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HCV ADVOCATE WEEKLY NEWS REVIEW: A Review of HCV, HBV and HIV/HCV Coinfection Related News and Highlights

Week Ending: September 25th, 2004

Alan Franciscus
Editor-in-Chief

In This Issue:

• IV Drug Needle Bill Is Signed
• Impact of Competing Risks on Observed Rate of Hepatitis C Progression
• Nonalcoholic Steatohepatitis: A Study of Fibrosis Using Repeat Liver Biopsies
• Disposable Plastic Hypodermic Needles to Prevent Spread of HIV, Hepatitis, Being Developed
• Spontaneous Hepatitis C Virus Clearance Occurs in up to 42% Recently Infected, HIV-Negative IDUs
• Research to Halt the Progress of Chronic Liver Disease
• Liver Transplantation in HIV-Infected Patients: The Impact of HCV and HBV Infection
• Influence of Portal Hypertension on Variceal Bleeding
• Alcohol Tied to 75,000 Deaths a Year in U.S. - Study
• Hbeag-Negative Chronic Hepatitis B Patients Have Higher Rates of Response to Peginterferon Alfa-2a than Lamivudine Alone
• Persistent Ascites and Low Serum Sodium Identify Patients at High Risk of Early Death
• Hepatitis Forum Educates Public- Hepatitis C Is Transmitted by Blood Contact
• Hepatitis Results Positive
• 8m Pakistanis May Have Hepatitis C


September 21st, 2004

IV Drug Needle Bill Is Signed
Source: Sacramento Bee
Margaret Talev

Authorizing the sale of syringes without prescriptions aims to curb AIDS, Hepatitis

Gov. Arnold Schwarzenegger on Monday signed into law what some advocates describe as one of the state's most important public health policies in two decades - a five-year experiment to reduce the spread of AIDS and other diseases among intravenous drug users by making needles and syringes available without a prescription.

The legislation leaves it to local governments across the state to decide whether to take part in the pilot project. Beginning next year, in cities and counties that embrace the concept, pharmacists will be permitted to sell adults up to 10 sterile needles and syringes at a time. The measure also decriminalizes possession of needles without a prescription.

"The consequences of sharing contaminated needles and syringes have taken a significant toll on the public's health," Schwarzenegger wrote in a message accompanying his signature.

"My administration supports this measure because it will prevent the spread of HIV, hepatitis and other blood-borne diseases among injection drug users, their sexual partners, and their children."

In signing SB 1159 by Sen. John Vasconcellos of Santa Clara, one of the most liberal Democrats in the Legislature, the Republican governor angered law enforcement groups and social conservatives who argue the program will simply put more dirty needles on the street while sending a message that drug use is acceptable.

"If an IV user needs drugs, they will not wait for a clean needle," said Michael Kennedy, president of the California Narcotics Officers' Association. "We just feel it's bad for public health and bad for public safety."

But Schwarzenegger did not go out on a limb. In recent years, a growing number of mainstream health organizations, from the California Medical Association to the Kaiser Permanente Medical Care Program, have joined the pharmacists and more liberal social activists in calling for such legislation.

Advocates say that one in five reported AIDS cases in California are linked to sharing contaminated needles, and that dirty needles translate to about 4,000 cases of HIV and hepatitis C combined in the state each year.

They also cite studies that suggest access to clean needles decreases the spread of disease. And they argue that fiscal conservatives could support such programs because, unlike needle exchanges, they cost government nothing and have the potential to save taxpayers money by reducing medical bills.

Glenn Backes, national health policy director for the Drug Policy Alliance, said California is one of only five states that still requires prescriptions for needle sales.

"It's huge," Backes said of the governor's signature. "This is the AIDS policy that's been left undone for 20 years. Because of the poisonous environment of the drug war, too many politicians were afraid to touch it."

Among them, Backes included Schwarzenegger's Democratic predecessor, Gray Davis. He twice vetoed similar needle bills, although the prior versions would have implemented a statewide program and allowed more needle purchases per visit.

"Davis' people never talked about what Davis wanted because the governor wanted it to simply go away," Backes said. "Davis was forever timid, afraid of being attacked from the right."

Schwarzenegger, who enjoys high approval ratings from voters, especially Republicans, and is still capitalizing on his movie persona as an action hero, is not as vulnerable on that front, Backes said.

Meanwhile, Schwarzenegger on Monday vetoed AB 2871, by Assemblywoman Patty Berg, D-Eureka, that would have eliminated a requirement that local governments continuously re-authorize needle and syringe exchange programs by declaring states of emergency.

The governor said that, although cumbersome, the emergency declarations help law enforcement and health officials keep such programs in check by ensuring public health benefits are outweighing community concerns.

