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Hepatitis C in Denver is booming, but a pill that tells doctors whether you’ve taken it could change that

By , The Denver Post

As cases of hepatitis C boom across Colorado and doctors work furiously to guide patients from diagnosis to cure, there is one challenge that can be surprisingly difficult. Patients have to take their medicine.

So now, as part of three ambitious studies that could radically improve the detection of hepatitis C and care for people who have it, researchers at Denver Health are trying something futuristic: a pill that will tell doctors whether a patient took it.

The pill, basically a gelcap, contains hepatitis C medicine and a microscopically small sensor that, when it hits the stomach, beams out a signal. (The sensor then dissolves harmlessly.) The signal gets picked up by a patch worn on the skin, and that patch syncs with an iPad that uses mobile networks to upload the information to the internet, where a doctor can see which patients haven’t taken their pills that day and give them a call to remind them.

Dr. David Wyles, the head of the hospital’s infectious disease division, said the pill will allow doctors to track better than ever how well people stick to a course of medication. But they also may discover vital new information about treating hepatitis C, a viral disease that impacts the liver and can be fatal but is also curable through often expensive medicines.

“We really don’t know how often you need to take your hepatitis C medication to be cured,” Wyles said.

This study — along with two others at Denver Health — comes at a time when hepatitis C cases are rising across Colorado.

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HCV screening lags for women, blacks, Hispanics

While hepatitis C screening improved recently, the increased rates are minimal and less than optimal among black individuals, Hispanics and women, according to a recently published study.

“There is substantial room for improvement,” Monica L. Kasting, PhD, from the H. Lee Moffitt Cancer Center, Florida, and colleagues wrote. “The new screening guidelines are meant to augment, not replace risk-based guidelines, but if they are not properly implemented, half of those chronically infected with HCV may fail to be identified.”

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Liver Diseases Seen in Primary Care – Live Course – Saturday, May 19, 8am-4:30pm

While nine of the 17 most common cancers of men and eight of the 18 most common cancers of women decreased in incidence in the U.S. (2009-2013), liver cancer had the greatest increase in incidence for both men and women (Annual Report to the Nation on the Status of Cancer, 1975 – 2014).

Death rates decreased for 11 of the top 16 cancers in men and for 13 of the top 18 cancers in women. However, liver cancer death rates increased for men and women (Ibid).

A study by the University of Alabama at Birmingham and the Global Burden of Disease Liver Cancer Collaboration found that one-third of liver cancer deaths were attributable to the hepatitis B virus (HBV), 30 percent to alcohol, 21 percent to the hepatitis C virus (HCV), and 16 percent to other causes, including Non-alcoholic steatohepatitis (NASH) (JAMA Oncology, October 5, 2017 online edition).

Primary care practices can have a profound effect on liver cancer incidence and death rates through readily available best practices recommended by the United States Preventive Services Task Force, the American Association for the Study of Liver Diseases, and the Infectious Disease Society of America, and identified in A National Strategy for the Elimination of Hepatitis B and C, National Academies, 2017, and the 2016 – 2020 Colorado Cancer Plan, produced by the Colorado Department of Public Health and Environment (CDPHE).

Hepatitis B

The Centers for Disease Control and Prevention (CDC) states that there are 350 million people worldwide and approximately 1.2 million people in the U.S. with the hepatitis B virus (HBV). CDPHE estimates there are 15,436 cases of chronic, unresolved hepatitis B and there has been an increase in reported cases over the last four years (2013-2016), primarily along the I-25 corridor. HBV is a vaccine-preventable contagious liver disease that is spread through blood, semen, or other body fluids. Hepatitis B can also be passed from an infected mother to her baby at birth. This course will discuss prevalence, high risk populations, vaccination, treatment, and health consequences of long-term infection.

