Hepatitis C: The Facts, The Epidemic

It is suspected that there are, at present, more than

5 million people in the United States that are infected

with Hepatitis C, and perhaps as many as 200 million

around the world. This makes it one of the greatest public

health threats faced in this century, and perhaps one of

the greatest threats to be faced in the next century.

Without rapid intervention to contain the spread of the

disease, the death rate from hepatitis C will surpass that

from AIDS by the turn of the century and will only get worse.

 Introduction

 Epidemiology is a medical term which, broadly put,

 encompasses the study of epidemics. Included in a typical

 epidemiologic investigation of a disease are the means and

 rates of transmission of the disease; identification and analysis

 of groups of people at risk of infection; study and

 identification of behaviors conducive to infection and disease

 transmission; accurate computation of overall prevalence;

 and other statistical factors that may be beneficial in

 understanding the disease (for example, are certain

 geographical regions, income groups, or ethnic groups more

 or less susceptible to infection).

 Epidemiological data is crucial in the prevention of deadly

 diseases like hepatitis C. It is likely to be some time before a

 cure is forthcoming, and thus it is of great concern to

 scientists and public health officials to understand the extent

 and spread of the disease, and take appropriate steps to retard

 and contain the illness. The ultimate defense against any

 disease is knowledge and awareness.

 However, hepatitis C presents a formidable challenge for

 epidemiological study. Known as the "silent epidemic",

 hepatitis C remains relatively unknown to the general public,

 and many of its victims have few or no symptoms for years,

 or even decades.

Epidemiological Factors

 Hepatitis C was only discovered in 1989, and since that time,

 studies of infected populations have grown in frequency and

 sophistication. Early assessments of the total numbers of

 infected individuals and rates of infection were greatly

 underestimated, and have been rapidly revised upwards. There

 is reason to believe that this trend will continue, and that

 current numbers are probably greatly underestimated. A

 number of factors must be taken into consideration when

 assessing the true extent and spread of hepatitis C.

 1. The disease is not generally recognized by the public, so

 levels of concern and testing are low.

 2. The medical community is not well educated about this

 disease, so many, many cases go unrecognized and untreated.

 Because of this same lack of knowledge, a majority of doctors

 do not recommend testing for hepatitis C to their patients, even

 if they are in high risk groups.

 3. In most cases, the disease is asymptomatic for years, even

 decades, before progressing to chronic liver disease. Because

 the largest numbers of people infected with the disease are

 believed to have been infected within the past 15-20 years, the

 true burden of infection may not become apparent for many

 years to come.

 4. Studies are almost always several years old before they are

 published - the data they are based upon sometimes even older

 - so published statistics are usually lower than current data

 would indicate.

 5. Sample populations used in studies are frequently not

 representative of high-risk groups. For example, studies of

 suburban populations, or studies involving blood donors,

 frequently miss large parts of the at-risk population, which

 might tend to be concentrated in cities or not regularly donate

 blood.

 6. The virus mutates frequently, resulting in strains of the virus

 which are undetectable by current assays. While researchers

 are always developing newer assays to detect new strains, they

 are inevitably a little behind. Some hepatologists (liver

 specialists) believe that the hepatitis C virus is in many cases

 able to elude detection by current means.

 7. Because of its frequent mutation and diverse genotypes, the

 use of different assays in different epidemiological studies has

 led to a great deal of discrepancy in methods and probable

 accuracy. Comparisons between these studies is thus risky and

 often inaccurate.

 8. More than 40% of currently recognized infected individuals

 contracted the disease through means unknown to them

 (although it is believed that most of these cases have identified

 risk factors associated with them - approximately 10% of cases

 have genuinely unknown means of transmission). This means

 that many of the people who are infected may not even be

 aware that they are at risk for this disease. Moreover, the

 existence of unknown means of transmission suggests that

 epidemiological studies based on current theories about

 transmission may not be representative.

 9. Less developed nations, particularly in the Third World,

 have little or no public education about the disease and have

 made few attempts to curtail the spread of the disease, so

 statistics from these regions are frequently flawed (and

 estimates often low).

 10. There is a great deal of political and social controversy

 concerning this disease, which has and will continue to result in

 inaccurate reporting or underreporting of rates of infection, by

 individuals, physicians, and public health agencies in this

 country and around the world.

