Emerging Epidemic
By Betsy Querna
3/13/06
Donnie Beitchman is walking today. Slowly. But he and Karen, his wife, are
grateful for each and every measured step down the hospital corridor on this
chilly, early-December afternoon. The trucking-company owner has endured two
major surgeries within weeks. He nearly died after part of his cancer-ravaged
liver was removed a couple of months ago. The organ didn't revive, a staph
infection and kidney failure followed, and four weeks later, Beitchman, 48, had
a liver transplant. Now, in his darkened room at Duke University Medical Center
in Durham, N.C., his face is still a jaundiced yellow and his fluid-filled
abdomen undulates like a waterbed when disturbed.
But Beitchman is alive. That makes him more fortunate than thousands of the
estimated 3.2 million Americans thought to be infected with the hepatitis C
virus. Each year roughly 10,000 people die from cancer, liver failure, and other
complications of the disease. It is the nation's most common chronic blood-borne
infection; about three times as many people are carrying hepatitis C virus as
are infected with HIV.
Yet hepatitis C may be the most lethal disease you've barely or never heard
about. Partly that's because it bides its time, often causing no symptoms for
decades--so 3 out of every 4 of those carrying the virus, say researchers, are
unaware they are infected. Shame, or at least embarrassment, is another reason.
Many of those with hepatitis C were infected by needles while experimenting with
drugs long ago and aren't eager to revisit or advertise their adventures. The
source of Beitchman's virus was likely a dirty tattoo needle more than 20 years
ago. "We didn't think about it back then," he says regretfully.
Deadly forecast. For many of these individuals, however, their past is becoming
their present as the virus emerges from hibernation. At the peak, in 1989,
nearly 300,000 people contracted hepatitis C, nearly 10 times the current rate,
and the millions who got it during this decade and before are fueling a
sustained burst of illness. "We're on the edge of a liver-disease epidemic,"
says Ian Williams, chief of epidemiology in the federal Centers for Disease
Control and Prevention's division of viral hepatitis. Physician office visits
for hepatitis C were an early indicator, jumping from 450,000 in 1996 to 1.5
million in 2002, according to a study last year in the journal Hepatology. Over
the next 10 years annual deaths are expected at least to double, perhaps triple.
And cases of liver failure and cancer, the two most serious complications of
hepatitis C, are rising and will probably climb faster.
The bright spot is that better therapies should arrive as well. Dozens of
companies are pouring money into research, and "there's almost a race on" to be
the first with an effective treatment, says Eugene Schiff, chief of hepatology
at the University of Miami School of Medicine. The current treatment, a
combination of interferon to help the immune system better attack the virus and
ribavirin to make the interferon more effective, cures fewer than half of those
infected with the most common viral strain found in Americans--and it's not easy
to endure. Side effects from the weekly injections of interferon for six to 12
months include fatigue, pain, gastrointestinal problems, and depression.
Ribavirin, taken as a pill, can cause severe anemia.
About 1 patient in 5 chooses to stop. Earl, a 50-year-old electrician from rural
North Carolina who wants no one besides his doctor and his family to know about
his condition, quit after four weeks and doesn't know whether he'll try again.
"It makes you feel like you wish you were dead," he says. Hedy Weinberg, who
successfully finished treatment six years ago, says she would nearly fall asleep
during daily activities. When driving, she says, "it was an effort to keep my
eyelids open so I could get home in the car." The 66-year-old Denver resident,
who contracted hepatitis C from a blood transfusion in 1967, subsequently
coauthored a book, Living With Hepatitis C: A Survivor's Guide, to help others
facing the same ordeal.
No guarantees. The drawbacks of existing therapy and the incoming wave of
patients have spurred pharmaceutical companies to develop bioengineered drugs
for hepatitis C. Some have begun testing patients, a few of whom have displayed
encouraging early results. "We clearly see things changing drastically in the
next 10 years," says Duke liver specialist John McHutchison. The new drugs, he
says, "offer great hope."
Hepatitis C patients could use a bit. After two decades, about 20 percent of
them develop cirrhosis from the virus's attack on the liver. Of those, each year
up to 4 percent will progress to liver failure and up to 7 percent will develop
cancer. A transplant is often the only way to save these patients. Beitchman is
indeed lucky: Of the roughly 17,000 people who need a new liver, 1,500 a year
die while parked on the waiting list.