Instructor: Michael Kriss, MD, Assistant Professor of Medicine, Gastroenterology – Hepatology, University of Colorado Hospital

Hepatitis C

The hepatitis C virus (HCV) is the most common blood borne infectious disease in the U.S., affecting approximately 3.5 million people. A 2017 prevalence study for Colorado estimated there are 50,153 people in the state with HCV. The disease wasn’t identified until 1989 and an accurate test to detect the virus in the blood supply wasn’t created until 1992. Before then, many baby boomers (born between 1945 and 1965) came into contact with infected blood through medical procedures, blood or blood product donations, air gun innoculations (primarily Vietnam vets), sharing works while injecting or snorting drugs, and tattooing in unsafe facilities. There are now multiple treatments on the market that are highly effective in curing patients of HCV. Pricing has come down so that most people, even those on Medicaid in Colorado, can access treatment. Patients who have had the virus for 20 or 30 years are at greater risk of cirrhosis and liver cancer due to the development of fibrosis. Meanwhile, we are seeing a surge in new HCV infections throughout the nation as a result of the opioid crisis and sharing works (needles, syringes, cotton, rinse water, and more).

Instructor: Sarah E. Rowan, MD, Associate Director, HIV and Viral Hepatitis Prevention, Denver Public Health

Alcoholic hepatitis

Alcoholic hepatitis is inflammation of the liver caused by drinking alcohol. It is most likely to occur in people who drink heavily over many years. However, the relationship between drinking and alcoholic hepatitis is complex. Not all heavy drinkers develop alcoholic hepatitis, and the disease can occur in people who drink only moderately. Just about everyone who has alcoholic hepatitis is malnourished. Drinking large amounts of alcohol suppresses the appetite, and heavy drinkers get most of their calories in the form of alcohol. Signs and symptoms of severe alcoholic hepatitis include: fluid accumulation in the abdomen (ascites); confusion and behavior changes due to a buildup of toxins normally broken down and eliminated by the liver; and kidney and liver failure.

Instructor: Clark Kulig, MD, Transplant Hepatology, Presbyterian/St. Lukes Medical Center

Non-alcoholic Steatohepatitis (NASH)

Nonalcoholic fatty liver disease (NAFLD) is a condition in which excess fat is stored in the liver. Heavy alcohol use does not cause this buildup of fat. Two types of NAFLD are simple fatty liver and nonalcoholic steatohepatitis (NASH). Simple fatty liver and NASH are two separate conditions. People typically develop one type of NAFLD or the other, although sometimes people with one form are later diagnosed with the other form of NAFLD. NASH is a form of NAFLD in which you have hepatitis—inflammation of the liver—and liver cell damage, in addition to fat in your liver. Inflammation and liver cell damage can cause fibrosis, or scarring, of the liver. NASH may lead to cirrhosis or liver cancer. Experts are not sure why some people with NAFLD have NASH while others have simple fatty liver. Only a small number of people with NAFLD have NASH. It’s estimated that about 20 percent of people with NAFLD have NASH. Between 30 and 40 percent of adults in the United States have NAFLD. About 3 to 12 percent of adults in the U.S. have NASH.

Instructor: Mary Ann Y. Huang, MD, MS, FAASLD, Transplant Hepatology, Peak Gastroenterology

Cirrhosis

Cirrhosis is a complication of liver disease which involves loss of liver cells and irreversible scarring of the liver. Alcohol and viral hepatitis B and C are common causes of cirrhosis, although there are many other causes. Cirrhosis can cause weakness, loss of appetite, easy bruising, yellowing of the skin (jaundice), itching, and fatigue. Diagnosis of cirrhosis can be suggested by history, physical examination and blood tests, and can be confirmed by liver biopsy. Complications of cirrhosis include edema and ascites, spontaneous bacterial peritonitis, bleeding from varices, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, hypersplenism, and liver cancer. Treatment of cirrhosis is designed to prevent further damage to the liver, treat complications of cirrhosis, and preventing or detecting liver cancer early. Transplantation of the liver is an important option for treating patients with advanced cirrhosis.

