tag:theconversation.com,2011:/uk/topics/hepatitis-c-1085/articlesHepatitis C – The Conversation2023-12-11T04:27:58Ztag:theconversation.com,2011:article/2164392023-12-11T04:27:58Z2023-12-11T04:27:58ZWe’re on track to eliminate hepatitis C, but stigma remains and reinfection is a risk<figure><img src="https://images.theconversation.com/files/564715/original/file-20231211-21-yubjnt.jpg?ixlib=rb-1.1.0&rect=244%2C325%2C5794%2C3630&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/back-view-man-standing-looking-through-2136042105">Shutterstock</a></span></figcaption></figure><p>Hepatitis C is a preventable but potentially life-threatening blood-borne virus. It primarily affects the liver and, if untreated, can lead to <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/cirrhosis-of-the-liver">cirrhosis</a> (scar damage) and cancer. </p>
<p>When direct-acting antivirals for hepatitis C arrived in 2016, they were described as a <a href="https://www.smh.com.au/politics/federal/turnbull-government-to-spend-1-billion-on-hepatitis-c-miracle-cures-for-all-20151219-glrib0.html">game changer</a>. They <a href="https://www.penington.org.au/wp-content/uploads/2022/07/The-Bulletin-April-2021.pdf">cured</a> chronic hepatitis C in <a href="https://www.nature.com/articles/510043a">more than 95% of cases</a>. So Australia adopted the World Health Organization’s target to <a href="https://www.nature.com/articles/510043a">eliminate hepatitis C</a> by 2030.</p>
<p>More than <a href="https://www.abc.net.au/news/2016-12-05/hep-c-drugs-australias-most-expensive/8094188">a billion dollars</a> has been invested in adding direct-acting antivirals to the Pharmaceutical Benefits Scheme, making treatment accessible to anyone covered by Medicare. By the end of 2022, <a href="https://unsw-primo.hosted.exlibrisgroup.com/primo-explore/fulldisplay?vid=UNSWORKS&docid=unsworks_modsunsworks_84935&context=L">about 60%</a> of people living with hepatitis C had been treated. </p>
<p>That’s a remarkable public health achievement. Life-changing for many and for some, literally life-saving. But what is life like for this growing group of people after they’ve been cured? And where are we still lagging in our efforts to combat hepatitis C?</p>
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<a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">Explainer: the A, B, C, D and E of hepatitis</a>
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<h2>Cure doesn’t always eliminate stigma</h2>
<p>The most common way of picking up hepatitis C in Australia is by sharing injecting equipment. As injecting drugs is widely disapproved of, and illegal in most parts of Australia, this has huge implications for people with hepatitis C. </p>
<p>The <a href="https://journals.sagepub.com/doi/10.1177/1357034X09347221">stigma associated with injecting drugs</a> means people with hepatitis C can experience persistent discrimination – in relationships, at work, and other settings. Research suggests <a href="https://www.unsw.edu.au/content/dam/pdfs/unsw-adobe-websites/arts-design-architecture/ada-faculty/csrh/2021-06-Stigma_Indicators_Monitoring_Project_Summary_Report.pdf">more than half</a> of people with hepatitis C experienced discrimination in a 12-month period. </p>
<p>Such discrimination happens <a href="https://academic.oup.com/cid/article/57/suppl_2/S51/394838">most commonly in health care</a>, when doctors, nurses and others health-care professionals become aware of someone’s hepatitis C status. This <a href="https://www.sciencedirect.com/science/article/pii/S1326020023001784?via%3Dihub">can include</a> withholding treatment, <a href="https://theconversation.com/mental-distress-is-much-worse-for-people-with-disabilities-and-many-health-professionals-dont-know-how-to-help-187078">diagnostic overshadowing</a> (when workers attribute physical symptoms of illness to mental health issues), rude or unwelcoming behaviour, and excessive infection control like double-gloving. This may lead some people to avoid seeking medical care entirely.</p>
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<img alt="GP talks to female patient" src="https://images.theconversation.com/files/564712/original/file-20231211-21-7k618h.jpg?ixlib=rb-1.1.0&rect=27%2C9%2C6132%2C4091&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/564712/original/file-20231211-21-7k618h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/564712/original/file-20231211-21-7k618h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/564712/original/file-20231211-21-7k618h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/564712/original/file-20231211-21-7k618h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/564712/original/file-20231211-21-7k618h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/564712/original/file-20231211-21-7k618h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Some health providers act differently when finding out about a patient’s history of hepatitis C.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-young-female-general-practitioner-gesturing-1917303137">Shutterstock</a></span>
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<p>Our recent research <a href="https://mh.bmj.com/content/early/2023/07/13/medhum-2023-012653">found</a> direct-acting antivirals do not necessarily cure these forms of stigma and discrimination. If medical records show a person has a history of hepatitis C, some health-care workers change the way they treat that person. </p>
<p>Their manner can change. The treatments they offer might change – for example, whether they will provide access to painkillers. Sometimes people are treated as if they are infectious, or as if they still have the virus when they don’t.</p>
<h2>The law can reinforce stigma and discrimination</h2>
<p>Laws and legal practices have been slow to respond to new treatments.</p>
<p>In insurance law, for instance, having once had hepatitis C has been considered a risk to insurance providers. This means affected people <a href="https://opal.latrobe.edu.au/articles/journal_contribution/Insurance_discrimination_and_hepatitis_C_Recent_developments_and_the_need_for_reforms/22091411">may not be</a> approved for travel, health or life insurance. Or, their premiums may be much higher, potentially pricing them out of the market and limiting their ability to travel, access health care or plan for their financial futures. </p>
<p>We would expect to see practices change with more effective treatments. But insurance practices and the actuarial data that insurers use is <a href="https://opal.latrobe.edu.au/articles/journal_contribution/Insurance_discrimination_and_hepatitis_C_Recent_developments_and_the_need_for_reforms/22091411">lagging</a> behind medical developments. </p>
<p>This is just one example of how laws and legal practices can exacerbate stigma and discrimination for people with a history of hepatitis C. Our <a href="https://opal.latrobe.edu.au/articles/report/Hepatitis_C-related_stigma_and_discrimination_in_a_post-cure_world_Summary_report_of_project_findings_and_recommendations/23909613/1">research found</a> this also occurs in <a href="https://journals.sagepub.com/doi/full/10.1177/09646639221115698">criminal law</a>, privacy law, <a href="https://www.tandfonline.com/doi/full/10.1080/1535685X.2023.2221950">social security and migration law</a>.</p>
<h2>People in prison are being left behind</h2>
<p>Prisons have high rates of injecting and <a href="https://theconversation.com/direct-acting-antivirals-can-cure-hepatitis-c-and-prisons-are-now-leading-efforts-to-eliminate-the-virus-182854">hepatitis C transmission</a> has historically been high. </p>
<p>While Australia has had <a href="https://www.sydneycriminallawyers.com.au/blog/australia-pioneered-drug-harm-reduction-and-must-continue/">a good track record</a> on reducing some harms associated with drug use in prisons, there is at least one <a href="https://www.hepatitisaustralia.com/news/renewed-calls-for-needle-syringe-programs-in-prisons-ahead-of-international-drug-users-day">glaring omission</a>: prisons don’t have access to a needle and syringe programs to ensure that people who use drugs can access sterile equipment. This means it’s much harder to prevent the transmission of hepatitis C and other blood-borne viruses in prisons.</p>
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Read more:
<a href="https://theconversation.com/sterile-needles-can-stop-the-spread-of-disease-in-prisons-heres-how-3644">Sterile needles can stop the spread of disease in prisons – here's how</a>
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<p>Yet <a href="https://www.health.gov.au/resources/collections/national-strategies-for-bloodborne-viruses-and-sexually-transmissible-infections?utm_source=health.gov.au&utm_medium=callout-auto-custom&utm_campaign=digital_transformation">current national hepatitis C policy</a> says harm reduction should be available in prisons. And the <a href="https://www.penalreform.org/resource/standard-minimum-rules-treatment-prisoners-smr/">Mandela Rules</a> – which are a set of international human rights principles – state that prisoners should receive the same standard of health care as those in the wider community.</p>
<p>Without sterile injecting equipment for people in prisons, people who have been cured of hepatitis C are at risk of reinfection. And Australia is less likely to eliminate hepatitis C. </p>
<h2>Elimination demands more than just treatment</h2>
<p>The world is watching as Australia tries to be one of the first countries in the world to <a href="https://www.health.gov.au/sites/default/files/documents/2022/06/fifth-national-hepatitis-c-strategy-2018-2022.pdf">eliminate hepatitis C</a>. The final national hepatitis C health strategy is expected to be released before the end of 2023. </p>
<p>But the number of people coming forward for treatment has <a href="https://unsw-primo.hosted.exlibrisgroup.com/primo-explore/fulldisplay?vid=UNSWORKS&docid=unsworks_modsunsworks_84935&context=L">dropped significantly</a>. Resources are being marshalled into <a href="https://pubmed.ncbi.nlm.nih.gov/34448668/">finding people</a>, and keeping the momentum going on elimination. </p>
<p>It is increasingly clear that we also need to direct resources to what happens “post-cure”, assuring people that stigma-free health care is available to them. We also need to tackle the laws, policies and practices that allow stigma and discrimination to linger in people’s lives. </p>
<p>Finally, we need to ensure people in prisons have access to sterile injecting equipment so they aren’t reinfected.</p><img src="https://counter.theconversation.com/content/216439/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Seear receives funding from the Australian Research Council's Discovery Scheme (DP200100941) and the Future Fellowship Scheme (FT200100099).</span></em></p><p class="fine-print"><em><span>Dion Kagan, Emily Lenton, and Sean Mulcahy do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Around 60% of Australians with hepatitis C have accessed treatment which usually cures the condition. But to eliminate the disease, we need to prevent re-infection and tackle stigma.Dion Kagan, Research Officer, Gender, Law and Drugs program, La Trobe UniversityEmily Lenton, Research officer, La Trobe UniversityKate Seear, Associate professor, La Trobe UniversitySean Mulcahy, Research Officer, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2155102023-11-02T09:59:22Z2023-11-02T09:59:22ZThe future of medicine: 50-year forecast offers hope for HIV and cancer patients and predicts climate change to increasingly set agenda<p>The Covid-19 pandemic has changed the way we think about health and revealed significant flaws within our health care systems. It has also raised questions about the role of technology, as well as ethical concerns about the distribution of wealth and its impact on global health. How will this collective awakening that we have experienced influence the coming years and decades? This was the subject of our <a href="https://www.sciencedirect.com/science/article/pii/S0016328723000010">research on the future of medicine</a>.</p>
<p>We utilised the Delphi method in a three-round study involving 22 experts from seven European countries. Participants included physicians, academics, and industry professionals. Despite a slight reduction in panel size in later rounds, study validity remained intact. Data were collected through audio or video responses and analysed using <a href="https://en.wikipedia.org/wiki/NVivo">NVivo</a> 12. The research focused on updating current medical trends, identifying key drivers for future development, and making health care foresights. Data were coded independently to minimise bias and formed the basis for questions in subsequent rounds.</p>
<h2>1 to 2 years: beta and data</h2>
<p>While we remain in “eternal beta” – a state in which products or drugs are tested through active use by a wide audience – sales of portable smart electronic devices will continue to grow thanks to advances in sensors, artificial intelligence (AI) and the proliferation of 5G technology. Data generated by personal devices will also increasingly be transferred to professional devices. This will enable doctors to treat their patients more holistically and better inform their prescriptions.</p>
<h2>2 to 5 years: the private sector strikes back, climate-related tensions</h2>
<p>Rising strains on public health care are likely to bolster the role of private entities. Innovations in this sector will likely hinge on smart sensors, the blockchain, and digital health records. Over the same period, climate change will exacerbate health issues such as malnutrition and water scarcity, especially in vulnerable regions, necessitating a broader health care response.</p>
<h2>5 to 10 years: innovations leading to inequalities</h2>
<p>Advancements in genomics are accelerating personalised medicine, enabling better prediction and treatment of genetic diseases. Technologies like drug-gene interaction studies allow for optimised drug dosing, while nanotechnology permits targeted micro-dosing, reducing complications. However, the high cost of these innovations will exacerbate health care disparities, potentially fuelling social conflict, especially as climate change imposes additional health burdens.</p>
<h2>10 to 30 years: climate change takes centre stage</h2>
<p>Global warming, which according to the World Health Organisation could claim the lives of around 250,000 people a year by 2030, risks exacerbating inequalities in access to health care. Various disasters (floods, heat waves, etc.) disproportionately affect disadvantaged populations who do not have the resources to cope. This could put a strain on existing health care infrastructures, leading to disparities in access to care.</p>
<p>In addition, global warming could lead to forced migrations, placing an additional burden on health care systems in regions receiving climate migrants and creating difficulties in accessing health care due to social, economic, and linguistic barriers.</p>
<p>Experts predict that, within 10 to 15 years, technological advances could be less effective in meeting the needs of racial- and ethnic-minority patient groups. Indeed, the lack of diversity in clinical trials, a widely debated topic in medical research today, could contribute to the reduced effectiveness of drugs on a broad population.</p>
<p>However, experts anticipate that this trend will gradually fade over the next 20 to 30 years. They believe that health care companies will gradually adapt their treatments for people from lower socio-economic backgrounds and minority ethnic groups.</p>
<h2>30 to 50: a quantum leap</h2>
<p>Finally, looking ahead half a century, experts predict the emergence of highly effective treatments and even cures for diseases such as HIV and hepatitis C. There is no doubt that considerable progress has been made in the prevention, diagnosis, and treatment of diseases, particularly cancer.</p>
<p>The experts in our study predict a significant leap forward in these areas. They do not necessarily envisage a complete cure for all types of cancer or the eradication of major diseases, but do foresee progress in diagnostic and therapeutic methods that will enable a higher percentage of patients to be successfully treated at an early stage.</p>
<p>Against this backdrop of progress, they nevertheless stress that antibiotic resistance remains a real challenge. It is true that the development of new antibiotic molecules is still relatively slow. Our experts draw our attention to certain initiatives that focus on modifying existing antibiotics to overcome resistance, while others are exploring the use of bacteriophages, or studying entirely new classes of antibiotics.</p>
<p>Technological advances and a faster pace of life will continue to take their toll on our mental health, perhaps even increasingly so, with mood disorders becoming widespread. We could also see an increase in depression and certain personality disorders. This would force patients and doctors to resort to preventive medication, or even a “magic pill”, to cure mental disorders.</p>
<p>In addition, the problem of chronic metabolic diseases such as cardiovascular disease, diabetes and obesity is set to worsen. Contributing factors include the increasing prevalence of sedentary lifestyles, unhealthy diets, and an ageing population.</p>
<p>The incidence of pancreatic cancer, for example, has risen sharply in recent years. Researchers attribute this not only to lifestyle factors such as smoking, obesity and poor diet, but also to long-term exposure to certain environmental pollutants. Understanding and addressing these links between health and the environment is therefore becoming crucial to the future of health care.</p>
<h2>The ageing challenge</h2>
<p>Finally, the ageing of the population represents another major challenge that will have a considerable impact on health care systems, and not just on Western systems. The prevalence of age-related diseases such as neurodegenerative disorders, osteoporosis and certain types of cancer is set to increase.</p>
<p>This trend will not only place a considerable burden on health services, but will also require major changes in the way health care is delivered. Emphasis will need to be placed on preventive measures, early detection and management of chronic diseases, as well as health care environments and services adapted to the elderly.</p>
<p>In short, as we move forward in time, we imagine progress in the use of technology. While some of us will be offered the means to extend our longevity and improve our quality of life, others may suffer significant health disadvantages, particularly as a result of climate change.</p>
<p>General practitioners will have a cross-sectional view of a patient’s overall state of health, while specialists will be able to provide more targeted treatments. Personal care will become an even hotter topic, as lifestyle choices will reflect a person’s financial resources and social status. This will allow a commercial industry to thrive on the challenges of modern life.</p><img src="https://counter.theconversation.com/content/215510/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Les auteurs ne travaillent pas, ne conseillent pas, ne possèdent pas de parts, ne reçoivent pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'ont déclaré aucune autre affiliation que leur organisme de recherche.</span></em></p>Climate change, inequality, the evolution of knowledge… Experts have been surveyed, and a consensus is emerging on what to expect from the effects of these factors in the medical field.René Rohrbeck, Professor of Strategy, Director EDHEC Chair for Foresight, Innovation and Transformation, EDHEC Business SchoolAhmed Khwaja, Professor of Marketing, Business & Public Enterprise, Head of the Marketing Subject Group, Cambridge Judge Business SchoolHeikki Karjaluoto, Professor of Marketing, University of JyväskyläIgnat Kulkov, Postdoctoral researcher, EDHEC Business SchoolJoel Mero, Associate professor of marketing, University of JyväskyläJulia Kulkova, Adjunct professor, University of TurkuShasha Lu, Associate Professor in Marketing, Cambridge Judge Business SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2126452023-09-28T15:52:33Z2023-09-28T15:52:33ZHepatitis C: Britons getting tattoos and cosmetic procedures abroad may be at risk – here’s how to avoid it<figure><img src="https://images.theconversation.com/files/550273/original/file-20230926-17-v9qc51.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6038%2C4010&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If proper sterilisation procedures are in place, your chances of contracting hepatitis C from a tattoo are extremely low.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cropped-close-bearded-tattoo-artist-working-2125291073">Hryshchyshen Serhii/ Shutterstock</a></span></figcaption></figure><p>A <a href="https://post.parliament.uk/research-briefings/post-pb-0038/">growing number of people</a> living in the UK are going abroad to have tattoos, piercings and cosmetic surgeries. Any procedure, no matter where it’s performed, can carry the risk of injury and infection. </p>
<p>But people heading abroad for cosmetic procedures may want to be extra cautious – with <a href="https://www.thetimes.co.uk/article/hepatitis-c-70-000-people-are-unaware-they-have-infected-0x7b5l39t">recent reports</a> suggesting thousands of UK residents may have <a href="https://news.sky.com/story/thousands-of-people-may-have-unknowingly-contracted-hepatitis-c-abroad-health-experts-warn-12950888">unknowingly contracted</a> hepatitis C this way.</p>
<p>Over <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7667440/">170 million people worldwide</a> are estimated to have hepatitis C. There are approximately one million new infections each year. In England, more than <a href="https://www.gov.uk/government/news/hepatitis-c-prevalence-falls-by-45-in-england#:%7E:text=The%20latest%20data%20published%20by,antivirals%20that%20cure%20the%20infection.">70,000 people</a> had hepatitis C in 2022. But many more could unknowingly be infected, as hepatitis C symptoms can take years to show up.</p>
<p>Hepatitis C can develop into severe and fatal liver disease if undiagnosed. But when caught early, treatment is <a href="https://www.nhs.uk/conditions/hepatitis-c/treatment/">over 95% effective</a> – highlighting just how important timely testing is. </p>
<h2>What is hepatitis C?</h2>
<p>Hepatitis C is caused by a virus that infects the liver. This virus is spread via <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239486/">contact with infected blood</a>. </p>
<p>Most transmission occurs via contact with contaminated implements, such as needles for recreational drug use. In <a href="https://onlinelibrary.wiley.com/doi/full/10.1046/j.1365-2893.2002.00329.x?sid=nlm%3Apubmed">rare cases</a>, hepatitis C can also be spread through sexual intercourse, or from an infected mother to an infant during childbirth.</p>
<p>Around 80% of people who contract hepatitis C will exhibit no symptoms whatsoever. The 20% that do experience a short, <a href="https://pubmed.ncbi.nlm.nih.gov/29773899/">flu-like illness</a> – with varying symptoms that may include fever, headache and muscle aches, fatigue, vomiting, diarrhoea and jaundice. </p>
<p>Symptoms can occur from <a href="https://www.sciencedirect.com/science/article/pii/S0955395915002042?via%3Dihub">two to 12 weeks</a> after catching the virus. Those who experience symptoms often don’t realise the severity of their illness.</p>
<p>Some people manage to clear the virus without treatment. But up to 85% of those infected develop <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3495628/">chronic hepatitis</a> – where the virus <a href="https://cks.nice.org.uk/topics/hepatitis-c/background-information/definition/">remains in the body</a>. </p>
<p>These people can show no signs of illness for years and are often unaware until more serious damage has occurred – which can take decades. Hepatitis C is still very treatable in chronic form, though treatments have <a href="https://pubmed.ncbi.nlm.nih.gov/34913652">better outcomes</a> the sooner they’re received.</p>
<p>Left untreated for years, <a href="https://www.nhs.uk/conditions/hepatitis-c/complications/">chronic hepatitis C</a> causes <a href="https://nutritionandmetabolism.biomedcentral.com/articles/10.1186/1743-7075-7-13#:%7E:text=Liver%20steatosis%20is%20a%20frequent,both%20epigenetic%20and%20genetic%20factors.">severe liver disease</a>. This can cause symptoms such as jaundice, swollen abdomen and legs, easily bleeding or bruising, intense itching, loss of appetite and nausea. </p>
<p>Cirrhosis (liver scarring) can also lead to <a href="https://www.hepatitis.va.gov/cirrhosis/patient/encephalopathy.asp">brain and nervous system damage</a> due to the build-up of toxins the liver normally removes. This can cause concentration and memory problems.</p>
<p>An estimated <a href="https://www.sciencedirect.com/science/article/pii/S2210740120303624?via%3Dihub">one in five people</a> with chronic hepatitis C develop a severe liver cancer called <a href="https://www.nhs.uk/conditions/hepatitis-c/complications/">hepatocellular carcinoma</a>. This is the second most deadly cancer globally, with a five-year survival rate of <a href="https://pubmed.ncbi.nlm.nih.gov/33579422/">just 10%-20%</a>. </p>
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<img alt="A digital drawing of a liver being attacked by hepatitis C viruses." src="https://images.theconversation.com/files/550274/original/file-20230926-17-bkcmql.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/550274/original/file-20230926-17-bkcmql.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/550274/original/file-20230926-17-bkcmql.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/550274/original/file-20230926-17-bkcmql.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/550274/original/file-20230926-17-bkcmql.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/550274/original/file-20230926-17-bkcmql.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/550274/original/file-20230926-17-bkcmql.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Hepatitis C can lead to severe complications.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/hepatitis-virus-human-liver-medical-research-2361027201">crystal light/ Shutterstock</a></span>
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<p>Age, excessive alcohol consumption, having other infections (such as HIV) and the <a href="https://pubmed.ncbi.nlm.nih.gov/33579422/">strain of hepatitis C virus</a> you’re infected with can all <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577946/">increase your risk</a> of developing hepatocellular carcinoma.</p>
<h2>Risk from medical or cosmetic procedures</h2>
<p>If proper sterilisation procedures are in place, your chances of contracting any infection is extremely low. But if surgical implements were used on someone with hepatitis C and not properly sterilised, you will probably catch it. Improper sterilisation also carries risk of other diseases, such as <a href="https://www.fitfortravel.nhs.uk/advice/disease-prevention-advice/blood-borne-virus-infections-including-hiv#:%7E:text=Hepatitis%20B%2C%20Hepatitis%20C%20and,medical%2C%20dental%20or%20surgical%20equipment">HIV and hepatitis B</a>.</p>
<p>Several studies have reported that tattoos done in <a href="https://pubmed.ncbi.nlm.nih.gov/16871571/">non-professional settings</a>, such as those <a href="https://journals.lww.com/ajg/abstract/2005/10000/risk_factors_for_hepatitis_c_on_the_texas_mexico.8.aspx">received in prisons</a>, carry an increased risk of contracting hepatitis C due to improper sterilisation. Even tattoos done in professional tattoo parlours may carry an increased risk if reusable needles aren’t <a href="https://www.sciencedirect.com/science/article/pii/S0140673696911721?via%3Dihub">adequately sterilised between clients</a>.</p>
<p>For piercings, the data is less clear. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4613802/">Many studies</a> have shown no increased hepatitis C risk from piercings – but these studies did not ask participants whether they’d had their piercing done in a professional parlour or at home. However, cases have been reported of hepatitis C being <a href="https://pubmed.ncbi.nlm.nih.gov/15243336">contracted from a piercing</a>, as well as from <a href="https://pubmed.ncbi.nlm.nih.gov/16264024/">swapping body piercing jewellery</a> with an infected person – so it’s important to be careful.</p>
<p>Although data is limited, this risk is probably the same for cosmetic and dental procedures. If proper sterilisation practices are in place and you go to an accredited surgeon or dentist, your risk of contracting hepatitis C is very low.</p>
<p><a href="https://www.ageb.be/ageb-journal/ageb-volume/ageb-article/1963/">Certain countries</a> have higher incidences of hepatitis C – such as Egypt, Mali, Malaysia, Italy, Thailand and Mauritius. Certain strains of the hepatitis C virus may also be more prevalent in certain destinations. </p>
<p>For example, the dominant hepatitis C strain in Nigeria has a <a href="https://www.mdpi.com/1999-4915/13/1/41">94-99% treatment success rate</a>. But in Thailand, the dominant strain is associated with <a href="https://pubmed.ncbi.nlm.nih.gov/31584833/">rapid chronic liver disease progression</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/33716089/">poorer treatment outcomes</a>. It’s worth being extra vigilant if you plan to have a procedure done when visiting these places. </p>
<h2>How can you avoid it?</h2>
<p>If you’re having any sort of medical, dental or cosmetic procedure, ask about the decontamination or sterilisation process of the implements. </p>
<p>In the UK, councils require tattoo and piercing parlours to use either single-use needles or have proper sterilisation methods to re-use equipment (most commonly via an <a href="https://www.steris.com/healthcare/knowledge-center/sterile-processing/everything-about-autoclaves#:%7E:text=Autoclaves%20are%20also%20known%20as,placed%20inside%20a%20pressure%20vessel.">autoclave</a>). If in the UK, ask to see the business’s licence to ensure they’re registered with a local council.</p>
<p>Other medical procedures, such as botox or fillers, are <a href="https://www.policybee.co.uk/blog/can-anyone-train-to-give-botox-uk#:%7E:text=The%20UK's%20drought%20of%20laws,can%20train%20to%20give%20Botox.">less tightly regulated</a>. With any injectable, ideally these should be done by a medical professional – such as a nurse or dentist.</p>
