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By Jeffrey Norris on February 23, 2012

Alex Monto, MD

Hepatitis C virus — not AIDS-causing HIV — is the leading chronic virus infection leading to death in the United States, and its victims most often are baby boomers. More than half who are infected do not know it.

Researchers from the U.S. Centers for Disease Control and Prevention (CDC) found in a study published in the February 21 issue of the Annals of Internal Medicine that hepatitis C had overtaken HIV as a cause of death in the United States by 2007.

Deaths in the United States due to HIV infection have been steadily decreasing, and  dropped below 13,000 in 2007, while deaths from hepatitis C infection have been steadily increasing, first surpassing 15,000 per year in 2007.

The good news, according to UCSF liver specialist Alex Monto, MD, is that there has been progress in fighting both diseases, and the kinds of drug combination strategies that have done so much to transform HIV infection from a death sentence to a manageable disease are poised to further boost cure rates for those infected with hepatitis C.

“We know that not enough people with risk factors get tested,” Monto says. “There are a lot of people walking around with hepatitis C who don’t know it.”

Monto directs the liver clinic at the UCSF-affiliated San Francisco Veteran’s Affairs Medical Center, one of four hepatitis C centers nationally within the VA system. Like boomers, veterans are disproportionately affected by hepatitis C. The VA cares for 165,000 patients who are chronically infected with the virus.

Three Million in U.S. Diagnosed with Hep C

Chronic Hepatitis C has been diagnosed in about three million people in the United States. It often causes no symptoms, and many who have been infected for years or even decades may remain unaware of it until symptoms finally appear. The ultimate cause of death attributable to chronic infection is cirrhosis or liver cancer, although the disease progresses to cirrhosis in fewer than half of cases. There is no vaccine.

“The main risk factor in the United States is past injection-drug use,” Monto says. “The others most at risk are those who received blood transfusions before 1992,” Monto says, referring to the year when high-quality screening of the blood supply was implemented.

Compared to HIV or hepatitis B, the risk of hepatitis C being transmitted by sex is low, Monto says, but among men who have sex with men there has been an increase in reports of the virus being sexually transmitted, more so among those who are infected with HIV.

“Anybody with a history of ever being exposed to injection drugs or who received a transfusion before the blood supply was screened should be tested,” Monto says. “That’s not controversial at all. What has been controversial is whether or not all baby boomers should be screened.”

Another study in this week’s edition of the journal suggests that a one-time blood test ordered by primary care providers to screen for antibodies to hepatitis C in those born between 1945 and 1965 would be cost effective — costing $2,874 for each chronically infected patient identified — and would lead to the identification of more than 800,000 previously undiagnosed cases.

Those who are chronically infected may be able to reduce the likelihood of disease progression by avoiding alcohol, by maintaining a healthy weight, and by being vaccinated against hepatitis A and hepatitis B, Monto says.

Treatment Often Cures Hepatitis C

About four out of five who are infected do not rid themselves of the virus without treatment. For about a decade the standard treatment was a combination of two drugs — pegylated interferon given once per week by subcutaneous injection, and daily ribavirin pills, with treatment lasting from six to 11 months. This treatment represented a vast improvement — offering cure rates of 40 percent to 50 percent in most patients, according to Monto.

Hepatitis C virus. Image by the U.S. Department of Veterans Affairs.

Within the past year two new drugs of a type known as protease inhibitors have become available. These are valuable for the 75 percent of U.S. hepatitis C patients infected with a form of the virus called genotype 1. With the protease inhibitors added to the mix, the duration of treatment may be shorter, and the cure rate has increased to about 70 percent in patients who have not previously been treated, Monto says. A cure may be less likely for those who have been previously treated, depending on how they responded to earlier treatment.

“New therapies are clearly getting better, and there are probably 25 to 30 new drugs in the pipeline, with many coming out in the next few years,” Monto says. “There are going to be drugs that are better than the ones we have so far.” Several UCSF researchers, including Monto, are helping to evaluate new drugs in clinical trials. UCSF researchers also are investigating the role of the immune system in hepatitis C and hepatitis B infection.