Instructor: Lisa Forman, MD, MSCE, Associate Professor of Medicine, Program Director, Gastroenterology – Hepatology, University of Colorado Hospital

Liver Cancer (Hepatocellular Carcinoma)

Each year in the United States, about 22,000 men and 9,000 women get liver cancer, and about 16,000 men and 8,000 women die from the disease. The percentage of Americans who get liver cancer has been rising for several decades, principally due to hepatitis C among baby boomers. Men died from liver cancer at more than twice the rate of women, and Hispanic men and women had the highest rates of getting liver cancer over all ethnicities. Many liver cancer cases are related to the hepatitis B virus or hepatitis C virus. Other behaviors and conditions that increase risk for getting liver cancer are: heavy alcohol use; cirrhosis; obesity; NASH; diabetes.

In its early stages, liver cancer may not have symptoms that can be seen or felt. However, as the cancer grows larger, people may notice multiple symptoms. Treatments may include: Surgical options, which are often limited due to underlying cirrhosis; ablative therapy; oral chemotherapeutic agents; or liver transplantation.

Instructor: Bahri Bilir, MD, Medical Director of Liver Transplantation, Presbyterian/St. Lukes Hospital

Liver Transplantation

A liver transplant is a surgical procedure performed to replace a diseased liver with a healthy liver from another person. The liver may come from a deceased donor or from a living donor. Family members or individuals who are unrelated but make a good match may be able to donate a portion of their liver. This type of transplant is called a living transplant. Individuals who donate a portion of their liver can live healthy lives with the remaining liver, which grows back to its full size. An entire liver (from a deceased donor) may be transplanted, or just a section. Because the liver is the only organ in the body able to regenerate, a transplanted portion of a liver can grow to normal capacity within weeks. Liver transplantation is the most curative option for someone with hepatocellular carcinoma. It was contraindicated in patients with HCC until 1996 when Milan criteria were developed related to number of lesions, lesion sizes, no vascular invasion, and no metastasis. The five year survival rate is greater than 70%. Approximately 17,000 patients are on the liver transplant waiting list, and 1,500 will die each year. Colorado has three transplant centers and you will be provided information for referral for liver transplantation.

Instructor: James R. Burton, MD, Associate Professor of Medicine, Medical Director of Liver Transplantation, University of Colorado Hospital

CME Credit

Application for CME credit has been filed with the American Academy of Family Physicians. Determination of credit is pending.

Learning Objectives

At the end of this course, you will be able to:

* Improve adherence to evidence-based clinical guidelines in practice.

* Synthesize appropriate diagnosis and treatment plans for the following conditions:

o Hepatitis B (HBV)

o Hepatitis C (HCV)

o Alcoholic hepatitis

o Non-alcoholic steatohepatitis (NASH)

* Understand the fundamental principles behind diagnosis and treatment of cirrhosis, liver cancer and understand the fundamental process of liver transplant and post-transplant management and outcomes

o Cirrhosis

o Liver cancer

o Liver transplantation

* Demonstrate ability to communicate effectively with the patient to ensure that diagnosis and treatment recommendations are understood.

* Recognize when to refer to or consult with other specialists to provide optimal patient care.

Liver Diseases Seen in Primary Care – Live Course

Event Agenda

Saturday, May 19, 2018

8:00 A.M. to 8:30 A.M. – registration and breakfast (provided)

8:30 A.M. – Opening remarks, John Reilly, Jr., MD, Dean, University of Colorado School of Medicine

8:40 A.M. to 9:40 A.M. – Hepatitis B – Michael Kriss, MD

9:40 A.M. to 10:40 A.M. – Hepatitis C – Sarah Rowan, MD

10:40 A.M. to 11:40 A.M. – Alcoholic Hepatitis – Clark Kulig, MD

11:40 A.M. to 12:40 P.M. – Non-Alcoholic Steatohepatitis (NASH) – MaryAnn Huang, MD, MS, FAASLD

