In 2014, the response rate to Hepatitis C treatments (number of people without detectable virus after treatments) was 75% to 80%, now it is 90% to 99%.
Dr. Doris Strader, gastroenterologist and hematologist at the UVM Medical Center tells us about the increasing knowledge of how to diagnose and treat Hepatitis C just in the past two years and what to do if you may be at risk. Listen to the interview or read the transcript below.
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The UVM Medical Center: Often, the most deadly terminal diseases are those that present no symptoms until serious damage has already occurred, and that’s the case with our topic today, hepatitis – a liver disease that kills more than one million Americans every year. On the positive side, diagnosis through simple blood testing can guide infected individuals to successful treatment, and medications for some forms of the disease are very effective. There have also been some gains in prevention. Here to tell us all about it today is Dr. Doris Strader, a Gastroenterologist and Hepatologist at the UVM Medical Center, and a Professor at the Larner School of Medicine.
Dr. Strader, thanks for coming.
Doris Strader: Thank you. I’m happy to be here.
The UVM Medical Center: So this is not a simple topic, because there are a couple of different forms of hepatitis, so if you can boil it down. What’s the overview?
Doris Strader: Okay, well, hepatitis is a virus, kind of like the cold or flu virus, but this is a virus that infects the liver. There are several viruses: A, B, C, D, E, F, G. We’re up to G now. Most of them do not cause too much trouble. Hepatitis A, B, and C, and D, which one gets only if they have hepatitis B, are the ones that are the most concerning. Hepatitis B is the most common hepatitis virus in the world. Hepatitis C, the most common one in the United States.
The UVM Medical Center: B is less serious than C, or do they both end up causing a lot of problems?
Doris Strader: Most people who develop hepatitis B in underdeveloped countries get it vertically. It’s transmitted from mother to fetus. The young children who develop the hepatitis B tend to not clear the virus, and so they have the virus for a very long time. But we do have a vaccination for infants, so if you can vaccinate these children when they are born, you can prevent the transmission. Hepatitis B that is contracted in adulthood usually results in resolution. We develop an antibody and we get over it, for the most part.
Hepatitis C, by contrast, is not transmitted generally from mother to child. It is something we acquire as adults, and for the most part, is totally asymptomatic. So people have no idea that they have it, and as a result, they go on for many years and decades with this virus, and accumulated inflammation and potential cirrhosis, and the consequences of that.
The UVM Medical Center: So when does it start showing up? I mean, how do people know that they’ve got it? What are some symptoms?
Doris Strader: Well, for the most part, as I said, it’s asymptomatic, and so most people don’t feel anything, or don’t notice anything. The majority of people who are diagnosed with hepatitis C go to their doctor for routine blood work, and the liver enzymes are elevated, or they go to donate blood, and the blood testing reveals that there is a problem.
More recently, people fall into a certain demographic of population, so people of a certain age, between 45 and 65, or people who have a history of IV drug use, or cocaine use. Something that would prompt their physician to obtain the blood work to look for hepatitis C, but most people do not have symptoms. They’re diagnosed as a result of going to their physician for some other reason.
The UVM Medical Center: So eventually, you just start having liver problems?
Doris Strader: In the worst case scenario, for someone who doesn’t know, they would end up with symptoms of cirrhosis or hepatitis. So, all of a sudden, they notice that their legs are starting to swell, or their belly is swelling with fluid. Or, God forbid, they come to the hospital with an upper GI bleed. They start vomiting up blood as a result of these dilated blood vessels in the esophagus, which are a consequence of this.
Or, some patients have what we call encephalopathy, so it’s increased confusion and disorientation over time, as a result of problems with the liver. But, as I said, the majority of people come for other reasons and they have their blood tested.
The UVM Medical Center: For hepatitis C, what’s the typical course? And how often is it terminal?
Doris Strader: Before 2014, the average person with hepatitis C had no idea that they had it. They probably developed it 20 or more years before they were diagnosed. Some old data suggests that it takes about 20 to 25 years to develop cirrhosis. Of those patients with cirrhosis, maybe 4% or 5% of those would get cancer of the liver. And then, of those patients with cancer of the liver, depending on the size of it when it was detected, some of them could be transplanted, some of those patients would die. After 2014, when we developed medications to treat it, those numbers hopefully will change.
If we are able to treat people prior to the development of cirrhosis, that’s best. Because then we can prevent the development of cirrhosis, and therefore, cancer. Because in hepatitis C, cancer develops in patients with cirrhosis, generally not in patients without cirrhosis. So if you prevent cirrhosis, you prevent cancer. The treatment can also manage patients with cirrhosis. So you can’t treat patients with cirrhosis. You don’t necessary melt that away, but there is some data to suggest that it may prevent the development of cancer as well. So the hope is that now that we have new medications to treat this, that we can prevent cirrhosis and/or cancer, and save lives, and decrease the number of patients with cirrhosis, the need for transplant and deaths.
The UVM Medical Center: You’re listening to Dr. Doris Strader. She’s a Gastroenterologist and Hepatologist at the UVM Medical Center, and Professor at the Larner School of Medicine. Our topic today is hepatitis. Particularly hepatitis C.
So if we can talk about veterans for just a second, because you used to work at a VA – why are Vietnam Vets at more risk?
