The recent news that a promising new drug therapy for hepatitis C will soon be available was missed by millions it should affect.
Most people with the virus still don't know they have it.
Hepatitis C is a quiet, deadly enemy, lurking in the livers of senior citizens who had contaminated blood transfusions years ago, turning up in middle-aged professionals who experimented with injecting drugs when they were younger.
Most carriers greet news of their infection with complete surprise, but the National Health and Nutrition Survey estimates that four million Americans may harbor this virus, most unwittingly. And, over time, most will develop liver disease that remains symptom-free almost to the point of liver failure.
The virus kills as many as 10,000 Americans each year, and the number of deaths is expected to triple in the next 10 to 20 years, according to the federal Centers for Disease Control and Prevention. It accounts for the majority of the nation's 4,000 liver transplants every year and leads to more than two-thirds of the 5.2 million chronic hepatitis cases.
It is widespread in Baltimore, affecting one of every five patients treated by the Johns Hopkins Hospital's emergency room, one in six of those treated by Hopkins' clinics for sexually transmitted diseases and one in 10 of those treated by the prenatal clinic. But HCV is not only the city's problem: It is the most common form of hepatitis treated at suburban Greater Baltimore Medical Center.
Unlike other strains of hepatitis, hepatitis C has no vaccine. So far, interferon treatment has been costly and riddled with side effects and has had limited long-term success in only 15 to 20 percent of those who have been treated.
The new drug therapy offers a better chance of slowing progression of this disease. The new treatment will add a daily, oral dose of ribavirin, an anti-viral drug, to the three times-a-week injections of alpha interferon, the only substance approved to treat hepatitis C.
Studies by the drug manufacturer Schering-Plough Corp. have shown that up to 49 percent of HCV patients had no detectable virus six months after completing the new treatment, compared to 5 percent of the patients taking interferon alone for the recommended six-month course of therapy.
The new treatment is in the hands of the FDA for final approval and is expected to be on the shelves sometime this summer.
David Thomas, associate professor of medicine and epidemiology at the Johns Hopkins Hospital, where the regimen has been tested, is enthusiastic about it.
"It's important because it works better than interferon alone and increases the number of people who get sustained response," he says. "Ribavirin does have some side effects - it causes people to lose some hemoglobin in their blood - but with appropriate monitoring it has not been a major issue."
As many as 8 of 10 people infected develop long-term problems. However, HCV often takes 20 years or more to cause symptoms such as jaundice, terrible fatigue and flu-like signs, which can flag cirrhosis, or scarring of the liver.
"It's not like hepatitis A, where you get infected, it's cured and that's it," says Ibrahim Razzak, chief of digestive disorders at GBMC. "Twenty percent will develop cirrhosis and about 1 to 5 percent will get liver cell cancer. It's important to detect those who have it."
Unless they know they are carriers, people with HCV may continue such risky behaviors as drinking alcohol, which can further the damage.
They could also pass it on to someone else.
Federal health officials have directed hospitals and physicians to contact approximately one million Americans who received blood before July 1992 given by donors who have been diagnosed with the virus.
Until accurate blood tests were developed to detect the virus, blood bank supplies were at risk for transmitting it. The risk of contracting HCV from a transfusion has dropped from one in every 100 pints of blood in the late 1960s to one in 100,000 now, according to the CDC.
Contaminated blood transfusions never accounted for more than 20 percent of the HCV cases, says the CDC's Joanna Buffington, a medical epidemiologist.
"The leading risk factor is using injection drugs," Dr. Thomas says. "And it has always been the leading factor [in recent decades]."
The HCV test consists of a blood test to detect the presence of antibodies. Additional tests may confirm the diagnosis and evaluate the strength of the virus in the body. A liver needle biopsy, usually required before drug therapy, ascertains how the disease has affected the liver.
Those who qualify for drug treatment must have active HCV infection and liver disease as shown from the biopsy.
The treatment is often not recommended for people in their 60s and 70s because their risk of dying from the disease is low. It is also not recommended for those with major heart disease or a history of depression or other psychiatric disorders. Alpha interferon can have many unpleasant side effects ranging from flu-like symptoms to depression.
Thomas is researching why some people get sick from HCV while others don't - knowledge that will help in treating the disease.
"What bothers me as a physician is that although the medications may be toxic, I cannot ascertain which patients need them," he says. "Some people could live out their whole lives with hepatitis C and die of some other cause. For others, the treatment could be lifesaving. And we don't know who's who right now."
Who should be tested
People who should take the blood test to be screened for the hepatitis C virus include anyone:
* Who had a blood transfusion or organ transplant before July 1992.
* Who has ever injected drugs, even once.
* Whose medical exams show elevated liver enzymes.
* Who received blood-clotting factor concentrates before 1987.
* Who has unexplained jaundice.
The best approach to hepatitis C remains prevention:
Never inject drugs or share objects such as razors, toothbrushes, nail clippers or body-piercing needles. Make sure sterile instruments are used for manicures and tattoos.
High-risk sexual activity - having multiple partners and a history of sexually transmitted diseases - and snorting cocaine (recreational users often share straws) may be associated with Hepatitis C transmission.
For more information, call the American Liver Foundation: 800-223-0179.
What the liver does
The liver refines and detoxifies everything you ingest and breathe and absorb through your skin. It converts the nutrients you eat into muscles, energy, hormones, and clotting and immune factors. It stores certain vitamins, minerals and sugars, regulates fat stores and controls the production and excretion of cholesterol. It destroys poisonous substances and metabolizes alcohol. The largest organ in your body, the liver is about the size of a football and weighs roughly 3 pounds.
Pub Date: 5/17/98