Think hepatitis C isn’t worth targeting? Read on!

Early screening, treatment prevent transplants

More than 30,000 Americans are living with a slow, silent time bomb set to cut them down with little warning in their most productive years.

An estimated 33,200 Americans were infected with the hepatitis C virus (HCV) in 1994 alone. Over the next 10 years, according to the American Liver Foundation in New York, about 30% of those now-asymptomatic people will slowly develop cirrhosis or inflammation of the liver, landing them on a waiting list for liver transplantation. Today, the Centers for Disease Control and Prevention in Atlanta (CDC) reports that 12,000 Americans die each year of HCV, with that annual death rate expected to reach 38,000 by 2010.

The tragedy of those statistics is twofold, notes John M. Vierling, MD, chairman of the board of directors of the American Liver Foundation and director of hepatology at Cedars-Sinai Medical Center in Los Angeles. "We can’t underestimate the impact of this disease. First, in the next 10 years we will see adults in their most productive, wage-earning years — their 30s and 40s — affected by hepatitis C to the point that they are debilitated and unable to be productive. Second, if treated in its early stages, roughly 40% of infected individuals respond well to available treatments and slow the progress of disease to the extent that it will not affect them in their lifetimes."

HCV is a silent, indolent disease process that takes years to manifest complications such as cirrhosis, he says. "This is why it’s so important for both American consumers and providers to be aware of the risk factors of HCV. It’s not effective to test all asymptomatic people for HCV, but if patients have a health history that puts them at risk, early testing and treatment may prevent a liver transplant down the road.

"Nearly 40% of all adults undergoing liver transplantation have liver damage related to HCV," adds Vierling. "The waiting list for transplantation was 7,300 three years ago with only 3,900 patients receiving transplant. Last year, that waiting list moved toward 14,000 with only 4,165 transplants done. That’s a nearly 50% increase in the transplant waiting list, and that figure is expected to rise. With a liver transplant costing between $225,000 and $300,000, we simply don’t have the resources to take care of people with chronic HCV that may necessitate a transplant down the road."

HCV may be spread by exposure to contaminated blood, fresh or dried, on infected needles, during a blood transfusion, or possibly through sexual intercourse. "The risk of spreading HCV through sexual intercourse is not clear. However, there is an increased risk of becoming infected with HCV in patients with multiple sex partners," Vierling says.

He urges case managers to suggest providers test the following at-risk individuals for HCV:

• those receiving blood transfusions, especially those receiving transfusions prior to 1990 when routine testing of blood donors for HCV began;

• intravenous drug users;

• health care workers or laboratory technicians exposed to blood and blood products;

• individuals who have undergone tattooing or body piercing.

The problem is that the symptoms of chronic HCV are generally very mild and vague. Infected individuals often are completely unaware there is a problem until significant liver damage has occurred, he says. "The liver is a silent organ. It has no nerve endings to send pain messages to the brain, so that patients can have inflammation of the liver for more than a decade and not know it."

Some symptoms of HCV infection may include general discomfort, fatigue, loss of appetite, nausea and vomiting, jaundice, small, red, spidery veins on the surface of the skin, pain or tenderness in the upper right abdomen, and fever.

Most HCV-infected individuals are identified after routine blood tests indicate elevated liver enzymes. However, Vierling adds that in many cases routine blood panels don’t reveal HCV infection, and more specific tests should be performed. (See chart on p. 133 for HCV-specific tests and recommended treatments.)

"Once HCV infection is identified, it may be cost-effective to consider a liver biopsy to provide a score or grade the inflammation and stage of cirrhosis or scaring of the liver," he notes. "We have increasingly effective therapies for HCV, but not to the extent that penicillin cures strep infections in nearly 100% of patients. Interferon therapy does cure HCV in about 40% of patients — not 100%."

For that reason, the first priority for treatment should be given to patients with the greatest likelihood to progress toward cirrhosis and those with mild cirrhosis that, left alone, could progress to a more serious stage, he notes. "Studies indicate that HCV-infected patients without any current signs of cirrhosis may never develop cirrhosis in their normal lifetime, making interferon therapy a possibly unnecessary expense."

There are three types of interferon currently approved for treatment of HCV. All can cause flu-like side effects, which include depression, headache, and decreased appetite. Those symptoms can be minimized by taking over-the-counter analgesics such as acetaminophen. However, because patients must remain on int erferon therapy for 12 to 24 months, the cost of treatment can be significant. In addition, interferon may depress bone marrow, leading to reduced levels of white blood cells and platelets. This means that patients must receive frequent blood tests to monitor white blood cells, platelets, and liver enzymes while on interferon therapy, which adds to the total cost of treatment, Vierling explains.

In addition to interferon, the Food and Drug Administration in Rockville, MD, recently approved the drug Rebetron from Scherring-Plough for HCV patients who have relapsed after initially responding to interferon therapy. "Rebetron is used in combination with one of the three approved interferons and has shown good results. The combination therapy may soon be approved for patients not previously treated with interferon as well," he says.

Even patients who do not appear to benefit initially from interferon treatment in terms of eliminating the virus often show significant slowing of disease progression, Vierling notes. "Many of these patients experience such a slowed rate of disease progression that they never suffer from cirrhosis and its complications in their normal life span."

He hopes providers will become more vigilant about testing individuals at risk for HCV.

"Case managers are in a good position to help get the message about HCV testing to providers. Only if we test at-risk populations can we identify the presence of infection and identify the appropriate medical care for HCV-infected individuals.

"There is a strong tendency for both patients and providers to deny anything may be going on in relatively healthy, asymptomatic individuals. We have little reference point for discussion of liver disease. It’s an educational issue that delivery systems must address."