<p>If you’re getting a procedure done and are unsure whether the implements are safe, ask to see it before it’s unpacked. Single use, sterile needles are always sealed in a packet. </p>
<p>Poor hygiene can also spread hepatitis C, so check these are being <a href="https://authoritytattoo.com/are-tattoo-needles-reusable">changed between clients</a> and that good hygiene practice is being done (such as washing of hands and changing gloves between clients). If in doubt, I would suggest not getting the procedure done at all. </p>
<p>If you’ve had a procedure done abroad (or in the UK a long time ago), I would recommend ordering a <a href="https://hepctest.nhs.uk/">test kit from the NHS</a>. It’s quick, easy and can be done at home. If it comes back positive, get treated as soon as possible as hepatitis C virus is a highly treatable infection.</p><img src="https://counter.theconversation.com/content/212645/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grace C Roberts receives funding from the MRC.</span></em></p>Hepatitis C treatments are up to 95% effective when caught early.Grace C Roberts, Research Fellow in Virology, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1937052022-11-22T13:25:50Z2022-11-22T13:25:50ZScientists uncovered the structure of the key protein for a future hepatitis C vaccine – here’s how they did it<figure><img src="https://images.theconversation.com/files/496217/original/file-20221118-14-r6a8me.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1999%2C1499&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Imaging the proteins on the surface of HCV has been challenging because of the virus's shape-shifting nature.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/hepatitis-c-virus-particles-illustration-royalty-free-illustration/1042127452">Juan Gaertner/Science Photo Library via Getty Images</a></span></figcaption></figure><p>The <a href="https://www.cdc.gov/hepatitis/hcv/index.htm">hepatitis C virus, or HCV</a>, causes a chronic liver infection that can lead to permanent liver scarring and, in dire cases, cancer. It affects around <a href="https://doi.org/10.1007/s42399-020-00588-3">71 million people worldwide</a> and causes approximately 400,000 deaths each year. While <a href="https://www.uptodate.com/contents/direct-acting-antivirals-for-the-treatment-of-hepatitis-c-virus-infection">treatments are available</a> for HCV-related infections, they are expensive, hard to access and do not protect against reinfection. A vaccine that can help prevent HCV infection is a major unmet medical and public health need. </p>
<p>One major reason there hasn’t been an HCV vaccine yet is that scientists have yet to identify the proper antigen, or the part of the virus would trigger a protective immune response in the body.</p>
<p>Decades of research have pinpointed <a href="https://doi.org/10.1038/nrmicro3098">HCV E1E2</a>, the only protein on the surface of the virus, as the most promising vaccine candidate. However, developing an HCV vaccine based on that protein is limited by uncertainty around what it looks like. Knowing the structure of the protein is necessary to figure out how the immune system responds to the virus.</p>
<p>So how do researchers capture the structure of single protein on a shape-shifting virus? </p>
<p>We are researchers who specialize in <a href="https://scholar.google.com/citations?user=Xejfx54AAAAJ&hl=en">microscopy</a> and <a href="https://scholar.google.com/citations?user=iQj9rSwAAAAJ&hl=en">vaccine design</a>. With new technology, we were able to <a href="https://doi.org/10.1126/science.abn9884">visualize the molecular details</a> of this elusive protein, unlocking key insights into how this virus works and offering a potential blueprint for a future vaccine.</p>
<p>This is how we did it.</p>
<h2>Challenges of capturing a shape-shifting virus</h2>
<p>One reason it has been so difficult to capture the structure of the HCV E1E2 protein is that it is both <a href="https://doi.org/10.1016/j.celrep.2022.110859">flexible and fragile</a>. It changes its shape so often and is so easily broken that it’s challenging to purify. </p>
<p>As an analogy, imagine a bowl of spaghetti drenched in tomato sauce. Now imagine trying to take a picture of each individual piece of spaghetti in the same position over time while the bowl is shaking. Hard to do, right? That’s what it was like to image the full E1E2 protein.</p>
<p>There were also <a href="https://doi.org/10.1126/science.1251652">technological barriers</a>. Until recently, available imaging techniques were limited in their ability to view microscopic proteins. <a href="https://chem.libretexts.org/Bookshelves/Analytical_Chemistry/Supplemental_Modules_(Analytical_Chemistry)/Instrumentation_and_Analysis/Diffraction_Scattering_Techniques/X-ray_Crystallography">X-ray crystallography</a>, for instance, is unable to capture molecules that frequently change and shape-shift, like HCV. Moreover, other options, such as <a href="https://chem.libretexts.org/Bookshelves/Analytical_Chemistry/Physical_Methods_in_Chemistry_and_Nano_Science_(Barron)/04%3A_Chemical_Speciation/4.07%3A_NMR_Spectroscopy">nuclear magnetic resonance spectroscopy</a>, required cutting large parts of the protein or chemically manipulating it in a way that would transform its physiological state and potentially alter its function.</p>
<p>So to examine the structure of E1E2, we needed a way to extract and purify, stabilize and trap the entire shape-shifting protein into one configuration.</p>
<h2>How to take a picture of protein</h2>
<p><a href="https://doi.org/10.1038/d41586-020-01658-1">Cryo-EM, or cryo-electron microscopy</a>, is a type of imaging technique that views specimens at cryogenic temperatures, in this case the boiling point of nitrogen: minus 320.8 degrees Fahrenheit (minus 196 Celsius). With temperatures that cold, ice freezes so quickly that it doesn’t have time to crystallize. That creates a beautiful glasslike frame around the protein of interest, allowing an unhindered view of every structural detail. Cryo-EM also requires very little protein to work, reducing the amount of material we would need to purify. </p>
<p>Winner of the <a href="https://www.nobelprize.org/prizes/chemistry/2017/press-release/">2017 Nobel Prize in chemistry</a> and <a href="https://doi.org/10.1038/nmeth.3730">Nature magazine’s 2015 “Method of the Year</a>” award, cryo-EM is superb for imaging biological macromolecules in their native, or natural, state in the aqueous environment of human blood. Cryo-EM was also pivotal for characterizing the <a href="https://doi.org/10.1038/nature17200">structure of the COVID-19 virus</a> and its variants.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Qq8DO-4BnIY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Cryo-EM has allowed researchers to see complex proteins they weren’t able to before.</span></figcaption>
</figure>
<p>So how do you take a picture of a protein? </p>
<p>First, we embedded the genetic code to make E1E2 in human cells in a petri dish so we would have sufficient amounts of protein to study. After purifying the protein, we <a href="https://caic.bio.cam.ac.uk/electron-microscopy/SpecimenPrep/PlungeFreezing">plunged it into liquid ethane</a> followed by liquid nitrogen. Liquid ethane is used to freeze the protein because it has a higher boiling point than liquid nitrogen. This means it is able to capture more heat before turning to a gas, allowing the protein to freeze much more quickly than it would in liquid nitrogen and avoid structural damage. </p>
<p>Once the protein was vitrified, or in a glasslike ice state, we were able not just to see its overall structure, but also to capture multiple individual configurations of the protein that it takes when it shape-shifts, including its less stable forms.</p>
<p>At this point, our protein was ready for its close-up. We employed a microscope that <a href="https://www.ccber.ucsb.edu/ucsb-natural-history-collections-botanical-plant-anatomy/transmission-electron-microscope">uses a beam of focused, high energy electrons</a> and a very fancy camera that detects how the elections bounce off the protein’s surface. This created a 2D image that we then mathematically transformed into a 3D model. And that was how we got the coveted “close-up” of HCV’s surface protein. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/jgEQ6A2-liU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">This video shows the newly identified 3D structure of the E1E2 protein on the surface of the hepatitis C virus. The two main subunits of the protein are colored in pink and blue. Sugar molecules are colored in green.</span></figcaption>
</figure>
<p>Our next step was then to assess the location of each amino acid, or building block of the protein, in 3D space. Because every amino acid has a unique shape, we used a computer program that could identify each one in our 3D map. This allowed us to manually reconstruct a high-resolution model of the protein, one building block at a time.</p>
<h2>A new tool to design an HCV vaccine</h2>
<p>Our 3D map and model of the HCV E1E2 protein supports previous research describing its structure while providing new insights into features that will help pave the way for a long-sought vaccine design against this virus. </p>
<p>For example, our structure reveals that the interface between the two main parts of the protein is stabilized by sugars and hydrophobic patches, or areas that push out water molecules. This creates sticky binding hubs along the protein and keeps it from falling apart – a potential site for protective antibodies and new drugs to target. </p>
<p>Researchers now have the tools to design antiviral drugs and vaccines against HCV infection.</p><img src="https://counter.theconversation.com/content/193705/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lisa Eshun-Wilson receives funding from the National Science Foundation. </span></em></p><p class="fine-print"><em><span>Alba Torrents de la Peña receives funding from Netherlands Organization for Scientific Research (NWO) Rubicon Grant 45219118. </span></em></p>Using a Nobel Prize-winning technique called cryo-EM, researchers were able to identify potential areas on the hepatitis C virus that a vaccine could target.Lisa Eshun-Wilson, Postdoctoral Scholar in Molecular and Cell Biology, The Scripps Research InstituteAlba Torrents de la Peña, Postdoctoral Fellow in Integrative Structural and Computational Biology, The Scripps Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1927462022-10-23T12:30:32Z2022-10-23T12:30:32ZPaying for plasma is the new normal: Why policy has changed decades after Canada’s tainted blood scandal<figure><img src="https://images.theconversation.com/files/491135/original/file-20221021-20-u4i9xy.JPG?ixlib=rb-1.1.0&rect=102%2C54%2C4449%2C2756&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Blood plasma and products made from it are used to treat conditions ranging from blood clotting disorders to immunodeficiencies to Rh-negative pregnancies.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/AP-Arnulfo Franco</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/paying-for-plasma-is-the-new-normal--why-policy-has-changed-decades-after-canada-s-tainted-blood-scandal" width="100%" height="400"></iframe>
<p>There has been a monumental policy shift in paying plasma donors in Canada.</p>
<p>In September, <a href="https://www.blood.ca/en/about-us/publications-and-reports/annual-reports">Canadian Blood Services</a> (CBS) made a <a href="https://www.grifols.com/en/view-news/-/news/grifols-enters-into-agreement-with-canadian-blood-services-to-accelerate-self-sufficiency-in-immunoglobulins-for-canada">15-year deal</a> with Spanish health-care giant Grifols for blood plasma collection and products. The deal upends the 1997 recommendations from the <a href="https://publications.gc.ca/site/eng/9.698032/publication.html?wbdisable=true">commission of inquiry into the tainted blood scandal</a> that urged no paid donations of blood or blood products.</p>
<p>More than 30,000 Canadians were infected with hepatitis C and another 2,000 contracted HIV from tainted blood and blood products during the ‘70s and ‘80s, resulting in more than <a href="https://www.thecanadianencyclopedia.ca/en/article/krever-inquiry">8,000 deaths</a>. </p>
<p>“The hemophilia community was decimated by HIV and hepatitis C through tainted blood,” David Page, national director of health policy at the <a href="https://www.chscontact.ca/">Canadian Hemophilia Society</a>, said at a <a href="https://sencanada.ca/en/Content/Sen/Committee/421/SOCI/53ev-54542-e">2019 Senate hearing</a>. </p>
<p>The <a href="https://publications.gc.ca/site/eng/9.698032/publication.html?wbdisable=true">Commission of Inquiry on the Blood System in Canada</a> released its final report in 1997. The recommendations were clear: do not pay blood donors, including those who donate plasma, “except in rare circumstances.” </p>
<h2>Policy shift</h2>
<p>Fast forward almost three decades and paying plasma donors is standard practice for <a href="https://giveplasma.ca/donors/compensation/">private plasma collection sites</a>. It’s supported by CBS (although it does not pay donors directly at its own sites), Health Canada and many of the groups most adversely affected by the tainted blood scandal, including <a href="https://chscontact.ca/chs-strongly-supports-cbs-plasma-initiative/">hemophiliacs</a> and those with <a href="http://www.cipo.ca/2022/08/15/update-on-canadian-blood-services-news/">primary immunodeficiency disorders</a> whose lives rely on plasma products.</p>
<figure class="align-center ">
<img alt="A window with the logo of Canadian Blood Services" src="https://images.theconversation.com/files/491136/original/file-20221021-3368-m4mvdw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/491136/original/file-20221021-3368-m4mvdw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/491136/original/file-20221021-3368-m4mvdw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/491136/original/file-20221021-3368-m4mvdw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/491136/original/file-20221021-3368-m4mvdw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/491136/original/file-20221021-3368-m4mvdw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/491136/original/file-20221021-3368-m4mvdw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In September, Canadian Blood Services made a deal with Spanish-based health-care giant Grifols for blood plasma collection and products.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jeff McIntosh</span></span>
</figcaption>
</figure>
<p>Paid plasma donors can donate up to twice per week and can earn in excess of $500 per month by donating at the maximum frequency and volume of plasma collected, according to <a href="https://giveplasma.ca/donors/compensation/">Canadian Plasma Resources</a>, a company with plasma collection centres in the <a href="https://giveplasma.ca">Prairie provinces as well as New Brunswick</a>. </p>
<p>What caused this policy shift? Essentially: enhanced donor screening, rigorous regulation by both <a href="https://www.canada.ca/en/health-canada/services/drugs-health-products/biologics-radiopharmaceuticals-genetic-therapies/activities/fact-sheets/plasma-donation-canada.html">Health Canada</a> and the U.S. Food and Drug Administration, viral inactivation by heat or solvent processes and synthetic methods to produce some plasma products, namely clotting factors. </p>
<p>Page’s opinion has changed. In an interview, he said he feels that sufficient measures have been put in place to make plasma products safe, and supports using plasma from paid donors as a necessity to meet the health-care needs of Canadians. </p>
<p>In the quarter of a century since the tainted blood scandal there has not been a single case of disease transmission via a blood product in Canada, Page pointed out. He attributed this to enhanced regulatory and safety measures. </p>
<h2>Canada’s plasma supply</h2>
<p>The change in policy reflects a little-recognized truth about Canada’s blood system: It doesn’t come close to meeting the nation’s need.</p>
<p>In 2017 Health Canada established an expert <a href="https://www.canada.ca/en/health-canada/programs/expert-panel-immune-globulin-product-supply-related-impacts-canada/protecting-access-immune-globulins-canadians.html">panel on Immune Globulin Product Supply and Related Impacts</a>. It reported that more than 80 per cent of fractionated plasma products, namely immunoglobulins, comes from imported product, almost all from paid donors in the United States. It has cost CBS more than <a href="https://www.blood.ca/en/about-us/publications-and-reports/annual-reports">$700 million</a> a year. </p>
<p>CBS has set an objective of reducing dependence on imports of plasma-derived immunoglobulins to at least 50 per cent, and must do so “with a degree of urgency” <a href="https://drive.google.com/file/d/1_H5PI2JZFqmD_VP7z1ESDrO5AZmAa0sO/view">says Graham Sher</a>, CEO of CBS. </p>
<p>The new <a href="https://www.grifols.com/en/view-news/-/news/grifols-enters-into-agreement-with-canadian-blood-services-to-accelerate-self-sufficiency-in-immunoglobulins-for-canada">deal with Grifols</a> will provide 2.4 million grams of plasma-derived immunoglobulins, collected from Canadian donors, helping CBS reach its targets. </p>
<p>The company entered the Canadian market in 2011 and has a plasma fractionation plant in Montréal and a plasma collection site in Winnipeg. In addition, Grifols plans to expand paid plasma donor sites in Ontario and British Columbia as agents of CBS. </p>
<p>Neither side will reveal the contract details.</p>
<p>The deal with Grifols, by itself, will not meet CBS’s 50-per-cent target. To make up the difference <a href="https://www.blood.ca/en/about-us/media/newsroom/securing-canadas-plasma-supply">CBS plans</a> to increase its own dedicated plasma collection sites from five to 11 by 2024. CBS’s own plasma donation sites will remain uncompensated. </p>
<h2>Plasma and plasma products</h2>
<figure class="align-center ">
<img alt="Gloved hands holding up an IV bag filled with yellow fluid" src="https://images.theconversation.com/files/491134/original/file-20221021-13-d4alyq.jpg?ixlib=rb-1.1.0&rect=154%2C32%2C5280%2C3837&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/491134/original/file-20221021-13-d4alyq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/491134/original/file-20221021-13-d4alyq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/491134/original/file-20221021-13-d4alyq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/491134/original/file-20221021-13-d4alyq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/491134/original/file-20221021-13-d4alyq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/491134/original/file-20221021-13-d4alyq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Plasma donation can take up to two hours, significantly longer than donating whole blood.</span>
<span class="attribution"><span class="source">(AP Photo/Juan Karita)</span></span>
</figcaption>
</figure>
<p>Plasma differs from the whole blood that is collected for transfusion at donor clinics across the country. </p>
<p>During plasma collection, red and white blood cells and platelets are returned to the donor, leaving a straw-coloured liquid called plasma. This process is called <a href="https://www.canada.ca/en/health-canada/services/drugs-health-products/biologics-radiopharmaceuticals-genetic-therapies/activities/fact-sheets/plasma-donation-canada.html">plasmapheresis</a>. </p>
<p>Essential proteins, such as albumin, clotting factors and immunoglobulins, are recovered from the plasma through <a href="https://www.blood.ca/en/about-us/media/newsroom/plasma-and-blood-system-supply-chain">fractionation</a>.</p>
<p>Such plasma is called “source plasma” and is used only after it has been treated to remove or inactivate viruses and other pathogens. CBS cannot supply sufficient source plasma products, namely immunoglobulins, from unpaid donors, to meet the needs of Canadians and has been buying fractionated plasma products since its inception in 1998. It spent more than $200 million on plasma in 2000 and within the last five years has spent more than <a href="https://annual2019.blood.ca/?_ga=2.139020853.760828163.1666374799-375334784.1662912652&_gl=1*1ba3sb6*_ga*Mzc1MzM0Nzg0LjE2NjI5MTI2NTI.*_ga_YHMRKTXXVD*MTY2NjM3NDc5OS44LjEuMTY2NjM3NTEzNy4wLjAuMA">$700 million per year</a>. </p>
<p>For patients with <a href="https://www.canada.ca/en/health-canada/programs/expert-panel-immune-globulin-product-supply-related-impacts-canada/protecting-access-immune-globulins-canadians.html">immunodeficiencies, those requiring protection from diseases such as rabies or tetanus or Rh-negative pregnant patients</a>, there are no other treatment options. </p>
<h2>Opposition</h2>
<p>Meanwhile, there is still opposition to paying plasma donors. <a href="https://bloodwatch.org/">BloodWatch</a>, a not-for-profit organization, opposes paying donors for plasma or other human tissues. It is a strong proponent of a fully public blood collection system, as is the <a href="https://www.healthcoalition.ca/">Canadian Health Coalition</a>. </p>
<p>BloodWatch cites safety, profit making and potential exploitation of plasma donors as reasons to reject the Grifols deal. A hybrid system of paid and unpaid donors competes with, and compromises, Canada’s ability to become self-sufficient, it argues.</p>
<p>The Canadian Hemophilia Society’s Page disagrees.</p>
<p>“We generally do not make drugs with our public health-care system,” he says, likening fractionated plasma products to drugs. Not least, he adds, plasma collection takes up to two hours, more than twice as long as conventional blood donation. </p>
<p><em>Dr. Sandor Demeter is Fellow of the Dalla Lana Fellowship in Global Journalism</em></p><img src="https://counter.theconversation.com/content/192746/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sandor Demeter does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There has been a monumental policy shift in paying blood plasma donors in Canada.Sandor Demeter, Associate Professor, Community Health Sciences, Rady Faculty of Health Sciences, University of ManitobaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1808432022-10-11T12:18:13Z2022-10-11T12:18:13ZBody piercings may be artistic, but they bring risks of infection, allergic reactions, scarring and urine leakage<figure><img src="https://images.theconversation.com/files/468874/original/file-20220614-14-17d8fw.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4970%2C3492&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Infections, scarring and hepatitis B and C are just some of the health problems caused by body piercing.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-woman-wearing-nose-and-lip-jewelry-portrait-royalty-free-image/DA23334?adppopup=true">Laurence Monneret/The Image Bank via Getty Images</a></span></figcaption></figure><p>Throughout history, body piercing <a href="https://allthatsinteresting.com/history-of-piercing">has been a symbol of beauty</a>, sexuality, ritual initiation and rites of passage. </p>
<p>Mayan royalty had their <a href="https://www.historyonthenet.com/the-maya-concept-of-beauty">tongues and genitals pierced</a>; during the Victorian era, many women <a href="https://www.thevintagenews.com/2018/11/04/victorian-fashion-fad/">pierced their nipples</a>. After World War II, tongue, nipple and genital piercings occurred in Germany. Today, body piercing remains <a href="https://www.newsweek.com/earliest-facial-piercing-africa-ancient-skeleton-1484600">common in tribal societies</a> throughout Africa, Asia and South America. </p>
<p>In the U.S., piercing <a href="https://doi.org/10.1016/j.jadohealth.2007.09.014">became mainstream during the 1990s</a> and is perhaps more popular than ever. </p>
<p>I am a <a href="https://www.umassmed.edu/derm-residency/meet-the-residents/">physician specializing in dermatology</a>. My colleagues and I have seen the medical complications that body piercing can cause. While people shouldn’t necessarily avoid piercings, they should be aware of the risks and best practices. It’s also critical to distinguish relatively safe ear piercings from more problematic and potentially dangerous piercings.</p>
<h2>Infections, scarring and nerve damage</h2>
<p>Medical problems arising from body piercings happen a lot; the incidence of complications could be as high as <a href="https://doi.org/10.1016/j.jadohealth.2007.09.014">one out of every five</a> individuals. </p>
<p>Some problems are relatively minor: jewelry allergy, bleeding, scarring and the formation of keloids, which are thick overgrowths of scar tissue. Nerve damage complications <a href="https://doi.org/10.2165/11593220-000000000-00000">are also possible</a> – and sometimes they affect internal organs or lead to <a href="https://www.sepsis.org/sepsisand/tattoos-body-piercings/">sepsis, a potentially fatal illness</a> that <a href="https://theconversation.com/sepsis-still-kills-1-in-5-people-worldwide-two-icu-physicians-offer-a-new-approach-to-stopping-it-175650">requires immediate medical attention</a>. </p>
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<figcaption><span class="caption">Should children have their ears pierced? A pediatric physician offers advice.</span></figcaption>
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<p>Other complications, less common, include <a href="https://doi.org/10.1086/345755">brain abscess</a> and <a href="https://doi.org/10.1016/j.jadohealth.2008.02.008">endocarditis</a>, a heart inflammation that can be life-threatening. It is unclear how these complications occur, but one hypothesis is that they are caused by infections from needles, perhaps from contaminated equipment used during the piercing.</p>
<p>Body piercing is also associated with transmission of <a href="https://doi.org/10.1097/MD.0000000000001893">hepatitis B and hepatitis C</a>. The risk may be from the piercing procedure. However, it’s also possible that piercings are not the problem; instead, the cause is other high-risk behaviors – drug use, gang affiliations and school truancy, for example – <a href="https://doi.org/10.1016/j.adolescence.2005.06.001">that can be associated with piercings</a>. </p>
<p>It is not uncommon for me to see skin inflammations caused by contact with jewelry metal. The <a href="https://doi.org/10.2165/11593220-000000000-00000">prevalence of the jewelry allergy increases</a> with the increase in the number of piercings a person has. </p>
<p>Up to 30% of people with body piercings are allergic to nickel, which is a common metal found in jewelry. If you have a nickel allergy, you can still wear jewelry, but just avoid nickel and wear platinum, stainless steel or gold instead. But don’t wear white gold – it may contain nickel. </p>
<h2>A warning on tongue and genital piercings</h2>
<p>Oral piercings – which include piercings of the upper or lower lip and tongue – can be associated with <a href="https://doi.org/10.3390/ijerph17020613">gingivitis, teeth chips, cracks and fractures, and gum recession</a>. These are caused by continuous traumatization of teeth and gums when the individual plays with the piercing.</p>
<p>Those with tongue piercings often experience <a href="https://doi.org/10.2165/11593220-000000000-00000">temporary tongue swelling, pain, difficulty eating and excessive salivation</a>. When the tongue or penis are pierced, a small amount of bleeding is expected, but <a href="https://pubmed.ncbi.nlm.nih.gov/12723842/">severe bleeding sometimes can occur</a>.</p>
<p>Indeed, many men with genital piercings <a href="https://doi.org/10.2165/11593220-000000000-00000">have reported complications</a>. The Prince Albert piercing – occurring at the end of the penis – is associated with a narrowing of the opening for urine; sometimes, new tracts are created that leak semen and urine. Rarely, it is associated with <a href="https://doi.org/10.1111/j.1743-6109.2010.01818.x">squamous cell carcinoma of the penis</a>. </p>
<p>Although piercings are generally safe when proper hygiene is followed, it’s critical to know the risks. Make sure you know the safety precautions and <a href="https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/piercings/art-20047317">insist that they are used</a>. Piercing salons may vary in terms of cleanliness and the experience of the practitioner. If you have questions about the establishment performing the piercing, you might try checking with your medical provider.</p>
<p>And a special word of warning for children who are undergoing a piercing: An experienced technician, nurse or doctor should perform the procedure. And because proper care is crucial to <a href="https://doi.org/10.1542/pir.2017-0218">decrease the chances of infection</a>, piercings should occur only once the child is mature enough to care for the area.</p><img src="https://counter.theconversation.com/content/180843/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vijaya Daniel does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Millions of Americans wear jewelry that pierces the ear, nose, lips, tongue and genital areas. But adorning yourself with metal body art can be a health hazard.Vijaya Daniel, Dermatology Resident, UMass Chan Medical SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1828542022-07-27T23:49:30Z2022-07-27T23:49:30ZDirect-acting antivirals can cure hepatitis C and prisons are now leading efforts to eliminate the virus<figure><img src="https://images.theconversation.com/files/473760/original/file-20220713-24-u56z33.jpg?ixlib=rb-1.1.0&rect=198%2C88%2C7139%2C3415&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pharmacist-holding-medicine-box-capsule-pack-1219007800">Shutterstock</a></span></figcaption></figure><p>While most medical attention has been on COVID, work has been underway to eliminate another viral disease, hepatitis C.</p>
<p>In Australia, approximately <a href="https://burnet.edu.au/system/asset/file/5001/BurnetKirby-hepC-2021-report.pdf">120,000 people</a> have hepatitis C. It’s mostly spread through injecting drugs using unsterile equipment. Left untreated, hepatitis C can cause liver damage, leading to cancer, liver failure and even death. </p>
<p>In 2016, Australians with hepatitis C gained access to a highly effective treatment option: direct-acting antivirals. These can cure hepatitis C in eight to 12 weeks. Australia took on the World Health Organization’s goal of eliminating hepatitis C by 2030. </p>