Not to Be Confused with Hepatitis B

Hepatitis B chronically infects about half as many as hepatitis C in the United States, and hits those of Asian descent especially hard — they account for half of hepatitis B infections. Hepatitis B is responsible for about 1,800 deaths yearly in the United States.

Despite the similar names, the two viruses are not closely related. Hepatitis B is spread much more easily through sexual intercourse, and passes from mother to newborn child much more easily. In most adults who become infected the immune system successfully controls infection. Only about five percent of adults exposed to hepatitis B become chronically infected, according to Monto.

There are vaccines for hepatitis B. A UCSF laboratory team led by William Rutter, PhD, now professor emeritus, first demonstrated that an uncontaminated source of material for a hepatitis B vaccine could be obtained by mass-producing viral proteins in genetically engineered, laboratory-grown yeast. This was the groundwork leading to the first marketed genetically engineered vaccine, made by Chiron, a company co-founded by Rutter.

Related Links:

The Increasing Burden of Mortality From Viral Hepatitis in the United States Between 1999 and 2007

The Cost-Effectiveness of Birth-Cohort Screening for Hepatitis C Antibody in U.S. Primary Care Settings

UCSF Liver Center

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Hepatitis C, a Leading Killer, Is Frequently Undiagnosed But Often Curable

A 2 percent prevalence of hepatitis C virus emerged recently in the U.S. adult population and this prevalence translates to an estimated 4.1 million persons in the U.S. Fifty percent of the cases arise in the Baby Boomers age group born between 1945 and 1964. The Centers for Disease Control and Prevention portrays hepatitis C viral infection as causing more deaths than HIV in the United States. Hepatitis C caused about 13,000 deaths in 2005 and the CDC projects the number of deaths to rise to 35,000 by 2030.

A blood test for antibodies to hepatitis C virus uncovers new cases of the disease. Since 20 to 30 years can elapse before symptoms arise, "silent killer" describes the disease. The HCV infection represents a principal cause of liver disease, cirrhosis and death. Many individuals remain unaware of the infection and the burden of the disease will continue to rise unless emphasis switches to detection, education and treatment for the Baby Boomer age group.

Rein and colleagues from the University of Chicago published in the Feb. 21 issue of Annals of Internal Medicine results of a study using a computer model to estimate how screening the Baby Boomer age group would reduce deaths significantly. The projected estimated cost shrinks to 50 percent less with utilization of this new method for screening and early treatment.

The Chronic Liver Disease Foundation supports expansion of the HCV screening for individuals in the Baby Boomer age group. The Foundation issued a position paper in support of the research results. The CDC at present recommends screening for high-risk groups only such as individuals with a history of injecting drugs, requiring blood transfusion before 1992 or receiving chronic kidney hemodialysis.

The Peer Review Committee at CDC is currently reviewing the research to determine a decision about this new concept. As required by federal law, the public can access review information at the Center for Disease Control and Prevention website.

References

Centers for Disease Control and Prevention (2006) The Prevalence of Hepatitis C Virus Infection in the United States. Annals of Internal Medicine, 144(10):705-714.

Rein, D.B. et al. (2012) The Cost-Effectiveness of Birth-Cohort Screening for Hepatitis C Antibody in U.S. Primary Care Settings. Annals of Internal Medicine, 156(4):263-270.

See the article here:
Baby Boomers: Testing for Hepatitis C Virus Could Save Your Life

NEW YORK (Reuters Health) - Hepatitis C has surpassed HIV as a killer of U.S. adults, and screening all "baby boomers" could be one way to stem the problem, according to two new government studies.

Hepatitis C is a liver infection caused by a virus of the same name that is usually passed through contact with infected blood. An estimated 75 to 85 percent of infections become chronic, which can eventually cause serious diseases like cirrhosis (scarring of the liver) and liver cancer.

In one of the new studies, researchers at the Centers for Disease Control and Prevention (CDC) found that by 2007, hepatitis C was killing more Americans than HIV -- the virus that causes AIDS.

In 2007, hepatitis C killed 15,100 Americans, accounting for 0.6 percent of all deaths that year. That compared with a little over 12,700 deaths related to HIV.

