Historical perspective of Hepatitis C virus
According to the National Center for Health Statistics (2006) Hepatitis C virus (HCV) infection is the most common chronic blood borne viral infection in the United States; about three times as many people are carrying hepatitis C virus as are infected with HIV. First identified in 1988, HCV is the causative agent for what was formerly known as A and B hepatitis, and is estimated to have infected as many as 242,000 U.S. citizen’s annually during the 1980’s. Since 1989, the annual number of new infections has declined by more than 80 percent to approximately 41,000 by 1998. A national survey (the third National Health and Nutrition Examination Survey [NHANES III]) of the civilian, non-institutionalized U.S. population found that 1.8 percent of U.S citizen’s (3.9 million) have been infected with HCV, of whom most (2.7 million) are chronically infected with HCV (National Center for Health Statistics, 2006). While new infections are declining steadily, the prevalence of liver disease caused by HCV is still rising due to the time lag between the onset of infection and clinical manifestations.
Hepatitis C may be the most lethal disease never heard about. Partly due to the time lag between the onset and the infection often causes no symptoms for decades. Those carrying the virus may never know or unaware they are infected. According to Betsy (2006) for many years, no one knew what was causing a rash of cases of serious liver disease; they could discern only that it was different from hepatitis A and B, which are acquired differently and usually are less serious, so it was called A and B hepatitis. The virus evaded detection until 1989, when scientists employed innovative techniques to find it. Even now, it is very difficult to study and only last year in 2005 were scientists able to grow it in a lab (Betsy, 2006).
Risk factors for infection
Hepatitis C cannot be transmitted for example, by hugging, shaking hands, or sharing glasses or utensils. The people that are most at risk for HCV transmission are intravenous users, individuals with a history of tattooing or body piercing, cocaine users, or long-term sex partners of HCV- positive patients-or even persons with a history of multiple sex partners. People with the disease should not share their toothbrushes or razors, which might carry minute amounts of blood. According to the Center for Disease Control (2006) the rate of sexual transmission is low, especially for people in monogamous relationships, it does rarely happen. The common risk factor during sexual contact is unprotected sex with multiple partners. While other types of exposures are more likely to transmit HCV (e.g., transfusion from an infected donor), they account for a smaller proportion of infections because of the relatively small proportion of the population in whom these exposures have occurred (Center for Disease Control, 2006). Although the risk for transmitting HCV infection through sexual intercourse is low, sex is a common behavior in the general population which may heighten the risk of transmission
According to the National Center for Health Statistics (2006) prior to the mid-1980’s there was a 7 percent to 10 percent risk hepatitis C from blood transfusion. This risk declined by more than 50 percent between 1985 and 1990 as a result of implementation of blood donor screening for HIV and surrogate testing for hepatitis C. In 1990, specific donor screening for HCV was implemented and by 1992 the risk of HCV infection from a unit of transfused blood was reduced to one in 100,000. As of 2001, the risk of HCV infection from a unit of transfused blood is less than one per million transfused units (National Center for Health Statistics, 2006).
Other risk factors that are associated with HCV infection are; clotting factor concentrates, which are plasma-derived products used to treat individuals with hemophilia, employment in the health care field, and birth to an HCV-infected mother. The use of virus inactivation procedures has reduced the risk of transmission HCV through plasma derived products. Currently, all immune globulin products undergo a virus inactivation procedure or test negative for HCV prior to release.
Treatment of Hepatitis C
The New York City Department of heath and Mental Hygiene (2006) suggest the ultimate goal of treatment for HCV is sustained virologic response (SVR), which is associated with a decreased risk for liver related death and overall mortality. The treatment of choice for infected patients is the combination of paginated interferon and ribavirin. Pegylated interferon is administered subcutaneously; ribavirin is taken orally (NYC Department of Health and Mental Hygiene, 2006). Adverse effects associated with treatment may result in patient having flu like symptoms early in treatment, depression, fatigue, concentration and memory disturbances, retinal disturbance. Because the available medication can cause serious adverse events, patients may choice not to purse pharmacologic therapy with their health care provider. Another aspect that is prevalent in the progression of HCV is the consequences of chronic liver disease from hepatitis C do not become apparent until 10 to 20 years after infection, which makes it difficult to implement strategies to prevent the spread of HCV.