<p>Thousands of Australians commenced treatment. But <a href="https://burnet.edu.au/system/asset/file/5001/BurnetKirby-hepC-2021-report.pdf">numbers have slowed recently</a>, prompting concern the goal of eliminating hepatitis C by 2030 may be unreachable. However, one sector has been making great progress in eliminating hepatitis C: prisons.</p>
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<a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">Explainer: the A, B, C, D and E of hepatitis</a>
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<h2>High rates of drug use among those entering prison</h2>
<p>In Australia and many other countries, the criminalisation of drug use results in the frequent incarceration of people who inject drugs. About <a href="https://kirby.unsw.edu.au/sites/default/files/kirby/report/JHP_National-Prison-Entrants-Report-2004-2007-2010-2013-2016.pdf">half of people entering prison</a> report a history of injecting drugs. </p>
<p>While drug courts and diversion programs help keep some people out of prison, more needs to be done to <a href="https://www.hri.global/files/2021/06/14/HRI_Briefing_Prisons_June2021_Final1.pdf">treat drug use as a health issue</a> rather than a criminal one. </p>
<p>The over-incarceration of people who inject drugs results in high rates of hepatitis C among the prison population. In 2016, of people entering prison who reported injecting drugs, <a href="https://kirby.unsw.edu.au/report/national-prison-entrants-bloodborne-virus-and-risk-behaviour-survey-report-2004-2007-2010">approximately 50%</a> had been exposed to hepatitis C but not all may have had an active infection. This compares with less than 1% of those entering prison who did not report injecting. </p>
<h2>Injecting drug use in prisons</h2>
<p>Imprisonment enables some people to stop using drugs, but others continue to inject, and some start injecting. </p>
<p>No Australian jurisdiction provides sterile injecting equipment to people in prison, despite this being available in the community. The likelihood of syringe sharing in prisons is therefore high, and increases the risk of hepatitis C transmission. </p>
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<a href="https://theconversation.com/prisons-need-better-drug-treatment-programs-to-control-infectious-diseases-62350">Prisons need better drug treatment programs to control infectious diseases</a>
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<p><a href="https://onlinelibrary.wiley.com/doi/10.1111/jvh.12701">One NSW study</a> estimated 10% of people who injected drugs in prison were newly infected each year. </p>
<p><a href="http://dx.doi.org/10.1016/S1473-3099(18)30469-9">Another study</a> found recent incarceration increases the risk of contracting hepatitis C by 62%.</p>
<h2>Access to hepatitis C care in prisons</h2>
<p>Direct-acting antivirals were listed on Australia’s Pharmaceutical Benefits Schedule (PBS) in 2016. These subsidised medicines were made available to all Australians, including people in prison. Prisoners are usually excluded from the federal government’s PBS subsidies, with medication costs falling to states and territories. </p>
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<p>While overall hepatitis C treatment rates stagnated in Australia, the prison sector accounted for a rising percentage of all people treated. Between March 2016 and February 2017, around <a href="https://doi.org/10.5694/mja2.50140">6% (2,052) of all hepatitis C treatments occurred in Australian prisons</a>. In 2020, this rose to <a href="https://burnet.edu.au/system/asset/file/5001/BurnetKirby-hepC-2021-report.pdf">37% (3,005)</a>. </p>
<p>For some people, prison is one of few places they can receive hepatitis C treatment. </p>
<p>A <a href="http://dx.doi.org/10.1016/j.jhep.2019.01.012">pilot evaluation</a> of a nurse outreach program in Victorian prisons found of the 416 people who started direct-acting antiviral treatment, most (86%) had never had hepatitis C care before. </p>
<p>An <a href="https://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(19)30536-5.pdf">additional 75 people</a> were released from prison before they could start treatment. After referral to their preferred physician, only 19 were prescribed direct-acting antivirals within six months of release. Seven of those people were treated only after they were re-incarcerated.</p>
<p>Many people leaving prison face <a href="https://pubmed.ncbi.nlm.nih.gov/34488074/">multiple challenges</a>, including housing instability, poverty, obtaining meaningful and reliable employment, and social connectedness. These are all potential barriers to accessing health care, including hepatitis C treatment.</p>
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Read more:
<a href="https://theconversation.com/incarcerated-people-with-disability-dont-get-the-support-they-need-that-makes-them-more-likely-to-reoffend-185395">Incarcerated people with disability don't get the support they need – that makes them more likely to reoffend</a>
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<p>Treatment in prison can also prevent new infections, as a <a href="https://doi.org/10.1016/S2468-1253(21)00077-7">recent study</a> showed. This same study also saw a reduction in people being reinfected with hepatitis C. </p>
<p>One Queensland prison has <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1753-6405.13238">even reported eliminating hepatitis C</a>. However, new entrants and the lack of prison-based needle and syringe programs have made it difficult to maintain its hepatitis C-free status. </p>
<h2>But prisons have more to do</h2>
<p>While significant progress has occurred, there is more work to be done within the prison sector to accelerate hepatitis C elimination. </p>
<p>Rapid point-of-care hepatitis C tests could be used to diagnose people entering prison, enabling anyone who tests positive to be promptly referred for treatment. </p>
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<img alt="Finger prick test" src="https://images.theconversation.com/files/473801/original/file-20220713-2704-4ivxxp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/473801/original/file-20220713-2704-4ivxxp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/473801/original/file-20220713-2704-4ivxxp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/473801/original/file-20220713-2704-4ivxxp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/473801/original/file-20220713-2704-4ivxxp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/473801/original/file-20220713-2704-4ivxxp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/473801/original/file-20220713-2704-4ivxxp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Point of care tests can promptly diagnose hepatitis C.</span>
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<p>Harm reduction is critical. Strategies proven highly effective in the community should be widely accessible inside prisons, including opioid substitution treatment and needle and syringe programs. Despite widespread support for prison-based needle and syringe programs and <a href="https://www.mja.com.au/journal/2015/203/8/salvaging-prison-needle-and-syringe-program-trial-australia-requires-leadership">international evidence</a> showing that they can operate without compromising safety, no Australian jurisdiction has introduced one. </p>
<p>Many people serving supervised correctional orders in the community are likely to have undiagnosed or untreated hepatitis C. Greater coordination and provision of health services across the criminal justice system – including police detention, the courts and community-based corrective services – will enable more people to be diagnosed and treated.</p>
<p>These measures will reduce rates of hepatitis C in prisons and in the community. </p>
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Read more:
<a href="https://theconversation.com/prisoners-need-drug-and-alcohol-treatments-but-aa-programs-arent-the-answer-102268">Prisoners need drug and alcohol treatments but AA programs aren't the answer</a>
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<p class="fine-print"><em><span>Freya Saich is a member of the Public Health Association of Australia. </span></em></p><p class="fine-print"><em><span>Alexander J. Thompson receives research funding from the National Health and Medical Research Council of Australia. He has received research funding for investigator-initiated projects focused on increasing testing and treatment for people living with hepatitis C, evaluation of novel treatments for people living with hepatitis C and evaluation and validation of novel diagnostics for hepatitis B from the following companies - Gilead Sciences, Abbvie, MSD Australia, Roche Molecular Systems, Inc (Gilead Sciences and Abbvie both produce DAAs that are used in Australia). In his clinical capacity, he has served on advisory boards to the following companies - Abbvie, Gilead Sciences, Roche Diagnostics, BMS, Merck, Immunocore, Janssen, Assembly Biosciences, Arbutus, Vir Biotechnology, Eisai, Ipsen, and Bayer. He has received speaker fees for presenting at educational conferences or seminars from the following companies - Abbvie, Gilead Sciences, Roche, BMS. He is a board member of the Gastroenterology Society of Australia.</span></em></p><p class="fine-print"><em><span>Jacinta A. Holmes receives research funding from the Gastroenterological Society of Australia and has received unrestricted research funding for investigator-initiated projects from Gilead Sciences (who produces DAAs) focused on point of care testing for hepatitis C infection. She has received speaker fees from AbbVie and Gilead Sciences for presenting at conferences, education sessions, and post-conference webinars (which may include updates regarding hepatitis C infection and treatment of hepatitis C infection).</span></em></p><p class="fine-print"><em><span>Rebecca Winter has previously received funding from the National Health and Medical Research Council. She holds an Honorary position at St Vincent's Hospital Melbourne and is an Adjunct Research Fellow at Monash University in the School of Population Health and Preventive Medicine. She is a member of the National Prisons Hepatitis Network.</span></em></p><p class="fine-print"><em><span>Timothy Papaluca does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Direct-acting antivirals can cure hepatitis C in eight to 12 weeks. But while the rate of uptake in Australia has slowed, a greater proportion of those undertaking treatment are in prison.Freya Saich, Lead Policy Officer, Burnet InstituteAlexander J. Thompson, Director, Gastroenterology Department, St Vincent's Hospital, The University of MelbourneJacinta Holmes, Clinical Associate Professor, The University of MelbourneRebecca Winter, Deputy Head, Justice Health Research Group, Burnet InstituteTimothy Papaluca, Assistant researcher, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1715402022-02-01T20:19:01Z2022-02-01T20:19:01ZSome cancers are preventable with a vaccine – a virologist explains<figure><img src="https://images.theconversation.com/files/432047/original/file-20211115-27-1mi04az.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C5825%2C2973&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some strains of the human papilloma virus (HPV) have been associated with cancers, especially cervical cancer.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/human-papilloma-virus-illustration-royalty-free-illustration/713780957?adppopup=true">Kateryna Kon/Science Photo Library via Getty Images</a></span></figcaption></figure><p>One-fifth. Nearly <a href="https://doi.org/10.1128/CMR.00124-13">20% of cancers worldwide</a> are caused by a virus. </p>
<p>These viruses don’t cause cancer until long after they initially infect a person. Rather, the viruses teach the cells they take over how to escape the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117903/">natural biological process of cell death</a>. This strategy sets these altered cells on a path for other genetic changes that <a href="https://doi.org/10.1016/0014-4827(90)90027-8">can cause full-blown cancer</a> years down the road. </p>
<p>As a <a href="https://scholar.google.com/citations?user=LyV-cJVvSncC">microbiologist and researcher of viruses</a>, I seek to understand how viruses affect living cells and the health of the people who are infected. These particular viruses are unique and interesting, both for their effects on patients and because of the potential ways they might be treated or prevented.</p>
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<h2>The viral landscape</h2>
<p>All known viruses can be categorized into one of 22 distinct families. Five of these families are called “<a href="https://doi.org/10.1016/S1470-2045(12)70137-7">persisting</a>,” because once a person is infected, the virus remains in their body for life. One example is the herpes virus that <a href="https://theconversation.com/the-chickenpox-virus-has-a-fascinating-evolutionary-history-that-continues-to-affect-peoples-health-today-168636">causes chickenpox in children</a> and can reappear later in life as shingles. This ability to survive over the long term helps the virus spread from person to person.</p>
<p>There are seven known viruses that can cause cancer. <a href="https://doi.org/10.1007/978-3-030-57362-1_2">Five of them</a> are members of persistent virus families. The <a href="https://www.cdc.gov/std/hpv/stdfact-hpv.htm">human papillomavirus</a>, commonly known as HPV and known to cause cervical cancer, is in the papilloma family. The <a href="https://www.cdc.gov/epstein-barr/about-ebv.html">Epstein-Barr virus</a>, which causes Hodgkin lymphomas, and the <a href="https://www.cancer.org/cancer/kaposi-sarcoma/causes-risks-prevention/what-causes.html">Kaposi’s sarcoma-associated virus</a>, are both in the herpes family. The <a href="https://www.who.int/news-room/fact-sheets/detail/human-t-lymphotropic-virus-type-1">human T-lymphotropic virus</a>, which can cause a type of leukemia, is what’s known as a retrovirus. And <a href="https://dx.doi.org/10.1098%2Frstb.2016.0276">Merkel cell polyoma virus</a>, which causes Merkel cell carcinoma, is in the polyoma family.</p>
<p>All five of these viruses contain genetic code for one or more proteins that teach cells how to avoid cell death, effectively immortalizing them and promoting cell growth. The cancer cells that develop from these oncogenic viruses all contain their original viruses’ genetic information, even when they appear years after the initial infection. But only a small percentage of people who are infected with one of these five oncogenic viruses ultimately develop the full-blown cancer associated with it.</p>
<p>The other two viruses, <a href="https://www.cdc.gov/hepatitis/hbv/index.htm#">hepatitis B</a>, in <a href="https://doi.org/10.1007/978-3-642-69159-1_2">the hepadna family</a>, and <a href="https://www.cdc.gov/hepatitis/hcv/index.htm#">hepatitis C</a>, in the <a href="https://www.ncbi.nlm.nih.gov/books/NBK1630/">flavi family</a>, are somewhat different. Most people infected with <a href="https://doi.org/10.1098/rstb.2016.0274">those viruses</a> are able to fight the infection through their own immunity and <a href="https://doi.org/10.1002/cld.576">eliminate the virus</a>. </p>
<p>However, in people who are not able to fight off the infection, long-term infections of these viruses often cause extensive liver damage. These people are at risk of developing a type of liver cancer called hepatocellular carcinoma, because the body’s attempts to repair the damaged liver tissue increase the chance of a cancer-related mutation. The viruses themselves do not teach the liver cells to become immortal or transform themselves, the way the other five oncogenic viruses do to the cells they target.</p>
<p>These viral-induced cancers are serious health threats. <a href="https://www.mayoclinic.org/diseases-conditions/hepatocellular-carcinoma/cdc-20354552#">Hepatocellular carcinoma</a>, for instance, <a href="https://doi.org/10.3389/fonc.2021.686962">kills approximately 800,000 people a year</a>, making it the third-deadliest cancer globally. About three-quarters of those killed have had hepatitis virus infections in the past.</p>
<p>HPV is similarly dangerous. The cervical cancer it causes <a href="https://doi.org/10.1016/S2214-109X(19)30482-6">kills some 311,000 people a year</a> worldwide, making it the deadliest cancer in women until recently. That number includes <a href="https://www.cdc.gov/cancer/hpv/statistics/index.htm">36,000 women in the U.S.</a> But HPV doesn’t just put women at risk. A similar number of people in the U.S. die each year from anal and throat cancers linked to HPV.</p>
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<img alt="A schoolgirl receives the HPV vaccination." src="https://images.theconversation.com/files/432049/original/file-20211115-17-1d9ea9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/432049/original/file-20211115-17-1d9ea9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=433&fit=crop&dpr=1 600w, https://images.theconversation.com/files/432049/original/file-20211115-17-1d9ea9b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=433&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/432049/original/file-20211115-17-1d9ea9b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=433&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/432049/original/file-20211115-17-1d9ea9b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=544&fit=crop&dpr=1 754w, https://images.theconversation.com/files/432049/original/file-20211115-17-1d9ea9b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=544&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/432049/original/file-20211115-17-1d9ea9b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=544&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The HPV vaccine is recommended for all children and adolescents, starting at age 11.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/schoolgirl-getting-vaccinated-royalty-free-image/871552754?adppopup=true">Peter Dazeley/The Image Bank via Getty Images</a></span>
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<h2>Reasons for optimism</h2>
<p>The <a href="https://www.elsevier.com/connect/the-hpv-vaccine-10-years-on">first viral vaccine to protect against HPV infection</a> and its <a href="https://www.kff.org/womens-health-policy/fact-sheet/the-hpv-vaccine-access-and-use-in-the-u-s/">associated cancers</a> was approved for use in the U.S. in 2006. It has proved to be <a href="https://www.theguardian.com/society/2021/nov/04/its-incredible-hpv-vaccine-saves-thousands-of-women-from-cervical-cancer-uk-study-shows">highly effective at preventing both HPV infection</a> and the <a href="https://www.cancer.gov/news-events/cancer-currents-blog/2020/hpv-vaccine-prevents-cervical-cancer-sweden-study">subsequent development of cervical carcinoma</a>. </p>
<p>HPV vaccines are now widely available around the globe. The HPV vaccine is <a href="https://www.mayoclinic.org/diseases-conditions/hpv-infection/in-depth/hpv-vaccine/art-20047292">safe, with very mild side effects</a>. It is recommended for children starting <a href="https://www.cdc.gov/vaccines/parents/diseases/hpv.html#">at ages 11 to 12</a>, since different individuals become sexually active at different ages. The <a href="https://www.cdc.gov/vaccines/vpd/hpv/hcp/vaccines.html">protective effects</a> of the vaccine <a href="https://www.cdc.gov/vaccines/vpd/hpv/hcp/safety-effectiveness.html">last beyond</a> <a href="https://kidshealth.org/en/teens/hpv-vaccine.html">10 years</a>, and booster shots are available. </p>
<p>Older people – typically up to 26 years of age – can also receive the HPV vaccine. By preventing infection in the first place, the vaccine also prevents the subsequent cancers that may result from a viral infection. </p>
<p>The vaccine for hepatitis B virus has been similarly successful over a longer time period. Introduced in 1986, it was recognized as <a href="https://www.hepb.org/prevention-and-diagnosis/vaccination/history-of-hepatitis-b-vaccine/">the first anti-cancer vaccine</a>. Since then, <a href="https://www.hepb.org/what-is-hepatitis-b/what-is-hepb/facts-and-figures/">more than a billion people</a> worldwide have received it. The vaccine <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">has been shown</a> to be <a href="https://www.hepb.org/prevention-and-diagnosis/vaccination/">extremely safe and effective</a>. </p>
<h2>Vaccines save lives</h2>
<p>The numbers of cancers prevented and lives <a href="https://canceratlas.cancer.org/taking-action/vaccines/">saved by the vaccines</a> against the hepatitis B virus and human papillomavirus are enormous and indisputable. Yet, as with the resistance to COVID-19 vaccines, vaccine hesitancy is an ongoing problem. In 2019, 46% of adolescents ages 13 to 17 in the U.S. had not received their <a href="https://www.cdc.gov/hpv/partners/outreach-hcp/hpv-coverage.html">recommended HPV vaccines</a>. In 2020 in Mississippi, <a href="https://www.americashealthrankings.org/explore/annual/measure/Immunize_HPV/state/MS">HPV vaccine coverage in adolescents</a> reached a meager 32%.</p>
<p>But the U.S. is better off than some other industrialized nations. In Japan, the current rate of HPV vaccine coverage in adolescents is less than 1% because of false reports of adverse events in 2013. Despite <a href="https://dx.doi.org/10.1186%2Fs12889-019-7097-2">repeated, definitive discrediting of these claims</a>, vaccine uptake in Japan has not rebounded.</p>
<p>Vaccination campaigns have eradicated <a href="https://www.cdc.gov/smallpox/index.html">smallpox</a> and effectively eliminated <a href="https://www.cdc.gov/polio/what-is-polio/polio-us.html">polio</a>, <a href="https://www.cdc.gov/measles/about/history.html">measles</a> and certain other infectious diseases. Let’s hope that ongoing vaccine efforts can make HPV-induced cancers and hepatitis B virus-induced cancers a thing of the past as well.</p><img src="https://counter.theconversation.com/content/171540/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ronald C. Desrosiers receives funding from the National Institutes of Health. </span></em></p>Some cancers are actually caused by viruses that linger for long periods in the body, or cause physical damage that later turns cancerous.Ronald C. Desrosiers, Professor of Pathology, Vice-chair for Research, University of MiamiLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1613722021-05-26T18:08:54Z2021-05-26T18:08:54ZPasha 108: Some good news in the fight against hepatitis C in Africa<figure><img src="https://images.theconversation.com/files/402365/original/file-20210524-21-1g5ey8d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>Globally, there are around 71 million people with hepatitis C. In Africa, more than 10 million people are infected with the virus.</p>
<p>The new oral therapies that have been developed to treat hepatitis C are much more effective and easier to take than the previous injections, and have fewer side effects.</p>
<p>In high-income countries, these drugs are known to work well. But the number of strains of the virus is limited in those countries. So it wasn’t known how useful the new drugs would be to treat other strains, mostly found in low-income countries. Over time the virus has become extremely genetically diverse.</p>
<p>A new study shows that the direct-acting antiviral drugs are also effective against more of the strains. They were shown to work against almost all the hepatitis C virus strains found across Africa. </p>
<p>This is valuable information for health systems in countries that have a limited infrastructure to diagnose infection, treat those who are infected and confirm that treatment has been successful. They need to know what works. </p>
<p>In today’s episode of Pasha, researchers John McLauchlan and Elihu Aranday-Cortes discuss hepatitis C and why the findings of their study are good news for low-income settings. </p>
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Read more:
<a href="https://theconversation.com/new-drugs-work-against-the-many-strains-of-hepatitis-c-found-in-african-countries-159462">New drugs work against the many strains of hepatitis C found in African countries</a>
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<p><strong>Photo:</strong><br>
“Destruction of hepatitis C virus, 3D illustration. Conceptual image for hepatitis C treatment” by Kateryna Kon found on <a href="https://www.shutterstock.com/image-illustration/destruction-hepatitis-c-virus-3d-illustration-525545272">Shutterstock</a></p>
<p><strong>Music:</strong>
“Happy African Village” by John Bartmann, found on <a href="http://freemusicarchive.org/music/John_Bartmann/Public_Domain_Soundtrack_Music_Album_One/happy-african-village">FreeMusicArchive.org</a> licensed under <a href="https://creativecommons.org/publicdomain/zero/1.0/">CC0 1</a>.</p>
<p>“Gimme That African Vibe by John Bartmann found on <a href="https://freemusicarchive.org/music/John_Bartmann/happy-trappy-positive-urban-beats/gimme-that-african-vibe">FreeMusicArchive.org</a> licensed under <a href="https://creativecommons.org/licenses/by/4.0">Attribution 4.0 International License.</a>.</p><img src="https://counter.theconversation.com/content/161372/count.gif" alt="The Conversation" width="1" height="1" />
New direct-acting antiviral drugs would work successfully in countries where numerous different strains of hepatitis C are found.Ozayr Patel, Digital EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1594622021-05-02T07:46:06Z2021-05-02T07:46:06ZNew drugs work against the many strains of hepatitis C found in African countries<figure><img src="https://images.theconversation.com/files/396794/original/file-20210423-13-1cznrtx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The hepatitis C virus has become extremely genetically diverse.</span> <span class="attribution"><span class="source"> Tashatuvango/shutterstock</span></span></figcaption></figure><p>Around the world, <a href="https://www.thelancet.com/journals/langas/article/PIIS2468-1253(16)30181-9/fulltext">71 million</a> people have been infected with the hepatitis C virus. The primary route of infection is through direct contact with another person’s blood. This means the virus can be transmitted in a number of ways, including intravenous drug use, tattooing, contaminated blood or blood products and surgical procedures.</p>
<p>Infection with this virus can lead to severe disease of the liver. Annually, there are about <a href="https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en/">400,000 deaths</a> resulting from the effects of infection. If the body fails to naturally clear the virus within a few weeks of initial infection, then it can remain in the liver for decades. This may gradually lead to cirrhosis or liver cancer. In addition, those carrying the virus are often stigmatised, which may prevent people from coming forward for testing or treatment.</p>
<p>There’s no vaccine available to prevent infection. For more than <a href="https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/hep.27377">20 years</a>, the only available treatment for infection relied on weekly injections of interferon combined with an oral drug called ribavirin. But this treatment was only successful in curing between <a href="https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en/">40% and 65%</a> of those who were infected. And it frequently led to adverse <a href="https://aasldpubs.onlinelibrary.wiley.com/doi/abs/10.1002/hep.510260720">side effects</a> (such as fatigue, nausea and depression) that could continue after treatment stopped. </p>
<p>Within the past few years, a <a href="https://www.thelancet.com/action/showPdf?pii=S2589-5370%2819%2930242-1">new series of drugs</a> called direct-acting antivirals have been developed, which give a much higher rate of curing infection (exceeding 90%). These drugs only need to be taken orally, and have very few side effects. They also require a relatively short course of treatment for 12 weeks – compared to as long as 48 weeks for interferon-based therapy.</p>
<p>The hepatitis C virus has evolved in different human populations for hundreds or even thousands of years. Over time the virus has become extremely genetically diverse. But the number of strains is limited in high-income countries where the new drugs are in use and known to be effective. </p>
<p>The question we sought to answer in our <a href="https://academic.oup.com/jid/advance-article/doi/10.1093/infdis/jiab110/6154708">recent research</a> was whether direct-acting antivirals would be effective in areas where many more strains are found, which are primarily low-income countries. Our findings show that these drugs would indeed be effective against most strains. This information is invaluable to countries with scarce treatment resources. More effective use of such resources ultimately will save more lives. </p>
<h2>Testing new treatments</h2>
<p>Our study examined a large cohort of people born in 32 African countries but living in the UK, who were infected with strains of the hepatitis C virus found in their country of birth. </p>
<p>Most of this group had received direct-acting antivirals to treat their infection. So we were able to combine an analysis of the genetic diversity of the hepatitis C virus strains with which they were infected and whether treatment had been successful. </p>
<p>Overall, we showed that direct-acting antivirals were very effective against almost all the hepatitis C virus strains found across Africa. There were two strains that did not respond well to some treatment combinations. But re-treating people with a different set of direct-acting antivirals led to successful cure in most cases.</p>
<p>This study is important because low-income countries face numerous challenges with hepatitis C virus infection. </p>
<p>In Africa, more than <a href="https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en/">10 million people</a> are infected with the virus. Most countries have a limited infrastructure to diagnose infection, treat those who are infected and confirm that treatment has been successful. In addition, the cost of direct-acting antivirals places an economic burden on many countries. </p>
<p>Therefore, it is important to catalogue all possible diverse strains of the virus and determine whether they respond to direct-acting antivirals treatment. The main problem with hepatitis C virus diversity is that some strains can have natural resistance to treatment. Since confirming successful treatment of infection is an added burden for low-income countries, it is crucial that the most appropriate direct-acting antivirals combinations are used in settings where potentially resistant strains may circulate. </p>
