Newsletter No 9 (April 1998)
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'New NHS - Same Dilemmas: Caring for drug users in the New NHS'
April 24th 1998 - Murrayfield Conference Centre, Edinburgh.
To continue the debate about working with drug users in general practice... The issues raised by the New NHS, Beyond methadone, Research Agenda, Effective Interventions.
If haven't already booked to come to the above conference - ring Courses and Conferences at the RCGP without delay on
Like hepatitis B and HIV, hepatitis C is a blood born virus being spread via blood and other bodily fluids. Most people who have a positive hepatitis C test have been completely unaware that they have been infected by the virus. They usually feel relatively well and generally have never been jaundiced, yet in half of all cases there is progressive ongoing liver damage. A few such people deteriorate rapidly, but in most cases serious disease does not occur until after an interval of 20-40 years. It is expected that after this time 10-20 per cent of all cases will have developed liver failure from hepatic cirrhosis (Ref 1) and about 5 per cent will go on to develop cancer of the liver. Thus, although chronic hepatitis C infection appears to run a gentle subclinical course, it is in fact a serious life-threatening disease which should not be under-rated.
Routes of spread
The most common route of spread is now known to be by drug users sharing contaminated injecting equipment. It can also be spread vertically from mother to child, and this occurs in about 10 per cent of cases where the pregnant mother has been infected with the virus (Ref 1). Sexual spread can occur but is rare. There has been reported spread within households, but most cases where this has been believed to occur a history of injecting drug use is usually present on closer questioning by a non-judgmental empathetic examiner (Ref 2). Nevertheless some so-called 'community acquired' cases of hepatitis C infection have probably been spread within households by the sharing of toothbrushes and razors. In the past some spread of the hepatitis C virus has occurred through the giving of infected blood transfusions or other blood products by hospitals, but since 1991 all blood transfusions and other blood products have been tested to exclude the virus, a test for hepatitis C having been first developed in 1989.
Prevalence surveys within the UK population show that in the ordinary general population there is a prevalence of between 0.1 and 1 per cent (Ref 3). The most reliable studies being between 0.8 and 0.9 per cent. The prevalence in organ donors is 1.08 per cent (Ref 4). A consensus of hepatologists has put the total UK figure of 450,000 people who have been infected by hepatitis C (Ref 5). Similar figures have been suggested by the British Liver Trust and the BMA (Ref 1). However studies of those attending blood transfusion services support much smaller figures, which have confused some people in the past. About 1 in 2,000 blood donors carry the virus (Ref 6). This equates to about 28,000 UK citizens. The lower figure in blood donors is almost certainly because drug users and those who have received blood or blood products are asked not to donate blood.
It is estimated that 2,000 haemophiliacs have received blood products infected with hepatitis C (Ref 7), and 3,000 people have acquired the virus through infected blood transfusions (Ref 3). If we add the 28,000 cases of those who attend blood transfusion services (which will include the community acquired sample, those who have become infected by sexual spread, and some of those who may have acquired the infection by vertical transmission) to the 2,000 haemophiliacs and the 3,000 people who have become infected through blood transfusions, we are left with those who have become infected by sharing injecting equipment. From these calculations we can estimate that of the 450,000 people estimately to have been infected with hepatitis C nationally, there are at least 400,000 people (at least 90 per cent of all cases) who have become infected from injecting drug use. This will include not just those who are currently attending drug services with a history of injecting, but those who have had a drug problem in the past, and those who have injected drugs recreationally or experimentally, even if this is just once at a party.
The hepatologists at Addenbrookes hospital have a number of cases of those who have just injected once in the 1960s or 1970s when they contracted hepatitis C infection and are now in liver failure. There has been to date only one national survey of the prevalence of hepatitis C in injecting drug users (Ref 8). This analysed the results 2,081 tests conducted throughout the UK and showed an overall national prevalence of 60 per cent positive tests for hepatitis C for injecting drug misusers attending drug services, the prevalence rates being:
|No. of replies||No. tested||Hep C +ve||% Hep C +ve|
|Rest of England||87||1369||786||57%|
It is difficult to estimate the number of new cases likely to arise in the future, but as the disease is endemic in the drug using population, the chances of acquiring the infection from a single incidence of sharing injecting equipment is high. It is possible that the number of cases which we have now could double as a result of newly acquired infections over the next 15 years. The other factor is that, for injecting drug users, hepatitis C is known to have a considerably higher prevalence in those with a history of imprisonment than in those with no history of having been in prison (Ref 9).
Course of the disease
There are two phases of illness with hepatitis C:
This lasts from 1 to 26 weeks after infection (5-12 weeks in 80 per cent of cases). Symptoms are mild; a few people (about 5 per cent) will have jaundice, more might feel sick and lethargic and have no appetite, but many people experience no symptoms at all. About 20 per cent of those who have acute hepatitis C appear to recover completely from the infection.
In 80 per cent of cases the disease is ongoing and there is a risk of spread of the infection to others. In 30 per cent of all cases the virus is demonstrable in the bloodstream, but there is no other evidence of disease. In 50 per cent of all cases there is progressive liver damage, but in 30-40 per cent of all cases, although the person may feel generally unwell and be unable to hold down a job through tiredness and general malaise, the disease, as far as we know, will not threaten life. In 10-20 per cent of all cases the illness will, after an interval of several years, become life-threatening with liver failure developing as a result of hepatic cirrhosis. About 5 per cent of all cases are expected to go on to develop cancer of the liver.
Implications for Health Services
There are major financial implications which the hepatitis C epidemic will impose on health services in the future and some of these are beginning to be felt already. Injecting drug use was rare before the end of the 1960s and therefore most people who have been infected have not yet surfaced with serious disease, although a few have. The long latent phase of chronic infection gives us a false sense of security. Hepatitis C has been described as a sleeping giant (Ref 10).
