HEPATITIS C VIRUS INFECTION: Epidemiology, Transmissions, and Western and Chinese Medicine

BY: Misha Cohen, OMD, L.Ac

Hepatitis C virus (HCV) infection is increasing in the United States and around the world today. More than three-quarters of those infected with HCV will develop chronic liver disease,1,2 and up to 20% will develop cirrhosis.3-5 It is estimated that there are 8,000 to 10,000 HCV-related deaths each year; the US Centers for Disease Control and the National Institutes of Health expect the rate to triple in the next 10 to 20 years.

Forty percent of all people with HIV infection are chronically infected with the hepatitis C virus. People with co-infection of HIV/HCV have double the risk of developing severe liver damage, and there is some evidence that the course of liver disease development is shorter.6

Hepatitis C virus infection is the most common chronic bloodborne infection in the United States. The Center for Disease Control estimates that during the 1980s, an average of 230,000 new infections occurred each year.7 The Third National Health and Nutrition Examination Survey, conducted during , indicated that an estimated 3.9 million Americans (1.8% of the population) have been infected with HCV. Most are chronically infected and may not be aware of their infection because they do not have apparent symptoms. Infected persons may transmit the virus to others and are at risk for chronic liver disease or other HCV-related chronic diseases during the 20 to 30 years following infection.

Hepatitis C virus infection is found in people of all ages. In the general population, the highest prevalence rates of chronic HCV infection are found among those aged 30-49 years and among males. However, the highest incidence of acute hepatitis C is among 20-39 year olds; men have a slightly higher rate of acute infections. Because most HCV-infected people are between 30 and 49 years old, the number of deaths caused by HCV-related chronic liver disease could increase significantly during the next 10 to 20 years as current HCV patients age.

While African Americans and whites currently have similar incidence of acute infection, African Americans have a substantially higher prevalence of chronic HCV infection than whites. Latinos have the highest rate of acute infection.8

HCV infection occurs at different rates among persons with different risk factors for infection. The highest prevalence of chronic infection is found among those with large or repeated direct exposures to blood through the skin; this group includes predominantly injecting drug users; persons with hemophilia who were treated with clotting factor concentrates produced before 1987; and people who received transfusions from HCV-positive donors. Moderate prevalence is found among those with frequent but smaller direct exposures through the skin such as long-term hemodialysis patients. Lower prevalence is found among those with mucosal or possible blood-to-blood exposure through the skin such as occurs with high-risk sexual practices or among those at risk for small, sporadic exposures through the skin (such as needle sticks among healthcare workers, for example). Lowest prevalence of HCV infection is found among those with no high-risk characteristics, such as volunteer blood donors.9

Most risk factors associated with HCV transmission in the United States were identified in case- control studies conducted by the Centers for Disease Control (CDC) during . The risk factors included: blood transfusion, injection drug use, patient care or clinical laboratory work employment, sex partner or household member who has had a history of hepatitis, multiple sex partners, and low socioeconomic level. These studies reported no association with military service or with exposures resulting from medical, surgical, or dental procedures, tattooing, acupuncture, ear piercing, or foreign travel, although it may be that the frequency of infection through these means may be too low to detect. Currently, the highest rate of acute infection is among injecting drug users. Acute HCV infection is basically undetected in people who have had transfusions and in hemophiliacs since the early 1990s, because the blood supply in the US has been tested for HCV since 1990, and even more sensitive tests were developed in 1992.

General symptoms of hepatitis C virus
Acute symptoms of hepatitis C virus include flu-like symptoms, dark urine, light stools, jaundice, fever, fatigue, anorexia, nausea, and itching skin.

Chronic HCV symptoms include fatigue, malaise, weakness, mild fevers, liver pain, decreased appetite, and itching skin. However, many persons infected with HCV do not have obvious symptoms, especially in the early stages of chronic infection with HCV.

WESTERN EVALUATION and TREATMENT

Western lab tests
The typical western lab tests for HIV include collecting liver enzymes data. The levels of the liver enzymes AST and ALT are elevated in chronic HCV infection about 70% of the time (note that this means that 30% of HCV patients do not experience elevation in liver enzyme levels despite chronic infection). Liver enzyme levels may fluctuate as part of the normal course of disease. High levels of ALT indicate that there is damage to the liver due to cell damage, but unless a liver biopsy is performed, it is impossible to know what level of damage has been done. If a client is presenting hepatitis symptoms, the practitioner should order hepatitis panels for hepatitis B and hepatitis C. If there are acute symptoms, an additional test for hepatitis A should be given. If the antibody tests are positive for HBV or HCV, viral load tests should be performed.

Western drug therapies
Western drug therapies may be appropriate for many patients. I advise consultation with a Western medical doctor to discuss the most current and appropriate treatment available for a particular patient.

Current western biomedical treatment is most likely to be combination interferon/ribavirin therapy. Clients need to talk with their western doctors about eligibility for these programs.