Those numbers are based on death certificates, and almost certainly underestimate the real scope, according to the CDC. Compared with HIV, hepatitis C infection is more likely to still be unrecognized at the time of a person's death.

"Hepatitis C mortality has, regrettably, been on the rise for a number of years," said Dr. John Ward, director of the CDC's viral hepatitis division and an author of the new study.

But, he told Reuters Health, "many of those deaths could be prevented."

Of the estimated 3.2 million Americans with chronic hepatitis infection, about half of them don't know it, according to the CDC.

That's because the initial infection causes no symptoms in most cases. Instead, the virus silently damages the liver over the years, and people may only discover they are infected when they develop irreversible liver cirrhosis.

Chronic hepatitis C is most common in "baby boomers" -- about two thirds of U.S. infections are in people born between 1945 and 1964, Ward's team notes in their report, which is published in the Annals of Internal Medicine.

That predominance among boomers has a lot to do with casual injection-drug use back in the 1960s, 70s and 80s, since sharing tainted needles is a major route for passing on the virus.

Some people also contracted hepatitis C through blood transfusions during that era. Since 1992, all blood donations in the U.S. have been tested for hepatitis C.

Baby boomers with hepatitis C are now getting to an age where the consequences of the infection would be evident, said Dr. Harvey Alter, a researcher with the National Institutes of Health who wrote an editorial on the new studies.

"The big issue is that most people with chronic infection are still not identified," Alter told Reuters Health.

Right now, health officials recommend that certain people at increased risk have blood tests to be screened for hepatitis C. That includes anyone who's used injection drugs, people who received blood transfusions or organ transplants before 1992 and people with HIV.

"But that approach hasn't been very effective," Alter said.

Another option, Ward said, would be to screen all baby boomers.

Experts are only seriously considering that option now because of recent advances in hepatitis C treatment.

Before 1990, the infection was virtually incurable. Then researchers found that a combination of two medicines, interferon and ribavirin, could boost the cure rate to 45 percent ("cure" meaning the virus is cleared from the body).

The downside is that the regimen is hard to take. Interferon has to be injected, and the whole treatment course takes about a year. The drugs can also have side effects ranging from flu-like symptoms to sleep problems to depression.

Less than a year ago, the U.S. approved two new oral drugs that, when added to the old regimen, send the cure rate to 70 percent. Adding either one of the drugs -- boceprevir (sold as Victrelis in the U.S.) or telaprevir (Incivek in the U.S.) -- can also cut the treatment time to about six months in some people.

The side effects are still there with the triple-drug approach. But with the high possibility of a cure, more people with chronic hepatitis C may want treatment, both Ward and Alter said.

So in a second study, the CDC researchers estimated the cost-effectiveness of doing one-time hepatitis C screening in all Americans born between 1945 and 1965.

They calculated that compared with the "status quo," screening baby boomers would catch an extra 808,580 cases of hepatitis C, at a cost of almost $2,900 for each one.

Ultimately, screening would prevent an extra 82,000 deaths, the CDC estimates -- assuming a certain percentage of people agree to treatment with interferon and ribavirin.

As far as cost-effectiveness, Ward said, that would put baby-boomer screening in line with other widely accepted types of screening, like tests for colon cancer and high blood pressure.

If screened people received one of the new hepatitis C drugs, that would save even more lives -- an additional 121,000 over current screening policy, the CDC says. But the cost would be greater, since both new drugs are very expensive.

Incivek costs nearly $50,000 for the whole course, while Victrelis rings up at roughly $26,000 to $48,000 depending on the duration of treatment.

Still, Alter, who supports baby boomer screening, said the approach looks to be "very cost-effective" -- especially when compared to the costs of treating cirrhosis and liver cancer, which are the most common reasons for liver transplants.

"The beauty of this is, it's six months to one year of treatment," Alter said.

Both Alter and Ward also pointed to other medications now in the drug industry's pipeline that are aimed at taking interferon injections out of the equation.

"Hopefully, we'll soon have oral therapies that are easier to take and have fewer adverse effects," Alter said.

