If you remember the '60s, you weren't there, Robin Williams famously quipped. Some who were there might not exactly remember a few of the things they did back in the day -- a one-night stand or a fleeting delusion that experimenting with injection drugs was a good idea. More than a few regrets no doubt followed the fun, excitement and experimentation of the era. But that seemingly distant past is catching up with serious consequences now. The Centers for Disease Control and Prevention has taken the unprecedented step of declaring a whole generation at higher than average risk of hepatitis C infection.
Among those traditionally at high risk for this inflammatory disease -- which can lead to liver damage, cirrhosis, liver failure or even liver cancer -- are people who have injected drugs, had a sexual partner with hepatitis C, had body piercings or tattoos with unclean equipment, received a blood transfusion before 1992 (the year a test became available to screen blood for the disease), and health care workers exposed to such contaminants via needle sticks.
Now, the CDC is urging everyone born between 1945 and 1965, whether they fall into previous high-risk categories or not, to be tested once for the Hepatitis C virus.
There are two good reasons for this advisory: No. 1 is that the generation that came of age in the '60s -- an era bookended roughly between the free-spirited Summer of Love (1967-8) and the cold slap of sexual reality that was the beginning of the AIDS epidemic (1980) -- make up the vast majority of Americans infected with hepatitis C. Reason No. 2: Breakthrough drugs now are available to treat the disease (they were approved in May 2011) and there is a good chance those with hepatitis C now can be cured of it.
Baby Boomers
There were many bullets to dodge as this generation moved into adulthood: the real ones in Vietnam and disease-borne woes, including AIDS and hepatitis C. Now, some two million baby boomers, or 75 percent of all patients with the disease, are infected with hepatitis C. They are a generation five times more likely to be infected than other adults. It's likely they were infected in their teens or 20s, a time so long ago and far away that they truly might not recall an incident that put them at risk.
My colleague Dr. Tram T. Tran, medical director of liver transplantation at Cedars-Sinai, offers her view on the CDC's recommendation on hepatitis C testing and she says this: "Patients who have had it for 30 or 40 years may be asymptomatic until they present with end-stage liver disease. Now we have therapies that are so successful that it's imperative we get them into treatment before they progress to liver disease and transplant."
In the intervening decades since those tumultuous '60s, research into potential risk factors for hepatitis C led to development of better screening methods to protect the blood supply, adoption of universal precautions such as the use of protective gloves in health care settings and education around issues of safe sex and needle exchange programs. As a result, the incidence of hepatitis C has decreased dramatically from 240,000 new cases a year in the 1980s to 26,000 new cases in 2004.
The disease, though, already had a foothold in the blood of hundreds of thousands of people of a certain age. Now in their mid-40s to mid-60s, most boomers probably have cleaned up their lifestyles already. Because the disease can remain silent for decades while it quietly damages the liver, the CDC estimates that a one-time hepatitis C screening of Baby Boomers could identify more than 800,000 new cases. And that translates to prevention of chronic liver disease, potentially saving the lives of 120,000 people.
New Treatments
Newly available treatments can cure the majority of hepatitis C patients. But, of course, they work only on patients who know they are infected and seek treatment.
The drugs for hepatitis C, approved last year, can dramatically improve treatment of the most common form of hepatitis C, curing 75 percent of patients; that compares with a 44 percent cure rate with standard treatment alone. In October 2011, the American Association for the Study of Liver Diseases updated its recommendations to include adding new therapies to the drugs already in use.
The new drugs are called direct-acting antivirals, and, so far, include telaprevir and boceprevir, compounds that are used with and to enhance the effect of the traditional treatment regimen of interferon and ribavirin. The new drugs block a key enzyme that the virus needs to spread, much the same way that protease inhibitors do for HIV patients. But unlike HIV-treatment, treatment for hepatitis C does not last a lifetime. A course of treatment usually runs six to 12 months, depending on the patient's response. The new regimen of drugs has had such a profound effect on the future of hepatitis C patients that my colleague, Dr. Fred Poordad, a leader in the field, has called 2011 "a pivotal and historic year in the story of hepatitis C treatment." Still, because the newly developed therapies involve multiple drugs administered to those infected for varying lengths of time, most physicians providing this care for now will be specialists, Tran says. There are notable side effects, including anemia, and patients must stringently follow a "complex" regimen of care that includes a weekly interferon injection and daily pills -- all aimed "to prevent resistance," she says.
Hepatitis A-B-C Primer
For patients, the different kinds of liver diseases called hepatitis can be confusing. Briefly, hepatitis A is a food-borne infection associated with poor hygiene. Found mostly in stools and blood, it spreads when food handlers fail to wash their hands after going to the bathroom. It also can be spread by oral-anal sex. Symptoms usually are mild and can include fatigue, nausea and vomiting, though some elderly patients or those with underlying liver disease can become very sick or even die. Those with hepatitis A must rest and avoid alcohol and acetaminophen, the active ingredient in Tylenol, because both can damage their liver.
Hepatitis B, like hepatitis C, is spread through sexual contact, exposure through contaminated blood, tattooing with unsanitary needles and shared injection drug needles. But with medical monitoring, bed rest and good health practices, the illness likely will go away in two to three weeks and the liver return to normal in a matter of months. About 5 percent of adults, and half of all children with hepatitis B, develop a chronic form of the disease. With treatment, the virus can be suppressed, but cannot be eliminated the way the hepatitis C virus can, says Dr. Tran.
Effective vaccines are available for both hepatitis A and B, though not for C. All infants routinely are vaccinated against hepatitis B and children up to age 18 who were not vaccinated as infants should be, as recommended by the CDC. Adults exposed to the virus (such as many in healthcare), as well as certain high-risk groups like IV drug users, prisoners, dialysis patients or people with multiple sex partners, also should be vaccinated. All children, as well as high-risk adults and adults working in or traveling to countries with high rates of the disease should be vaccinated against hepatitis A. This advisory may be particularly pertinent in multicultural California, as it covers Mexico, Central and South America, Eastern Europe, Africa and Asia (except for Japan).
The news for hepatitis C treatment is likely to get even better in the not too distant future. "Treatment is evolving so quickly," says Tran. "In the next several years, it'll probably be a more simple combination oral pill."