and Clinical Infection Research; a joint venture between the Medical School Hannover (MHH) and the Helmholtz Centre for Infection Research (HZI), Hannover, Germany ; Department of Neuropathology, Charité– Universitätsmedizin Berlin, Berlin, Germany ; Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany ; Department of Neurology, Hannover Medical School, Hannover, Germany ; and Department of Neuropathology, Prion and Dementia Research Unit, University Medical Center, Göttingen, Germany

Correspondence to Dr. rer. nat. Thomas Pietschmann, Division of Experimental Virology, Twincore Center for Experimental and Clinical Infection Research, Feodor-Lynen-Straße 7-9, 30625 Hannover, Germany. E-mail: thomas.pietschmann@twincore.de

*These authors contributed equally to this work.

Copyright © 2010 Blackwell Publishing Ltd

extrahepatic reservoir • HCV • hepatitis C Virus • neuroblastoma • SKNMC


Summary. Patients with chronic hepatitis C virus (HCV) infection show an increased incidence of nervous system disorders such as chronic fatigue syndrome, depression and cognitive dysfunction. It is unclear whether this is because of HCV replication in the brain and in peripheral neuronal cells or to more indirect effects of HCV infection on the central or peripheral nervous system. The aim of this study was to investigate whether cells originating from these tissues are permissive for HCV cell entry, RNA replication and virus assembly. Among eight cell lines analysed, the human peripheral neuroblastoma cell line SKNMC expressed all HCV entry factors and was efficiently infected with HCV pseudoparticles (HCVpp) independent of the HCV genotype. All remaining cell types including human neuroblastoma and glioblastoma cell lines and microglial cells lacked expression of at least one host factor essential for HCV entry. When transfected with HCV luciferase reporter virus RNA, inoculated with HCV reporter viruses or challenged with high-titre cell culture–derived HCV, none of these cells supported detectable HCV RNA replication. Thus, in conclusion, this comprehensive screening did not reveal evidence directly strengthening the notion that HCV enters and replicates in the central nervous system. However, productive viral entry into the peripheral neuroblastoma cell line SKNMC indicates that HCV may penetrate into certain nonhepatic cell types which may serve as viral reservoirs and could modulate viral pathogenesis.

Received February 2010; accepted for publication March 2010

10.1111/j.1365-2893.2010.01339.x About DOI

Patient preferences and assessment of likely adherence to hepatitis C virus treatment.

J Viral Hepat. 2010 Jun 22. [Epub ahead of print]

Brett Hauber A, Mohamed AF, Beam C, Medjedovic J, Mauskopf J.
RTI International, RTP, NC.


Summary. To estimate patient preferences for attributes of hepatitis C virus (HCV) treatment and patients' assessment of the likely effect of treatment attributes on treatment adherence, HCV patients >/=18 years old completed an online survey that included nine 2-alternative choice questions. Each choice question was defined by the probability of sustained viral response (Efficacy), injection frequency (Frequency), duration of flu-like symptoms after every injection (Flu), injection device (Device), average number of days of work missed each week (Lost Work Days), probability of reversible hair thinning while on treatment (Alopecia) and probability of developing clinical depression while on treatment (Depression). We estimated a mean relative importance weight for each attribute. Patients also answered three rating questions to assess the extent to which treatment attributes might affect adherence. Hundred and fifty patients completed the survey. Efficacy was the most important attribute with a mean relative importance weight of 10 [95% CI: 7.9-12.1]. The remaining attributes were ranked in order of importance as follows: Depression (4.4 [95% CI: 3.6-5.1]), Flu Days (Frequency x Flu) (3.7 [95% CI: 2.2-5.3]), Lost Work Days (2.9 [95% CI: 2.3-3.5]), Alopecia (1.3 [95% CI: 0.7-1.9]) and Device (1.2 [95% CI: 0.4-2.0]). Patients with prior treatment experience were less likely to indicate that treatment attributes would affect adherence. Patients also indicated that increases in the number of flu days would increase the likelihood of nonadherence to treatment. Sustained viral response is the most important treatment attribute to patients but treatment side effects might affect treatment adherence.

PMID: 20579276 [PubMed - as supplied by publisher]