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HEPATITIS C VIRUS INFECTION Epidemiology, Transmission, Western and Chinese Medicine

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 percent will develop cirrhosis.3-5 It is estimated that there are 8,000 to 10,000 HCV-related deaths each year, and 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 (HCV). People with co-infection of HIV/HCV have double the risk of developing of severe liver damage, and there is some evidence that course of liver disease development is shorter. 6

Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States. The Centers for Disease Control and Prevention (CDC) estimate that during the 1980s, an average of 230,000 new infections occurred each year. The Third National Health and Nutrition Examination Survey conducted from 1988 to 1994 indicated that an estimated 3.9 million Americans (1.8%) have been infected with HCV. Most are chronically infected and might 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 of chronic HCV infection is found among those aged 30-49 years and among males. However, the highest incidence of acute hepatitis C is among 20-39 year olds, with men having a slightly higher rate of acute infections. Because most HCV-infected people range between 30-49 years old, the number of deaths caused by HCV-related chronic liver disease could increase significantly during the next 10-20 years as the ageing HIV population develop a greater likelihood of complications. While African Americans and whites currently have a similar incidence of acute infection, African Americans have a substantially higher prevalence of chronic HCV infection than do whites. Latinos have the highest rate of acute infection. 8

HCV infection occurs with different prevalence 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 including 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 exposure 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 in high-risk sexual practices or among those with small, sporadic through-the-skin exposures such as occur with needle sticks among healthcare workers. The lowest prevalence of HCV infection is found among those like volunteer blood donors who have no high-risk characteristics.

Most risk factors associated with HCV transmission in the United States were identified in case-control studies conducted by the Centers for Disease Control and Prevention (CDC) from 1978 to 1986. These risk factors included blood transfusion, injection drug use, patient care or clinical laboratory employment, sex partner or household member who has had a history of hepatitis, multiple sex partners, and low socioeconomic level. The studies reported no association with military service or exposures resulting from medical, surgical, or dental procedures or from tattooing, acupuncture, ear piercing, or foreign travel; it may be that the frequency of infection through these means may be too low too 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, with more sensitive tests being 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/TREATMENT

Western Lab Tests

The typical Western lab tests for Hepatitis C virus include collecting liver enzymes data. The levels of the liver enzymes AST and ALT are most commonly elevated in chronic HCV infection about 70% of the time (note that this means that 30% of 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. However, unless a liver biopsy is done, it is basically impossible to know what level of damage has been done to the liver. If a client is having 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. And if the antibody tests are positive for HBV or HCV, viral load tests should be done.

Western Drug Therapies

Western drug therapies may be appropriate for an individual. I advise consultation with a Western medical doctor in order to discuss the most current and appropriate treatment available for the particular individual.

Current Western bio-medical treatment is most likely combination interferon/ribavirin therapy. Clients need to talk with their Western doctor 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 percent (and most probably in the 15% to 20% range).10-13 In people with HIV co-infection, there may be less indication for treatment because many ARV therapies may also cause liver damage or because the HCV may create difficulties in metabolizing 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, as well as the possibility of lowering white blood counts and platelets through bone-marrow suppression. Ribavirin may cause sudden, severe anemia as well as birth defects. If clients along with their Eastern and Western practitioners decide to use a combination of Eastern and Western therapies, the specific treatment approaches should be dicussed with both practitioners. Some herbal therapies may be inappropriate in conjunction with interferon therapy. Chinese medicine, however, is highly effective for managing the 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, LAc, 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 of becoming infected and for children (see the guidelines of the Hepatitis Foundation, whose phone number appears at the end of this section).

People who do not have adequate antibodies to Hepatitis B virus (HBV) should have 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 with hepatitis C who have not had hepatitis A i should have a Hepatitis A vaccination. Immune globulin can be given to provide temporary immunity for up to 3 months. If one has not had hepatitis A and has not been vaccinated after exposure to hepatitis A, immune globulin should be given as soon as possible after exposure, and no later than 2 weeks.

For more details and for guidelines on vaccination and Western treatment, please contact the Hepatitis Foundation International at 1-.

CHINESE TRADITIONAL MEDICINE FOR HCV

Many people with Hepatitis C virus and HIV/AIDS are turning to Chinese traditional medicine, which has a rich history in the treatment of chronic hepatitis. Hepatitis Band increasingly, Hepatitis Care prevalent throughout China, accounting for the increased risk of hepatocellular carcinoma in the mainland Chinese population. The Chinese medical system has been dedicated to solving the problem for many years, and has worked to eliminate sources of hepatitis as well as to develop treatments for hepatitis using both Chinese traditional medicine and Western medicine.

At the International Symposium on Viral Hepatitis and AIDS held in Beijing, China 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% percent of patients in this practice report use of 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 physician.

Chinese medicine uses nutrition, acupuncture, heat therapies such as moxibustion, exercise, massage, meditation, and herbal medicine for the treatment of people with hepatitis C virus. 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 the 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 indicates that acupuncture alone may have an effect in lowering and normalizing liver enzyme levels. 2-3

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

References

1. Shakil AO, Conry-Cantilena C, Alter HJ, Hayashi P, Kleiner DE, Tedeschi V, et al. Volunteer blood donors with anitbody to hepatitis C virus: Clinical, biochemical, virologic, and histologic features. The Hepatitis C Study Group. Annals of Internal Medicine. 1995, Vol. 123, No. 5, Pages .

