Vaccine for Hepatitis Badly Needed

http://www.vh.org/adult/patient/internalmedicine/aba30/1998/chronicliverdisease.html

Ian Maclean Smith, M.D.
Emeritus Professor
Department of Internal Medicine
University of Iowa Hospitals and Clinics
Creation Date: April 1998
Last Revision Date: April 1998
Peer Review Status: Internally Peer Reviewed

When we only had tests for hepatitis A and hepatitis B it was called Non A Non B hepatitis. It most often followed blood transfusion. We know since 1988 that 97% of Non A Non B hepatitis is caused by hepatitis C virus (Hepatitis C Virus). It is one of six viruses (A,B,C,D,E,G) that cause most viral liver damage. It can cause acute or chronic liver disease, cirrhosis or scarred liver (Greek for orange yellow the autopsy liver color) and liver cancer. Alcohol worsens this disease. Two thirds of new IV drug users acquire Hepatitis C Virus within 12 months. There are nearly 4 million Americans infected with hepatitis C with 30,000 new infections yearly. (20% of all hepatitis.) It causes 9,000 deaths annually and is the leading reason for liver transplant.

Transfusion disease largely has been prevented by switching from professional to volunteer blood donors and by using sensitive tests for hepatitis C. Transfusion hepatitis now only occurs once in every 100,000 transfusions. Hepatitis C Virus still occurs in intravenous drug users, after unsanitary tattooing or body piercing, and after needle stick accidents in medical personnel. Hepatitis C can rarely be sexually transmitted and there is spread from infected mother to infant in less than 1%.There is no effective vaccine.

Hepatitis C Virus positive individuals should not donate blood or semen. They should practice safe sex although transmission by this route is very low, and should not share razors or toothbrushes. IV drug users should use needle exchange programs or quit.

Hepatitis C Virus is an RNA virus and its structure varies so its numerous subtypes can escape body immune surveillance. Spontaneous cure occurs in only 5 to 15%, the rest become chronic. Infection is often unrecognized, less than a quarter are diagnosed early. Those who develop symptoms feel ill (malaise) and weak or lack appetite. Anti viral antibodies first present after 1 to 3 weeks, can be detected in 90% by three months. Liver function tests especially ALT rise above normal. Liver biopsies show inflammation around the liver (portal) blood vessels. Later the virus kills liver cells and leaves scar tissue (cirrhosis), which increases portal blood pressure, with fluid leakage into the abdomen (ascites), jaundice, brain cloudiness, and vomiting of blood from esophageal vessels bypassing the liver. Progress to cirrhosis occurs in at least 20%, and cirrhosis has a 10-year fatality rate of 20%. However once complications occur (ascites, bleeding, or confusion) fewer than 50% survive five years. Chronic extended hepatitis leads to liver cancer in about 13% after 10 years especially in older men.

Patients with high sustained ALT for 6 months, positive evidence of Hepatitis C Virus RNA, and a liver biopsy showing scarring and liver cell death should be treated with alpha interferon, 3-5 million units 3 times weekly for 12 months. Heavy drinking or illicit drug use make treatment ineffective. Some patients treated with interferon get flu-like symptoms. This lessens with time but about 5% quit. Ribivarin (an experimental drug) given orally may increase the alpha interferon response rate. Hepatitis A and B vaccination is recommended for all Hepatitis C Virus patients.

A lot has happened since the 1970s but much more must be learned. This is a miserable disease. A vaccine and better antiviral agents are urgently needed.