12:40 P.M. to 1:30 P.M. – lunch (provided)

1:30 P.M. to 2:30 P.M. – Cirrhosis – Lisa Forman, MD, MSCE

2:30 P.M. to 3:30 P.M. – Liver Cancer – Bahri Bilir, MD

3:30 P.M. to 4:30 P.M. – Liver Transplantation – Jay Burton, MD

Registration Fees

Early Bird $55 (available through May 12)

Standard $65

Payable by check to Liver Health Connection or through our Donate button/PayPal account on our web site, http://www.liverhealthconnection.org. Specify that it is for the Liver Diseases Live Course and include your contact information for registration receipt.

Location

University of Colorado Hospital

Anschutz Medical Campus

Research Building 2, Krugman Conference Hall

Aurora CO

(a map and parking information will be sent after registration)

This live course is produced by Liver Health Connection in support of the 2017 Health and Human Services National Strategy for the Elimination of Hepatitis B and C. It is supported by the Colorado Academy of Family Physicians and the University of Colorado School of Medicine.

Scientists warn 90% of hepatitis B sufferers remain unaware of silent killer

About 300 million people worldwide are living with hepatitis B, yet the majority of cases remain undiagnosed or untreated, researchers have found.

According to a study published on earlier this month in the Lancet Gastroenterology & Hepatology journal, roughly 90% of people infected by the virus, which is incurable but manageable, are unaware they have it.

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Testing for hepatitis C lags with baby boomers despite high infection rate

Laurie McGinley, Washington Post

Testing for hepatitis C, a major cause of liver cancer, is lagging behind among the group of Americans with the highest rate of infection: baby boomers.

study published Tuesday showed that only about 13 percent of baby boomers were tested in 2015, up just slightly from 12 percent in 2013. U.S. public health authorities recommend all people in that demographic — those born between 1945 and 1965 — be screened for hepatitis C.

“If we want to make a dent in the rising rate of liver cancer, we need to get the population with a high rate of infection screened and treated,” said Susan Vadaparampil, the study’s senior author and a researcher at Moffitt Cancer Center in Tampa.

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Injection drug use harm reduction decreases HCV prevalence

This study in Europe projects that a combination of more opioid substitution therapy, syringe access programs and hepatitis C treatment can decrease hepatitis C prevalence.  If such policies were applied to the US, we’d probably see even greater reductions.

Model projections of scaled-up opioid substitution therapy and needle and syringe programs in Europe demonstrated a potential reduction in hepatitis C prevalence of 18% to 79% and could reduce treatment scale-up need by 20% to 80%.

“Preventing HCV transmission among people who inject drugs (PWID) is critical for averting future liver disease in Europe and elsewhere and new HCV infections in this group,” Hannah Fraser, PhD, from the University of Bristol, United Kingdom, and colleagues wrote. “Primary prevention through opioid substitution therapy (OST) and high-coverage needle and syringe programs (NSPs) can reduce HCV transmission among PWID and averts new HCV infections, but substantial reductions in HCV prevalence are unlikely to be achieved without scaling-up HCV treatment.”

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Updated Colorado Resource Directory now available!

The newly updated Liver Health Connection 2018-2020 Colorado Directory of Resources is now available! Full of resources on medical clinics and hospitals, testing locations, syringe access and harm reduction programs, informative websites on viral hepatitis and liver disease, housing, employment and health care coverage, the Directory of Resources is an invaluable starting point for people at risk of or living with viral hepatitis and other liver diseases.
Agencies, organizations, providers or individuals who would like copies of the new Directory can contact us at info@liverhealthconnection.org.  You can also down load a PDF of the directory here below.

Are You Part of the Silent Epidemic?