For now, the screening focus in the U.S. is on baby boomers. Whether it could be a good idea in younger generations is not clear.

New hepatitis C infections in the U.S. are down sharply since the 1980s, according to a CDC study published last year.

In the mid-1980s, roughly 70 of every million Americans developed acute hepatitis C each year. Between 1994 and 2006, that rate was 90 percent lower: only seven per million per year.

As it stands, there are roughly 18,000 new hepatitis C infections each year -- most of which occur in injection-drug users.

SOURCE: and Annals of Internal Medicine, February 21, 2012.

(This story update clarifies that Victrelis and Incivek are U.S. brand names, in paragraph 21)

More here:
Hepatitis C killing more Americans than HIV: studies

When South African hip-hop duo Die Antwoord played "Fok Juule Naaiers," the first single off latest album Ten$ion -- the track that opened the group's Noise Pop gig last night at the Regency Ballroom -- for its LA manager, they were told it had some problems. The problem's name was homophobia, their manager ventured. US audiences, he said, don't take kindly to the F-word (I wish that were consistently true).

In response, Die Antwoord released this video. It is entitled "F-word," the version of that term that lacks my lavish commitment to political correctness

Ninja, a.k.a. Watkin Tudor Jones, says the usage is all good because he has good homo friends, and that one of them is Hi-Tek, the group's DJ, who opened up last night's show with his charming "Fok Juule Naaiers" verse. Assorted lyrics below:

DJ Hi-Tek will fuck you in the ass, punk ass white boy

Look at you scared/Scared of a real man

Fuck it 'til you love me, [F-word]

So, was this song Hi-Tek's coming out party? What a bummer party.

Of course, the crowd (sold out to the gills -- I had press credentials and still had to beg, borrow, and perform mild thievery to get in) ate it all up. Die Antwood's stage show is less weird than its videos, because matching them would entail wearing coats made of live rats, which would be hard to get through customs.

Emcee Yolandi Vi$$er without her album cover blood-soaked visage is massively sexy on stage (the whole group looks like they hit the gym hard together). By the end of the show, she had stripped down to running shoes, spandex shorts, and a midriff-bearing pink tee with "zef" printed inside a heart. She always looks like her clothes are about to fall off. Next to Ninja in his orange running shoes and signature Dark Side of the Moon underwear (infamous jiggling penis beneath), they looked like they were hosting a really agressive workout video. Ninja crowdsurfed, constantly. Let no one say that Die Antwoord doesn't work it out on stage.

Yolandi Vi$$er at the Regency last night.

And, Ninja. Guardian photos by Caitlin Donohue

And it is a good show. Yolandi hype-chirps after Ninja's every line. She spins around five times and picks up her verse right on cue, and the two reverse roles with Ninja cooing after her lines end. New single "I Think You're Freaky" was a huge hit, particularly, one imagines, with the guy in a rubber pig mask sweating balls in the front row, a couple in the middle of the crowd wearing the hooded plushie onesies that Die Antwoord rocked -- weirdly, always weirdly -- in its "Umshini Wam" video. The front lighting blacks out after songs, silhouetting Ninja and Yolandi's distinctive haircuts. They are unapologetic in their stage presence, crowd love.

Earlier that day, afraid of not getting on the list for the show, I lurked outside Upper Playground's Fifty24SF gallery, where Ninja had spent the day painting the walls with the black chicken scratches and Evil Boy engorged penis characters that now adorn Die Antwoord merch, stage sets, and his own body. At 4 p.m., there was a line of Die Antwoord fans lined up to greet Yolandi and Ninja. You could cut the line if you bought a $200 Evil Boy latex toy.

Few people did. First-in-liner Stephanie Farrell, who came straight from school for the signing didn't. But she got what she wanted out of her wait: a really awkward experience with her idols. 

"What was your interaction with them like?" I asked her while looking at the Die Antwoord's signatures, written in her wire-bound, lined notebook. 

"They didn't say anything, it was really awkward. I was like 'hey,' and they were like 'hey.'"

"But are you still a fan?"

"Absolutely. I didn't expect it to be a normal experience whatsoever."