About the Writer
The Bee's Margaret Talev can be reached at (916) 326-5540 or mtalev@sacbee.com.

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Impact of Competing Risks on Observed Rate of Hepatitis C Progression
Source: www.gastrohep.com

Researchers in America report on the effect that competing risks have on the observed rate of fibrosis progression of chronic hepatitis C (CHC), in the most recent issue of Gastroenterology.

Previous studies about the natural history of chronic hepatitis C (CHC) have shown that age at the time of infection is correlated with the rate at which hepatic fibrosis progresses.

However, the presence of a competing risk, namely higher mortality from natural causes, may contribute to this observation.

Terry Therneau and colleagues at the Mayo Clinic and Foundation in Minnesota carried out a simulation experiment to measure the magnitude of the effect of competing risks on the observed rate of fibrosis progression of CHC.

The researchers created a computer-based probabilistic model in which fibrosis of CHC progressed from stage 0 to 4 (cirrhosis) in 20-year-old and 50-year-old male and female cohorts.

The rate of fibrosis progression was randomly assigned to each simulated individual from a distribution common to all age- and sex-specific cohorts.

The cohorts also experienced mortality from natural causes according to the 2000 census data.

The group found that the observed median time to reach cirrhosis for the 50-year-old cohorts was 20.4 ± 0.2 years compared with 29.7 ± 0.2 for the 20-year-old cohorts.

The median time to reach cirrhosis in men was 24.2 ± 0.6 years compared with 25.9 ± 0.6 in women (P = 0.01).

Overall, the researchers found that the observed rate of progression was slowest among young women.

Similarly, accelerating mortality from natural causes, simulating the impact of comorbid conditions that shorten survival, reduced the observed time to reach cirrhosis.

Dr Therneau concluded, "Even if the underlying rate of fibrosis progression in CHC was held constant, the time to reach cirrhosis will be observed to be substantially shorter in subjects with a higher competing mortality."

Gastroenterology2004;127(3)

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Nonalcoholic Steatohepatitis: A Study of Fibrosis Using Repeat Liver Biopsies
Source: www.gastrohep.com

Published in this month’s Hepatology is a study evaluating fibrosis progression in nonalcoholic steatohepatitis using repeat liver biopsies.

Nonalcoholic steatohepatitis may cause severe fibrosis, cirrhosis and hepatocellular carcinoma, however, supporting evidence is based on indirect data.

Few research groups have evaluated the progression of fibrosis by examining results of repeat liver biopsies.

Researchers in Argentina undertook this study in order to assess the rate of fibrosis progression in untreated patients with nonalcoholic steatohepatitis.

106 patients in total were available for the study and out of these, a second liver biopsy was offered to those who had undergone their first biopsy at least 3 years before.

These patients were not given pharmacological therapy.

The samples were all evaluated blindly and variables were compared between patients with (group P) and without (group NP) fibrosis progression.

In total, 22 patients (median age 45 years; 13 women; diabetes in 8, obesity in 10 patients) underwent a second liver biopsy 4.3 years after the first.

The researchers found fibrosis progression in 7 patients in group P (31.8%), and they found no progression in 15 of the patients in group NP.

The group reported no differences between both groups regarding age, gender, diabetes, hyperlipidaemia, ALT levels, AST-to-ALT ratio levels, albumin levels, prothrombin activity, steatosis, or inflammation.

Obesity was found to be significantly more prevalent in group P (86%) than in group NP (27%).

Basal body mass index was higher in group P than group NP. Time between biopsies was no different between groups.

The group concluded that progression of liver fibrosis occurred in a third of nonalcoholic steatohepatitis patients 4.3 years after the first liver biopsy, and obesity and body mass index were the only associated factors with such progression.

Hepatology2004;40(4):820-826

September 22nd, 2004


Disposable Plastic Hypodermic Needles to Prevent Spread of HIV, Hepatitis, Being Developed
Source: Medical News – UK

A doctor who works for CDC's National Immunization Program and a mechanical engineer from the Georgia Institute of Technology have received a $60,000 seed grant to develop disposable plastic hypodermic needles for use in developing countries to prevent the spread of HIV and hepatitis through unsafe medical practices, the Atlanta Journal-Constitution reports.

Dr. Robert Chen, who helped found the World Health Organization's Safe Injection Global Network, and Jonathan Colton, a mechanical engineer who specializes in new types of plastics and the design of car and ship parts, are attempting to overcome the "engineering challenges" of converting pliable plastic into viable hypodermic needles, according to the Journal-Constitution.

"The challenge is to fashion a thin enough needle able to pierce skin and allow liquid to flow through rapidly without bending," Colton said, adding, "It's easier to disable a plastic needle than a steel needle, and it's easier to recycle the material."