By Nikki Hayes, MPH
Chief, Comprehensive Cancer Control Branch, CDC

from blogs.cdc.gov

You’ve heard of mammograms to find breast cancer and tests to find colorectal (colon) cancer. But do you know how to help prevent liver cancer?

There’s no screening test for liver cancer. But there is a screening test for hepatitis C, which is the leading cause of liver cancer.

What Is Hepatitis?

Hepatitis is inflammation in the liver that is caused by infection by a virus or by alcohol abuse. There are several types of viral hepatitis. A, B, and C are the most common. Any of the hepatitis viruses can cause liver problems, including deadly liver cancer.

Do You Need to Get Tested for Hepatitis C?

Hepatitis C has been called a “silent epidemic” because most people who have it don’t know they are infected. Also, as addiction to opioid painkillers becomes more common, the number of people with hepatitis C is going up, too.

People born between 1945 and 1965 have 75% of all hepatitis C infections among all adults. So if you saw the Beatles debut, gave peace a chance, or were a disco baby, chances are you’re five times more likely than other adults to have hepatitis C. And we know that liver disease and liver cancer are on the rise.

Finding out whether you have the virus is the first step. Ask your doctor about a test at your next checkup. If you have hepatitis C, there are things you and your doctor can do to help you avoid more severe liver disease or liver cancer.

February Is Cancer Prevention Month!

CDC’s National Comprehensive Cancer Control Program is helping states, territories, and tribal areas in the United States keep their residents over 50—and everyone else, too—up-to-date about ways to help prevent liver cancer.

If you want to know more about hepatitis C, or if you may be at risk for other types of hepatitis, CDC can help.

Speak up for Senate Bill 40 – the Harm Reduction bill!

Senate Bill 40 (SB 40) is a harm reduction bill package being proposed in the Colorado Legislature that passed out of the Opioid Interim Committee with bipartisan support this past fall.  The bill includes naloxone access for school nurses, syringe exchange out of Emergency Departments, and a pilot supervised use site in Denver.
Your advocacy is needed today to support this bill!  SB 40 will next go to the Senate Committee and some of the Senators on that committee need some convincing.
Senator Vicki Marble (Vicki.Marble.Senate@state.co.us, 303-866-4876) needs to hear from HER constituents.  If you live in her district (Firestone, Johnstown, Mead, Broomfield, Erie, Longmont, Northglenn, and Windsor, CO), please contact her to express your support.
For everyone else, please call and email:
Senate President, Kevin Grantham
Senator Grantham has expressed reservations about SB 40 but we need his leadership for a healthier and safer Colorado.
Please also email these three senators on the Senate Committee:
Sample Email:
Subject line: Support SB 40!!

My name is X, I live in (insert city/county/zipcode) and I am emailing you today in support of SB 40 and asking that (insert Senator’s name here) vote yes!! I strongly support harm reduction public health policies in Colorado and I really, really want to see this bill pass.

I join the voices of treatment providers, drug users, recovery community, businesses, faith community, moms, and so many more that want to reduce the amount of overdose deaths in Denver and in the state of Colorado.  Coloradans die in our state of overdose every 9 hours and 36 minutes.  Access to Naloxone in schools, syringe exchange out of Emergency Departments, and the opportunity for a Denver pilot for supervised use site is the direction that I would like to see Colorado take in the midst of this epidemic.  Your yes vote will save lives.  Sincerely, (you).

Hepatitis C – It’s About More Than Liver Disease

The “Hepatitis C – It’s About More Than Liver Disease” project of the National Viral Hepatitis Roundtable (NVHR) aims to increase awareness among the healthcare and patient communities about the extrahepatic manifestations (EHMs) associated with chronic Hepatitis C virus (HCV) infection. Through the provision of educational materials and opportunities to engage in discussion, the project promotes the recognition of HCV infection as a systemic disease that requires a comprehensive approach to care in order to improve patient health outcomes.

READ MORE HERE

Fact Sheet 1 – Health Effects of Hepatitis C Outside of the Liver