In the "[F-word]" video, Ninja says that people from the United States who are upset by the way they use that and other (N-word) offensive bullshit should quit being a little less PC and learn from "your brothers and sisters here in the dark depths of Africa," where a local saying is translated into "we are one." He then grabs his Evil Boy dolls, a black one and a white one, and knocks their monster toy dicks together while repeating the "we are one" phrase in a high-pitched voice. "That's why they say South Africa is a rainbow nation."

Weird. 

Photos of Die Antwoord's Ninja painting the inside of the Fifty24SF gallery are by John Orvis

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Die Antwoord's athletic use of the F-word

WATERLOO --- It turns out Rick Kimbley's next-to-last day as acting postmaster in Waterloo was a productive one.

After Friday, Kimbley will return to the Des Moines after three months in Waterloo, and he leaves behind a processing center that will remain open and active.

On Thursday, U.S. Rep. Bruce Braley announced that mail processing facilities in Waterloo and Cedar Rapids are no longer being considered for closure by the U.S. Postal Service.

The move preserves 150 positions at the Waterloo post office. Had a closure been ordered, those workers probably would have had to be placed elsewhere, perhaps out of town.

"It's a great day for the workers," said Kimbley, who Monday will give way as acting postmaster to Ron Ralph from the Cedar Rapids Post Office.

Kimbley was asked how long the local postal processing operation would remain open.

"The only information we have is it’s not being considered for consolidation at this time," he said.

The Waterloo center processes 300,000 to 500,000 pieces of mail daily, "depending on the day,” said Kimberly Karol, a 19 1/2-year employee who in January became local president of the American Postal Workers Union.

"We’re very pleased that it’s going to continue to process mail here," she said. "That’s really good news for the community and people that work here,” Karol said. "It’s also good for the communities we service, because we do processing for a large part of northeastern Iowa."

Karol, who became the top union representative in January after 15 years as vice president, also noted her colleagues have not gotten any indication how long the center will stay open.

"The postal service continues to have financial challenges, and they’re going to look at ways to meet those challenges," she said. "We still have some things to get resolved."

Braley made the announcement today “after multiple conversations with the United States Postal Service” according to a press release from his office.

"Braley has been fighting to save these facilities for months," the release continued.

"Rain, snow and sleet don’t stop our postal workers, and I’m proud to say that Washington bureaucrats won’t, either," Braley said. "I’m glad to see that the U.S. Postal Service has finally gotten the message that now is the wrong time to lay off hundreds of workers. We still have a lot of work to do to save more post offices around the state, but this is good news today for Iowa workers."

The USPS confirmed with Braley's office earlier this morning that the mail processing facilities in Waterloo and Cedar Rapids will remain open. Braley is a member of the Oversight and Government Reform Committee, which has legislative authority over the USPS.

In September 2011, Rep. Braley sent a letter to Postmaster General Patrick Donahoe urging him not to close these facilities.

Evansdale

Evansdale residents also received good news recently, as far as postal service goes. A ruling by the Postal Regulatory Commission resuscitated hope the city’s post office could re-open.

The U.S. Postal Service and a related agency recently delivered some good new to the metro area.

The commission on Jan. 18 remanded the U.S. Postal Service’s decision to close the Evansdale Post Office for further consideration. A postal service spokesman says the agency is reviewing the decision.

Mayor Chad Deutsch, who appealed the closing along with resident Craig Chilton, is optimistic the office in the Evans Crossing strip mall will open again soon.

"I’m just ecstatic about the decision," Deutsch said. "It evidently confirms our arguments that it’s a busy post office and it wasn’t going to save money by closing it. I have faith the postal service will look at the facts and open it back up."

Whether that will happen is undetermined. The commission’s ruling only requires the postal service re-evaluate its decision to shutter the facility last October.

"(The Postal Service) is taking it under advisement. ... I’m waiting to see where we go from here," said Richard Watkins, USPS spokesman for much of Iowa.

Kimbley, said agency officials haven’t talked to him about the future of the Evansdale Post Office, which is a branch of the Waterloo Post Office.

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UPDATE: Postal workers relieved by word that mail processing operations staying open