 Because of these factors, the number of documented cases of

 hepatitis C have represented only a tiny fraction of the total

 number of individuals actually believed to be infected - and

 estimates of total infected populations are likely to be low in

 relationship to actual rates of infection. These issues should not

 lead to the belief that accurate estimates cannot be made, but

 rather should make clear that recent and future figures of the

 incidence of the disease in the United States and the world will

 likely be lower than the true incidence for some time to come.

Prevalence - United States

 Hepatitis C has only recently gained very much attention with the

 American medical community, and  has still not received much in

 the way of national attention. Studies have only recently been

 given real priority.

 A medical survey of a representative group of Americans tested

 between 1988 and 1994 concluded that approximately 1.8% of the

 general population of the United States carried the antibody to

 hepatitis C in their bloodstream, which placed the the number of

 Americans with Hepatitis C Virus at 3.9 million persons. More recent studies

 using newer assays have pushed the suspected rate of infection up

 to around 2.5%, indicating that around 4.5 million Americans are

 probably infected.

 The pace of newly acquired Hepatitis C Virus infection in the U.S. seems

 to have slowed somewhat in the last decade. It is estimated

 that in the 1980s incidence of newly contracted hepatitis C

 may have reached as much as 180,000 persons a year. By

 1995 that figure is believed to have been reduced to 28,000 a

 year. This decrease in infection is attributed to the introduction

 of Hepatitis C Virus screening of transfused blood, a decline in Hepatitis C Virus

 infections via I.V. drug from needle-exchange programs and

 the like, and a general improvement in public awareness of

 risky behaviors due to the success of the AIDS awareness

 campaigns. However, almost one-half of newly acquired

 infections can still be traced to injection drug use.

High Risk Groups - United States

 Many of the high risk groups for hepatitis C are easily identified,

 due to practices resulting in frequent exposures to blood or risk

 factors for transmission.

 Blood transfusions currently seem to account for only approximately

 5-10% of all cases of hepatitis C. Prior to 1990, there were no

 tests for hepatitis C against the blood supply, and the rate of

 post-transfusion hepatitis was between 8% and 10%. Anyone

 who received a blood transfusion prior to that time is at risk for

 having been infected. Incidence among hemophiliacs, who

 receive frequent transfusions of blood and blood products, is

 particularly high, ranging between 25-40%. Women who have

 had Cesearean sections prior to 1990 represent another

 significant risk group, as these operations were frequently

 accompanied by blood transfusion.

 Blood tests have greatly reduced the rate of post-transfusion

 hepatitis C - CDC estimates the risk factor for

 transfusion-contracted Hepatitis C Virus during the 1990-1993 period at

 5%, and risk of infection was brought down to less than 1%

 after 1993. Today, the risk of post-transfusion infection is

 negligible, at approximately 1 per 100,000 units of blood.

 Blood banks also now also notify donors if they detect the

 virus.

 IV drug users represent the largest single risk group. Hepatitis

 C infection among intravenous drug users occurs at an

 alarming rate. As with HIV, the sharing of contaminated

 needles and syringes increases the chance of infection

 dramatically: incidence of Hepatitis C Virus antibody rates among I.V. drug

 users has surpassed 50 percent in many studies and almost

 reached 100 percent in others. Within only six months to a

 year after beginning intravenous drug use, 50-80 percent of

 drug users test positive for the hepatitis C antibody. I.V. drug

 users account for about 30-40% of all identified cases, and

 about 50 percent of all new cases of the disease.

 Sexual contact has been clearly identified as a means of

 transmitting hepatitis C. Several studies of risk factors in sexual

 activity found rates of infection between 1 and 18% for

 homosexually active individuals, 1 to 10% among

 heterosexually active individuals, and 1 to 12% among female

 prostitutes, with the primary risk factors for infection being

 greater numbers of partners, unprotected sex, simultaneous

 infection with other STD's, and traumatic sexual activity.

 Seroprevalence for long term partners of hepatitis C patients

 was found to be around 5%.

 Household contact with another household member that has

 hepatitis C has also been strongly implicated, and this, in

 combination with heterosexual exposure, is believed to be

 responsible for approximately 13% of all infections. The

 incidence of household-member transmission cases has more

 than doubled since 1990. Maternal-infant transmission has also

 been documented as a mode of spread, occuring in no more

 than six percent of children of hepatitis C positive mothers.