Doris Strader: During the Vietnam Era and before, there were a number of reasons that these veterans could have contracted hepatitis C. One of them has to do with the method of vaccine injection in the military in the past. So for yellow fever vaccines, et cetera, that veterans were getting, many of them were vaccinated sort of in a row. So you’d give a vaccine, and then the next guy would come along, and you give a vaccine. And so some of these were done in multi-injector needles, and so it’s possible that they could have been transmitting the virus from one to another.
The UVM Medical Center: So they didn’t change the needle?
Doris Strader: There were multi-injector needles, so it was possible to inject more than one person with the same vaccination needle. Vietnam Veterans fall in the age cohort, between those born between 1945 and 1965, that are at the greatest risk, whether they’re veterans or not, for hepatitis C. Probably because they grew up in a period in which the risks of drug abuse, et cetera, were not known. And hepatitis C, we did not know very much about hepatitis C, as well.
The UVM Medical Center: So if you have a veteran as a patient, do you just automatically test them?
Doris Strader: There are some cohorts of patients that should probably be considered for testing, and veterans are one of them, as well as people born between 1945 and 1965. Patients who have a history of IV drug use should be tested. And of course, people who work in the medical profession who would be exposed to needles and/or needle sticks should be tested. And then, there are a host of other risk factors that are listed for testing patients for hepatitis C.
The UVM Medical Center: So you did indicate that there is some good news. And as of 2014, you’ve got more options for treatment. Talk about that.
Doris Strader: Before 2014, the only treatment that was available was interferon and ribavirin. It was a long treatment. Most of the time, about a year, 48 weeks of treatment. It was an uncomfortable treatment for many people. It was injectable. And the likelihood of response was relatively low. Probably less than about 30% to 35%. It was a difficult treatment to take. There were many side effects associated with it. After 2014, after lots of research in the virology of hepatitis C – meaning how the virus actually behaved in and outside of the body – researchers were able to identify certain medications that attacked the virus at certain points along its replication cycle, and were able to develop medications that could eliminate the virus.
And over time, over the past couple of years, we’ve gotten better at it. Such that, probably in 2014, the response rate, which means the number of people without detectable virus after treatment, was about 75% to 80%. Now, it’s upwards of 90% to 99%. So we are now talking about a cure of hepatitis C in the majority of patients who are treated. So this is a big deal, we go from not being able to identify the virus in the late 1970’s or ’80s, to being able to cure it, as of 2017.
The UVM Medical Center: And what’s the treatment like?
Doris Strader: The treatment is pretty simple these days. So it is a matter of taking one to four pills, depending upon which treatment regimen. There’s several regimens that you take, for as short as eight weeks, to up to 24 weeks, depending upon what’s going on. The side effect profile of the majority of these is very minimal. There may be a rash or some discomfort, but not the same side effects we saw in patients on interferon. And most patients can expect to have undetectable virus about four weeks after they start, and then again at the very end of treatment. And for the majority of patients, this means cure.
Now, I always tell my patients this and I think it’s important to know: “Cure is not immunity”. So they are not immune to hepatitis C. It’s not a vaccine. It just means they’re cured. You can be reinfected. And I have had patients who have taken the medicine who have been cured and think this means, “Okay. I can do whatever I want now,” and they come back re-infected. So the two things that cure does not do: it does not make you immune to hepatitis C and it does not necessarily melt away liver damage that’s already been done, if you have severe liver damage. If you have cirrhosis, you’re not necessarily going to have the liver you had when you were 20. Now that is controversial now, and some data, ongoing data will show if there is a possibility that some of that can improve over time.
The UVM Medical Center: And vaccines?
Doris Strader: Lots of research, looking at creating vaccines for hepatitis C. It’s been tough, because hepatitis C has what we call quasi-species, which means it mutates very frequently. So the virus that you have today, it’s not necessarily the virus you have three months from now. And so it’s very difficult for the host, the person’s immune system to recognize a virus, because it keeps changing. Therefore, it’s difficult to make a vaccine that will recognize the virus, because it continually mutates.
The UVM Medical Center: It’s kind of like the flu, right?
Doris Strader: Yeah. Kind of like the flu.
The UVM Medical Center: What’s your sense of the vaccine? Do you think, at some point, we’ll get on top of all that?
Doris Strader: Yeah, I think so. Probably in the next 20 to 25 years, some enterprising young person will figure out how to be able to identify some sort of constant region in the virus that does not change, that we can target for vaccine development. But as of today, we’re not able to do it.
The UVM Medical Center: So, bottom line for folks listening: who should be thinking about getting tested? We know veterans from that time period, but who else?
Doris Strader: People born between 1945 and 1965 should probably consider being tested. People with a history of IV drug use should probably be tested. And providers who work in the medical profession – if they are exposed to needle sticks and that kind of thing – also should consider being tested. There is some data suggesting that universal testing may be cost effective. It’s a blood test. However, that means it has to be followed-up. So if you’re tested and found to be positive, then something has to happen, thereafter. But I think, that certainly those groups that I mentioned, and certainly anyone who is concerned about it, should probably talk to their doctor about being tested. It’s a pretty simple test.
The UVM Medical Center: Well, it’s good to get awareness out there, because it does affect quite a few folks and good for them to know that there’s positive news, as far as treatment. I’m sorry to say, we’re out of time, but I want to thank my guest very much, Dr. Doris Strader,a Gastroenterologist and Hepatologist at the UVM Medical Center, and Professor at the Larner College of Medicine. Thanks very much for coming.
Doris Strader: My pleasure.