Hepatitis C cases are on the rise

Fallout from opioid crisis; baby boomers urged to get tested

NEW HAVEN — The epidemic of opioids, with increased sharing of syringes, has been accompanied by a spike in cases of hepatitis C, which can lead to liver failure and death.

Meanwhile, the lack of an effective test for the viral disease before 1992 and the high rate of injected-drug abuse in the 1970s has led the federal Centers for Disease Control and Prevention to call for all adults born between 1945 and 1965 to be tested for the contagious blood-borne disease.

“We are seeing more cases of recently acquired hepatitis C infection, primarily through young individuals,” said Dr. Joseph Lim, director of the Yale Viral Hepatitis Program.

“This is of great importance ... because we have believed that hepatitis C is a curable disease that has been on the decline for the past 20 years,” Lim said. “But very recently, between 2010 and 2015, new hepatitis C infections have tripled in the United States and there is concern in young people between 20 and 29, according to the CDC.”

The CDC reports more than 3.5 million people living with hepatitis C nationally.

The problem is serious enough that in 2014, Gov. Dannel P. Malloy signed into law “a mandate for hepatitis C screening for all baby boomers,” Lim said. “Three-fourths of all patients with hepatitis C are born in those years 1945-1965,” he said.

“The baby boomer peak in 1955 coincides with the peak of drug injection in the late ’60s and early to mid-’70s,” said Robert Heimer, professor of epidemiology and director of the Yale School of Public Health’s Emerging Infections Program.

Hep C “is a very indolent, slow-progressing viral infection,” Heimer said. “It actually doesn’t kill the infected cells.” Instead, the body’s immune system attacks the infected cells, he said. While the liver does regenerate, “pockets of cell death called necrosis” develop.

The problem with the disease is, in many cases, symptoms don’t occur until years after infection. According to hepchope.com, one in

30 baby boomers is infected and most aren’t aware of it, which is why the CDC is recommending that they be tested. Also, “there remains a stigma between hepatitis C and drug use,” Lim said.

“Many of our patients are individuals who used drugs once or twice but never abused drugs ... but now unknowingly have the disease,” he said. “Up to half of all individuals with hepatitis C in the United States remain unaware of infection.”

According to Dr. Richard Martinello, medical director for hospital epidemiology and infection control at Yale New Haven Hospital, 25 percent of those infected with hepatitis C will recover without treatment. The rest, however, “develop a chronic infection,” he said. “They have the virus in their liver; they have the virus in the blood.

“People who have chronic hepatitis C infections often have no symptoms at all. Others may feel tired, fatigued, but often they’re not aware of any problems,” Martinello said.

He said the rate of hepatitis C is “rising directly due to the opioid crisis, and one of the most common ways hepatitis is transmitted is through the use of shared needles,” shooting up heroin or methamphetamine.

“It’s a major problem,” Martinello said. “A proportion of persons who have hepatitis C will go on to develop liver failure and that’s a fatal complication ... especially if they have other diseases or they’re a drinker.” Cirrhosis is another danger, as is liver cancer.

Besides contaminated syringes, hepatitis C can be spread, at a much lower rate, through blood transfusions and sexual contact. “Sexual transmission of hepatitis C is thought to be very inefficient,” Martinello said. “The rate of the noninfected person becoming infected is pretty low.”

More effective treatment

The most positive development has come in treatment, which is less onerous and more effective than in the past. “Hepatitis C wasn’t described until the 1980s and a test for hepatitis C wasn’t developed until the late 1980s . ... There was no way to

screen for it,” Martinello said.

Previously, interferon and ribavirin were given over a 12-month period. “It was a treatment that made you miserable and depressed,” Martinello said. “It was very expensive and it didn’t work.”

“This combination was only marginally effective,” Heimer said, and included side effects such as anemia, pain and flu-like symptoms for months at a time. “There seemed to be little point in pushing the treatment.”

Martinello called the new drugs coming onto the market “amazing.”

“Many of our patients ... can be on oral-only regimens. A few tablets once a day and you take it for eight to 12 weeks,” he said. “In large part, the patients tolerate it extraordinarily well and we see cure rates in the 95 percent range.”

For the rest, there are alternatives that can be tried.

“The only drawback is these drugs are expensive,” Martinello said. “It could be as much as $100,000 retail for the 12 weeks.” But Medicaid and many insurers will cover the treatment, and “it’s cheaper than paying for cancer down the line or liver failure.”

Martinello said the U.S. Department of Veterans Affairs has spent $1 billion to get more than 180,000 infected veterans from the Vietnam era tested.

“For many years, it’s been a real focus for the Department of Veterans Affairs to engage those vets with hepatitis C, getting them into treatment and curing them,” Martinello said. About 80,000 have been cured so far, he said.

Dr. Frederick Altice, director of the Yale School of Medicine’s HIV in Prisons Program and its Community Health Care Van, among other roles, treats patients suffering from addiction and those who have infectious diseases.

“We are actually diagnosing a lot of new cases clinically,” he said. “We’re starting to get younger injectors who we’re screening, so we’re testing them for hepatitis C — people who are new and entering addiction treatment.

“We are making some dent, but certainly not a sufficient dent without a major outreach in testing. Every addiction treatment in the country in my mind should be testing people for

hepatitis C.”

He said another way the virus can be transmitted is by snorting cocaine through a straw. “That’s very efficient,” he said.

“I’ve been taking care of the prisoners on the methadone program at the Whalley Avenue jail and just recently three new cases were detected,” Altice said. “We’re also trying to improve the way we provide treatment. We’re trying to transform (treatment) ... so that the classical HIV clinics will also provide hepatitis C treatment.”

It’s important treatment for both viruses be started together because referring an HIV-positive patient to a different clinic for hepatitis treatment “is incredibly inefficient . ... Patients just don’t go. About 20 percent do, but most don’t.”

He said a weak link in locating hepatitis-positive patients is in rural and suburban areas.

“We need to find more effective ways of identifying people,” including using social media, Altice said. “Once you step outside the urban centers, there’s almost no treatment.”

Lim agreed “the hardesthit area appear to be rural areas of Appalachia, the Midwest and New England.” In Massachusetts and Maine “they have twice the (national) average for new hepatitis C cases,” he said.

At the Yale Viral Hepatitis Program, the protocol includes “an initial assessment, an educational class where patients learn in detail about the disease ... pharmacy check for drug interactions” and partnering with mental health and substance abuse programs “to address psychiatric and drug use disorders.”

Among the programs Lim works with are the Cornell Scott-Hill Health Center and the Fair Haven Community Health Center.

Heimer agreed “over the last six years or so we have seen an absolute revolution in hepatitis treatment.”

Now, he said, “I think the easiest thing to do is get the test, settle it, you’re done . ... “We have other screening tests whose accuracy rates are much lower,” including prostate tests and mammograms, “which are not particularly effective.”

The hep C test detects antibodies to the virus, which are evidence of current or previous infection. “Even for the people who test positive, 30 percent will have cleared the virus already and won’t need the treatment,” Heimer said.

The hepatitis C test is “a pretty frank yes or no. It’s a one-time yes or no, so just do it,” he said.