 Around 2% of all cases of hepatitis C are thought to be

 contracted through the occupational risk (needle-stick injuries,

 blood spills, etc) involved with the health care profession.

 Prisoners have enormous incidence of infection - rates reported

 in some California prisons exceed 80%, with certain institutions

 reporting nearly 100% of their prisoners infected.

 Some skin piercing practices, notably tattooing, body piercing, and

 acupuncture, have contributed significantly to the spread of Hepatitis C Virus,

 particularly in less industrialized nations. Tattooing in particular

 poses a serious risk. Even in the presence of good sterilization,

 studies have suggested that the ink used in tattooing can become

 contaminated and transmit the virus.

 Several studies have shown that adequate blood can be present

 in other body secretions to transmit infection. Cocaine users

 have an abnormally high risk of infection due to the fact that

 they frequently share snorting straws, which may have small

 amounts of blood-carrying mucous on them. Such indirect

 sources of blood may explain many cases of inter-household

 transmission.

 Less obvious, specialized risk factors have been identified

 resulting from indirect exposures to blood - including

 manicures, shared toothbrushes and razors, and straight razors

 in barber shops.

 Particular racial, ethnic, and income groups are at higher risk of

 infection. An ethnic analysis in one earlier, somewhat underestimated

 study (1994) determined that Caucasian Americans statistically

 accounted for the most number of infected persons, while the

 highest incidence rates were among African and Hispanic

 Americans. The highest prevalence of the disease was found in

 middle-aged people (30 to 49 years old) who accounted for 3%

 -4% of the cases. Prevalence among black men in this age

 group approached 9% to 10%. Gender, however, did not

 emerge as a significant risk factor in the population as a whole.

 In the United States, blacks have the highest incidence rates,

 followed by Native Americans, Hispanics, and whites.

 Similarly, low income groups seem to have the highest risk of

 infection. In one study at the inner city VA Hospital in

 Washington, D.C., one in five people admitted tested positive

 for Hepatitis C Virus. Similar results (18%) were obtained at the John

 Hopkins University Hospital, located in Baltimore's inner city.

 The higher incidence among certain racial, ethnic, and income

 groups is probably the result of higher rates of other cofactors,

 but may also be the result of unidentified modes of

 transmission. Many groups showing high incidence of infection

 do not have obvious correlations with known modes of

 transmission, pointing towards the existence of unknown routes

 of transmission. For example, there is a serious question as to

 why many alcoholics are infected with Hepatitis C Virus. In many surveys,

 about a third of people who are alcoholics are also infected

 with the Hepatitis C Virus virus. Whether alcoholics are in fact more prone

 to infection has not been firmly established.

Associated Health Costs - United States

 Although few prospective long-term survival and health care cost

 studies are available for hepatitis C, it has been possible to estimate

 the life-long economic impact of the disease for both the individual

  patient and for the U.S. population with chronic hepatitis B.

 Lifetime health care costs for a patient with chronic hepatitis B has

 been estimated at $65,000 in the absence of liver transplantation.

 For the 150,000 HBV carriers with significant liver damage, the

 lifetime health care costs in the U.S. have been estimated to be $9

billion.   Assuming an estimated survival of 25 years, the annual health

care

 costs for the affected U.S. population with chronic hepatitis B is $360

 million. Based on the same economic analysis, treatment of chronic

 hepatitis B with interferon is projected to increase life expectancy

 by about three years and reduce the aggregate health care costs.

 Hepatitis C can only represent a far greater economic cost.

 While it infects about 3 and a half more times as many people

 in the United States than does hepatitis B, more than 80% of

 hepatitis C patients will develop chronic liver disease, as

 compared to only 20% of hepatitis B patients. Limited data

 suggest that 15-20% of those with chronic hepatitis C will

 develop cirrhosis within a five-year period, and as many as

 25% may have cirrhosis by 10-20 years. The risk of

 developing liver cancer is uncertain, but may approach or

 exceed 1% during the first 20 years of infection and increase

 thereafter. Hepatitis C is responsible for about one-third of all

 liver transplants in the United States. Approximately 1,000

 patients are transplanted each year for liver disease due to

 hepatitis C. With the cost per liver transplantation in the range

 of $280,000 for one year, liver transplantation for hepatitis C

 alone reaches a cost of nearly $300 million per year.