The researchers said that the needles could be melted to "render reuse impossible" and recycled to be made into water containers, eating utensils or bricks, which would reduce disposal concerns, the Journal-Constitution reports.

Chen said that up to half of injections administered in developing countries are unnecessary, according to the Journal-Constitution. WHO estimates that the 16 billion injections administered annually in developing countries cause 260,000 cases of HIV, 21 million cases of hepatitis B and two million cases of hepatitis C. CDC and Georgia Tech both funded the grant, and Colton "is in discussions with a leading medical device company" about the plastic needles.

However, the needles will have to be tested in animals and humans before they are marketed, the Journal-Constitution reports (Wahlberg, Atlanta Journal-Constitution, 9/22).

http://www.kaisernetwork.org/daily_reports
/rep_hiv.cfm#25864

Spontaneous Hepatitis C Virus Clearance Occurs in up to 42% Recently Infected, HIV-Negative IDUs
Edwin J. Bernard
Source: Aidsmap- UK

Between 24% and 42% of HIV-negative injecting drug users (IDUs) recently infected with the hepatitis C virus (HCV) became spontaneously HCV-negative within two years of being diagnosed with acute HCV infection, according to a retrospective cohort study from Australia appearing in the latest issue of the Journal of Infectious Diseases, now available online. The proportion of patients clearing HCV depends on the HCV diagnosis: HCV antibody-positive (42%) or with a detectable HCV viral load (24%).

Previous studies of spontaneous HCV clearance have estimated that between 10% and 50% of people newly infected with HCV spontaneously clear their infection in the absence of anti-HCV therapy before it becomes chronic - usually defined as the persistence of HCV viral load for more than six months. However, the majority of these studies have been based on the presence of clinical symptoms of acute HCV infection, which do not always appear, and not always in IDUs, despite the fact the majority of new HCV infections occur through injecting drug use.

The authors of this study used data collected from a central Sydney free health clinic, aimed at the prevention of HIV and other sexually transmitted infections in those at-risk, including IDUs. A total of 99 IDUs who attended the clinic between January 1992 and May 2002 had evidence of newly acquired HCV infection, of whom only two were also HIV-positive. Just over half (53%) were female, and 12% self-identified as Aboriginal.

The cohort began injecting drugs at a median age of 15, and became HCV infected at an estimated median age of 22. The drug most commonly injected in the year prior to HCV infection was heroin, with 64% injecting at least daily and 63% reporting sharing drug injecting equipment. The appearance of clinical symptoms was rare, with only eight percent diagnosed with documented jaundice - the majority were diagnosed through a positive HCV-antibody test.

This study did not document cases acquired through sexual transmission.

Fifty-seven (58%) of the 99 IDUs in this clinic cohort had two or more documented HCV viral load (RNA) test results after the estimated date of infection, and viral clearance (defined as two consecutive undetectable HCV RNA test results) occurred in 24 of the 57 (42%), with a median time to viral clearance of 5.9 months. However, there was a wide variation in the time taken for viral clearance to occur, from 1.4 to 11.2 months. Analysis of the data using Kaplan-Meier estimates suggested that 23%, 38% and 40% would spontaneously clear their HCV infection after six, twelve and 24 months, respectively.

Aware that some individuals receive a false positive diagnosis of HCV, the authors then restricted their analysis to the 33 (58%) of the 57 IDUs who also had a detectable HCV viral load within a year of the estimated time of infection. Here, eight of the 33 (24%) experienced spontaneous viral clearance. Analysis of the data using Kaplan-Meier estimates suggested that 6%, 23% and 26% would spontaneously clear their HCV infection after six, twelve and 24 months, respectively.

Further analysis revealed no significant differences in demographic, clinical or behavioural factors between those who cleared HCV and those who became chronically infected. There were also no significant differences seen between the 57 with HCV viral load data and the rest of the cohort. Although those IDUs whose alanine aminotransferase (ALT) liver function test normalised to less than 40 IU/L were almost twice as likely to clear HCV than those who did not, this did not reach statistical significance (hazard ratio, 1.90; 95% confidence interval, 0.77 - 4.65: p = 0.16). Previous studies have found several factors that predict viral clearance, including female gender, ethnicity, symptomatic HCV, and lack of HIV co-infection. The authors suggest that this cohort may be too homogenous (the majority being female, white, asymptomatic and HIV-negative) to tease out these differences. Of note, the one individual with documented HIV co-infection out of the 57 included in the analysis did not clear their HCV.