<h2>Improving treatment in Africa</h2>
<p>Our study shows that more potent direct-acting antiviral drugs would work successfully in countries where numerous different strains are found, including those with strains that are resistant to some of the less potent direct-acting antivirals combinations. </p>
<p>Hence our study feeds into the information needed to select the best suite of drugs for curing hepatitis C in low-income environments. Moreover, since the World Health Organisation has mandated the global elimination of hepatitis C by <a href="https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en/">2030</a>, our study contributes to that goal by confirming the crucial role that direct-acting antivirals will play.</p><img src="https://counter.theconversation.com/content/159462/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John McLauchlan receives funding from the UK Medical Research Council and the Medical Research Foundation. </span></em></p>Direct-acting antivirals have mostly been used in countries with high incomes. These drugs would be effective against most hepatitis C strains. which are primarily low-income countries.John McLauchlan, Professor of Viral Hepatitis, University of GlasgowLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1475532020-10-07T17:17:29Z2020-10-07T17:17:29ZHow an Alberta researcher’s discovery of hepatitis C led to the Nobel Prize and saved lives<figure><img src="https://images.theconversation.com/files/362247/original/file-20201007-24-1eo4lzg.jpg?ixlib=rb-1.1.0&rect=107%2C44%2C2766%2C1917&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hepatitis C led to an estimated 400,000 deaths in 2016.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>This year, the Nobel Prize in physiology or medicine was awarded to virologists Harvey J. Alter and Charles M. Rice and biochemist Michael Houghton for the <a href="https://www.nobelprize.org/prizes/medicine/2020/summary/">discovery of the hepatitis C virus</a>. This recognition is yet a further testimonial of the need for discovery research to address the ravages of viral disease.</p>
<p>Hepatitis C infection led to <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-c">an estimated 400,000 deaths in 2016</a>. Similar to the SARS-CoV-2 virus that causes COVID-19, hepatitis C is an RNA virus. However, hepatitis C enters the body through the blood stream, where it then attacks the liver to lead to cirrhosis and liver cancer. </p>
<p>There is no vaccine for hepatitis C virus, but the basic science discoveries of the Nobel laureates have contributed to the development of <a href="https://www.nobelprize.org/prizes/medicine/2020/press-release/">antiviral drugs</a>. </p>
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<a href="https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="From left, Harvey J. Alter, Michael Houghton and Charles M. Rice." src="https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">This combination of photos shows, from left, Harvey J. Alter, Michael Houghton and Charles M. Rice, who jointly won the Nobel Prize for medicine on Oct. 5, 2020, for their discovery of the hepatitis C virus. The major source of liver disease affects millions worldwide.</span>
<span class="attribution"><span class="source">(Rhoda Baer/National Institutes of Health, Richard Siemens/University of Alberta, AP Photo/John Minchillo)</span></span>
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<h2>Chimpanzee No. 910</h2>
<p>In 1989, Houghton — alongside biochemist Qui-Lim Choo, geneticist Amy Weiner and virologists George Kuo, Lacy Overby and Daniel Bradley — reported the <a href="http://doi.org/10.1126/science.2523562">discovery of a new virus they named hepatitis C</a>. At the time, nothing was known about this virus. </p>
<p>So, how did the researchers go about deciphering experimental information to come up with the identification of a new virus? The team infected chimpanzees with <a href="https://doi.org/10.1111/j.1478-3231.2008.01925.x">serum from a patient diagnosed with hepatitis of unknown cause</a>. The key experimental animal was a chimpanzee named No. 910; DNA and RNA were extracted from its plasma. </p>
<p>Using molecular biology techniques of the time, complementary DNA was made in the test tube to the nucleic acids extracted from the chimpanzee plasma. The complementary DNA was then inserted into a bacterial virus known as a bacteriophage lambda. These bacterial viruses are used to infect E. coli to make proteins in large quantities. </p>
<h2>New virus discovery</h2>
<p>To the amazement of Houghton and his team, the serum from a hepatitis patient contained antibodies that recognized proteins made in this way. These antibodies had detected a previously unknown lethal virus. Further experimentation with rigorous controls established that this represented a new RNA virus. A <a href="http://doi.org/10.1126/science.2496467">blood test</a> was developed to detect patients infected with this virus they had discovered.</p>
<p>In 1975, Howard Alter discovered a form of lethal hepatitis in <a href="https://doi.org/10.1016/S0140-6736(75)90234-2">some patients who had received blood transfusions</a>. Later, Charles Rice proved <a href="http://doi.org/10.1126/science.277.5325.570">that the virus Houghton and his colleagues had discovered was the cause of this form of hepatitis</a>.</p>
<h2>Biotech Nobels</h2>
<p>The Nobel Prize recognizes the work he conducted at the biotech company Chiron Corporation. The discovery is not the first Nobel Prize given to a biotech discovery — the polymerase chain reaction method, or PCR, used today to test for the SARS-CoV-2 virus is also a consequence of a biotech discovery. This <a href="https://www.jstor.org/stable/24996713">discovery was made by Kary Mullis</a>, who received the <a href="https://www.nobelprize.org/prizes/chemistry/1993/mullis/facts/">1993 Nobel Prize in chemistry</a> for his work done at Cetus Corporation, one of the first biotechnology companies. </p>
<p>The innovations exemplified by these two Nobel Prizes heralds a new direction in discovery research through the talent and resources attracted to biotechnology via venture capital.</p>
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Read more:
<a href="https://theconversation.com/the-road-to-covid-19-testing-the-role-of-a-canadian-biotech-pioneer-143176">The road to COVID-19 testing: The role of a Canadian biotech pioneer</a>
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<p>Houghton and his team developed a hepatitis C vaccine that is now in pre-clinical testing. He is also at the front lines of addressing the COVID-19 pandemic. His current research — <a href="https://cihr-irsc.gc.ca/e/52175.html">funded by the Canadian Institutes of Health Research</a> — aims to develop a vaccine against the key protein of these viruses that infects humans.</p>
<p>Houghton was recruited to Canada in 2010 in part through the Canada Excellence Research Chair program. Houghton’s 10 years in Edmonton as Director of the Li Ka Shing Applied Virology Institute has already <a href="https://edmontonsun.com/opinion/columnists/hicks-on-biz-u-of-a-researchers-hot-on-the-trail-of-covid-19">led to the development of drugs for hepatitis C, as well as others that might be used to treat COVID-19</a>.</p>
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<figcaption><span class="caption">Michael Houghton was named as the Canada Excellence Research Chair in Virology in 2010.</span></figcaption>
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<p>Until recently, Canadian health research leaders could be funded for their research through the <a href="https://cihr-irsc.gc.ca/e/51524.html">Foundation Grants program of CIHR</a>. Regrettably, this <a href="https://cihr-irsc.gc.ca/e/51431.html">program has now been terminated</a>. This may be jeopardizing our hope for sustained excellence at the highest level to assure that we have the best talent for discovery research.</p>
<p>The recognition to Houghton in Alberta will hopefully embolden efforts to support our trailblazers throughout Canada, as we navigate through the COVID-19 pandemic.</p>
<p><em>John Bergeron gratefully acknowledges Kathleen Dickson as co-author.</em></p><img src="https://counter.theconversation.com/content/147553/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Bergeron does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Michael Houghton, an Edmonton-based virologist, was one of the recipients of this year’s Nobel Prize for physiology or medicine for the discovery of hepatitis C.John Bergeron, Emeritus Robert Reford Professor and Professor of Medicine, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1475212020-10-05T13:58:29Z2020-10-05T13:58:29ZA researcher reflects on progress fighting hepatitis C – and a path forward<figure><img src="https://images.theconversation.com/files/361658/original/file-20201005-20-uz1dfq.jpg?ixlib=rb-1.1.0&rect=180%2C167%2C4412%2C2923&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The hepatitis C virus was discovered in 1989 – research that's now earned a Nobel Prize.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/hepatitis-c-virus-hcv-causes-blood-borne-hepatitis-news-photo/1158016725">BSIP/Universal Images Group via Getty Images</a></span></figcaption></figure><p>When I began my medical career in Hong Kong in the early 1980s, I chose to focus on hepatitis B, in part because it was very common and because the hepatitis C virus had not yet been discovered. I witnessed the devastation that this virus caused – cirrhosis, liver failure and liver cancer – and the lack of treatments we could offer to patients.</p>
<p>Back then, scientists knew there was another type of hepatitis, but no one could identify it, so we called it non-A, non-B hepatitis. I would never have imagined that during the course of my career I would witness the <a href="http://doi.org/10.1126/science.2523562">discovery of what came to be known as hep C</a> and the <a href="http://doi.org/10.1056/NEJMoa1402454">development of a cure</a> for nearly all patients with <a href="http://doi.org/10.1056/NEJMoa1402355">chronic hepatitis C in 2014</a>.</p>
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<a href="https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="three scientist projected on screen at announcement" src="https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=459&fit=crop&dpr=1 754w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=459&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=459&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Announcement that the 2020 Nobel Prize in Physiology or Medicine will go to three researchers who identified the hepatitis C virus.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/nobel-committee-members-patrik-ernfors-and-gunilla-karlsson-news-photo/1228905071">Jonathan Nackstrand/AFP via Getty Images</a></span>
</figcaption>
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<p>Underscoring the importance of these discoveries for global human health, this year’s <a href="https://www.nobelprize.org/prizes/medicine/2020/summary/">Nobel Prize in Physiology or Medicine</a> was awarded jointly to Harvey J. Alter, Michael Houghton and Charles M. Rice for the discovery of the hepatitis C virus.</p>
<p>The development of treatments over the past 30 years reflects the amazing progress the field has made in tackling hepatitis C in a relatively short period of time. Initially, in the late 1980s, before a diagnostic test became available, some physicians started treating well-characterized cases of non-A, non-B hepatitis (hep C) with interferon, a natural protein that the body makes to fight viruses, and ribavirin, an antiviral drug. These medications were not specifically developed for hepatitis C, had to be given as injections for 6-12 months, had many side effects and resulted in a cure in only half of the patients who received treatment. It took more than two decades for the first direct-acting antiviral drugs to be approved by the FDA. </p>
<p>I remember the excitement when I and my colleagues tested one of the new drug combinations in patients and saw the virus count drop from more than 1 million to less than 20 within two weeks. <a href="http://doi.org/10.1056/NEJMoa1104430">We published the results</a> of our pilot study in the New England Journal of Medicine in 2012. Although the study involved only 21 patients, it was considered a watershed moment because it was the first study to prove that a combination of oral pills without interferon can cure hepatitis C.</p>
<p>Effective treatment for hepatitis C has become even more relevant today in light of the recent surge in new cases of hepatitis C due to rising opioid use.</p>
<h2>A pricey drug and new generics</h2>
<p>The first combo pill with two drugs that inhibits different steps in hepatitis C replication was <a href="http://www.gilead.com/news/press-releases/2014/10/us-food-and-drug-administration-approves-gileads-harvoni-ledipasvirsofosbuvir-the-first-oncedaily-single-tablet-regimen-for-the-treatment-of-genotype-1-chronic-hepatitis-c">approved by the FDA in 2014</a>. This pill is taken once a day for 8-12 weeks, has little to no side effects and improved the cure rate to 90-95%. It was hailed as a magical cure, but it came with a price tag of US$94,500 for a 12-week course of treatment. That led many insurers in the United States and national health departments in other countries to limit access to treatment. </p>
<p>Since then, <a href="http://doi.org/10.1056/NEJMoa1512610">several other</a> <a href="http://doi.org/10.7326/M15-0785">combo pills with</a> <a href="http://doi.org/10.1056/NEJMoa1702417">similar cure rates</a> that are equally well-tolerated have become available, and the cost has markedly decreased. In addition, low-cost generics and special pricing arrangements are available in many resource-limited countries. </p>
<p>While the current price of hepatitis C virus drugs is still very high, one needs to remember that for 95 percent of patients, this is a cure. It is unlike medicines for many illnesses that need to be taken for a long time, sometimes for the rest of the patients’ lives. Indeed, a cure for hepatitis C virus has allowed some patients who were on the liver transplant waiting list to <a href="https://doi.org/10.1016/j.jhep.2016.05.010">reverse their liver failure</a>, making transplantation unnecessary. This is good news not only for these patients but also for others on the waiting list. </p>
<p>The remarkable success of hepatitis C treatment has reenergized efforts to find a cure for hepatitis B. Current treatments can suppress hepatitis B virus replication but do not eliminate it. Most patients need to be on long-term treatment to prevent flare-ups of hepatitis when the virus reemerges after treatment is stopped. </p>
<h2>Deaths from hepatitis B and C infections rising worldwide</h2>
<p>Learning from the hepatitis C experience and with better understanding of the biology of hepatitis B virus and improved animal models, pharmaceutical companies are developing <a href="https://doi.org/10.1002/hep.29323">drugs that target different steps of the hepatitis B virus life cycle</a>. While a cure for hepatitis B will be more challenging because it can integrate into the patient’s DNA, enabling it to evade the patient’s immune response, I am optimistic that we will witness the availability of new combinations of drugs that will move us nearer the goal of a hepatitis B cure. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Members of Delhi Network of Positive People, a support group for HIV-positive people, in 2014 urged the Indian government to allow production of generic versions of direct-acting antivirals that could help thousands get affordable oral doses of medicine to control hepatitis C. Infection progresses more rapidly to damage the liver in HIV-positive patients.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/India-Health/14d6bce6d8fe430db7970e2bce717083/4/0">Saurabh Das/AP Photo</a></span>
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<p>But the news is not all positive. While we’ve seen mortality rates from HIV, tuberculosis and malaria decline in recent years, deaths from hepatitis B and C have risen. Globally, an estimated <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">257 million people have chronic hepatitis B virus infection</a>, and <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-c">71 million have chronic hepatitis C virus</a>. Together hepatitis B and C caused more than 1.34 million deaths in 2015. This led the World Health Organization to challenge countries around the world to develop national plans to <a href="http://apps.who.int/iris/bitstream/handle/10665/206453/WHO_HIV_2016.04_eng.pdf?sequence=1">eliminate these two viruses by 2030</a>. </p>
<p>Hepatitis B virus and hepatitis C virus are usually spread through contact with blood or body secretions such as semen from infected persons by sharing needles or sexual exposure. But they can also be spread through contaminated needles used for medical treatment, which continues to happen in many parts of the world. In addition, hepatitis B virus can be spread from infected mothers to newborn babies unless vaccination is given immediately after birth. </p>
<p>For people with hepatitis C virus, roughly two-third suffer chronic infection. For hepatitis B virus, the chance of chronic liver infection decreases the later the patient encounters the virus: the likelihood is 90% if infected during infancy; 20-30% if infected during childhood; and 2-5% if infected in adult life. Some people infected with hepatitis B virus or hepatitis C virus can recover on their own, but many develop chronic infections lasting more than six months and often years or lifelong. Those with chronic infection are at risk of cirrhosis (severe liver damage), liver failure and liver cancer. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">In 2017, a San Diego family was among several hundred people living in a campground for the homeless, set up to curb the worst hepatitis A outbreak in the United States in decades.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Homeless-Crisis-on-the-Coast-San-Diego/b0d09b99f82249138623efa6177d2e5f/33/0">Gregory Bull/AP Photo</a></span>
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<h2>Opioid epidemic, homeless lead to rise in hepatitis B and C infections</h2>
<p>In the United States, the number of new hepatitis B virus and hepatitis C virus infections has been decreasing for many years, but <a href="http://doi.org/10.2105/AJPH.2017.304132">this trend has been reversed</a> during recent years <a href="http://doi.org/10.1056/NEJMp1716871">due to the opioid epidemic</a> as more people use injection drugs, share needles or other paraphernalia and practice high-risk sexual behavior. This is particularly true for hepatitis C, where the number of new cases in the past 10 years has more than doubled, highlighting the need for a preventive vaccine, which is a vital tool to eliminate hepatitis C. The increase in number of new cases of hepatitis B is smaller and mainly seen in adults in their 30s because most younger persons have benefited from hepatitis B virus vaccination. </p>
<p>When we talk about viral hepatitis, the focus is on hepatitis B and C because they can cause chronic infection, while hepatitis A causes only acute infection and will not lead to cirrhosis or liver cancer. However, since 2016, many states in the U.S. have witnessed outbreaks of hepatitis A. The Centers for Disease Control and Prevention received more than 2,500 reports of hepatitis A between January 2017 and April 2018 associated with person-to-person transmission, with risk factors in <a href="https://emergency.cdc.gov/han/han00412.asp">two-thirds of these cases being drug use or homelessness</a> or both. In Michigan, where I live, 859 cases of hepatitis A, including 27 deaths, were reported between July 2016 and June 2018. We can prevent hepatitis A through vaccination and improved hygienic conditions. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=863&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=863&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=863&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1085&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1085&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1085&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">World Hepatitis Day is celebrated on July 28, the birthday of Dr. Baruch S. Blumberg, a Philadelphia researcher who shared the 1976 Nobel Prize in physiology or medicine for his discovery of the hepatitis B virus.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Obit-Blumberg/af5f0cf91a8a473582fb4fb5cf5106b8/1/0">Eddie Adams/AP Photo</a></span>
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<p>World Hepatitis Day occurs annually on July 28, a day chosen in honor of the late Baruch Blumberg, who received a Nobel Prize for discovering the hepatitis B virus. Today is another cause for celebration as a second Nobel is awarded for hepatitis research, this time for the discovery of hepatitis C virus. I marvel at how much progress we have made in the last three decades and am delighted to be not just an observer but also a contributor to the progress. Our work is not finished. Much more needs to be done to completely eliminate new cases of viral hepatitis and deaths from chronic hepatitis B and C. </p>
<p><em>This is an updated version of an <a href="https://theconversation.com/the-thrill-of-curing-hepatitis-c-and-the-pain-of-watching-the-disease-surge-with-opioid-abuse-99568">article originally published in July 2018</a>. It has been updated to include news of the 2020 Nobel Prize.</em></p><img src="https://counter.theconversation.com/content/147521/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna Suk-Fong Lok has served on advisory panels of Roche, Viravaxx, and Spring Bank. She receives research funding from Bristol-Myers Squibb, Gilead, the National Institutes of Health, and the Patient Center for Outcome Research Institute provided to the University of Michigan. </span></em></p>The 2020 Nobel Prize for Physiology or Medicine goes to the discoverers of the hepatitis C virus. There’s an effective cure but homelessness and the opioid epidemic are driving a surge in infections.Anna Suk-Fong Lok, Professor of Internal Medicine, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1432082020-07-27T16:03:20Z2020-07-27T16:03:20ZWhy Nigeria must find everyone who has hepatitis and doesn’t know it<figure><img src="https://images.theconversation.com/files/349477/original/file-20200726-35-zkdsr6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/nurse-from-the-orange-county-florida-health-department-news-photo/1161105795?adppopup=true">Paul Hennessy/SOPA Images/LightRocket via Getty Images </a></span></figcaption></figure><p>World Hepatitis Day – 28 July – is an opportunity <a href="https://www.who.int/campaigns/world-hepatitis-day">to raise awareness of hepatitis</a> and encourage commitments of governments, policy makers and the public towards eradication of this dangerous disease. </p>
<p>The World Health Organisation has chosen “hepatitis free future” as its <a href="https://www.who.int/campaigns/world-hepatitis-day">theme</a> this year and is focusing on prevention of hepatitis B among mothers and newborns. The World Hepatitis Alliance has chosen the theme <a href="https://www.worldhepatitisday.org/">“find the missing millions”</a> – the millions of people who have hepatitis B but are not aware of it. </p>
<p>In Nigeria alone, there could be <a href="https://www.hepb.org/blog/journey-hepatitis-elimination-nigeria/#:%7E:text=Nigeria%2C%20with%20an%20estimated%20population,Impact%20Survey(NAIIS)%20report.">about 15 million people</a> who are unaware that they are infected. The danger of this is that some of them could go on to develop liver disease, including cancer. They could also continue to infect others around them, especially family members and sexual partners. This is why it is important to screen family members and sexual contacts of anyone diagnosed with hepatitis B virus infection.</p>
<p>Hepatitis means inflammation of the liver and viral causes are the most common. </p>
<p>There are five types of hepatitis virus, named A, B, C, D and E. Hepatitis B (HBV) and C (HCV) are the most common cause of long-term liver damage, accounting for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6232563/">about 90% of deaths</a> from viral hepatitis. Hepatitis D virus is not a complete virus and can only affect those who already had hepatitis B. </p>
<p>Hepatitis A & E viruses are transmitted by faeco-oral routes. Faeco-oral routes means pathogens in faecal particles pass from one person to the mouth of another person. This is usually as a result of poor hygiene and lack of adequate sanitation. </p>
<p>Hepatitis B, C and D are transmitted through vertical transmission, child to child transmission, transfusion of unscreened blood, use of unsterilised equipment for surgical procedures, indiscriminate use of sharp objects such as local circumcision, tribal marking, ear piercing, tattoos, reuse of needles and syringes and unprotected sexual intercourse. Vertical transmission refers to passage of a pathogen from mother to baby immediately before and after birth. It might occur through direct contact during or after birth.</p>
<h2>Prevalence</h2>
<p>HBV and HCV are international public health problems, chronically infecting <a href="https://www.hepb.org/what-is-hepatitis-b/what-is-hepb/facts-and-figures/">292 million</a> and <a href="https://idpjournal.biomedcentral.com/articles/10.1186/s40249-019-0528-6#:%7E:text=Global%20epidemiology%20of%20HCV%20infection,ranging%20from%200.5%20to%206.5%25.">71 million</a> people respectively worldwide. The two viruses cause <a href="https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en/">about 1 million deaths annually</a>. But the burden of hepatitis is not evenly spread. The sub-Saharan African and Western Pacific regions account for <a href="https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en/">about 68% of all chronic hepatitis B infections</a>. The reason for this discrepancy is the delay in the availability of vaccines and frequency of risky behaviours in these regions.</p>
<p>A recent <a href="https://www.hepb.org/blog/journey-hepatitis-elimination-nigeria/">study</a> in Nigeria found the prevalence of hepatitis B and C in the country to be 8.1% and 1.1% of the population respectively. This means that about 19 million Nigerians have hepatitis B or C. We found in <a href="https://pubmed.ncbi.nlm.nih.gov/32096684/">our research</a> that about 11% of Nigerian patients with hepatitis B also had hepatitis D. The co-existence of hepatitis B and D is a greater threat to liver health than hepatitis B virus alone.</p>
<p>Unfortunately, most patients with hepatitis B and hepatitis C infections are asymptomatic and can remain so until the liver is significantly damaged. The World Health Organisation has <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">estimated</a> that only about 10% and 19% of patients with chronic HBV and HCV are aware of their infections. Hepatitis B and C viruses could lead to <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b#:%7E:text=A%20small%20subset%20of%20persons,the%20liver">liver cancer</a> if not properly treated. The median survival of patients with hepatocellular carcinoma (liver cancer) in sub-Saharan Africa is <a href="https://pubmed.ncbi.nlm.nih.gov/28403980/">less than three months</a>. </p>
<p>The <a href="https://www.soghin.org.ng/">Society of Gastroenterology and Hepatology in Nigeria</a> advocates in its <a href="https://www.ajol.info/index.php/njgh/article/view/131493">HBV guideline</a> that all unimmunised adults in Nigeria should be screened for hepatitis B infection, especially when they visit a hospital for whatever reason. This is to ensure that the millions of people with asymptomatic infection are diagnosed and treated, if need be. </p>
<p>It’s not known whether all healthcare workers are following this advice.</p>
<h2>Prevention and treatment</h2>
<p>The World Health Organisation <a href="https://apps.who.int/iris/bitstream/handle/10665/246177/WHO-HIV-2016.06-eng.pdf?sequence=1">aims</a> to reduce new HBV infections by 90% and deaths by 65% by 2030. The United Nations also placed combating hepatitis as <a href="https://www.who.int/sdg/targets/en/">the third target of goal 3</a> of its sustainable development goals.</p>
<p>Though HBV has no cure, it is preventable through vaccination and avoidance of risky behaviours that promote its transmission. There is no effective vaccine that can prevent hepatitis C but it is curable with the available medications. </p>
<p>Prevention of mother to child transmission is the most important intervention to reduce the incidence of chronic hepatitis B. This is because, unlike adults who acquire the infection, 90%-95% of children who acquire the infection from their mothers will have persistent infection until adulthood. All pregnant mothers should be screened for HBV but screening and treatment are unaffordable for many of these women.</p>
<p>HBV vaccination has been incorporated into the routine immunisation programme for children in Nigeria since the late 1990s and it is free. Two things that stand in the way of prevention efforts in Nigeria are the cost of the investigations of HBV and HCV, which are not covered by the national health insurance scheme, and the knowledge of health workers. </p>
<p>In another <a href="https://www.researchgate.net/publication/343193627_Knowledge_of_hepatitis_B_virus_and_vaccination_uptake_among_hospital_workers_in_south_west_Nigeria">study</a> we conducted, only 44% of health workers were aware of the mother to child route of transmission of HBV. </p>
<p>Though hepatitis B has no cure, there are effective medications that reduce the possibility of liver damage and cancer. Because they are imported to Nigeria, though, these medications are not necessarily affordable or available. This reduces the compliance of patients on this drug.</p>
<p>As we mark the 2020 World Hepatitis Day, government and nongovernmental organisations should create greater awareness of screening. Those found positive should then be linked with treatment centres. There should be continuous education of all health workers on hepatitis routes of transmission and treatment. </p>