 Moreover, the average lifetime cost for hepatitis C, in the

 absence of liver transplant, has been estimated to be about

 $100,000 for individual patients. Assuming that 80% of the 4.5

 million Americans believed to be infected develop chronic liver

 disease, the total lifetime cost for this group (3.6 million) will

 be a staggering $360 billion in today's dollars. Assuming an

 estimated survival of 40 years, the annual health care costs for

 the affected U.S. population with chronic hepatitis C may be as

 high as $9 billion.

Worldwide Prevalence

 Hepatitis C is a global disease. While not every nation in the world

 has had adequate means to survey its population for incidence of the

 virus, enough statistics have been compiled to demonstrate the

 enormous threat posed by hepatitis C. Hepatitis C, in combination

 with hepatitis B, now accounts for 75% of all cases of liver disease

 around the world.

 Hepatitis C shows significant genetic variation in worldwide

 populations, evidence of its frequent rates of mutation and

 rapid evolution. There are six basic genotypes of Hepatitis C Virus, with

 15 recorded subtypes, which vary in prevalence across

 different regions of the world. Each of these major genotypes

 may differ significantly in their biological effects - in terms of

 replication, mutation rates, type and severity of liver damage,

 and detection and treatment options - however, these

 differences are not yet clearly understood.

 Figures from epidemiological studies in different regions of the

 world show wide variance in Hepatitis C Virus prevalence patterns, though

 it is clearly evident that the incidence of Hepatitis C Virus is higher among

 less developed nations. The prevalence of hepatitis C is lowest

 in Northern European countries, including Great Britain,

 Germany and France. According to one survey, the prevalence

 of Hepatitis C Virus antibodies in blood donors averages less than 1% for

 the region. (However, other studies have suggested that rates

 of infection may be much higher, comparable to rates in the

 U.S. - approximately 2.5%). Higher rates have been reported

 in Southeast Asian countries, including India (1.5%), Malaysia

 (2.3%), and the Philipines (2.3%). The incidence in Japan was

 1.2%. Alarming rates were reported for many African nations,

 reaching as high as 14.5% in Egypt.

 These studies, when added together, suggest that over 200

 million people around the world are infected with hepatitis C -

 an overall incidence of around 3.3% of the world's population.

 Statistically, as many people are infected with Hepatitis C Virus as are with

 HIV, the virus that causes AIDS. Without large scale efforts to

 contain the spread of Hepatitis C Virus and treat infected populations, the

 death rate from hepatitis C will surpass that of AIDS by the

 turn of the century and will only get worse.

Copyright 1998 Trustees of Dartmouth College

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

  Every day you may make progress.

  Every step may be fruitful.

  Yet there will stretch out before you

    an ever-lengthening, ever-ascending,

    ever-improving path.

  You know you will never get

    to the end of the journey.

  But this, so far from discouraging,

   only adds to the joy and glory of the climb.

                     Winston Churchill

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

  http://www.geocities.com/HotSprings/5633

                 The Hepatitis Place

--------------------  68  --------------------

Date: Mon, 16 Nov 1998 16:04:48 -0500

From: "Jere Hough" <jlhough@prodigy.net>

Subject: Repost: INFO:  The Facts: Hepatitis C (Excellent article!)

-----Original Message-----

From: owner-hepc@ariess.com [mailto:owner-hepc@ariess.com] On Behalf Of

Lynn

Sent: Friday, June 12, 1998 12:57 PM

To: HEPC@ariess.com

Subject: INFO: The Facts: Hepatitis C

The Facts: Hepatitis C

  Hepatitis is a disease characterized by inflammation of the

  liver, usually producing swelling and, in many cases,

  permanent damage to liver tissues. A number of agents

  can cause hepatitis, including infectious diseases, chemical

  poisons, drugs and alcohol. Hepatitis C is a contagious viral

  disease that leads to serious, permanent liver damage, and in

  many cases, death.