The authors conclude that in this cohort of young, mostly white, injecting drug users, of whom 98% were HIV-negative, between 24% and 42% cleared their HCV spontaneously in the two years following a positive HCV antibody test. “Although estimated viral clearance rates varied according to the strictness of the case definition, there were no baseline demographic, clinical or behavioural factors associated with clearance,” they write, adding that “the vast majority of clearances occurred within the initial 12 months after the estimated time of infection."

"The inclusion of IDUs who had experienced HCV antibody seroconversion, rather than acute clinical hepatitis alone, makes our study more broadly representative of newly acquired HCV infection than most previous studies have been.”

Reference
Jauncey M et al. Clearance of hepatitis C virus after newly acquired infection in drug users. J Infect Dis 190: 1270-1274, 2004.

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Research to Halt the Progress of Chronic Liver Disease
News-Medical in Medical Research News

A University of Queensland researcher is working to halt the progress of chronic liver disease, which affects a quarter of million Australians.

There is currently no effective treatment for halting the progress of chronic liver disease in the 50% of people who fail anti-viral therapy.

A liver transplant may be the only treatment for the 15 to 20% of these sufferers that progress to end stage liver disease, but these people are faced with the lack of donor organs.

Dr Julie Jonsson is a member of the Liver Research Group based at the Princess Alexandra Hospital, and has found a protein molecule known as angiotensin, which may be a key to stopping progression of the disease.

“High levels of production of angiotensin are associated with increased liver damage,” Dr Jonsson said.

“With a better understanding of how angiotensin influences this damage, drugs can be developed to target this process.”

She said the need for new treatments was becoming critical due to a predicted increase in the frequency of the disease.

Obesity is linked to fatty liver disease and recent dramatic increases in obesity are expected to cause a corresponding rise in chronic liver disease Dr Jonsson said.

“Those in the advanced stages with cirrhosis, may require a liver transplant,” she said.

“It is estimated by the year 2020 more than 2000 Queenslanders will require a liver transplant.

“However, only about 50 donor organs are available each year so there is a desperate need for therapeutic treatments that will delay or reverse the progression of the disease.”

She said one of the most common causes of chronic liver disease is infection with the hepatitis C virus. Other causes include alcohol and immune, metabolic or genetic disorders.

“The limited treatments available include advising patients to avoid alcohol,” Dr Jonsson said.

“Work from our group has also suggested that losing weight may be helpful, regardless of the cause of the liver disease.”

http://www.uq.edu.au/

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September 23rd, 2004


Liver Transplantation in HIV-Infected Patients: The Impact of HCV and HBV Infection
Source: www.gastrohep.com

October’s issue of Liver Transplantation provides a report into liver transplantation as a therapeutic option for HIV positive patients infected with hepatitis C or B.

Liver transplantation (LT) in human immunodeficiency virus (HIV)-positive individuals is considered to be an experimental therapy with limited reported worldwide experience, and little long-term survival data.

At present, published data suggest that the short-term outcome is encouraging in selected patients.

The Institute of Liver Studies at King’s Hospital in London has submitted a report on 14 HIV-infected liver allograft recipients.

Researchers compared the outcomes from this group with patients coinfected with hepatitis C virus (HCV) and a non-HCV group.

A total of 14 HIV-infected patients (12 male, 2 female, age range 26-59 years) underwent LT between January 1995 and April 2003.

The indications for LT were HCV (n = 7), hepatitis B virus (HBV; n = 4), alcohol-induced liver disease (n = 2), and seronegative hepatitis (n = 1); 3 patients presented with acute liver failure.

At LT, researchers found that CD4 cell counts (T-helper cells that are targets for HIV) ranged from 124 to 500 cells/microL (mean 264), and HIV viral loads from <50 to 197,000 copies/mL.

“LT is an acceptable therapeutic option in selected HIV patients.”—Liver Transplantation

The research group exposed 9 out of the 12 patients to highly active antiretroviral therapy (HAART) before LT.

In the non-HCV group (n = 7), all patients are alive, all surviving more than 365 days (range 668-2,661 days).

The researchers had no patients experiencing HBV recurrence, and graft function was found to be normal in all 7 patients.

However, the researchers reported that 5 of 7 HCV-infected patients died after LT at 95-784 days (median 161 days).

A total of 4 patients died of complications due to recurrent HCV infection and sepsis, despite antiviral therapy in 3 of them.

A total of 3 patients experienced complications relating to HAART therapy.

The group concluded that these results of LT in HIV-infected patients with HBV or other causes of chronic liver disease indicate that LT is an acceptable therapeutic option in selected patients.

However, they asserted that longer follow-up in a larger series is required before a conclusive directive can be provided for HCV / HIV coinfected patients requiring LT.

Liver Transplantation;2004;10:1271-1278.