<p>In addition to measures which are free according to <a href="https://www.hepb.org/assets/Uploads/Nigeria-Hepatitis-Guidelines-TX-guidelines.pdf">national policy</a>, screening for HBV and HCV should be free. Large procurement of treatment drugs or encouragement of their local production should also be encouraged so that they are affordable and available. This will help to ensure a hepatitis free Nigeria.</p><img src="https://counter.theconversation.com/content/143208/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kolawole Oluseyi Akande does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>About 19 million Nigerians have hepatitis but most of them don’t know it.Kolawole Oluseyi Akande, Lecturer, Gastroenterology & Hepatology Unit and Consultant Gastroenterologist & Hepatologist , University of IbadanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1315532020-07-15T04:26:04Z2020-07-15T04:26:04ZHIV testing people who spit at police or health workers won’t actually protect them<figure><img src="https://images.theconversation.com/files/339952/original/file-20200605-67355-6wf9k4.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sydney-nsw-australia-february-11-2020-1643342308">Shutterstock</a></span></figcaption></figure><p>People who expose a police officer or emergency worker to body fluids would be compelled to have their blood tested for HIV, hepatitis B and hepatitis C, under a <a href="https://www.dcj.nsw.gov.au/__data/assets/pdf_file/0020/726221/Mandatory-disease-testing-for-those-who-attack-frontline-workers.pdf">proposed law in NSW</a>. </p>
<p>But this law isn’t needed to protect first responders. We already have evidence-based protocols that are working well to protect them from blood-borne infections.</p>
<p>Rather, the proposed law is a political reaction to a problem that doesn’t need fixing. It is also not supported by scientific evidence or <a href="http://testingportal.ashm.org.au/hiv">Australian government policy on HIV testing</a>.</p>
<h2>What is NSW proposing?</h2>
<p>In November last year, the NSW government <a href="https://www.dcj.nsw.gov.au/__data/assets/pdf_file/0020/726221/Mandatory-disease-testing-for-those-who-attack-frontline-workers.pdf">proposed legislation</a> which gives authorities the power to test a person for HIV, hepatitis B or hepatitis C if they have deliberately exposed a front-line worker to their body fluids (saliva or blood).</p>
<p>Examples might be if a person bites a police officer restraining them during an arrest or protest; someone biting or scratching a youth justice or corrections officer; or a person behaving unpredictably, exposing ambulance officers to their body fluids.</p>
<p>The mandatory testing order would come from senior officers within the worker’s own agency. If the person does not comply, they can be forced to do so. They have 48 hours to appeal to the NSW chief health officer. Anyone who refuses a mandatory testing order will be committing an offence, with a maximum 12 months prison term or an A$11,000 fine, or both.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/swearing-in-public-is-still-illegal-but-you-probably-wont-be-charged-if-youre-white-127512">Swearing in public is still illegal, but you probably won’t be charged if you’re white</a>
</strong>
</em>
</p>
<hr>
<h2>Is this happening elsewhere?</h2>
<p>Five states have legislation that allows mandatory testing, according to a <a href="https://napwha.org.au/wp-content/uploads/2019/09/2019_NAPWHA_TheSystemIsBroken.pdf">report</a> by the National Association of People Living with HIV. </p>
<p>The proposed NSW model is closest to the one <a href="https://napwha.org.au/wp-content/uploads/2019/09/2019_NAPWHA_TheSystemIsBroken.pdf">Western Australia</a> introduced in 2014, where police can order testing. This resulted in 377 testing orders in the first four years. </p>
<p>In contrast, in <a href="https://napwha.org.au/wp-content/uploads/2019/09/2019_NAPWHA_TheSystemIsBroken.pdf">Victoria</a> the chief health officer has the power to order a test or issue a public health order to enforce it if necessary. In those same four years, <a href="https://napwha.org.au/wp-content/uploads/2019/09/2019_NAPWHA_TheSystemIsBroken.pdf">not a single person</a> was ordered to be tested.</p>
<h2>What’s the risk of transmission anyway?</h2>
<p>Outside of sexual transmission, HIV is transmitted through blood. Police and corrections officers are far less likely to be exposed to a blood-borne virus than hospital workers. <a href="https://doi.org/10.1093/occmed/kqn083">When exposure does occur</a>, it tends to be less serious. </p>
<p>There does not appear to be any recorded case of an Australian police officer being infected with HIV in the course of their duties.</p>
<p>Rates of HIV infection in the community are dropping anyway. <a href="https://kirby.unsw.edu.au/report/hiv-viral-hepatitis-and-sexually-transmissible-infections-australia-annual-surveillance">Around 0.1%</a> of the Australian population is living with HIV. <a href="https://kirby.unsw.edu.au/report/hiv-viral-hepatitis-and-sexually-transmissible-infections-australia-annual-surveillance">The vast majority</a> are on effective treatment which reduces transmission to zero. By 2022, Australia’s aiming for <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/ohp-bbvs-1/$File/HIV-Eight-Nat-Strategy-2018-22.pdf">virtual elimination</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/339954/original/file-20200605-67387-1nt44ky.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/339954/original/file-20200605-67387-1nt44ky.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/339954/original/file-20200605-67387-1nt44ky.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/339954/original/file-20200605-67387-1nt44ky.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/339954/original/file-20200605-67387-1nt44ky.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/339954/original/file-20200605-67387-1nt44ky.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/339954/original/file-20200605-67387-1nt44ky.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/339954/original/file-20200605-67387-1nt44ky.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The chance of front-line workers contracting HIV at work are almost zero.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/coogee-beach-sydney-australia-15-december-776091742">Shutterstock</a></span>
</figcaption>
</figure>
<p>As hepatitis C and HIV are blood-borne viruses, saliva alone cannot transmit them. Sometimes, the mouth can be contaminated with blood, particularly if there has been traumatic injury. But contact between bloody saliva and intact skin <a href="https://ashm.org.au/resources/sexual-health-resources-list/police-and-blood-borne-viruses/">does not transmit hepatitis C or HIV</a>. </p>
<p><a href="https://dx.doi.org/%2010.1111/hiv.12625">A 2018 study</a> bringing together more than 30 years of studies in HIV transmission concluded:</p>
<blockquote>
<p>There is no risk of transmitting HIV through spitting, and the risk through biting is negligible.</p>
</blockquote>
<p><a href="https://i-base.info/htb/34171">A similar 2018 study</a> looked at the risk of hepatitis C transmission and concluded the risk “appears to be very low”.</p>
<p>Of the blood-borne viruses, hepatitis B, the most transmissible of these viruses, is completely preventable through a vaccine all front-line workers receive.</p>
<h2>What’s happening now?</h2>
<p>In NSW and nationally, if someone is exposed to another person’s body fluids at work, they are assessed by health care workers in their agency. </p>
<p>The nature of the exposure, the possibility the other person could have a blood-borne virus (or if known, whether they are infected) and the resulting risk are considered when evaluating both the injury and the need for testing. If needed, they are tested according to <a href="http://testingportal.ashm.org.au/hiv">policies</a> informed by scientific evidence.</p>
<p>But the overwhelming majority of injuries, including bites, <a href="https://dx.doi.org/%2010.1111/hiv.12625">do not</a> <a href="https://i-base.info/htb/34171">carry a risk of transmision</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/339956/original/file-20200605-67399-fgwogw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/339956/original/file-20200605-67399-fgwogw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/339956/original/file-20200605-67399-fgwogw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/339956/original/file-20200605-67399-fgwogw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/339956/original/file-20200605-67399-fgwogw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/339956/original/file-20200605-67399-fgwogw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/339956/original/file-20200605-67399-fgwogw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/339956/original/file-20200605-67399-fgwogw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">We already have evidence-based protocols to decide who needs testing for blood-borne viruses.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/swab-pressed-onto-injection-site-during-521751805">Shutterstock</a></span>
</figcaption>
</figure>
<p>In the rare scenario, where the risk of HIV infection cannot be ruled out, the worker may be offered medications to prevent infection, and follow-up blood tests.
<a href="http://www.pep.guidelines.org.au/">These medications</a> dramatically reduce risk of transmission but must be taken within 72 hours of the exposure. </p>
<p>Workers potentially exposed to hepatitis C can be monitored for infection, and given medications with <a href="https://doi.org/10.1111/liv.13673">near 100% cure rate</a> if required. </p>
<p>So current measures are more than adequate to deal with all situations a police officer or other front-line worker will confront, and have been so since these issues were first addressed in the early 1990s.</p>
<h2>Compulsory testing could cause harm</h2>
<p>Front-line workers deserve our support and protection. But if these workers feel anxiety or distress related to their risk of contracting blood-borne viruses then their health services must more adequately reassure them. </p>
<p>New measures won’t help reduce their already low risk of transmission and therefore don’t provide any additional reassurance. Focussing on getting the other person tested might increase their anxiety when the risk is negligible, irrespective of the person’s status. </p>
<p>In the rare higher risk situations, perhaps an ambulance officer injured while at a car accident where there is massive blood loss, the risk of a blood-borne infection needs to be assessed and <a href="https://ashm.org.au/resources/sexual-health-resources-list/police-and-blood-borne-viruses/">preventive medicine</a> offered. Delaying this assessment while waiting for the results of compulsory testing has the real potential to harm the worker. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/patients-have-rights-heres-how-to-use-yours-121637">Patients have rights. Here's how to use yours</a>
</strong>
</em>
</p>
<hr>
<p>The proposed legislation also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2835402/">stigmatises</a> people living with blood-borne viruses, incorrectly depicting them as dangerous, creating unnecessary fear, <a href="https://hivlawcommission.org/supplement/">leading to discrimination</a>.</p>
<p>We are working with the board of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (the peak body representing HIV, viral hepatitis and sexual health workers) and <a href="https://hivlegal.ashm.org.au/mandatory-testing-for-hiv/">oppose mandatory testing measures</a> as neither necessary nor useful.</p><img src="https://counter.theconversation.com/content/131553/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicholas Medland's research receives institutional funding from the Australian Government National Health and Medical Research Council and from Gilead Sciences.</span></em></p><p class="fine-print"><em><span>Elizabeth Crock is affiliated with ANZANAC Victorian Branch (Australian and New Zealand Association of Nurses in AIDS Care), an Australian Nursing and Midwifery Federation Special Interest Group.
</span></em></p>Proposals in NSW to force someone who spits at or bites a frontline worker to be tested for HIV and other blood-borne viruses are a real problem - for workers and the public.Nicholas Medland, Sexual health physician, epidemiologist, researcher. (President-elect and vice-president Australasian Society of HIV, Viral Hepatitis and Sexual Health Medicine), UNSW SydneyElizabeth Crock, Honorary Senior Research Fellow, Faculty of Medicine, Dentistry and Health Sciences., University of Melbourne; HIV Clinical Nurse Consultant with Bolton Clarke, Board Member Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM), The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1317472020-02-14T04:30:51Z2020-02-14T04:30:51ZSaying sex increases cancer risk is neither totally correct, nor in any way helpful<figure><img src="https://images.theconversation.com/files/315404/original/file-20200214-10980-1v5pmq8.jpg?ixlib=rb-1.1.0&rect=3%2C3%2C2584%2C1718&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>A study <a href="https://srh.bmj.com/content/early/2020/01/07/bmjsrh-2019-200352">published today</a> claims to have found a link between having had ten or more sexual partners and an increased risk of cancer. But it’s not as simple as that.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1228131343265075200"}"></div></p>
<p>While having a sexually transmissible infection (STI) can <a href="http://www.ashasexualhealth.org/stis-and-cancer/">increase the risk</a> of certain types of cancer, using a person’s lifetime number of sexual partners as a marker of their likely sexual health history is one of several flaws in this research.</p>
<p>The evidence from this study isn’t strong enough to conclude that having had multiple sexual partners increases a person’s risk of cancer.</p>
<p>Misinterpreting these findings could lead to stigma around STIs and having multiple sexual partners.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-can-sex-affect-your-risk-of-getting-cancer-27854">Health Check: can sex affect your risk of getting cancer?</a>
</strong>
</em>
</p>
<hr>
<h2>What the study did</h2>
<p>The research, published in the journal BMJ Sexual & Reproductive Health, used data from 2,537 men and 3,185 women participating in the <a href="https://www.elsa-project.ac.uk/">English Longitudinal Study of Ageing</a>, a nationally representative study of adults aged 50+ in England.</p>
<p>The average age of participants was 64. Most were married or living with a partner, white, non-smokers, drank alcohol regularly, and were at least moderately active once a week or more.</p>
<p>Participants were asked to recall the number of people with whom they had ever had vaginal, oral or anal sex in their lifetime. The researchers grouped the responses into four categories shown in the table below.</p>
<p><iframe id="ekbx3" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/ekbx3/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>The researchers then examined associations between lifetime number of sexual partners and self-reported health outcomes (self-rated health, limiting longstanding illness, cancer, heart disease and stroke). </p>
<p>The researchers controlled for a range of demographic factors (age, ethnicity, partnership status, and socioeconomic status) as well as health-related factors (smoking status, frequency of alcohol intake, physical activity, and depressive symptoms).</p>
<h2>What the study found</h2>
<p>Men with 2-4 partners and 10+ partners were more likely to have been diagnosed with cancer, compared to men with 0-1 partners. There was no difference between men with 0-1 partners and 5-9 partners.</p>
<p>Compared to women with 0-1 partners, women with 10+ partners were more likely to have been diagnosed with cancer. </p>
<p>Women with 5-9 partners and 10+ partners were also more likely to report a “limiting longstanding illness” than those with 0-1 partners. </p>
<p>The authors don’t specify what constitutes a limiting longstanding illness, but looking at the questions they asked participants, we can ascertain it’s a chronic condition that disrupts daily activities. It’s likely these ranged from mildly irritating to debilitating.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/new-gardasil-9-vaccine-boosts-teens-protection-from-hpv-and-cervical-cancer-by-23-90922">New Gardasil 9 vaccine boosts teens' protection from HPV and cervical cancer by 23%</a>
</strong>
</em>
</p>
<hr>
<p>There was no association between number of sexual partners and self-rated general health, heart disease or stroke for either men or women.</p>
<p>Notably, while statistically significant, the effect size of all these associations was modest.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/315409/original/file-20200214-10985-1fa8nt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/315409/original/file-20200214-10985-1fa8nt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=362&fit=crop&dpr=1 600w, https://images.theconversation.com/files/315409/original/file-20200214-10985-1fa8nt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=362&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/315409/original/file-20200214-10985-1fa8nt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=362&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/315409/original/file-20200214-10985-1fa8nt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=455&fit=crop&dpr=1 754w, https://images.theconversation.com/files/315409/original/file-20200214-10985-1fa8nt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=455&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/315409/original/file-20200214-10985-1fa8nt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=455&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Misunderstanding these results could create stigma around STIs, which can deter people from sexual health check ups.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>What does number of sexual partners have to do with cancer risk?</h2>
<p>There is a reason for investigating whether a person’s lifetime number of sexual partners has anything to do with their cancer risk. If you’ve had a lot of sexual partners, it’s <a href="http://www.eurekaselect.com/131203/article">more likely</a> you’ve been exposed to an STI. Having an STI can <a href="http://www.ashasexualhealth.org/stis-and-cancer/">increase your risk</a> of several types of cancer. </p>
<p>For example, human papillomavirus (HPV) is <a href="https://www.sciencedirect.com/science/article/abs/pii/S0753332218328178?via%3Dihub">responsible for 30%</a> of all cancers caused by infectious agents (bacteria, viruses or parasites), contributing to cervical cancer, penile cancer, and cancers of the mouth, throat and anus.</p>
<p>Viral hepatitis can be transmitted through sex, and having chronic hepatitis B or C <a href="https://www.cancer.org/cancer/liver-cancer/causes-risks-prevention/risk-factors.html">increases the risk</a> of liver cancer.</p>
<p>Untreated HIV <a href="https://acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/cncr.25547">increases the risk</a> of cancers such as lymphomas, sarcomas and cervical cancer.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-truvada-prep-the-game-changer-that-will-end-new-hiv-transmissions-in-australia-93652">Is Truvada (PrEP) the game-changer that will end new HIV transmissions in Australia?</a>
</strong>
</em>
</p>
<hr>
<h2>How can we make sense of this?</h2>
<p>The authors of the study acknowledge the numerous limitations of the analysis and recommend further work be done to confirm their findings. We must interpret their results with this in mind.</p>
<p>Their use of lifetime number of sexual partners as a proxy measure for STI history is a key problem. While there is an association between having a higher number of partners and an increased risk of STIs, <a href="http://www.eurekaselect.com/131203/article">many other factors</a> may be important in determining a person’s risk of being infected with an STI. </p>
<p>These include whether they’ve practised safe sex, what type of infection they might have encountered, and whether they’ve been vaccinated against, or treated for, particular infections.</p>
<p>Further, the analysis was based on cross-sectional data – a snapshot that doesn’t account for changes over time. Participants were asked to recall information from the past, rather than having measurements taken directly at different time points. It’s not possible to establish causation from a cross-sectional analysis.</p>
<p>Even if the association is confirmed in prospective, longitudinal studies, the findings may not apply to other groups of people.</p>
<p>Recent advances in vaccine development (such as the wide availability of the <a href="https://www.gynecologiconcology-online.net/article/S0090-8258(17)30774-6/fulltext">HPV vaccine</a>), better STI prevention (such as the use of pre- and post-exposure prophylaxis – <a href="https://aidsinfo.nih.gov/understanding-hiv-aids/infographics/46/prep-vs--pep">PreP and PEP</a> – for HIV) and more effective therapy (for example, <a href="http://www.eurekaselect.com/155557/article">direct-acting antiviral agents</a> to treat hepatitis C) will reduce the impact of STIs on cancer risk for those who can access them.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/315410/original/file-20200214-11005-1mzfxq5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/315410/original/file-20200214-11005-1mzfxq5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/315410/original/file-20200214-11005-1mzfxq5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/315410/original/file-20200214-11005-1mzfxq5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/315410/original/file-20200214-11005-1mzfxq5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/315410/original/file-20200214-11005-1mzfxq5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/315410/original/file-20200214-11005-1mzfxq5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">We now have a vaccine to prevent HPV, which in turn reduces the risk of cervical and other cancers.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>People with higher numbers of sexual partners were more likely to smoke and drink frequently (increasing the risk of cancer), but also to do more vigorous physical activity (decreasing the risk of cancer). </p>
<p>For women, a higher number of sexual partners was associated with white ethnicity; for men, with a greater number of depressive symptoms. Although the researchers controlled for these factors, these points highlight some inconsistencies in the pattern of results.</p>
<p>The researchers also couldn’t explain why a greater number of sexual partners was associated with a higher likelihood of a limiting chronic condition for women, but not for men.</p>
<p>Ultimately, this study raises more questions than it answers. We need further research before we can use these results to inform policy or improve practice.</p>
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Read more:
<a href="https://theconversation.com/stigma-and-lack-of-awareness-stop-young-people-testing-for-sexually-transmitted-infections-80265">Stigma and lack of awareness stop young people testing for sexually transmitted infections</a>
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<p>The paper concludes by saying enquiring about lifetime sexual partners could be helpful when screening for cancer risk. This is a very long stretch based on the evidence presented.</p>
<p>This approach could also be harmful. It could invade privacy and increase <a href="https://www.publish.csiro.au/sh/SH10070">stigma</a> about having multiple sexual partners or having an STI.</p>
<p>We know experiencing stigma <a href="https://www.sciencedirect.com/science/article/abs/pii/S0889854516300924?via%3Dihub">can discourage</a> people from attending sexual health screenings and other services.</p>
<p>It would be better to put limited health resources towards improving prevention, screening and treatments for STIs.</p><img src="https://counter.theconversation.com/content/131747/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jayne Lucke receives funding from the Australian Research Council and the National Health and Medical Research Council. She has served as a Director of Family Planning Queensland and been Chief Investigator on an ARC Linkage Grant that received cash and in-kind support from Family Planning New South Wales and Bayer Australia.</span></em></p>New research reveals a link between a diagnosis of cancer and a lifetime number of 10 or more sexual partners. But there are some flaws in the research we need to consider in interpreting the results.Jayne Lucke, Honorary Professor, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1225472019-10-15T07:19:09Z2019-10-15T07:19:09ZIn contrast to Australia’s success with hepatitis C, our response to hepatitis B is lagging<figure><img src="https://images.theconversation.com/files/297001/original/file-20191015-98666-1matifh.jpg?ixlib=rb-1.1.0&rect=20%2C0%2C4446%2C2991&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">While hepatitis B can't be cured in the same way hepatitis C can, effective treatment is available.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Around one-third of Australians living with hepatitis C <a href="https://kirby.unsw.edu.au/report/monitoring-hepatitis-c-treatment-uptake-australia-issue-10-june-2019">have been cured</a> in the last four years.</p>
<p>Hepatitis means inflammation of the liver. Hepatitis C is one of five varieties of viral hepatitis (A-E), and alongside hepatitis B, is responsible for the majority of illness caused by hepatitis. </p>
<p>Australia’s response to hepatitis C is seen as a leading example around the world, and the elimination of the disease as a major public health threat is looking like an <a href="https://theconversation.com/eliminating-hepatitis-c-an-ambitious-but-achievable-goal-24485">increasingly achievable goal</a>.</p>
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Read more:
<a href="https://theconversation.com/australia-leads-the-world-in-hepatitis-c-treatment-whats-behind-its-success-81760">Australia leads the world in hepatitis C treatment – what's behind its success?</a>
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<p>But the situation is much less promising for Australians living with hepatitis B, which is now the most common blood-borne viral infection in Australia. It affects more people than <a href="https://kirby.unsw.edu.au/report/hiv-viral-hepatitis-and-sexually-transmissible-infections-australia-annual-surveillance">hepatitis C and HIV combined</a>.</p>
<p>In our research <a href="https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/hep.30899">published today</a>, we show Australia is falling short of its targets to reduce the burden of hepatitis B. Looking to the way we’ve responded to hepatitis C may set us on a better path. </p>
<h2>Hepatitis C treatment</h2>
<p>There were an estimated <a href="https://kirby.unsw.edu.au/report/hiv-viral-hepatitis-and-sexually-transmissible-infections-australia-annual-surveillance">182,144 people</a> living with chronic hepatitis C in Australia at the end of 2017. </p>
<p>A number of important drugs were listed on the Pharmaceutical Benefits Scheme (PBS) from 2016, making curative treatments available to nearly all Australians living with hepatitis C. </p>
<p>The number of treatments being initiated has <a href="https://kirby.unsw.edu.au/report/monitoring-hepatitis-c-treatment-uptake-australia-issue-10-june-2019">fallen significantly</a> since the early peak, and significant differences exist in who has accessed the treatments across Australia. Nonetheless, Australia’s <a href="https://theconversation.com/australia-leads-the-world-in-hepatitis-c-treatment-whats-behind-its-success-81760">response to hepatitis C</a> is highly regarded as an example of how to rapidly scale up hepatitis C treatment in a population, including among <a href="https://www.journal-of-hepatology.eu/article/S0168-8278(18)32494-2/fulltext">people who inject drugs</a>.</p>
<p><a href="https://www.journal-of-hepatology.eu/article/S0168-8278(19)30275-2/fulltext">Recent data</a> from New South Wales demonstrate access to hepatitis C cures has led to a drop in the number of people with hepatitis C dying from liver cancer, with the <a href="https://theconversation.com/three-charts-on-the-state-of-stis-and-blood-borne-viruses-in-australia-86298">bend in the curve</a> coinciding with listing of these new treatments on the PBS in 2016. </p>
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Read more:
<a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">Explainer: the A, B, C, D and E of hepatitis</a>
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<h2>Hepatitis B treatment</h2>
<p>There were an estimated <a href="https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/hep.30899">221,420</a> people living with chronic hepatitis B in Australia in 2017. Along the trajectory of the disease, those who have liver disease or are at risk of developing liver disease require treatment. </p>
<p>Unlike hepatitis C, hepatitis B cannot be cured with current treatments, so ongoing antiviral therapy is required. This is similar to the treatment received by someone with HIV. </p>
<p>Although not a cure, the available treatments are effective. Current hepatitis B treatments have been associated with <a href="https://www.journal-of-hepatology.eu/article/S0168-8278(15)00004-5/fulltext">reducing the risk of liver cancer</a> by around 50% in the first five years of treatment.</p>
<p>Scaling up such treatment and care will be a critical element in reversing the <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1753-6405.12889">increasing tide</a> of liver cancer deaths in Australia. </p>
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<img alt="" src="https://images.theconversation.com/files/297038/original/file-20191015-98648-b1l6vv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/297038/original/file-20191015-98648-b1l6vv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/297038/original/file-20191015-98648-b1l6vv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/297038/original/file-20191015-98648-b1l6vv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/297038/original/file-20191015-98648-b1l6vv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/297038/original/file-20191015-98648-b1l6vv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/297038/original/file-20191015-98648-b1l6vv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Hepatitis can cause mild to severe liver damage.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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</figure>