Even a transplant doesn't guarantee an end to the disease. As is typical, the
virus reappeared within weeks after Beitchman's surgery. Currently the amount of
virus in his body is low, but because he's on immunosuppressants to prevent
organ rejection, his immune system is less able than usual to battle the virus.
Indeed, some patients with transplants can see their new liver develop cirrhosis
in as little as five years.
While hepatitis C therapy is grueling, it is far better than none at all, which
was what victims faced until the early 1990s. "The treatment is not fun," says
Schiff. "But we can cure the disease in about half the people. And I mean cure
it."
His emphasis is deliberate. For many years, no one knew what was causing a rash
of cases of serious liver disease; they could discern only that it was different
from hepatitis A and B, which are acquired differently and usually are less
serious, so it was called non-A, non-B hepatitis. The virus evaded detection
until 1989, when scientists at Chiron Corp. employed innovative techniques to
find it. Even now, it is very difficult to study--only last year were scientists
able to grow it in a lab. A vaccine is being tested in clinical trials but isn't
expected anytime soon. So defeating the disease when it finally shows up is
crucial. "This is a very clever virus," says Michael Houghton, a Chiron
scientist who led the team that discovered the virus and who is working on a
vaccine. "It can persist in ways that we don't quite understand."
Researchers' limited ability to decipher the virus has hampered the hunt for a
new and better treatment. While the current therapy boosts the body's natural
defenses, it doesn't attack the virus directly. The approaches being
investigated will target certain known regions of the virus, like using a guided
missile instead of an atomic bomb, says Joshua Boger, CEO of Vertex, one of the
pharmaceutical research firms racing to develop new cures. Targeted drugs should
both improve effectiveness and reduce side effects. "We're going to look back in
five years," says Boger, "and just say, 'Wow.'"
Vertex and pharmaceutical giant Schering-Plough are focusing on protease
inhibitors, drugs best known for their success in treating HIV. Scientists and
doctors agree that protease inhibitors and the similar polymerase inhibitors are
the most promising. They slow the spread of the virus in the liver by binding to
and disabling areas the virus needs to replicate. In small groups of patients,
using drugs with and without interferon and ribavirin, both Schering and Vertex
have seen the level of virus in the blood fall to undetectable levels in just a
couple of weeks. Standard treatment in patients with the same strain of virus
generally takes several months.
The FDA has given both companies' efforts fast-track status, most likely
accelerating the approval process. Even assuming approval, however, it will be
several years or more before doctors can use the drugs, which haven't yet been
proved safe in large-scale studies. But many are optimistic it is only a matter
of time. New drugs are "going to happen," says Schiff. "The question is, is it
going to be five years or closer to 10 years?" He and others expect that
hepatitis C will eventually be treated with a cocktail, mixing protease and
polymerase inhibitors, ribavirin or newer, more tolerable substitutes, and,
perhaps, interferon.
Mainstream. The pressing current need is to encourage testing. Many people don't
know they need testing or, worse, choose to stay ignorant because of a stigma
surrounding the disease. Those infected "are often treated like lepers, and it's
totally unjustified," says Schiff. Back in the 1970s, he says, "people were
experimenting with drugs. These people are now in their 50s. They're mainstream
America. They're not drug addicts."
They do need to be somewhat cautious, however. Hepatitis C cannot be transmitted
casually--for example, by hugging, shaking hands, or sharing glasses or
utensils. But people with the disease should not share their toothbrushes or
razors, which might carry minute amounts of blood. And while the rate of sexual
transmission is very low, especially for people in monogamous relationships, it
does rarely happen. "We tell people who have a partner with hepatitis C to use
condoms," says the CDC's Williams.
One of those trying to correct stereotypes of hepatitis C patients is Dee
Lemmon, 46, who briefly dabbled with IV drugs when she was younger. Treated and
free of the virus since 2000, she is now president of an advocacy and support
group for hepatitis C patients in northern Georgia. "We're taxpayers, we have
jobs, we are contributing members of society," she says. "We screwed up when we
were kids. People do that."
AS THE TOLL CLIMBS
Deaths from complications of hepatitis C are projected to peak in 2015.
Annual deaths in thousands
PEAK: 19,529
9,433
18,942
Source: John Wong, Tufts University School of Medicine
http://www.usnews.com/usnews/health/articles/060313/13hepc.htm