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Influence of Portal Hypertension on Variceal Bleeding
Source: www.gastrohep.com

A report published in this October’s issue of Hepatology finds that increased portal pressure estimated by early HVPG measurement is a main determinant of treatment failure and survival in variceal bleeding.

Alberto Monescillo and colleagues from Spain, investigated the possibility that increased portal pressure during variceal bleeding may have an influence on the treatment failure rate, as well as on short- and long-term survival.

The usefulness of hepatic hemodynamic measurement during the acute episode has not been prospectively validated, and no information exists about the outcome of hemodynamically defined high-risk patients treated with early portal decompression.

The research group took hepatic venous pressure gradient (HVPG) measurements within the first 24 hours after admission from the 116 consecutive participants.

These patients had cirrhosis with acute variceal bleeding which had been treated with a single session of sclerotherapy injection during urgent endoscopy.

“Early TIPS placement reduced treatment failure and 1-year mortality”—Hepatology

The researchers found that 64 of all patients included had an HVPG less than 20 mm Hg (low-risk [LR] group), and 52 patients had an HVPG greater than or equal to 20 mm Hg (high-risk [HR] group).

Patients were randomly allocated into those receiving transjugular intrahepatic portosystemic shunt (TIPS; n = 26) within the first 24 hours after admission and those not receiving TIPS (HR-non-TIPS group).

The HR-non-TIPS group were found to have more treatment failures (50% vs. 12%,), transfusional requirements (3.7 vs. 2.2), need for intensive care (16% vs. 3%), and worse actuarial probability of survival than the LR group.

The group’s results showed that early TIPS placement reduced treatment failure (12%), in-hospital and 1-year mortality (11% and 31%, respectively).

Dr Monescillo concluded, “Increased portal pressure estimated by early HVPG measurement is a main determinant of treatment failure and survival in variceal bleeding”.

He added, “Early TIPS placement reduces treatment failure and mortality in high risk patients defined by hemodynamic criteria”.

Hepatology;2004:40:793-801.

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Alcohol Tied to 75,000 Deaths a Year in U.S. - Study
Paul Simao
Source: Reuters

ATLANTA--- Alcohol abuse kills some 75,000 Americans each year and shortens the lives of these people by an average of 30 years, a U.S. government study suggested on Thursday.

Excessive alcohol consumption is the third leading cause of preventable death in the United States after tobacco use and poor eating and exercise habits.

The Centers for Disease Control and Prevention, which published the study, estimated that 34,833 people in 2001 died from cirrhosis of the liver, cancer and other diseases linked to drinking too much beer, wine and spirits.

Another 40,933 died from car crashes and other mishaps caused by excessive alcohol use.

Researchers considered any man who averaged more than two drinks per day or more than four drinks per occasion to be an excessive drinker. For women it was more than one drink per day or more than three drinks per occasion.

"These results emphasize the importance of adopting effective strategies to reduce excessive drinking, including increasing alcohol excise taxes and screening for alcohol misuse in clinical settings," the study said.

Men accounted for 72 percent of the excessive drinking deaths in 2001, and those 21 and younger made up 6 percent of the death toll.

Light or moderate drinking can benefit a person's health, but heavy drinking increases the risk of high blood pressure, heart disorders, certain cancers and liver disease.

Excessive drinkers are also more likely to die in car accidents.

The United States aims to cut the rate of alcohol-related driving fatalities to 4 deaths per 100,000 people by 2010, a 32 percent drop from 1998.

September 24th, 2004


Hbeag-Negative Chronic Hepatitis B Patients Have Higher Rates of Response to Peginterferon Alfa-2a than Lamivudine Alone
Source: www.gastrohep.com

The New England Journal of Medicine reports that patients with HBeAg-negative chronic hepatitis B given peginterferon alfa 2a, had higher rates of response than those given lamivudine aloneAvailable treatments for hepatitis B e antigen (HBeAg)-negative chronic hepatitis B are associated with poor sustained responses. As a result, nucleoside and nucleotide analogues are typically continued indefinitely, a strategy associated with the risk of resistance and unknown long-term safety implications.

Researchers from several countries compared the efficacy and safety of peginterferon alfa-2a (180 mcg once weekly) plus placebo in 177 patients, peginterferon alfa-2a plus lamivudine (100 mg daily)in 179 patients , and lamivudine alone in 181 patients with HBeAg-negative chronic hepatitis B.

Each group of patients was treated for 48 weeks and then researchers followed them for an additional 24 weeks.

The researchers found that after 24 weeks of follow-up, the percentage of patients with normalization of alanine aminotransferase levels or hepatitis B virus (HBV) DNA levels below 20,000 copies per milliliter was significantly higher with peginterferon alfa-2a monotherapy and peginterferon alfa-2a plus lamivudine than with lamivudine monotherapy.