<h2>Targets</h2>
<p>By 2030, the <a href="https://www.who.int/hepatitis/strategy2016-2021/ghss-hep/en/">World Health Organisation</a> has set out that 90% of people with hepatitis B should be diagnosed, 80% of those who meet criteria for treatment should be treated, and deaths due to hepatitis B should be reduced by 65% relative to 2015 globally.</p>
<p>In Australia, our <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/ohp-bbvs-1">Third National Hepatitis B Strategy</a> sets targets to be achieved by 2022, including diagnosing 80% of people, engaging 50% of people in care, treating 20% of people, and reducing deaths due to hepatitis B by 30%.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/three-charts-on-cancer-rates-in-australia-where-liver-cancer-is-on-the-rise-while-other-types-fall-79572">Three charts on: cancer rates in Australia, where liver cancer is on the rise while other types fall</a>
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<p>Measuring progress towards these targets is complicated and requires consideration of a range of demographic and other factors. Considering most people living with hepatitis B in Australia were <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1753-6405.12826">born overseas</a> or are <a href="https://theconversation.com/dr-g-yunupingus-legacy-its-time-to-get-rid-of-chronic-hepatitis-b-in-indigenous-australia-81672">Aboriginal or Torres Strait Islander peoples</a>, up-to-date estimates of Indigenous status and migration flows into and out of Australia are essential. Estimates of the prevalence of hepatitis B in different groups and detailed information about the natural history of hepatitis B in individuals over time is also important.</p>
<h2>Our research</h2>
<p>Taking these complexities into account, we’ve constructed <a href="https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/hep.30899">a mathematical model</a> simulating the burden of hepatitis B in the Australian population from 1951 to 2030. We wanted to see how Australia is faring in terms of meeting national and international targets.</p>
<p>By 2022, if current trends continue, the proportion of people diagnosed will reach 71% (short of the 80% goal). Some 11.2% of Australians living with hepatitis B will be on treatment (short of the 20% target). But we estimate the proportion who actually need treatment is around 30%, so we have a long way to go. </p>
<p>In related work <a href="https://ashm.org.au/programs/Viral-Hepatitis-Mapping-Project/">mapping the burden of hepatitis B</a> and estimating differences in treatment and care nationally we estimate only 20% of people living with hepatitis B are engaged in care (either being appropriately monitored or receiving treatment). Again, this is well short of the 50% target.</p>
<h2>So why aren’t we meeting these targets?</h2>
<p>Broader inequities in health access and outcomes for culturally and linguistically diverse groups and Aboriginal and Torres Strait Islander peoples play a substantial role. Together they represent <a href="https://ashm.org.au/programs/Viral-Hepatitis-Mapping-Project/">over two-thirds</a> of Australians living with hepatitis B. </p>
<p>Current delivery of treatment and care differs across the country. The experience and strategies used in those areas with higher levels of treatment and care should be examined and shared to address the inequities observed across Australia.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/eliminating-hepatitis-c-an-ambitious-but-achievable-goal-24485">Eliminating hepatitis C – an ambitious but achievable goal</a>
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<p>Like hepatitis C, Australia’s response to the needs of people living with HIV is viewed as being of a high standard. Two elements central to our responses to hepatitis C and HIV are currently missing for hepatitis B.</p>
<p>The first is strong, ongoing community engagement and leadership of the response by those affected. While organisations representing people living with HIV have existed since the 1980s and for hepatitis C since the 1990s, engagement with people living with hepatitis B has lagged well behind.</p>
<p>The second is treatment and care primarily being delivered in the community by primary care clinicians (especially GPs) – rather than in hospitals and by specialists, as is the case for most people living with hepatitis B. Many patients prefer seeing GPs and find this more convenient than waiting for hospital appointments and seeing specialists. This can be especially true for people living far from major hospitals, reflected in the fact hepatitis B treatment uptake is much lower than average in <a href="https://www.onlinelibrary.wiley.com/doi/epdf/10.1111/1753-6405.12693">regional and rural areas of Australia</a>.</p>
<h2>Making it happen</h2>
<p>Although both factors are priorities for action in the National Hepatitis B Strategy, progress will require ongoing funding and coordinated efforts by the Commonwealth, state and territory governments, primary health networks, and other partners. </p>
<p>The impact will be measured, not just in modelled estimates, but in real lives saved. While we’re not yet on track to meet our targets for hepatitis B in Australia, <a href="https://aasldpubs.onlinelibrary.wiley.com/doi/abs/10.1002/hep.30899">our modelling</a> suggests even with the relatively low current uptake of treatment and care, 2,300 Australian lives were saved between 2000 and 2017, which otherwise would have been lost to liver cancer and liver failure caused by hepatitis B. </p>
<p>If we can translate what has been learned in our HIV and hepatitis C responses to increase access to essential care for Australians living with hepatitis B, thousands more lives can be saved in the next decade and beyond.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dr-g-yunupingus-legacy-its-time-to-get-rid-of-chronic-hepatitis-b-in-indigenous-australia-81672">Dr G. Yunupingu's legacy: it's time to get rid of chronic hepatitis B in Indigenous Australia</a>
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<img src="https://counter.theconversation.com/content/122547/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Benjamin Cowie receives funding from public bodies and research organisations including the Australian Government Department of Health, the Victorian Department of Health and Human Services, the World Health Organization, the Victorian Cancer Agency, and the Royal Melbourne Hospital Foundation. He receives no funding or in-kind support from pharmaceutical companies or other for-profit health related industries. </span></em></p><p class="fine-print"><em><span>Karen McCulloch receives funding from the Australian Government Department of Health. </span></em></p><p class="fine-print"><em><span>Nicole Romero receives funding from the Australian Government Department of Health.</span></em></p>Curing thousands of Australians with hepatitis C is one of the public health success stories of recent years. We can take lessons from this as we continue in the fight against hepatitis B.Benjamin Cowie, Director, WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and ImmunityKaren McCulloch, Research Fellow, The University of MelbourneNicole Romero, Epidemiologist, WHO Collaboating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and ImmunityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1204612019-08-21T15:46:27Z2019-08-21T15:46:27ZLiver disease: how new intelligent testing could save thousands of lives<figure><img src="https://images.theconversation.com/files/288801/original/file-20190820-170914-1kn0n2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/diverse-people-friends-hanging-out-drinking-336896096">Shutterstock</a></span></figcaption></figure><p>Since the 1970s, liver disease in the UK has <a href="https://www.bmj.com/content/352/bmj.i124">increased</a> by more than 400%, particularly in people under 65 – in marked contrast to all other major causes of death which have been decreasing in younger age groups. This epidemic has been driven by alcohol, obesity and <a href="https://www.nhs.uk/conditions/hepatitis-c/">hepatitis C</a>.</p>
<p>The liver is the factory of the body, making vital proteins and breaking down waste products or excreting them. Liver disease is usually a silent disease in its early stages. Liver function tests (LFTs) are routinely available blood tests associated with liver damage, so should be able to detect liver problems early on. Millions of these tests are performed each year in the UK by doctors and nurses for a multitude of symptoms and problems ranging from feelings of tiredness, to yellowing of skin (in white people) or the whites of the eyes, due to <a href="https://www.nhs.uk/conditions/jaundice/">jaundice</a>.</p>
<p>LFTs are commonly abnormal due to a variety of reasons, such as drinking too much, fatty liver caused by obesity, infections, rare liver diseases and some cancers – but they can be a sign of curable potentially fatal liver disease. </p>
<p>But it is complex to sort out what to do about them – many people with abnormal LFTs are not investigated because of the complex pattern of investigation. In those who are, current care is geared to find an explanation via a lengthy process of investigation and ruling things out, with costs to patients and the NHS in terms of money and time – many people drop out along the way.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/288802/original/file-20190820-170946-3hb8hf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288802/original/file-20190820-170946-3hb8hf.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=266&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288802/original/file-20190820-170946-3hb8hf.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=266&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288802/original/file-20190820-170946-3hb8hf.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=266&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288802/original/file-20190820-170946-3hb8hf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=334&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288802/original/file-20190820-170946-3hb8hf.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=334&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288802/original/file-20190820-170946-3hb8hf.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=334&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="license">Author provided</span></span>
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<p>This misses an opportunity to diagnose and treat liver disease at an early stage. With the dramatic rise in the rate of testing and the number of resulting abnormalities, this is not sustainable. So how do we investigate the abnormal LFTs to maximise health gain and minimise health costs?</p>
<h2>Rules, clinical facts and algorithms</h2>
<p>We use a smarter application of existing knowledge and technology. To solve the problem, we developed a set of rules for the diagnosis of many liver diseases using only blood results – for both the cause of the liver damage as well the severity of it – combined with simple clinical facts, such as alcohol intake and body mass index.</p>
<p>In effect, we reduced what a liver specialist does when they see a patient to a set of rules that could be used to create algorithms that would give a specific diagnosis to many patients, and a helpful management plan to the rest who may need to manage lifestyle factors. We went on and <a href="https://www.journal-of-hepatology.eu/article/S0168-8278(19)30354-X/abstract">tested this set of rules</a> to show that they did work as well as actually consulting a liver specialist.</p>
<p>The other component that allows our new system to work is in the blood sciences laboratory. When a blood sample arrives in the lab, it has a bar code and is placed on a large track system, like a model train track. A computer directs the sample to all the machines it needs to go through to have all the required tests performed. The computer also has the ability to change what happens to the sample depending on the first results.</p>
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<img alt="" src="https://images.theconversation.com/files/288803/original/file-20190820-170922-1ywhc2h.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288803/original/file-20190820-170922-1ywhc2h.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=383&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288803/original/file-20190820-170922-1ywhc2h.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=383&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288803/original/file-20190820-170922-1ywhc2h.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=383&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288803/original/file-20190820-170922-1ywhc2h.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=481&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288803/original/file-20190820-170922-1ywhc2h.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=481&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288803/original/file-20190820-170922-1ywhc2h.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=481&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="license">Author provided</span></span>
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<p>So we created “intelligent liver function testing” or “iLFT”. In the new system the GPs who suspected liver disease in a patient selected the intelligent LFT pathway in the lab test requesting system and entered clinical details – BMI, alcohol intake and presence of high blood pressure, high cholesterol or diabetes. The algorithm was integrated with the lab’s information management system, allowing appropriate biochemistry, haematology, virology and immunology tests to cascade if the initial LFTs were abnormal.</p>
<p>The iLFT algorithm then combined the clinical information, test results and fibrosis (the extent to which tissue is damaged) scores to generate a diagnosis and/or management plan available as a web link for quick access on the GPs computer. The system generates 32 outcomes, varying from a clear cut diagnosis to a description of what has been found and suggestions for further investigation. This maximises the diagnosis of early liver disease. iLFT uses a synthesis of existing evidence combined with new algorithms that can be integrated into current lab biochemical analysers and technology to produce a diagnosis in many patients.</p>
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<img alt="" src="https://images.theconversation.com/files/288804/original/file-20190820-170956-9h33xo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288804/original/file-20190820-170956-9h33xo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=227&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288804/original/file-20190820-170956-9h33xo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=227&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288804/original/file-20190820-170956-9h33xo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=227&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288804/original/file-20190820-170956-9h33xo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=285&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288804/original/file-20190820-170956-9h33xo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=285&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288804/original/file-20190820-170956-9h33xo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=285&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="license">Author provided</span></span>
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<p>So on any sample sent for LFTs it would be possible to generate a diagnosis or prognosis. The system was trialled and showed that all patients can be investigated, increasing diagnosis of liver disease by 44%, and over an average patient lifetime this is an average saving of £3,216 per head.</p>
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<img alt="" src="https://images.theconversation.com/files/288805/original/file-20190820-170918-do56ct.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288805/original/file-20190820-170918-do56ct.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=281&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288805/original/file-20190820-170918-do56ct.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=281&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288805/original/file-20190820-170918-do56ct.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=281&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288805/original/file-20190820-170918-do56ct.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=353&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288805/original/file-20190820-170918-do56ct.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=353&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288805/original/file-20190820-170918-do56ct.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=353&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="license">Author provided</span></span>
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<p>In a system that is currently failing to offer a diagnosis to all patients with abnormal results on their liver function tests, iLFT increases diagnosis, improves quality of care and is cost effective. A switch to this new system could be achieved with minor changes to working practices and existing lab systems. iLFT has won multiple awards and is now the standard care in NHS Tayside – and other units and hospitals across the UK are now exploring its potential for their own patients.</p><img src="https://counter.theconversation.com/content/120461/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Dillon receives funding from chief scientist's office of the Scottish department of health. </span></em></p>A new test which capitalises on existing knowledge and technology will increase diagnoses, speed up the process and save the NHS millions of pounds.John Dillon, Professor of Hepatology and Gastroenterology, University of DundeeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1119552019-02-28T11:41:25Z2019-02-28T11:41:25ZA new way to pay for innovative drugs, provide universal access and not break the bank<figure><img src="https://images.theconversation.com/files/261320/original/file-20190227-150718-2gacs7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sen. Chuck Grassley, R-Iowa, chair of the Senate Finance Committee, prepares for the Feb. 26, 2019 hearing with CEOs from several U.S. drug makers.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Senate-Drug-Prices/deaf2df9290341db926692b08fbf443f/4/0">Pablo Martinez Monsivais/AP Photo</a></span></figcaption></figure><p>On the heels of congressional testimony by the <a href="https://www.wsj.com/articles/live-analysis-drug-company-ceos-take-the-hot-seat-before-congress-11551191988">CEOs of major drug makers</a>, there are some important things to keep in mind. The U.S. faces a drug pricing crisis in large part because pharmaceuticals are in a golden age of advancement. A new pill cures hepatitis C. Immunotherapies devour cancer cells. Regenerative medicine promises longer life spans. </p>
<p>All of that advancement comes at a high cost. Drug companies seek recovery through high prices, which guarantees profits but reduces widespread access to the remedies. In particular, <a href="https://www.medicaid.gov/">Medicaid</a>, the federal and state health program for the poor, disabled and elderly, which enrolls 70 million Americans, <a href="https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2019/02/21/the-health-202-states-scramble-to-head-off-future-medicaid-shortfalls/5c6db0641b326b71858c6bec/?utm_term=.e30475b6c8ee">faces major hurdles</a> in paying for lifesaving treatments. </p>
<p>It has turned into a politically explosive predicament. A National Academies of Science consensus <a href="http://www.nationalacademies.org/hmd/reports/2017/national-strategy-for-the-elimination-of-hepatitis-b-and-c.aspx">report</a> which I was involved with and a <a href="https://annals.org/aim/fullarticle/2681481/novel-strategy-increasing-access-treatment-hepatitis-c-virus-infection-medicaid">paper</a> in a leading medical journal that I authored suggests a way out, and Louisiana will be the first state to put this solution into practice.</p>
<h2>A novel approach in a very poor state</h2>
<p>Louisiana, which has a severe hepatitis C problem, is on the cusp of proving to other states that drug companies can make the money they need, while every Medicaid recipient who needs a cure gets one. </p>
<p>Nationally the hepatitis C story is a scandal. Even with a cure on the market, more than <a href="https://www.cdc.gov/media/releases/2016/p0504-hepc-mortality.html">20,000</a> Americans still die of the disease each year, more than the combined toll of 60 other infectious diseases. The reason for this high death toll is the <a href="https://www.nbcnews.com/health/health-news/hepatitis-c-cure-eludes-patients-states-struggle-costs-n870846">high price tag of the curative drugs</a> and as a result Medicaid <a href="https://www.chlpi.org/state-medicaid-programs-continue-restrict-access-hepatitis-c-drugs/">restricts access to these drugs</a>. </p>
<p>In Louisiana, only <a href="https://www.nola.com/politics/index.ssf/2018/07/louisiana_hepatitis_c.html">384 of the 35,000</a> infected people who are on Medicaid or in prison got treatment in 2017 because of the prohibitive cost. Prices have dropped by two-thirds from the introductory level of US$80,000 per treatment, but even at that level eliminating the disease among Medicaid recipients would cost the state $700 million. Louisiana, which like other states shoulders part of Medicaid costs with the federal government, could afford that only if it blew up its budget for schools and health care, among other services. </p>
<p>The state is now on a path to secure immediate treatment for all infected prisoners and people on Medicaid by buying a license from a drug company. It is a concept that can be applied to other ground breaking remedies. The idea was first outlined in a <a href="http://www.nationalacademies.org/hmd/reports/2017/national-strategy-for-the-elimination-of-hepatitis-b-and-c.aspx">consensus report</a> for the National Academies of Sciences, Engineering and Medicine and later in a <a href="https://annals.org/aim/fullarticle/2681481/novel-strategy-increasing-access-treatment-hepatitis-c-virus-infection-medicaid">paper</a> in the Annals of Internal Medicine. Here is how it will work: </p>
<p>Louisiana spent <a href="https://www.statnews.com/pharmalot/2019/01/10/louisiana-hepatitis-netflix-drug-prices/">$35 million last year</a> on hepatitis C treatments spread among several pharmaceutical companies. On Jan. 10, 2019, the state announced that it intends to use that amount as leverage, drawing the companies into a competition for the state’s business. </p>
<p>Louisiana is seeking to negotiate a contract with a single drug manufacturer to provide all the hepatitis pills the state needs for a lump sum, payable annually over a five-year contract that is roughly equal to the state’s current $35 million hepatitis C spending among all makers. Once a contract is signed in April, the company that won the contract will stand ready to supply as many pills as the state requires. The price-per-pill model disappears, so Louisiana can treat as many patients as it wants without worrying about the costs of treating additional patients. </p>
<p>Louisiana State Health Director Rebekah Gee spearheaded the effort to establish a license after the NAS study was published. The strategy exploits market competition among firms in a voluntary transaction that nevertheless breaks the current stranglehold high prices have over access to the medicines. </p>
<p>Under the status quo of “price-based contracting,” firms derive profits from high prices, which in turn means reduced access to the drugs. Instead, the Louisiana system is based on what is called “revenue based contracting,” which severs the link between profits and restricted access. That is, a firm that wins the contract with the state can ensure profitability by negotiating an appropriate lump sum payment, guaranteed over five years. Once a lump sum payment is set, the state’s cost of providing drugs to additional patients is close to zero because the contract stipulates that the pharmaceutical company is obligated to meet the volume of the state’s needs.</p>
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<img alt="" src="https://images.theconversation.com/files/261370/original/file-20190228-150721-2xq5tf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/261370/original/file-20190228-150721-2xq5tf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=410&fit=crop&dpr=1 600w, https://images.theconversation.com/files/261370/original/file-20190228-150721-2xq5tf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=410&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/261370/original/file-20190228-150721-2xq5tf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=410&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/261370/original/file-20190228-150721-2xq5tf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=516&fit=crop&dpr=1 754w, https://images.theconversation.com/files/261370/original/file-20190228-150721-2xq5tf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=516&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/261370/original/file-20190228-150721-2xq5tf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=516&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Packages of Sovaldi, one of the drugs that cures hepatitis C, in Paris.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/paris-france-feb-9-2017-male-583382596">Hadrian/Shutterstock.com</a></span>
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<p>The question now is will drug makers participate in a competition to license their product to the state. The early outlook is positive. <a href="https://www.statnews.com/pharmalot/2019/01/10/louisiana-hepatitis-netflix-drug-prices/">Gilead and Merck</a>, makers of major hepatitis C drugs, both told the state in 2018 that they were interested, and AbbVie has said it intends to participate. </p>
<p>The deadline for submitting a proposed contract is Feb. 28, 2019, and the state hopes to implement the program by July 1. At that point, Louisiana could begin eradicating hepatitis C in its Medicaid and prison populations.</p>
<p>Other states should not be far behind. A long-awaited <a href="https://www.nga.org/wp-content/uploads/2018/08/Public-Health-Crises-and-Pharmaceutical-Interventions.pdf">report</a> from the National Governors Association on controlling drug costs endorsed the idea. In January 2019, <a href="https://www.statnews.com/pharmalot/2019/02/06/washington-netflix-hepatitis-drug-prices/">Washington state</a> began soliciting bids from drug makers for a guaranteed price for its Medicaid beneficiaries. </p>
<p>There is every reason to believe that the licensing model will work for containing costs of other expensive new drugs as well. States, or a consortium of states, can offer long-term contracts that can assure drug companies of the return they need to satisfy shareholders and pay for development costs. The large number of possible contracts in the 50 states means there is plenty of business for companies to seek. </p>
<p>Licenses are a time-tested way to guarantee streams of revenue to manufacturers while lowering users’ marginal costs to zero. This model is common in many knowledge-based industries such as software where product development costs are high but once a product is developed, the cost of providing the product to an additional user is close to zero. It’s time to implement this pricing model in health care. It can lead us out of our prescription drug crisis by bringing universal access without breaking the bank.</p><img src="https://counter.theconversation.com/content/111955/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Neeraj Sood has been a paid scientific advisor to several organizations in the health care industry including health insurers, drug distributors, pharmacuetical firms, economic consulting firms, litigation consulting firms, health care start-ups, and professional organizations.</span></em></p>As concern grows for the escalating prices of prescription drugs, a novel approach to lower the price of drugs to treat hepatitis C in Louisiana holds promise, a policy expert says.Neeraj Sood, Professor of Public Policy, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1088542018-12-17T16:22:42Z2018-12-17T16:22:42ZChronic fatigue syndrome: new evidence of biological causes<figure><img src="https://images.theconversation.com/files/250999/original/file-20181217-181905-14h3aji.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Flea, the bass player with the Red Hot Chili Peppers, suffered from chronic fatigue syndrome.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/773107435?src=qXRriSfi0adOMG8pdhcM1w-1-59&size=medium_jpg">Christian Bertrand/Shutterstock</a></span></figcaption></figure><p>Chronic fatigue syndrome (CFS) affects up to <a href="https://ammes.org/how-many-people-have-mecfs/">24m people</a>, globally, but little is known about its causes. Our latest study unravels some of this mystery. The results suggest that an overactive immune system may trigger this long-term condition. </p>
<p>People with chronic fatigue syndrome, also known as myalgic encephalomyelitis (ME), experience severe mental and physical tiredness that isn’t alleviated by rest. Some people also experience flu-like symptoms, cognitive impairment and sleep disturbances. </p>
<p>The symptoms overlap with those experienced in immune system disorders, and some infections are known to precede the condition. But measurements of immune function in these patients have proven inconsistent, with some finding evidence of immune activation, while others find none. As a result, the role of the immune system is still unclear. One reason for this may be that we are measuring immune activation too late when the patient is already unwell and visiting the doctor for the first time.</p>