The National Center for Health Statistics (2006) suggests surveillance is essential to determine the effectiveness of national, state, and local hepatitis C prevention efforts. However, surveillance for hepatitis C is complicated by the absence of a laboratory test that can differentiate newly acquired infections from infections acquired in the past. Although acute hepatitis (i.e., clinical illness) is reportable in all states, only a few states conduct surveillance for acute cases of hepatitis C to monitor disease incidence. However, approximately 30 states have requirements for reporting of HCV positive laboratory tests, most of which represent persons with resolved or chronic HCV infection (National Center for Health Statistics, 2006). The major surveillance in uses by the CDC is the NHANES III and sentinel surveillance study. NHANES III identified the high prevalence of HCV infection in the United States. The intensive sentinel surveillance conducted in 6 counties is another surveillance done by the CDC for chronic liver disease to determine trends in chronic hepatitis C. Estimates of HCV infection incidence primarily depend on data from the Sentinel Counties Study. Fos and Fine (2005) indicate sentinel surveillance targets selected sites. Collected data are used to provide impact assessment of intervention strategies and in-depth study of demographics and behavioral aspects of the population (Fos & Fine, 2005 p.151). Surveillance programs from an epidemiological prospective help to enhance understanding of the natural history of HCV infection, monitor national trends in chronic hepatitis C, and provide estimates of the contribution of HCV infection to chronic liver disease in the United States. The surveillance of HCV ultimately serves to continually monitor the conditions that increase the risk of transmission.
Morbidity of Hepatitis C
According to the National Association of County and City Officials (2006) currently there are an estimated four million U.S. citizen’s infected with Hepatitis C (HCV), eight to ten thousand of whom die each year from the disease. Further, the cost of HCV is estimated to be more than $600 million per year in medical and work-loss expenses (National Association of County and city Officials, 2006). The dilemma for health care professional is clear, due to the lack of a fast progression of the disease and the association with liver disease it is very difficult to medically manage the disease and prevent infection. The Center for Disease Control (2006) indicates, about 15 percent to 25 percent of persons with acute hepatitis C resolve their infection without further problems. The remainder develops a chronic infection and about 60 percent to 70 percent of these persons develop chronic hepatitis. Cirrhosis of the liver develops in 10 percent to 20 percent of persons with chronic hepatitis C over a period of 20-30 years, and hepatocellular carcinoma (liver cancer) in 1 percent to 5 percent (Center for Disease Control, 2006).
HCV impact on health care organizations and providers
HCV pose a problem for health care organizations and providers. It is almost a stealth disease and tracking the incidence of HCV is nearly impossible. There are no reliable clinical or laboratory markers for acute HCV infection. The Center for Disease Control (2006) indicates symptoms are lacking or non-specific in at least 80% of newly infected patients, anti-HCV antibody appears only months after exposure, and HCV-related chronic liver disease develops insidiously and take decades to present (Center for Disease Control, 2006).
Knowledge about hepatitis C is complex and rapidly evolving. Because hepatitis C was only recently described, health care professionals are often not aware of current information concerning diagnosis, medical management, and prevention of this disease. Feather more the Center for Disease Control (2006) indicates there are no federal funding available to support nationwide establishment of hepatitis C counseling and testing services at the state or local level. In response to this lack of federal funding, a number of state and local health departments have funded hepatitis C counseling and testing projects (Center for Disease Control, 2006). Most of these local programs have relied heavily on technical support and materials developed by the CDC.
Because there are not enough funds and specialists to care for everyone infected with HCV, much of the care for these patients is shifting to primary care providers. According to the New York City Department of Health and Mental Hygiene (2006) when a patient is diagnosed with chronic HCV infection, the primary care provider is involved in the initial stages to counsel, take further diagnostic and screening tests, and vaccination. If the primary care providers are aware of the most current pharmacologic recommendations then they may initiate therapy on the patient (New York City Department of Health and Mental Hygiene, 2006). The primary care providers must have the ability to screen, diagnose, and care for HCV infected patient or be able to refer those patient to a specialist.
The questions that most providers must answer when treating and planning strategies for HCV are; how to identify risk groups? Who should be tested? Clearly those who have received tainted blood or blood products and injection drug users are the main groups. But what about those with a history of tattooing or body piercing, cocaine users, or long-term sex partners of HCV- positive patients-or even persons with a history of multiple sex partners. Apply epidemiological data to assess the trend in HCV is vital in developing strategies for health care organizations. One of the many drawbacks in HCV is there can be a lag in time between the onset of infection and clinical manifestations. Individuals who have the disease may seek clinical services late in the progression of the disease. Using epidemiological data and surveillance monitoring as indicators may serve to identify current trends in HCV. The knowledge that is acquired by current epidemiological concepts can be use by health care organizations to implement prevention planning for those individual who are affected and infected with HCV.
Dr. Gilton Grange
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Managing Hepatitis C. 25(3)13-20