They also found that rates of sustained suppression of HBV DNA to below 400 copies per milliliter were 19 percent with peginterferon alfa-2a monotherapy, 20 percent with combination therapy, and 7 percent with lamivudine alone.

“Adverse events, including pyrexia, fatigue, myalgia, and headache, were less frequent with lamivudine.”—New England Journal of Medicine

None of the patients given lamivudine alone were found to have lost Hep B surface antigen compared to 12 of the patients in the peginterferon groups.

The group noted that adverse events, including pyrexia, fatigue, myalgia, and headache, were less frequent with lamivudine monotherapy than with peginterferon alfa-2a monotherapy or combination therapy.

Dr Marcellin commented, “When given peginterferon alfa-2a, patients with HBeAg-negative chronic hepatitis B had significantly higher rates of response, sustained for 24 weeks after the cessation of therapy, than with lamivudine alone.”

He added, “The addition of lamivudine to peginterferon alfa-2a did not improve post-therapy response rates.”

New England Journal of Medicine: 2004:12 (351): 1206-1217

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Persistent Ascites and Low Serum Sodium Identify Patients at High Risk of Early Death
Source: www.gastrohep.com

Persistent ascites and low serum sodium identify patients with cirrhosis as having a high mortality risk despite low MELD scores, states a report published in the most recent issue of Hepatology.

Despite the sickest patients taking priority for liver transplants, pre-transplant death remains common, and many early deaths occur despite initially low Model for End-stage Liver Disease (MELD) scores.

Researchers in Virginia, America studied 507 cirrhotic United States’ veterans who had been referred for consideration of liver transplantation between 1997 and 2003, in order to identify additional predictors of early mortality.

Most of the patients were male (98%) and in 88% of the cases cirrhosis was found to be caused by hepatitis C and/or alcohol.

The researchers analyzed data for a total of 296 patients referred prior to February 27, 2002 (training group).

Any findings were then validated by further analysis of 211 patients referred subsequently (validation group).

61 patients from the training group, (21%), died within 180 days without transplantation. Their median initial MELD score was 21.

MELD score, persistent ascites, and low serum sodium (<135 meq/L) were found to be independent predictors of early mortality.

"Persistent ascites and low serum sodium identify patients with cirrhosis as having a high mortality risk despite low MELD scores."—Hepatology

Where patients had a MELD score of less than 21, the researchers found that only low serum sodium and persistent ascites were independent predictors of mortality.

For patients with MELD scores above 21, only MELD was independently predictive.

Analysis of the validation group then confirmed the prognostic significance of persistent ascites and low serum sodium for low MELD score patients.

Risk varied continuously with worsening hyponatremia.

The researchers found that modifying MELD, by including points for persistent ascites and low serum sodium, improved prediction of early pre-transplant mortality in low MELD score patients.

Dr Heuman concluded, “Persistent ascites and low serum sodium identify patients with cirrhosis as having a high mortality risk despite low MELD scores”.

He commented that “Further prospective studies are required into ascites, hyponatremia, and other findings indicative of hemodynamic decompensation that may be prognostic indicators in patients awaiting liver transplantation”.

Hepatology; 2004:40:802-810

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Hepatitis Forum Educates Public- Hepatitis C Is Transmitted by Blood Contact
Laura Florez
Source: Visalia Times – Delta

It ruined his kidney, his liver and most recently, Robert Katz of Lindsay says, Hepatitis C played a part in the death of his wife.

Three months ago Katz’ wife, Linda, died of liver cancer—a disease that some claim can be caused by Hepatitis C. The virus was alive in her body.

“She was a non-smoker, a non-drinker, she was perfect,” Katz, 56, said. “I believe in my heart that I was the one who gave it to her.”

According to the county and the Hepatitis C Support Project, a small number of people can contract the disease sexually.

Dubbed the “silent epidemic,” because people can be infected, but not feel sick, Hepatitis C is a blood-borne virus that is transmitted by direct blood-to-blood contact. It attacks cells in the liver and multiplies.

Katz, whose health has suffered from the virus and even put him into comas—one that lasted as long as 44 days—is just one of several Valley residents who shared their stories Thursday with health providers at a community forum in Visalia.

The forum, put on by the Hepatitis C Support Project, a national health organization, was an attempt to create awareness of the disease, Alan Franciscus, executive director of the organization, said.

“Our goal is to educate as many people as we can,” he said. “People are scared to death when they find out they have Hepatitis C.”

Hepatitis C has infected an estimated 2.7 million Americans, Franciscus said. In California, a state with one of the highest incident rates in the country, there are an estimated 600,000 residents infected.

The picture is no different in Tulare County, said Roberta Torres, a public health nurse and communicable disease coordinator for the county’s Health and Human Services Agency.