<p>Infections are random events, which makes it difficult to study what happens in response to the infection that leads to CFS (anecdotal evidence suggests many patients recall that their condition started after a viral infection, and studies of <a href="https://academic.oup.com/jid/article/196/1/4/843612">post-infective fatigue syndrome</a> support this. This means we are left with the unanswered question: why is it that some people with common infections go on to develop CFS?</p>
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<img alt="" src="https://images.theconversation.com/files/250939/original/file-20181217-185234-oju53e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/250939/original/file-20181217-185234-oju53e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/250939/original/file-20181217-185234-oju53e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/250939/original/file-20181217-185234-oju53e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/250939/original/file-20181217-185234-oju53e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/250939/original/file-20181217-185234-oju53e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/250939/original/file-20181217-185234-oju53e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">CFS is characterised by extreme tiredness.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1017688225?src=txQpmDJj6U0TjhzsH4Ay8Q-1-5&size=medium_jpg">fizkes/Shutterstock</a></span>
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<h2>Triggering an immune response</h2>
<p>For our study, published in <a href="https://www.sciencedirect.com/science/article/pii/S0306453018301963">Psychoneuroendocrinology</a>, we examined 55 patients with hepatitis C who were being treated with interferon-alpha, a drug that triggers a powerful immune response in order to combat the hepatitis C virus. While interferon-alpha is successful at fighting the virus, it can induce a wide range of debilitating side effects, including fatigue, making people receiving this treatment a suitable group to study to learn more about what might cause CFS. </p>
<p>Our approach is novel because it allowed us to take pre-treatment measurements to explore possible risk factors that might have predisposed some of the group to develop a CFS-like illness. This is something that’s almost impossible to achieve in actual CFS without a cohort of thousands to track who does and doesn’t become unwell. </p>
<p>We knew exactly how long the patients would be exposed to the immune trigger (interferon-alpha) and could track them through treatment. Finally, we could follow them up six months later, when they’d fulfilled the criterion of experiencing persistent fatigue for at least six months.</p>
<p>Comparing patients who would go on to experience the CFS-like illness (18 patients) to the rest of the patients who recovered normally, we found higher levels of IL-10, an inflammatory protein, which is part of the coordinated immune response before treatment even began. Once treatment began, those who went on to develop extreme fatigue had much greater increases in IL-10 and IL-6 (another inflammatory protein) compared with those who didn’t develop CFS-like symptoms. </p>
<p>However, as in <a href="https://academic.oup.com/cid/article/45/6/732/284312">previous studies</a>, there was no evidence of continued immune activation six months after treatment when the CFS-like illness was established. This was also true of the group of patients with CFS we used as a comparison group, who were even more severely fatigued, but had lower levels of inflammation than our interferon-alpha treated group six months after treatment – and were in fact no different from another comparison group of healthy volunteers. This suggests that while an exaggerated immune response may be responsible for leading patients on a trajectory to develop CFS, it is no longer there by the time CFS is diagnosed. Rather, this early activation may have an effect on other organs, for example, which lead to biological changes associated with more chronic fatigue and the other symptoms endured by these patients. </p>
<p>While our interferon-alpha treated group did not have a formal CFS diagnosis, it suggests the need for an earlier examination of the inflammatory response, and perhaps a greater focus on those suffering from more severe symptoms at the time of the acute sickness to identify those at risk. And further studies are needed to better understand the biological mechanisms linking the earlier exaggerated immune activation to the persistence of fatigue later on.</p><img src="https://counter.theconversation.com/content/108854/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alice Russell has received additional support from the National Institute of Health Research Collaborative for Applied Health Research and Care (NIHR CLAHRC) </span></em></p><p class="fine-print"><em><span>Carmine Pariante has received research funding from Johnson & Johnson as part of a programme of research on depression and inflammation, and research funding from the Medical Research Council (UK) and the Wellcome Trust for research on depression and inflammation as part of two large consortia that also include Johnson & Johnson, GSK and Lundbeck.</span></em></p>A better understanding of CFS could lead to new treatments.Alice Russell, Clinical Trial Research Manager, King's College LondonCarmine Pariante, Professor of Biological Psychiatry, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1048052018-10-12T14:41:43Z2018-10-12T14:41:43ZNot all people are equally vulnerable to hepatitis C – new study<figure><img src="https://images.theconversation.com/files/240412/original/file-20181012-119144-roo41w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pygmies in the Dzanga-Sangha Forest Reserve, Central African Republic.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/451013683?src=-mbe-8gY9fmnem3XMgS-sg-1-79&size=medium_jpg">Sergey Uryadnikov/Shutterstock.com</a></span></figcaption></figure><p>The hepatitis C virus (HCV) infects around 1% of the human population and is a devastating pathogen. In most people, it silently infects the liver for decades, often causing life-threatening inflammation, scarring and even cancer. How the virus achieves this feat has long puzzled scientists.</p>
<p>In our latest study, published in <a href="https://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1007307">PLOS Pathogens</a>, we found that a molecule that defends against HCV and other pathogens is weaker in humans than in our closest relative, the chimpanzee. This weakened molecule might have made it easier for some viruses, such as HCV, to infect humans and cause disease. </p>
<p>We are not defenceless against HCV. Our liver responds to infection by producing antiviral molecules called interferons. You can think of these molecules as the antiviral alarm system. Interferons are made rapidly once an invader has been spotted inside a cell. They are then released by the infected cell where they float across the nearby cells, warning them that a virus is near and forcing them to defend themselves by making hundreds more antiviral molecules.</p>
<p>In particular, we produce what is known as “lambda” – interferons against HCV that work well in liver cells. Strangely, one interferon lambda, called IFNL4, is associated with a reduced chance of clearing HCV, making it easier for the virus to silently infect the liver for decades. How an antiviral molecule appears to help a virus to sustain infection over such a long time, and how this may have evolved, remains a mystery.</p>
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<span class="caption">Hepatitis C virus.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1074829304?src=RrPNZemextoyawJtcArIpQ-1-8&size=medium_jpg">Tatiana Shepeleva/Shutterstock.com</a></span>
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<h2>Rare find</h2>
<p>The long evolution of humans in Africa and later global spread has resulted in genetically diverse populations of humans, each adapted to suit local environments and diseases.</p>
<p>In our recent study, we searched through all the known genetic diversity of the IFNL4 gene, including that of chimpanzees, to identify whether people who carried versions had different abilities to block viral replication. We hoped this would shine a light on the paradoxical role of IFNL4 during HCV infection. </p>
<p>What we found surprised us. A very rare version of IFNL4, which is only found in pygmies (hunter-gatherers from central Africa), was far better able to inhibit HCV infection in the lab. Even more surprisingly, this version had similar properties to the chimpanzee IFNL4. Nearly all humans, except this group of hunter-gatherers, produce a weaker version of IFNL4.</p>
<h2>Protective response</h2>
<p>This more antiviral version of IFNL4, found in chimpanzees and a small pocket of Central African hunter-gatherers, was better able to turn on hundreds of antiviral molecules when it was added to cells in the lab. This heightened antiviral response was similar to what was found when we compared the genes produced in the liver in response to HCV in people and in chimpanzees. That is, chimpanzees appeared to mount a greater antiviral response to HCV than humans, turning on anti-HCV molecules and enhancing the immune response.</p>
<p>Chimpanzees are the only animal – other than humans – that can be infected by HCV, which is the reason they were used to study the virus and find effective antiviral drugs and vaccines. However, testing in chimpanzees is now banned.</p>
<p>Correlating with this stronger antiviral response is the fact that HCV infection in chimpanzees is less pronounced than in humans. Chimpanzees don’t develop serious hepatitis C. The virus appears to replicate more slowly, and it might be more difficult for HCV to gain a foothold in chimpanzees. Also, despite searching, scientists have been unable to find natural HCV infection in chimpanzees in the wild. </p>
<p>Our finding that very early in human evolution we evolved an antiviral molecule with a reduced ability to block viral infections, might help explain the insidious nature of HCV – and possibly other viral infections – in humans.</p>
<p>One remaining mystery is what drove early humans to reduce the antiviral activity of IFNL4 and why do a handful of people retain it? We may not have the answers for a while, but studying the immune responses in our chimpanzee cousins in the wild, or in people who still carry the more antiviral version of IFNL4, may unlock some of the mysteries behind the role of IFNL4 in virus infection.</p><img src="https://counter.theconversation.com/content/104805/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span><a href="mailto:john.mclauchlan@glasgow.ac.uk">john.mclauchlan@glasgow.ac.uk</a> receives funding from the UK Medical Research Council. </span></em></p><p class="fine-print"><em><span>Connor G G Bamford does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Somewhere along our evolutionary path, we lost the ability to defend against hepatitis C. But not all humans lost this ability.Connor G G Bamford, Virologist, University of GlasgowJohn McLauchlan, Professor of Viral Hepatitis, University of GlasgowLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/995682018-07-27T10:44:04Z2018-07-27T10:44:04ZThe thrill of curing hepatitis C and the pain of watching the disease surge with opioid abuse<figure><img src="https://images.theconversation.com/files/229342/original/file-20180725-194124-1tkmdup.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hepatitis C rates have risen in the U.S. as drug use and opioid abuse have risen. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/male-junkie-hand-trying-grab-injection-1115261123?src=2tTYAQPj0tPMFOFpJMv2yQ-2-1">By Zephyr_p/shutterstock.com</a></span></figcaption></figure><p><em>An updated version of this article was published on Oct. 5, 2020. <a href="https://theconversation.com/a-researcher-reflects-on-progress-fighting-hepatitis-c-and-a-path-forward-147521">Read it here</a>.</em></p>
<p>When I began my medical career in Hong Kong in the early 1980s, I chose to focus on hepatitis B, in part because it was very common and because the hepatitis C virus had not yet been discovered. I witnessed the devastation that this virus caused – cirrhosis, liver failure and liver cancer – and the lack of treatments we could offer to patients.</p>
<p>Back then, scientists knew there was another type of hepatitis, but no one could identify it, so we called it non-A, non-B hepatitis. I would never have imagined that during the course of my career I would witness the <a href="http://doi.org/10.1126/science.2523562">discovery of what came to be known as hep C</a> and the <a href="http://doi.org/10.1056/NEJMoa1402454">development of a cure</a> for nearly all patients with <a href="http://doi.org/10.1056/NEJMoa1402355">chronic hepatitis C in 2014</a>. </p>
<p>The development of treatments over the past 30 years reflects the amazing progress the field has made in tackling hepatitis C in a relatively short period of time. Initially, in the late 1980s, before a diagnostic test became available, some physicians started treating well-characterized cases of non-A, non-B hepatitis (hep C) with interferon, a natural protein that the body makes to fight virus, and ribavirin, an antiviral drug. These medications were not specifically developed for hepatitis C, had to be given as injections for 6-12 months, had many side effects and resulted in a cure in only half of the patients who received treatment. It took more than two decades for the first direct-acting antiviral drugs to be approved by the FDA. </p>
<p>I remember the excitement when I and my colleagues tested one of the new drug combinations in patients and saw the virus count drop from more than 1 million to less than 20 within two weeks. <a href="http://doi.org/10.1056/NEJMoa1104430">We published the results</a> of our pilot study in the New England Journal of Medicine in 2012. Although the study involved only 21 patients, it was considered a watershed moment because it was the first study to prove that a combination of oral pills without interferon can cure hepatitis C. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=863&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=863&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=863&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1085&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1085&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1085&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">World Hepatitis Day is celebrated on July 28, the birthday of Dr. Baruch S. Blumberg, a Philadelphia researcher who shared the 1976 Nobel Prize in physiology or medicine for his discovery of the hepatitis B virus.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Obit-Blumberg/af5f0cf91a8a473582fb4fb5cf5106b8/1/0">Eddie Adams/AP Photo</a></span>
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<p>Effective treatment for hepatitis C has become even more relevant today in light of the recent surge in new cases of hepatitis C due to rising opioid use.</p>
<h2>A pricey drug and new generics</h2>
<p>The first combo pill with two drugs that inhibits different steps in hepatitis C replication was <a href="http://www.gilead.com/news/press-releases/2014/10/us-food-and-drug-administration-approves-gileads-harvoni-ledipasvirsofosbuvir-the-first-oncedaily-single-tablet-regimen-for-the-treatment-of-genotype-1-chronic-hepatitis-c">approved by the FDA in 2014</a>. This pill is taken once a day for 8-12 weeks, has little to no side effects and improved the cure rate to 90-95%. It was hailed as a magical cure, but it came with a price tag of US$94,500 for a 12-week course of treatment. That led many insurers in the United States and national health departments in other countries to limit access to treatment. </p>
<p>Since then, <a href="http://doi.org/10.1056/NEJMoa1512610">several other</a> <a href="http://doi.org/10.7326/M15-0785">combo pills with</a> <a href="http://doi.org/10.1056/NEJMoa1702417">similar cure rates</a> that are equally well-tolerated have become available, and the cost has markedly decreased. In addition, low-cost generics and special pricing arrangements are available in many resource-limited countries. </p>
<p>While the current price of hepatitis C virus drugs is still very high, one needs to remember that for 95 percent of patients, this is a cure. It is unlike medicines for many illnesses that need to be taken for a long time, sometimes for the rest of the patients’ lives. Indeed, a cure for hepatitis C virus has allowed some patients who were on the liver transplant waiting list to <a href="https://doi.org/10.1016/j.jhep.2016.05.010">reverse their liver failure</a>, making transplantation unnecessary. This is good news not only for these patients but also for others on the waiting list. </p>
<p>The remarkable success of hepatitis C treatment has reenergized efforts to find a cure for hepatitis B. Current treatments can suppress hepatitis B virus replication but do not eliminate it. Most patients need to be on long-term treatment to prevent flares of hepatitis when the virus reemerges after treatment is stopped. </p>
<h2>Deaths from hepatitis B and C infections rising worldwide</h2>
<p>Learning from the hepatitis C experience and with better understanding of the biology of hepatitis B virus and improved animal models, <a href="https://doi.org/10.1002/hep.29323">drugs that target different steps of the hepatitis B virus life cycle</a> are being developed. While cure for hepatitis B will be more challenging because it can integrate into the patient’s DNA, enabling it to evade the patient’s immune response, I am optimistic that we will witness the availability of new combination of drugs that will move us nearer the goal of an hepatitis B virus cure. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Members of Delhi Network of Positive People, a support group for HIV-positive people, shout slogans during a protest in New Delhi, India, Friday, March 21, 2014. The activists urged the Indian government to allow production of generic versions of direct-acting antivirals, that can help thousands get affordable oral doses of medicine to control hepatitis C. Infection progresses more rapidly to damage the liver in HIV-positive patients, and co-infection of HIV and hepatitis C virus is common among HIV-infected injection drug users.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/India-Health/14d6bce6d8fe430db7970e2bce717083/4/0">Saurabh Das/AP Photo</a></span>
</figcaption>
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<p>But the news is not all positive. While we’ve seen mortality rates from HIV, TB and malaria decline in recent years, mortality from hepatitis B and C has risen. Globally, an estimated <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">257 million people have chronic hepatitis B virus infection</a>, and <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-c">71 million have chronic hepatitis C virus</a>. Together hepatitis B and C caused more than 1.34 million deaths in 2015. This led the World Health Organization to challenge countries around the world to develop national plans to <a href="http://apps.who.int/iris/bitstream/handle/10665/206453/WHO_HIV_2016.04_eng.pdf?sequence=1">eliminate these two viruses by 2030</a>. </p>
<p>Hepatitis B virus and hepatitis C virus are usually spread through contact with blood or body secretions such as semen from infected persons by sharing needles or sexual exposure. But they can also be spread through contaminated needles used for medical treatment, which continues to happen in many parts of the world. In addition, hepatitis B virus can be spread from infected mothers to newborn babies unless vaccination is given immediately after birth. </p>
<p>For hepatitis C virus, roughly two-third suffer chronic infection. For hepatitis B virus, the chance of chronic liver infection decreases the later the patient encounters the virus: 90% if infected during infancy; 20-30% if infected during childhood; and 2-5% if infected in adult life. Some people infected with hepatitis B virus or hepatitis C virus can recover on their own, but many go on to chronic infection (lasting more than six months and often years or lifelong). Those with chronic infection are at risk of cirrhosis (severe liver damage), liver failure and liver cancer. </p>
<h2>Opioid epidemic, homeless lead to rise in hepatitis B and C infections</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">In this Nov. 8, 2017, photo, Christine Wade sits among her children in front of their donated tent in the city-sanctioned encampment on a parking lot in San Diego. The Wade family is among several hundred people living in the city’s first campground open for the homeless, set up to curb the worst hepatitis A outbreak in the United States in decades.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Homeless-Crisis-on-the-Coast-San-Diego/b0d09b99f82249138623efa6177d2e5f/33/0">Gregory Bull/AP Photo</a></span>
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</figure>
<p>In the United States, the number of new hepatitis B virus and hepatitis C virus infections has been decreasing for many years, but <a href="http://doi.org/10.2105/AJPH.2017.304132">this trend has been reversed</a> during recent years <a href="http://doi.org/10.1056/NEJMp1716871">due to the opioid epidemic</a> as more people use injection drugs, share needles or other paraphernalia and practice high-risk sexual behavior. This is particularly true for hepatitis C, where the number of new cases in the past 10 years has more than doubled, highlighting the need for a preventive vaccine, which is a vital tool if we want to eliminate hepatitis C. The increase in number of new cases of hepatitis B is smaller and mainly seen in adults in their 30s because most younger persons have benefited from hepatitis B virus vaccination. </p>
<p>When we talk about viral hepatitis, the focus is on hepatitis B and C because they can cause chronic infection, while hepatitis A causes only acute infection and will not lead to cirrhosis or liver cancer. However, starting late 2016, many states in the U.S. have witnessed outbreaks of hepatitis A. The Centers for Disease Control and Prevention received more than 2,500 reports of hepatitis A between January 2017 and April 2018 associated with person-to-person transmission, with risk factors in <a href="https://emergency.cdc.gov/han/han00412.asp">two-thirds of these cases being drug use or homelessness</a> or both. In the state of Michigan, where I live, 859 cases of hepatitis A including 27 deaths were reported between July 2016 and June 2018. We can prevent hepatitis A through vaccination and improved hygienic conditions. </p>
<p>World Hepatitis Day occurs annually on July 28, a day chosen in honor of the late Baruch Blumberg, who received a Nobel Prize for discovering the hepatitis B virus. I marvel at how much progress we have made in the last three decades and am delighted to be not just an observer but also a contributor to the progress. Our work is not finished. Much more needs to be done to completely eliminate new cases of viral hepatitis and deaths from chronic hepatitis B and C.</p><img src="https://counter.theconversation.com/content/99568/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna Suk-Fong Lok has served on advisory panels of Roche, Viravaxx, and Spring Bank. She receives research funding from Bristol-Myers Squibb, Gilead, the National Institutes of Health, and the Patient Center for Outcome Research Institute provided to the University of Michigan. </span></em></p>July 28 is World Hepatitis Day, and with an effective cure for hepatitis C there is much to celebrate. But homelessness and the opioid epidemic are driving a surge in hepatitis infections.Anna Suk-Fong Lok, Professor of Internal Medicine, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/980612018-06-15T03:08:09Z2018-06-15T03:08:09ZDoctors are drowning in a tsunami of liver disease and cancer<figure><img src="https://images.theconversation.com/files/223082/original/file-20180613-32342-ty2dm8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hepatitis B, hepatitis C and obesity all play a part in the rising incidence of liver cancer -- in Canada and globally.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Deaths from liver cancer in Canada have doubled over the past 25 years. And to make matters worse, there’s an epidemic of liver cancer on the horizon if action isn’t taken soon.</p>
<p>While less people are dying from most major cancers — such as breast cancer and lung cancer — liver cancer (hepatocellular carcinoma or HCC) is bucking the trend and heading in the wrong direction. </p>
<p>In 1993, <a href="http://www.cancer.ca/en/cancer-information/cancer-type/liver/statistics/?region=on">liver cancer rates in Canadian men</a> were five cases per 100,000 population. By 2017 this had risen to 9.9 cases. </p>
<p>For women, rates are much lower, but the trend is the same. In 1993, 1.6 Canadian women per 100,000 were diagnosed with liver cancer; by 2017 this had almost doubled. In hard numbers this means that last year 1,900 men in Canada were diagnosed with liver cancer and 580 women. A total of 950 men died from liver cancer and 270 women.</p>
<p>This is not unique to Canada; a <a href="http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx">similar pattern is seen in the United States, the United Kingdom, Australia and most other developed countries</a>.</p>
<p>At this week’s <a href="http://www.globalhepatitissummit2018.com/">Global Hepatitis Summit</a> in Toronto (June 14-17), I will be among a group of liver cancer experts exploring these trends. </p>
<h2>The role of hepatitis and obesity</h2>
<p>What are the reasons for this increase, and why are they being discussed at the Global Hepatitis Summit? It is because both <a href="https://www.liver.ca/patients-caregivers/liver-diseases/hepatitis-b/">hepatitis B</a> and <a href="https://www.liver.ca/patients-caregivers/liver-diseases/hepatitis-c/">hepatitis C</a> are serious liver infections that cause inflammation. </p>
<p>When left untreated, both infections can progress to liver scarring, cirrhosis, liver cancer and, ultimately, an early death.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/223081/original/file-20180613-32307-12y84lc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">3D image of cirrhosis of the liver.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Today, there are an estimated 230,000 Canadians with hepatitis B and 250,000 with hepatitis C. Almost half of each group do not know they are infected, which hugely increases their risk of progression to serious liver disease and cancer. </p>
<p>An enormous effort will be needed from provincial and territorial governments —with federal government support — to find, diagnose and treat these missing patients and to link them to care.</p>
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Read more:
<a href="https://theconversation.com/why-all-canadian-infants-need-a-hepatitis-b-vaccination-98060">Why all Canadian infants need a hepatitis B vaccination</a>
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<p>Also contributing to Canada’s liver cancer problem is the <a href="https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009620">obesity epidemic</a>: about two thirds of Canadian men and half of women are thought to be overweight or obese. </p>
<p>Some one in five Canadians have some degree of <a href="https://www.liver.ca/patients-caregivers/liver-diseases/fatty-liver-disease/">non-alcoholic fatty liver disease</a> (NAFLD), which causes inflammation and can progress to cirrhosis and liver cancer.</p>
<h2>A lack of liver cancer specialists</h2>
<p>Canada’s limited number of liver specialists (less than 100 nationwide) and a few oncologists dealt with around 5,000 cases of liver cancer during 2017. </p>
<p>However, the hepatitis B and C epidemics, combined with Canada’s continuously increasing obesity problem, threaten to drown liver cancer specialists with new cases in the coming decades — with numbers reaching tens of thousands annually over the next 20 years.</p>
<p>We are completely unprepared to deal with such an epidemic of liver cancer. Not only would we be submerged in the sheer number of cases, the financial considerations for provinces and territories and the federal government would be phenomenal. </p>
<p>And many of these liver cancers strike people in their 50s, when they are still of working age. So families are not only in danger of losing a loved one, but possibly the main breadwinner in their family unit.</p>
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<img alt="" src="https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/223080/original/file-20180613-32342-1rbu8w9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">As obesity in Canada shows no signs of retreating, new treatments for fatty liver disease could play a part in helping to reduce future incidences of liver cancer.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Not only is Canada’s system of liver specialists being gradually overwhelmed, but there is also a shortage of new liver specialists interested in HCC being trained.</p>
<p>Graduating liver specialists (hepatologists) tend not to specialise in liver cancer. Nor is it a popular speciality in oncology. However, this area is a growing field and there are plenty of opportunities for young physicians to do both practice and research. </p>
<p>Provinces and territories must also take a fresh look at remuneration for liver specialists, who are generally not as well paid as those in other specialities such as gastroenterology.</p>
<p>It may be necessary to develop some special programs to address this issue and boost recruitment in order to deal with the tsunami of liver disease and cancer that Canada is facing.</p>
<h2>How to reverse the trend</h2>
<p>However, the news is not all bad. Even though Canada’s incidence and mortality rates for liver cancer have doubled over the last 25 years, the actual numbers are much better for Canada than other developed nations. With six new cases per 100,000 population per year, Canada’s liver cancer incidence is lower than <a href="https://www.aihw.gov.au/reports/cancer/acim-books/contents/acim-books">Australia</a> (7.4) the <a href="https://seer.cancer.gov/csr/1975_2015/results_merged/sect_14_liver_bile.pdf">U.S.</a> (9.2) and the <a href="http://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/liver-cancer">U.K.</a> (9.6).</p>