Reducing the epidemic: Fortuitously the setting up of local drug services, needle exchange and all the other measures put in place in the UK in the late 1980s to prevent the transmission of HIV (Ref 11), may also have helped to limit the spread of hepatitis C. The hepatitis C epidemic could be considerably worse had these measures not been undertaken. Because of this the BMA has recently recommended that "the AIDS prevention budget needs to be increased and also used to contain the already extensive hepatitis C epidemic among injecting drug users. This budget should, perhaps, be renamed 'the bloodborne virus budget' " (Ref 12). (See Notes from the Editor).
Investigations: Every person who tests positive for hepatitis C should be referred by their general practitioner to a specialist for further investigation. The only investigation which can detail clearly what is happening is a liver biopsy. The cost of just investigating, following up, and monitoring will be extensive.
Treatment: If treatment is appropriate interferon is normally given, although in the past this has only been successful over the long term in 25 per cent of cases. However recent evidence shows that if it is given for longer (9 months to one year) it is more effective. A standard course of interferon treatment over 6 months costs approximately £1,500, but, compared to the amount that would be needed to treat liver failure and cancer of the liver, this cost is relatively small. Newer drugs are becoming available, in trials. Ribavirin, an oral broad spectrum antiviral is showing some promising results when used in combination with interferon.
Prevention: The best course of action is prevention, through advice and help to drug users to stop them sharing injecting equipment, through the provision of oral methadone to opiate injectors, and through needle exchange and the provision of condoms. Those who have a positive test for hepatitis C can be helped to prevent or slow down progression of the disease in three ways in particular: by helping them to minimize their consumption of alcohol, as even half a pint of beer can be demonstrated to cause temporary liver damage in a normal person, and many drug users also drink alcohol excessively; by ensuring that they are immunised against hepatitis B as the combination of the two virus infections at the same time is known to considerably worsen the prognosis; and by helping to ensure that they do not share injecting equipment again because, as well as the probability that they will transmit the virus to others, they themselves can get repeated infections with the hepatitis C virus which will worsen their own prognosis. There are also some types and sub-types of the hepatitis C virus which cause a more aggressive disease.
Remember to test and vaccinate all injecting drug users for hepatitis B: Apart from those already infected with hepatitis C, it would be cost effective to ensure that all drug users with a history of, or a potential for, injecting are immunised against hepatitis B. Regrettably there is no vaccine available against the hepatitis C virus, nor is there likely to be in the near future.
1. BMA Board of Science and education. (1996) A guide to hepatitis C. BMAssociation.
2. Personal communication. Dr G. Alexander, hepatologist, Addenbrook's Hospital.
3. Calman, K.C. (1995) Hepatitis C and blood transfusion look back. Letter from the Chief Medical Officer. Department of Health.
4. Wreghitt, T.G. et al. (1994) Transmission of hepatitis C virus by organ transplantation in the United Kingdom. Journal of Hepatology, 20, p. 768-772.
5. Rogers, A. (1995) Chronic hepatitis C: the patient's perspective. Clinical Review. Current Aspects of Hepatitis C. Hospital Update, February 1995, p.16.
6. Irving, W.L. et al. (1994) Chronic hepatitis in United Kingdom blood donors infected with hepatitis C virus. British Medical Journal, 308, p. 695-696.
7. Zinn, C. et al. (1995) Countries struggle with hepatitis C contamination. British Medical Journal, 310, p.417-418.
8. Waller T, Holmes, R. (1995) Hepatitis C: scale and impact in Britain. Druglink, 10, (5), p. 8-11.
9. McBride, A.J., Ali, I.M., & Clee, W. (1994) Hepatitis C and Injecting Drug Use in Prisons. British Medical Journal, 309 (6958), p.876.
10. Alter, M.J. (1991) Hepatitis C: a sleeping giant? American Journal of Medicine, 91, (3B), p.112S-115S.
11. Stimson, G.V. (1996) Has the United Kingdom averted an epidemic of HIV-1 infection among drug injectors? (and Commentaries) Addiction, 91, (8), p.1085-1098.
12. Report by the British Medical Association. (1997) The Misuse of Drugs. London: Harwood Academic Publishers.
- Studies from the USA & Australia show that, even amongst those informed of, and applying HIV prevention strategies, it is possible to identify opportunities for HCV transmission. It seems probable that HCV can be transmitted by the sharing of injecting paraphernalia such as water containers, spoons and filters and even through common injecting environments where small amounts of blood being found on tables are transferred to an injecting site. There needs to be campaigns to highlight to injecting drug users and health workers the need for further behaviour change and stress the differences between HCV and HIV prevention messages.
Are we using needle exchanges to pass on this message? And are we ready to add water, filters and spoons to our needle exchanges, to try to help reduce transmission of hepatitis C, even if it is, at present against the law? Let us know what you think?
- Traditional Chinese Medicine (TCM), both in the form of acupuncture and herbs is being used to treat hepatitis C, with some encouraging results and tends to be better tolerated by some sufferers of the condition, than interferon. See 'The Hepatitis C Handbook by Matthew Dolan, published by Catalyst Press, 1997 for more details of these treatments and greater details of hepatitis C.
We are trying to obtain monies to launch a national network to stimulate research and support practitioners, in primary care, examine the care and management of drug users. If you haven't already and you are interested contact:
Dr Berry Beaumont
23 Jackson Road
London N7 6ES
Tel: (0171) 607 4992
This Newsletter was originally created by:
- Chris Ford
- Brian Whitehead
- Jean-Claude Barjolin