“Hepatitis C is our second most commonly reported communicable disease in Tulare County. Chlamydia is the first,” she said.

Since 1999, 2,223 new cases of Hepatitis C have been reported to Tulare County health officials by public and private physicians, Torres said. That’s more than the 376 cases of AIDS and Human Immunodeficiency Virus together that have been reported to the county in the past 20 years, she said.

“This by far is the giant in our closet, healthwise,” she said.

But because not all doctors report the disease, even though they are required to by law, the numbers aren’t completely accurate, she says.

What people need to know, she says, is that they don’t have to inject drugs to get the virus.
“It can be a dirty tattoo needle, a contaminated needle in a pierced ear—a nose,” she said. “There’s a very high [infection] rate.”

When infected, some people don’t experience symptoms—things like fatigue, fever, loss of appetite and nausea.

“This is a tragic disease because you don’t necessarily diagnose people early. It turns productive people into sick individuals,” she said.
Although there is no vaccine or cure for the virus, there are treatments. But they are costly, Torres said. The medications alone can cost a person about $1,200 to $1,800 a month.

Overall, treatments work on about half of people who use them, Franciscus said.

“Doctors are actually using the cure word now, which is very controversial,” he said.

But in order to get treatment, people first need to know they have the disease. That doesn’t always happen, Katz said, at least not in Tulare County.
“There needs to be more awareness,” he said.

For example, in Fresno County, Katz said there is a blood-mobile that goes out to areas to test people for Hepatitis C. He’d like to see something like that make its way into Tulare County.

“I’m trying to live through it. That’s why I’m doing this,” he said.

Torres agreed that Tulare County does need help, but said Thursday’s forum was a step in the right direction.

“We are not a county of a lot of resources and support groups,” she said.

“But [it’s] a chance to look at the extent of the problem in the Valley, hear from those infected, what their needs are, and share with other clinics the extent of the problem. It’s a beginning.”

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Hepatitis Results Positive
Dana Yates, Daily Journal staff
Source: San Mateo Daily Journal

Hospital officials are contacting an unknown number of patients who tested positive for hepatitis C after a sterilization mishap at Kaiser Hospital in Redwood City earlier this year.

Hospital officials won’t say how many blood tests came back positive of the 2,116 people notified of their potential risk. The secrecy is being maintained so people who have yet to be notified will not be alarmed, said Dr. Scott Smith, chief of infectious disease at the medical center.

“It doesn’t appear that there is [an excessive] amount,” Smith said.

Of the positive tests, a certain amount will be false positives and others could be different forms of hepatitis. Another portion could test positive for prior exposure to the disease. There is no way to tell until doctors perform additional tests that are expected to take a couple of months, Smith said.

Kaiser is communicating the test results to patients quickly and asking them to have follow-up tests done. Not all tests have been returned yet.

As first reported in the Daily Journal Sept. 8, the patients were potentially exposed to the communicable disease after a piece of gastrointestinal testing equipment was not properly sanitized between Oct. 30, 2003 and May 3, 2004.

The tools in question are called endoscopes, flexible hollow tubes often outfitted with a camera to let physicians see inside. After use, they are manually disinfected with detergent and brushes and placed in an automatic machine for further cleansing. The machinery is what may have malfunctioned.

Kaiser sent the patients certified letters over Labor Day weekend explaining the low risk of exposure but also urging tests.

Similar incidents have happened at other facilities. In late April, Kaiser Permanente Medical Center in South Sacramento informed 1,300 patients that endoscopes used in certain procedures were improperly disinfected.

8m Pakistanis May Have Hepatitis C
Source: Pakistan Link

ISLAMABAD: The number of Hepatitis C patients has increased alarmingly during last five-years in Pakistan as liver disfunctioning has become the leading cause of deaths in Rawalpindi during this period.

According to data available here from various sources, the unstoppable deadly Hepatitis C virus has become a major cause of mortality in Pakistan, in the absence of any effective measure by the Ministry of Health and other authorities.

The experts of liver diseases believe that the re-use of syringes and contaminated surgical instruments in dental clinics and hospitals are two major reasons for the spread of Hepatitis B and C, media report said.

The estimates of Pakistan Society of Hepatology (PSH) suggest that there are 8 million patients of Hepatitis C in the country with a concentration of disease in some parts of central Punjab including Gujrawnwala and Mandi Bahauddin. As many as 6,000 patients of Hepatitis C and B are annually given medical advice at only one hospital of Rawalpindi.

“Every month around 500 Hepatitis B or C patients visit Getsroenterology and Liver (GIL) Clinic of Holy Family Hospital that works only for one day a week. This means 6,000 annual patients,” said General Secretary of PSH Dr Umar, who is also in charge of GIL.