2. Seeff LB, Buskell-Bales, Wright EC, Durako SJ, Alter HJ, Hollinger FB, et al. Long-term mortality after transfusion-associated non-A, non-B hepatitis. The National Heart, Lung, and Blood Institute Study Group. New England Journal of Medicine. 1992, Vol. 327, No. 27, Pages .

3. Fattovich G, Giustina G, Degos F, Tremolada F, Diodati G, Almasio P, et al. Morbidity and mortality in compensated cirrhosis type C: A retrospective follow-up study of 384 patients. Gastroenterology. 1997, Vol. 112, No. 2, Pages .

4. Di Bisceglie AM, Goodman ZD, Ishak KG, Hoofnagle JH, Melpolder JJ, Alter HJ. Long-term clinical and histopathological follow-up of chronic posttransfusion hepatitis. Hepatology. 1991, Vol. 13, No. 6, Pages .

5. Kiyosawa K, Sodeyama T, Tanaka E, Gibo Y, Yoshizawa K, Nakano Y, et al. Interrelationship of blood transfusion, non-A, non-B hepatitis and hepatocellular carcinoma: Analysis by detection of antibody to hepatitis C virus. Hepatology. Vol. 12, No. 4.1, Pages .

6. Cohen and Gish, The Hepatitis C Help Book. St, Martin's Press, 2000, Page 68.

7. MMWR 47(RR19); 1-22 10/16/1998.

8. MMWR 47(RR19); 23-39 10/16/1998.

9. Reichard 0, Norkrans G, Fryden A, Braconier JH, Sonnerberg A, Weiland 0. Randomised, double-blind, placebo-controlled trial of interferon alpha-2b with and without ribavirin for chronic hepatitis C. The Swedish Study Group. Lancet. 1998, Vol. 351, No. 9096, Pages 83-87.

10. Sostegni R, Ghisetti V, Pittaluga F, Marchiaro G, Rocca G, Borghesio E, et al. Sequential verus concomitant administration of ribavirin and interferon alfa-n3 in patients with chronic hepatitis C not responding to interferon alone: Results of a randomized, controlled trial. Hepatology. 1998, Vol. 28, No. 2, Pages .

11. Schalm SW, Hansen BE, Chemello L, Bellobuono A, Brouwer JT, Weiland 0, et al. Ribavirin enhances the efficacy but not the adverse effects of interferon in chronic hepatitis C. Meta-analysis of individual patient data from European centers. Journal of Hepatology. 1997, Vol. 26, No. 5, Pages .

12. Schvarcz R, Yun ZB, Seonnerborg A, Weiland 0. Combined treatment with interferon alpha-2b and ribavirin for chronic hepatitis C in patients with a previous non-response or non-sustained response to interferon alone. Journal of Medical Virology. 1995, Vol. 46, No. 1, Pages 43-47.

13. Chen Z, et al. Clinical analysis of chronic hepatitis B treated with TCM compositions Fugan No. 33 by two lots. [Abstract, Page 2]. International Symposium on Viral Hepatitis and AIDS, April 1991, Beijing, China. Sponsors: Beijing Association of Integration of Traditional and Western Medicine and The China Medical Association.

14. Wang C, He J, Zhu C. Research of repair of liver pathologic damage in 63 cases of hepatitis with severe cholestatis by blood-cooling and circulation-invigorating Chinese herbs. [Abstract. Page 5]. International Symposium on Viral Hepatitis and AIDS, April 1991, Beijing China. Sponsors: Beijing Association of Integration of Traditional and Western Medicine and The China Medical Association

15. Zhao R, Shen H. Antifibrogenesis with traditional Chinese herbs. [Abstract, Page 20]. International Symposium on Viral Hepatitis and AIDS, April 1991, Beijing, China. Sponsors: Beijing Association of Integration of Traditional and Western Medicine and China Medical Association.

16. Batey RG, Bensoussen A, Hossain MA, Bollipo S On-line report, Gasteroenterology Unit and Cathay Herbal Labs, Sydney Australia. 1998.

17. Deng D. 30 cases of hepatitis C treated with Song Zhi mixture. Hunan Journal of Traditional Chinese Medicine. 1997, Vol. 13, No. 6, Pages 27-28.

18. Yao Z, Liu Mi, Wang C. A preliminary report on the effect of 911 granules on chronic viral hepatitis of the B and C types. Journal of Integrated Traditional and Western Medicine. 1995, Vol. 3

19. Li H, et al. Qingtui Fang applied in treating 128 cases of chronic hepatitis C. Chinese Journal of Integrated Traditional and Western Medicine for Liver Diseases. 1994, Vol. 4, No. 1, Page 40.

20. Wu C, et al. 33 patients with hepatitis C treated by TCM syndrome differentiation. Chinese Journal of Integrated Traditional and Western Medicine for Liver Diseases. 1994, Vol. 4, No. 1, Pages 44-45.

21. Gish R. California Pacific Medical Center, Liver Transplant Specialist, personal communication, 1996.

22. 12th International AIDS Conference Geneva, abstract book, June 1998.

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