 Hepatitis & Hepatitis C

 Hepatitis is a disease characterized by inflammation of the

 liver, usually producing swelling and, in many cases,

 permanent damage to liver tissues. A number of different

 agents can cause hepatitis, including infectious diseases,

 chemical poisons, drugs and alcohol. Viral hepatitis refers to a

 set of at least six viruses that are known to cause hepatitis:

 hepatitis A (HAV), hepatitis B (HBV), hepatitis C (Hepatitis C Virus),

 hepatitis D (HDV), hepatitis E (HEV), and hepatitis G(HGV).

 Recent scientific evidence also suggests the existence of

 other, as yet unidentified hepatitis viruses.

 The most common types of viral hepatitis are hepatitis A, B,

 and hepatitis C. Both hepatitis B and C can lead to serious,

 permanent liver damage, and in many cases, death.

 There are two primary types of viral hepatitis, food-borne

 and blood-borne hepatitis. The former, which is spread

 through contaminated food and water, does not cause chronic

 liver disease. By contrast, bloodborne viral hepatitis may lead

 to long-term, persistent infections and chronic liver disease

 that has lethal consequences many years after infection.

Food Borne Hepatitis

 Hepatitis A

 Hepatitis A is usually transmitted by drinking water or eating food

  that has been contaminated with fecal matter containing

  the virus. Thus, the risk of contracting hepatitis A generally depends

  on the hygenic and sanitary conditions in a given area. The

  Centers for Disease Control estimates that 150,000 people in the

  United States are infected each year by hepatitis A, a low rate

  compared to the underdeveloped countries. There are two approved

  vaccines available in the U.S. for protection against hepatitis A.

 As is common with the other forms of viral hepatitis, the

 infected person may not have any symptoms. When they do

 occur, symptoms resembling the flu normally appear during the

 first four weeks of infection. These include fatigue, nausea,

 vomiting, pain in the liver area, dark urine or light colored

 stools and fever. Liver function tests are elevated, with many

 adults developing jaundice. Most people recover from the

 hepatitis A virus within six months without any serious health

 problems.

 Fecal matter from an infected person has a high concentration

 of the virus. The virus can survive in fecal matter on a person's

 hand or other surfaces for three to four hours at normal room

 temperatures. Eating utensils are a frequent source of infection,

 as are contaminated shellfish and I.V. drug use. Intimate

 contact of any kind with an infected person can also transmit

 the virus.

 A very small percentage of people, frequently those having

 pre-existing liver disorders, risk serious complications from

 hepatitis A. Federal mortality statistics for 1992 listed hepatitis

 A as the primary cause of death for 82 people in the United

 States.

 Hepatitis E

 Hepatitis E, whose symptoms and methods of transmission

 resemble hepatitis A, is caused by a virus commonly found in

 the Indian Ocean region, Africa, and in underdeveloped

 countries. Testing for hepatitis E is being developed but is not

 yet available commercially. The symptoms of hepatitis E are

 like those of hepatitis A, although the period of illness may be

 as long as several months. Hepatitis E is rarely, if ever,

 responsible for causes of chronic hepatitis.

 Adequate sanitation and good personal hygiene reduces the risk

 of hepatitis A and E. Water should be boiled prior to its use if

 any question of safety exists. Similarly, in areas where

 sanitation is questionable, food should be cooked well and

 fruits peeled. Those planning to travel to areas where hepatitis

 A or E is widespread are advised to take immune globulin

 before leaving.

 Blood Borne Hepatitis

 Hepatitis B Virus

 Hepatitis B virus (HBV), formerly called serum hepatitis, is much

  more prevalent than HIV ( the virus that causes AIDS). An

 estimated 1.2 million Americans are currently chronic carriers of

 HBV, with more than 300 million carriers in the world. Hepatitis B

 may develop into a chronic disease (lasting more than 6 months)

 in up to 10% of the newly infected people each year. If left

 untreated, the risk of developing cirrhosis (scarring of the liver) and

 liver cancer is greatly increased.

 This disease is much more infectious than HIV. It is

 transmitted through infected blood and other body fluids

 (seminal fluid, vaginal secretions, breast milk, tears, saliva and

 open sores). In the U.S., hepatitis B is spread predominantly

 through sexual contact. Other risk groups include health care

 workers, prison inmates and personnel, IV drug users, and

 recipients of blood transfusions prior to 1975. In families, it

 appears that the virus can be casually spread from adults to

 children.