A study of Ravian Research Forum conducted at Rawalpindi hospitals, Holy Family Hospital, District Headquarters Hospital (DHQ) and Rawalpindi General Hospital (RGH) has shown that Hepatitis and other liver diseases are the most common causes of death in Rawalpindi along with cardiac diseases.

The study was conducted by doctors serving at these hospitals by collecting data in their respective wards. The researchers analysed the data of deaths during a period of five years after 1998, which showed 20 per cent to 25 per cent deaths with liver-related diseases. A random sample of 2,000 deaths was analysed, according to the president of Rawalian Research Foundation. The same data suggests 20 per cent deaths occurred due to cardio-vascular diseases during this period.

According to another research, around 8,500 patients visited the emergency department of Holy Family Hospital during the year 2000, out of which 20 per cent patients were suffering from liver diseases, while 27 per cent were had cardio-vascular diseases.

In Islamabad, the situation is not different, as a senior doctor of Pakistan Institute of Medical Sciences (PIMS), Dr Tashfeen Adam, is examining around 300 Hepatitis B and C patients per month alone. His other colleague, Dr Javed But and Dr Muzaffar Gul, two other senior hepatologists are also examining a large number of patients annually.

The experts have warned that Hepatitis C is the most dangerous liver disease as no vaccine is available to cure the disease and whatever treatment that is available is very costly.

The virus of Hepatitis C was discovered in 1989 while the Hepatitis B virus in 1965.

“Around Rs 60,000 to Rs 70,000 are required for a six month medical treatment of Hepatitis C” said Dr Tashfeen Adam. He said the cases of Hepatitis C have increased during the last 10 years due to better diagnoses and disease identification facilities. He predicted that Hepatitis C will increase further and the portion of population affected with the virus will rise to 20 per cent to 25 per cent. He said strict measures, legislation and awareness are required to check the spread of disease.

Dr Tashfeen Adam was not happy with the government’s performance in eradicating Hepatitis C and said that funds must be allocated to curb this menace instead of spending huge amount on the prevention of HIV/AIDS which is not a big issue in Pakistan, as compared to Hepatitis. He opined that the multiple use of syringes in small hospitals and fake clinics was a major reason for the spread of Hepatitis C.

The PIMS specialist said dental clinics, and operation theaters of small hospitals also pose a serious threat. The General Secretary of Pakistan Society of Hepatology (PSH), Dr Omar also said the government was ignoring the real issue and its resources were wrongly focussed on the prevention of HIV/AIDS. He said the government is running a National AIDS Control Programme (NACP) and it had allocated Rs 270 million in the current fiscal year for this programme but no amount has been allocated for Hepatitis prevention.

He stressed the need for a National Hepatitis Control Programme under government patronage. “The real issue of Pakistan is Hepatitis B and C but government is focusing on HIV/AIDS prevention which is primarily the issue of West.”

Dr Omar was of the view that the only was to control this deadly disease is to make people aware about the virus. He said the government should sponsor a five-minute duration advertisement on TV to create awareness about Hepatitis B and C. “If awareness about the means of virus transmission is created in every citizen of Pakistan, it is possible for the government to curb the disease permanently.”

He also suggested that the government should decrease the price of disposable syringes to discourage the re-use of syringes “The low cost or free treatment for infected pool will decrease the problem” he said. He said there was no liver treatment institute in the country despite the fact that liver disease is a major killer in Pakistan. He hoped that the government would include liver diseases in four catastrophic diseases in the 10th five-year programme.

The survey revealed that the dental department of PIMS and Holy Family Hospital Rawalpindi has no system of data collection regarding contraction of Hepatitis B and C virus from surgical equipment.

“It is not possible for us to conduct pre-operation and post-operation Hepatitis test of all the patients with our meager resources,” said Dr Zahoor Ahmad, Assistant Professor at the Dental Surgery Department of PIMS.

He was not sure that no virus can transmit through surgical equipment of PIMS dental surgery department but he said maximum care is being observed to sterilize the equipment after every use. He said the tests could not be performed for every patient who came to hospital for minor dental treatment but yes the test are done before operating the complicated surgeries involving surgery of jaws.

When contacted, the Federal Minister for Health, Nasir Khan, said the government is alive to the situation regarding the threat of Hepatitis B and C. “We have included Hepatitis B vaccine in our routine free immunization programme to protect new born babies from this virus.” he said. However, he said, it was not possible for the government to provide free vaccine to whole population of the country. “We can only target vulnerable groups like doctors, paramedical staff, commercial sex workers and drug-addicts.”

It is important to mention that provision of Hepatitis B vaccine for newly born babies is a donor-funded project and the government has not allocated an amount for this project.

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