Recent studies of interferon/ribavirin combination therapy have shown higher sustained response rates than found with interferon alone; however, these rates remain well below 50% (and most probably in the 15% to 20% range).10-13 In people with HIV co-infection, there may be less indication for treatment due to many ARV therapies that may also cause liver damage; HCV may also create difficulty in the metabolization of medications for HIV.

There are a number of side effects of drug therapy, including flu-like syndromes, headaches, fatigue, fevers, anorexia, nausea, vomiting, hair loss, and depression; white blood counts and platelets may also be lowered due to bone marrow suppression. Ribavirin may cause sudden, severe anemia as well as birth defects.

If the client along with their eastern and western practitioners decide to use a combination of eastern and western therapies, the specific treatment approaches should be discussed with both the eastern and western practitioners. Some herbal therapies may be inappropriate in conjunction with interferon therapy. Chinese medicine, however, is highly effective for the management of side effects of drug therapies. It may also be used as an alternative in some cases.

A list of herbs and drugs that are considered liver toxic will be available in the appendices of The Hepatitis C Help Book by Misha Cohen, OMD, L.Ac. and Robert Gish, MD.

Hepatitis vaccinations
Acute infection with other forms of viral hepatitis is highly dangerous for people with HCV; consequently, vaccination for hepatitis A and B is suggested. These vaccinations are also generally recommended for those at risk for becoming infected and for children (consult the guidelines of the Hepatitis Foundation International, available by calling 1-).

It is highly recommended that people who do not have adequate antibodies to the hepatitis B virus (HBV) receive an HBV vaccination. Three injections over a 6 to 12 month period are required to provide complete protection. Some people do not develop enough antibodies to become immune to HBV.

People who have hepatitis C but who have not had hepatitis A should receive a hepatitis A vaccination. Immune globulin can be given to provide temporary immunity for up to 3 months. People who have not had hepatitis A and have not been vaccinated after exposure to hepatitis A should receive immune globulin as soon as possible after exposure, and no later than 2 weeks.

CHINESE TRADITIONAL MEDICINE FOR HCV

Many people with hepatitis C virus, as well as those with HIV/AIDS, are turning to Chinese traditional medicine, which has a rich history in the treatment of chronic hepatitis. Hepatitis B-and, increasingly, hepatitis C-are prevalent throughout China, accounting for the increased risk of hepatocellular carcinoma in the mainland Chinese population. The Chinese medical system has worked to eliminate sources of hepatitis and has developed treatments for hepatitis using both Chinese traditional medicine and western medicine.

At the International Symposium on Viral hepatitis and AIDS held in Beijing in April 1991, more than 100 papers on viral hepatitis were presented, several of which documented the positive results of studies of Chinese herbal medicine. Studies of herbal antivirals and Xue-cooling and Xue-circulating herbs for repairing liver damage supported the hundreds of years of practical experience with Chinese herbs for the symptoms of hepatitis.14-16 A literature review by Dr. Kevin Ergil in 1995 revealed the use of at least 55 herbal formulas that may be used to treat hepatitis clinically. There have also been some recent herbal studies in China and Australia that showed positive results in hepatitis C using formulas similar to those used widely in clinics in the United States.17-21

In the United States, Chinese traditional medicine is a popular complementary or alternative therapy among patients with chronic liver disease. A 1996 anecdotal report from one of the largest clinical hepatology practices in San Francisco suggests that at least 20% to 30% of patients in this practice report using Chinese herbal interventions for hepatitis.22 The level of use is probably underestimated because patients often choose not to divulge the use of complementary and alternative medicine therapies to their western primary care physicians.

Chinese medicine uses nutrition, acupuncture, heat therapies such as moxibustion, exercise, massage, meditation, and herbal medicine to treat people with HCV. Protocols have been developed that have successfully helped HIV- and HCV-infected people to decrease symptoms, normalize or lower liver enzyme levels, and slow down progression of liver disease. A pilot study conducted among people co-infected with HIV and hepatitis at the Quan Yin Healing Arts Center in 1995 indicated that acupuncture alone may have an effect in lowering and normalizing liver enzyme levels.23

In future articles, I will discuss nutrition, herbal medicine, acupuncture, and other ways in which people with HIV/HCV co-infection can engage in self-care.

For more detailed information, please see The HIV Wellness Sourcebook, Henry Holt, 1998 and The Hepatitis C Help Book, Misha Cohen and Robert Gish, St. Martin's Press, 2000.

Misha R. Cohen, Doctor of Oriental Medicine and Licensed Acupuncturist, is an internationally recognized practitioner, lecturer and leader in the field of traditional Chinese medicine and is the author of The Chinese Way to Healing: Many Paths to Wholeness (Perigee, 1996), The HIV Wellness Sourcebook (Holt, 1998) and The Hepatitis C Help Book (St. Martin's Press, 2000). POZ Magazine named her one of the Top 50 AIDS Researchers in the Country in 1997.