<p>A similar pattern is seen with mortality: Canada’s death rate for liver cancer (three per 100,000 population) is less than half that of the U.S. and Australia (both 6.6) and the U.K. (8.7). </p>
<p>I believe this is due to our excellent record in finding cases of liver cancer very early, when they can still be successfully operated and treated. The U.S. obviously lacks universal health coverage and the U.K. has a high level of alcoholic liver disease contributing to the epidemic there.</p>
<p>To reverse the increasing trend in liver cancer in Canada and elsewhere, a combination of things will need to occur. First, more patients with hepatitis B and hepatitis C must be diagnosed and treated or cured. Second, new therapies within the next decade should also greatly improve care and prognosis for hepatitis B. </p>
<p>Finally, because obesity in Canada shows no signs of retreating, we will be dependent on new treatments in the pipeline for fatty liver disease. It is unclear at this point how many cases of cirrhosis and liver cancer this will prevent.</p><img src="https://counter.theconversation.com/content/98061/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Morris Sherman sits on safety committees for Merck, Celsion, Sirtex and Adaptimmune, all of which have products currently under test for the treatment of hepatocellular carcinoma</span></em></p>To prevent the epidemic of liver cancer that looms on the horizon, we need to tackle hepatitis B, hepatitis C and obesity.Morris Sherman, Affiliate Scientist, Toronto General Hospital Research Institute (TGHRI) and Emeritus Professor, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/981282018-06-13T23:12:20Z2018-06-13T23:12:20ZCan you rely on the drugs that your doctor prescribes?<figure><img src="https://images.theconversation.com/files/222864/original/file-20180612-112599-1wl397r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The reliability of a new guideline for the management of chronic hepatitis C is questionable, given the financial conflicts of interest documented by its authors. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>The <em>Canadian Medical Association Journal</em> (CMAJ) has just published a <a href="http://www.cmaj.ca/content/190/22/E677">new guideline for the management of hepatitis C</a> — a disease that is underdiagnosed and undertreated in Canada. </p>
<p>This guideline is aimed at doctors and details recent advances in treating adults with chronic hepatitis C virus infection. It was produced by a committee from the Canadian Association for the Study of the Liver (CASL).</p>
<p>As the complexity of medical care grows exponentially, clinical guidelines such as this become increasingly important in helping doctors weave their way through the diagnosis and treatment of disease. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2219863/">As the number of guidelines increases, so too does their influence</a>. </p>
<p>Well-constructed medical guidelines can be a boon to patient care, but <a href="http://dx.doi.org/10.1136/ebmed-2017-110845">poor guidelines have the potential for harm</a>. There are two interrelated threats. The first is when committee members have a financial conflict of interest (FCOI) with companies producing products recommended in the guidelines. The second occurs when guidelines rely on poor quality evidence.</p>
<p>In the lead up to the <a href="http://www.globalhepatitissummit2018.com">Global Hepatitis Summit 2018</a>, to be held in Toronto on June 14-17, we believe there are reasons to be concerned about this new hepatitis C guideline on both counts.</p>
<p>First, all eight authors of the CMAJ article, including the chair, declared FCOI with companies that produced the drugs recommended in the guideline. Second, the committee did not include an expert on evidence evaluation or someone representing the public or patients. </p>
<h2>Do guidelines recommend the best drugs?</h2>
<p>One of the authors of this article (Joel Lexchin) was part of a study that looked at <a href="https://doi.org/10.1186/s12913-016-1646-5">FCOI in Canadian medical guidelines</a>. We examined 28 guidelines that recommended drug treatment for a wide variety of diseases. </p>
<p>In more than 25 per cent of these documents, over half of the authors disclosed FCOI with manufacturers of drugs that they recommended. </p>
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<img alt="" src="https://images.theconversation.com/files/222869/original/file-20180612-112605-1qqi3m5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/222869/original/file-20180612-112605-1qqi3m5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/222869/original/file-20180612-112605-1qqi3m5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/222869/original/file-20180612-112605-1qqi3m5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/222869/original/file-20180612-112605-1qqi3m5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/222869/original/file-20180612-112605-1qqi3m5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/222869/original/file-20180612-112605-1qqi3m5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">3D illustration of the hepatitis C virus (HCV)</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>The <a href="https://doi.org/10.1111/jep.12016">guideline for the treatment of patients with major depressive disorder</a> from the American Psychiatric Association was studied by Lisa Cosgrove, the second author of this article. Financial ties to industry were disclosed by all members of this guideline development committee. </p>
<p>The presence of this FCOI may have been the reason why fewer than half of the studies cited in support of the recommendations met criteria for high quality and why 17 per cent did not measure clinically relevant results.</p>
<p>To guard against the corruption of guidelines, safeguards have been put in place. The U.S. Institute of Medicine (IOM), now the National Academy of Medicine, has <a href="https://www.ncbi.nlm.nih.gov/books/NBK209539/">recommendations about the membership on guideline committees</a>. According to them, the chair and the majority of members should be free of FCOI and the committee should include an expert in the evaluation of evidence and a patient or public representative. </p>
<p>When the highly respected <a href="http://www.cochrane.org/">Cochrane organization</a> produces medical guidelines, it explains in detail why studies are included or excluded. It also evaluates the multiple sources of bias that potentially exist in all studies.</p>
<p>The point about bias is extremely important as there is <a href="http://www.cochrane.org/MR000033/METHOD_industry-sponsorship-and-research-outcome">good evidence that studies financed by drug and device manufacturers are much more likely to report positive results</a> and conclusions, compared with studies with any other source of funding.</p>
<p>Finally, guidelines produced by industry-tied authors tend to <a href="http://ebm.bmj.com/content/ebmed/23/1/33.full.pdf">recommend expensive drugs</a> despite a lack of evidence for their safety and efficacy.</p>
<h2>Silent on many questions</h2>
<p>So, how valuable is a guideline for the management of hepatitis C, in which eight authors declared FCOI with recommended drug producers? How reliable are the recommendations from a committee that did not document how evidence was evaluated or include a public or patient representative?</p>
<p>The committee did attempt to get around some of these deficiencies. First the guideline explicitly states: “No funding, direct or in kind, was provided to the guideline panel for this work.” Second, “in order to manage competing interests, the final guideline was vetted by the Canadian Association for the Study of the Liver membership, and specifically by the association’s executive.” Third, the “guideline was circulated by email to community organizations that represented patients.”</p>
<p>Who were the community organizations and did they have ties with the companies making the drugs the guideline recommends? The guideline is silent on these questions. </p>
<p>Who is on the executive of CASL? Do they as individuals have links with industry? Does the association itself have links? </p>
<p>Getting even partial answers to these questions requires some digging. A simple Google search on “Canadian Association for the Study of the Liver” doesn’t produce any direct links. The closest is a link to the <a href="https://canlivj.utpjournals.press/">Canadian Liver Journal</a>. Visit this page, click around a few more times and eventually you get to the <a href="http://www.hepatology.ca">CASL website</a>.</p>
<p>There are 33 people on the executive board including three of the guideline committee members; so, executive committee members were reviewing what they themselves had written. </p>
<p>Did the other 30 members have any FCOI to declare? There’s no information about these people on the website. The website does say that CASL only <a href="http://www.hepatology.ca/wp-content/uploads/2016/12/EndorsementPolicy_May192015_v4.pdf">endorses requests produced by a not-for-profit organization</a> and that it “does not endorse or support any commercial diagnostic or therapeutic products.” </p>
<p>But <a href="http://www.hepatology.ca/?page_id=1817">Gilead Science, Merck and AbbVie were all 2018 sponsors of Association Hepatology Fellowships</a>. Gilead and AbbVie both produce hepatitis C drugs and <a href="https://www.reuters.com/article/us-merck-co-hepatitis-c/merck-to-stop-development-of-hepatitis-c-treatments-idUSKCN1C41QD">Merck was working in this field</a> until October 2017. </p>
<p>Does CASL get money from drug companies? Silence once more.</p>
<p>There is nothing in the guideline about why studies were included or excluded, nothing about how the information was abstracted from the studies and nothing about whether they were checked for biases.</p>
<h2>Guidelines must be bias-free</h2>
<p>The appearance of this guideline in the CMAJ raises serious questions about the journal’s standards for publishing guidelines. The article was peer reviewed and FCOI was declared, but should the journal do more? </p>
<p>Should it require the composition of guideline committees to conform to the standards set by the National Academy of Medicine? </p>
<p>Should there have to be information about FCOI of the organization sponsoring the guidelines? </p>
<p>Should there have to be explicit information about how studies were selected and evaluated?</p>
<p>Guidelines have to be seen as free of bias in order for doctors to have confidence in them. The new hepatitis C guideline published by the <em>Canadian Medical Association Journal</em> fails the bias test.</p><img src="https://counter.theconversation.com/content/98128/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In 2015-2018, Joel Lexchin was a paid consultant on three projects: one looking at indication-based prescribing (United States Agency for Healthcare Research and Quality), a second to develop principles for conservative diagnosis (Gordon and Betty Moore Foundation) and a third deciding what drugs should be provided free of charge by general practitioners (Government of Canada, Ontario Supporting Patient Oriented Research Support Unit and the St Michael’s Hospital Foundation). He also received payment for being on a panel that discussed a pharmacare plan for Canada (Canadian Institute, a for-profit organization). He is currently a member of research groups that are receiving money from the Canadian Institutes of Health Research and the Australian National Health and Medical Research Council. He is member of the Foundation Board of Health Action International and the Board of Canadian Doctors for Medicare.</span></em></p><p class="fine-print"><em><span>Lisa A Cosgrove does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In the run up to the Global Hepatitis Summit 2018, new guidelines for the management of hepatitis C should come under scrutiny – for financial conflict of interest and quality of evidence.Joel Lexchin, Professor Emeritus of Health Policy and Management, York University, Emergency Physician at University Health Network, Associate Professor of Family and Community Medicine, University of TorontoLisa A Cosgrove, Professor Counseling Psychology Doctoral Program, UMass BostonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/940292018-03-28T02:57:56Z2018-03-28T02:57:56ZVictorian drug law reform recommendations are welcome – but must include prisoners<figure><img src="https://images.theconversation.com/files/212328/original/file-20180327-109196-1vyvz8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Victorian report recommends the law be changed to allow peers to distribute needles and other clean injecting equipment.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The results of a major drug law inquiry <a href="https://www.parliament.vic.gov.au/images/stories/committees/lrrcsc/Drugs_/Report/LRRCSC_58-03_Full_Report_Text.pdf">were tabled</a> in the Victorian parliament this week. The landmark final report contains 50 recommendations for reform to Victoria’s drug laws and policies.</p>
<p>Many of the proposals for reform, if implemented, have the potential to improve social, economic and other outcomes for people who use drugs in Victoria. In this sense, the report is a welcome step forward. But the report falls short in some areas, especially for Victorian prisoners.</p>
<h2>Moving away from a criminal justice approach</h2>
<p>The report recommends a “reorientation” of Victoria’s drug law and policy. This would involve a move away from viewing drug use as a criminal law problem, and toward viewing it as a social and health policy matter. </p>
<p>A common theme throughout the report is the need to tackle blood-borne viruses (BBVs) – especially hepatitis C and HIV – among people who use drugs. </p>
<p>Several of the recommendations are targeted measures that have the real potential to reduce BBV transmission. </p>
<h2>Why is there a focus on BBV transmission and prevention?</h2>
<p>Approximately 200,000 Australians <a href="https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-and-stis-australia-2017">live with hepatitis C</a>. Around 90% of these are people who inject drugs. Hepatitis C can be associated with a range of <a href="https://theconversation.com/eliminating-hepatitis-c-an-ambitious-but-achievable-goal-24485">significant health problems</a>, including chronic fatigue, depression, cirrhosis and liver cancer.</p>
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Read more:
<a href="https://theconversation.com/why-theres-no-legal-barrier-to-a-melbourne-drug-injecting-room-despite-political-setbacks-73373">Why there's no legal barrier to a Melbourne drug injecting room, despite political setbacks</a>
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<p>People who inject drugs <a href="https://www.routledge.com/Making-Disease-Making-Citizens-The-Politics-of-Hepatitis-C/Fraser-Seear/p/book/9781409408390">may acquire BBVs</a> when they share needles or other injecting equipment with a person who has the virus.</p>
<p>Australia has been at the forefront of BBV prevention over many decades, especially through its nationwide network of <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/Needle+and+Syringe+Program-1">Needle and Syringe Programs</a> (NSPs). People who inject drugs have access to free and low cost injecting equipment through NSPs.</p>
<p>Unfortunately, <a href="https://www.ncbi.nlm.nih.gov/pubmed/19387355">not everyone</a> who needs access to sterile needles and injecting equipment can get them. Significant numbers of people who inject drugs continue to share used injecting equipment, and are therefore at risk of contracting BBVs.</p>
<p>Sharing of used equipment is driven by issues relating to access, not demand. Some people do not use NSPs, whether through fear, stigma, lack of knowledge, or because they find <a href="https://search.informit.com.au/documentSummary;dn=462107503809225;res=IELHSS">services inconvenient to access</a>.</p>
<p>If additional sterile injecting equipment is distributed within the community, when and where it is needed, the rate of blood-borne transmissions will fall. If people who inject drugs could pass on sterile equipment to those who do not access services, this could tackle the service gap and prevent BBV transmissions.</p>
<p>However, passing on sterile equipment – a practice known widely in the community as “peer distribution” – is <a href="http://www8.austlii.edu.au/cgi-bin/viewdoc/au/legis/vic/consol_act/dpacsa1981422/s80.html">currently a criminal offence</a>.</p>
<h2>Allowing peer distribution of clean needles and injecting equipment</h2>
<p>The Victorian report recommends that the law be changed to allow peers to distribute needles and other clean injecting equipment. This is a simple, straightforward measure that has the potential to directly reduce BBV transmission, especially if it is accompanied by measures to expand NSP coverage.</p>
<p>The report also recommends that coverage and access be improved through a range of measures, including public hospitals and more automatic dispensing machines.</p>
<p>Victoria would be following the lead of other jurisdictions, including <a href="http://www.parliament.tas.gov.au/bills/Bills2015/pdf/notes/6_of_2015-Fact%20Sheet.pdf">Tasmania</a> and the <a href="http://www.legislation.act.gov.au/b/db_53829/">ACT</a>, which have recently lifted their bans on peer distribution.</p>
<p>The ACT reforms were based in part on <a href="https://www.ncbi.nlm.nih.gov/pubmed/26118796">our own research</a>. We argued that the prohibition on peer distribution was unnecessary and outdated, was out of step with current practice, and at odds with <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/ministerial-drug-alcohol-forum">Australia’s National Drug Strategy</a> and focus on harm reduction.</p>
<p>We also argued that if the prohibition were lifted, it would help reduce the spread of BBVs such as hepatitis C and HIV. Indeed, these laws were introduced even before hepatitis C had been isolated. </p>
<h2>No elimination without decriminalisation and other reforms</h2>
<p>Importantly, since <a href="https://www.annualreviews.org/doi/abs/10.1146/annurev-pharmtox-011112-140254">our research</a> into the prohibition on peer distribution was published, new drugs (direct acting anti-virals) for the treatment of hepatitis C have appeared. These have been heralded as revolutionary, with the <a href="https://theconversation.com/eliminating-hepatitis-c-an-ambitious-but-achievable-goal-24485">potential to cure hepatitis C</a>. These medicines have now been added to Australia’s Pharmaceutical Benefits Scheme. </p>
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Read more:
<a href="https://theconversation.com/australia-leads-the-world-in-hepatitis-c-treatment-whats-behind-its-success-81760">Australia leads the world in hepatitis C treatment – what's behind its success?</a>
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<p>However, elimination programs must be implemented with primary prevention. Although these medicines are promising, there is a risk that efforts to control new infections may be undermined if complementary harm reduction strategies are not available. </p>
<p>Indeed, advocates <a href="https://www.hepatitisaustralia.com/newsarticles/world-hepatitis-summit-no-elimination-without-decriminalization/3/11/2017">have argued</a> there can be “no elimination without decriminalisation” and other reforms. This is especially the case where there are legal barriers to the roll out of prevention programs such as peer distribution.</p>
<p>If Victoria does finally end the ban on peer distribution, there will be pressure on other states, including New South Wales and Queensland, to follow. There is a growing momentum for reform, made more urgent by the possibility that doing nothing will undermine the roll-out of direct acting anti-virals.</p>
<h2>Prison reforms also must be considered</h2>
<p>We were disappointed the report did not recommend reforms within Victorian prisons that would help to minimise the risk of BBV transmission. </p>
<p>The reality is that drug use does occur in Victorian prisons. Prisons <a href="https://nuaa.org.au/wp-content/uploads/2017/01/Stories-From-the-Other-Side_needs-reformatting.pdf">have even been called</a> an “incubator” for BBVs and in-prison acquisition of hepatitis C <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0162399">has been documented</a>. </p>
<p>We had hoped the report would include a recommendation for Australia’s first-ever prison NSP. The failure to establish a prison NSP not only undermines attempts to eliminate hepatitis C in Australia, but <a href="https://www.parliament.vic.gov.au/images/stories/committees/lrrcsc/Drugs_/Submissions/126_2017.03.16_-_Dr_K_Seear_-_submission.pdf">arguably</a> breaches the <a href="https://www.penalreform.org/resource/standard-minimum-rules-treatment-prisoners-smr/">Mandela Rules</a> – a set of international principles that require prisoners receive the same standard of health care as those in the wider community.</p>
<p>The Victorian report includes a recommendation to “monitor” the situation in prisons, and defer some of these issues to an advisory body. We remain hopeful the advisory body will consider prison reforms alongside the other welcome recommendations in the report. </p>
<p>Without them, there is a risk of inequitable and inconsistent approaches to BBV transmission across the state – and the country – at a time when consistency is urgently needed.</p><img src="https://counter.theconversation.com/content/94029/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Seear is a current recipient of an Australian Research Council DECRA Fellowship (DE160100134). She also receives funding from the Australian Research Council Discovery Scheme and has previously received funding to conduct research on alcohol and other drug issues from the Academy of Social Sciences Australia, the Australian Institute of Criminology and the Queensland Mental Health Commission.</span></em></p><p class="fine-print"><em><span>Carla Treloar receives funding from the Commonwealth government and state governments, the Australian Research Council and the National Health and Medical Research Council. The Centre for Social Research in Health is supported by the Australian Commonwealth government. </span></em></p><p class="fine-print"><em><span>Kari Lancaster has received funding from Australian Commonwealth and state governments, and is the recipient of a UNSW Scientia Fellowship. The Centre for Social Research in Health is supported by the Australian Commonwealth government.</span></em></p>Victoria should implement a new report’s recommendation to allow peers to distribute clean injecting equipment, but it needs to go further to ensure safe drug use in prison.Kate Seear, Associate Professor in Law and Academic Director of the Springvale Monash Legal Service, Monash UniversityCarla Treloar, Director, Centre for Social Research in Health, Social Policy Research Centre, UNSW SydneyKari Lancaster, Scientia Fellow, Centre for Social Research in Health, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/909792018-02-05T09:49:37Z2018-02-05T09:49:37ZCan England really eliminate hepatitis C by 2025?<figure><img src="https://images.theconversation.com/files/204735/original/file-20180204-19921-3pnw69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/559630771?src=EcfCLqUhuXJOLzuTvXA3zw-1-40&size=medium_jpg">nokwalai/Shutterstock</a></span></figcaption></figure><p>The World Health Organisation set a goal to eliminate hepatitis C by 2030. The NHS recently announced that it will go one better than that: it will eliminate the disease in England by <a href="http://www.pharmatimes.com/news/nhs_plans_to_be_first_to_eliminate_hepatitis_c_1219469">2025</a>. In theory, the goal is achievable, but there are still significant challenges to overcome. </p>
<p><a href="https://www.nhs.uk/conditions/hepatitis-c/">Hepatitis C</a> is a viral infection that causes chronic liver disease, which can lead to life-threatening complications. Thankfully, a new class of drugs, known as direct-acting antivirals (DAAs) has revolutionised hepatitis C treatment. A three month course of DAAs can clear hepatitis C from the blood. </p>
<p>The drugs aren’t perfect, though. They have a failure rate of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4970473/">around 10-15%</a>. However, the real problem with eliminating the disease lies in the hidden nature of the hepatitis C epidemic in the UK.</p>
<p>For many years it was known that some blood donations, or products made from blood, such as factor VIII used to treat haemophilia, contained an unknown virus that inflammed the liver (hepatitis) in patients who received a transfusion. The identity of this virus remained unknown until the mid-1980s when the development of new technologies allowed the virus to be identified by its gene sequence. </p>
<p>Tests on blood donations soon followed, designed to help prevent the transmission of the virus by transfusion or during surgery. As these tests were applied more widely, though, the real extent of the problem with hepatitis C virus began to emerge. </p>
<p>By the early 1990s, it became clear that many more people were infected than previously thought. Two groups were particularly affected: those who had been infected through medical treatment (including some children who had been infected by their mother either in the womb or during the process of birth), and a second much larger group who had used illegal drugs (injecting or inhaling drugs through the nose). Many of the infected people had not used drugs for years.</p>
<p>Hepatitis C doesn’t usually cause symptoms in the early stages of infection, but the virus remains in the liver, causing a hidden and silent infection in at least 80% of cases. (In 20% of cases, the patient’s immune system manages to clear the virus on its own.) Over decades, the infection causes progressive liver damage. By the time the patient begins to suffer from fatigue as a result of the infection, liver failure and liver cirrhosis has usually set in. This can progress to liver cancer (hepatoma) and premature death. Globally, hepatitis C virus infection is now a leading cause of liver transplantation.</p>
<p>As with many viral infections, at first there were few treatment options. The antiviral drug interferon was tried with limited success. Treatment was improved when interferon was combined with a second antiviral drug, ribavirin. However, some strains of the virus proved very difficult to treat, requiring 12 months of continuous therapy, and even then the infection sometimes returned <a href="https://link.springer.com/content/pdf/10.1007/s11901-006-0014-z.pdf">once treatment stopped</a>. </p>
<p>The development of DAAs has revolutionised treatment of hepatitis C virus infection. Now, short treatment courses effectively cure the infection in a high percentage of cases. Because of this, transmission of the infection between people can be stopped, leading to the enticing prospect that hepatitis C virus infection could be eliminated. </p>
<p>Elimination should not of course be confused with eradication. So far, only one human virus infection, smallpox, has been eradicated. Others, <a href="http://www.who.int/features/factfiles/polio/en/">such as polio virus</a>, are close to global eradication.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/204612/original/file-20180202-162087-11w6jl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/204612/original/file-20180202-162087-11w6jl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/204612/original/file-20180202-162087-11w6jl8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/204612/original/file-20180202-162087-11w6jl8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/204612/original/file-20180202-162087-11w6jl8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/204612/original/file-20180202-162087-11w6jl8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/204612/original/file-20180202-162087-11w6jl8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Hepatitis C virus.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/484370686?src=-nUn9GHvj9eSGHQy4l81cg-1-3&size=medium_jpg">fotovapl/Shutterstock</a></span>
</figcaption>
</figure>
<h2>A hidden disease</h2>
<p>The current problem with hepatitis C infection is not how we should treat it, it is rather how do we identify those who are infected so that they can be guided into treatment and cure. For those who contracted infection through medical interventions and do not know they are infected, they may not yet be suffering the symptoms of long-term infection that would cause them to seek medical help. The biggest problem, however, lies with drug users – a social group that tends to actively avoid the health system for fear of being challenged or stigmatised because of current or former drug use. </p>
<p>In order to reach these two groups of infected people, new approaches to diagnosis outside of conventional healthcare facilities need to be much more widely applied. Simple rapid tests on blood or saliva specimens that can be used anywhere, or even self-collection of blood dried onto filter paper spots (known as “<a href="https://en.wikipedia.org/wiki/Dried_blood_spot">DBS testing</a>”), offer ways to greatly extend the numbers of people who come forward for diagnosis. The wider application of these tests will be an essential step in persuading people who may be in denial about their risk of infection into a programme that offers a cure. </p>
<p>Hepatitis C virus could be eliminated. The treatment to do this is available, it appears to be <a href="https://www.ncbi.nlm.nih.gov/pubmed/28836278">cost effective</a> and the technology to provide quick and easy diagnosis is available. However, a concerted and coordinated effort to reach the infected, but untested public, will be necessary if the NHS is to achieve its worthwhile goal of eliminating hepatitis C in England by 2025.</p><img src="https://counter.theconversation.com/content/90979/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Klapper received funding from the Greater Manchester Hepatitis C Strategy. He is affiliated with The Labour Party. </span></em></p><p class="fine-print"><em><span>Pam Vallely is affiliated with The Liberal Democrats Party. </span></em></p>If England eliminates hepatitis C, it will be the first country to do so. But how feasible is it?Paul Edward Klapper, Chair Professor, University of ManchesterPam Vallely, Chair in Graduate Education, University of ManchesterLicensed as Creative Commons – attribution, no derivatives.