 The onset of hepatitis B is gradual. As with other forms of

 hepatitis, most people who get hepatitis B have no recognizable

 signs or symptoms. But some people do experience flu-like

 symptoms, such as loss of appetite, nausea and vomiting,

 fever, weakness, tiredness, as well as mild abdominal pain.

 Less common symptoms are dark urine and yellowing of the

 skin and eyes (jaundice). The only way these diseases can be

 positively identified is through blood tests. However, over 90

 to 95 percent of adult patients recover within six months, while

 5 to 10 percent develop chronic hepatitis or become carriers.

 Severe manifestations of chronic HBV infection include

 development of scarring of the liver (cirrhosis), and liver

 cancer which usually occurs decades later.

 An HBV carrier is someone who has had hepatitis B in their

 blood for more than six months. A carrier usually has no signs

 or symptoms of HBV but remains infected with the virus for

 years or for a lifetime and is capable of passing the disease on

 to others. Two types of vaccine are available to prevent

 hepatitis B.

 Hepatitis D Virus

 Infection with hepatitis D (HDV) occurs only in patients

 already infected with hepatitis B. Hepatitis D is spread mainly

 by contaminated needles and blood. I.V. drug users have a

 high incidence. The simultaneous infection with HBV and

 HDV produces more severe illness, and higher rates of long

 term liver failure, than HBV alone. The disease is usually

 self-limited, and due to its co-dependence on HBV, hepatitis D

 is effectively prevented via the HBV vaccine.

 Hepatitis G

 A newly identified strain of hepatitis, hepatitis G is currently

 under study. The first major study of virus has reported that

 those infected by means other than blood transfusions did not

 develop chronic liver disease, although for most the virus

 remained in their blood for several years. It is not clear at this

 time how widespread hepatitis G is, what the means of

 transmission are, or what its precise effects are on infected

 patients.

 Other Hepatitis Viruses

 There is accumulating evidence that other hepatitis viruses exist

 - in part due to the fact that the known viruses (A through G)

 do not explain all cases of hepatitis that are believed to be

 caused by viruses. Detailed studies are currently underway.

 However, the clinical significance and public health impact of

 other hepatitis viruses remains unknown.

The Silent Epidemic: Hepatitis C

 The identification of the hepatitis C virus in 1989 solved a

 growing mystery. Over the past ten years, large numbers of

 hepatitis victims had begun to appear, apparently with a virally

 caused disease. But when examined, these patients tested

 negative for both hepatitis A and B. The unknown disease was

 known as non-A, non-B hepatitis. When a test was developed

 in 1990 to identify individuals infected with hepatitis C, hepatitis C

 was found to be responsible for the majority of these cases - and it

 has quickly proved to present a frightening challenge.

 In contrast to most other types of hepatitis, more than 80% of

 hepatitis C (Hepatitis C Virus) infections become chronic and lead to liver

 disease. Hepatitis C, in combination with hepatitis B, now

 accounts for 75% of all cases of liver disease around the world.

 Liver failure due to hepatitis C is the leading cause of liver

 transplants in the United States.

 Since hepatitis C infection is typically mild in its early stages, it

 is rarely diagnosed and is often not recognized until its chronic

 stages when it has caused severe liver disease. With a typical

 cycle of disease from infection to symptomatic liver disease

 taking as long as 20 years, the true impact of this disease on

 our growing infected population will not be apparent for many

 years. For this reason, it is often referred to as the "silent

 epidemic".

 It is suspected that there are, at present, more than 4.5 million

 people in the United States that are infected with hepatitis C,

 and more than 200 million around the world - making it one of

 the greatest public health threats faced in this century, and

 perhaps one of the greatest threat to be faced in the next

 century. A vaccine against hepatitis C may not be available for

 many years to come, and there are already many times more

 people infected with Hepatitis C Virus as have HIV (the virus that causes

 AIDS). Without prompt intervention to treat infected

 populations and prevent the spread of disease, the death rate

 from hepatitis C will surpass that from AIDS by the year 2000

 - and it can only get worse.

Transmission of Hepatitis C

 Hepatitis C is believed to be transmitted only by blood. However,