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The link between viral hepatitis and opioid use



For the Gazette
Monday, October 22, 2018

That our nation, our state, our region and our county are in the midst of an opioid crisis of epidemic proportions is well known. In fact, it’s the motivation for this monthly column: to educate about the prevalence of opioid misuse and initiatives launched to prevent overdose deaths and increase access to treatment and recovery.

A lesser known, but increasingly concerning risk heavily linked to the opioid crisis is viral hepatitis, a highly contagious infectious disease. Viral hepatitis is a liver infection that if left untreated can lead to death. The three types of viral hepatitis, A, B and C, cause similar symptoms in acute stages, including fatigue, nausea, fever, belly pain, yellow skin/eyes, though they are spread in different ways.    Rates of hepatitis B and C have been climbing steadily in recent years, especially among young people who are IV drug users because they are spread by sharing needles and other drug paraphernalia used to prepare and inject drugs. They are also spread via accidental needle sticks, which is why it is crucial to properly dispose of needles.

Another threat is hepatitis A, for which the state Department of Public Health issued an alert last month proclaiming an outbreak and urging vaccination of people at risk for contracting it, including IV drug users, people who are homeless or those who have unstable housing.

What follows is information about each of the strains, and what is being done locally to prevent their spread:

Hepatitis C, the most common, is also the most dangerous. According to the Centers for Disease Control, approximately 3.5 million people in the country have it, and roughly 41,000 are infected each year. It kills approximately 8,000 people in the US each year. It can cause liver cancer and lead to cirrhosis of the liver.

Injection drug use is believed to be the root cause of nearly two-thirds of all U.S. cases of hepatitis C. In fact, according the American Journal of Public Health, it is estimated that 70–90 percent of people who inject drugs for 10-plus years are infected with hepatitis C.

Rates of hepatitis C infections have gone through peaks and valleys — experiencing upticks in the 1940s-60s due to contaminated medical equipment, and in the 1970s largely through blood transfusions. Transmission rates went down when medical professionals gained understanding about transmission and responded with appropriate precautions and after blood testing weeded out potentially infected blood.

We are again seeing an uptick in cases, this time related to injection drug use. Definitive numbers of people infected with the hepatitis C virus are hard to come by because many carriers are symptom-free. Unfortunately, this means they may unknowingly transmit the virus to others. Hepatitis C is highly treatable — even curable — with antiviral drugs, but screening is essential.

Hepatitis B, which affects an estimated 850,000 people in the United States, and sees about 21,000 new infections a year, is the leading cause of liver cancer. It is spread through blood, semen, and other bodily fluids. In addition to liver cancer, it can lead to chronic liver disease and liver failure. It can be spread through sexual contact and sharing items like razors and toothbrushes as well as through shared drug paraphernalia. There is a vaccine for hepatitis B.

Hepatitis A, the least common, causes approximately 4,000 infections a year. The disease can last from a few weeks to several months and most people recover with no lasting damage (though in very rare cases it can be fatal.) It is spread through oral-fecal contact, even in microscopic amounts, which is why people living without proper plumbing are at high risk.

According to the state DPH, 65 cases of a severe strain of acute hepatitis A have been reported in Massachusetts since April (with a high number requiring hospitalization). There have also been similar outbreaks in other states reported by the CDC. The hepatitis A vaccine is highly effective and both DPH and the CDC recommend vaccinating high risk groups, such as people living in homeless encampments. Frequent hand washing and hand sanitizer can be effective in decreasing transmission.

So, what are we doing about these hepatitis risks?

Part of my job as health director for the city of Northampton involves monitoring, tracking and reporting the spread of infectious diseases. Since I started in 2014, hepatitis C rates have been on our watch list because we’ve had cases every year, and we hoped to head off the alarming spikes seen in many parts of the country.

I’ve been repeatedly surprised that hepatitis C rates in the city have remained fairly stable. I believe this is a direct result of the good work being done by Tapestry Health through its syringe access programs. According to one study, injection drug users who live more than 10 miles away from a needle exchange program are 80 percent more likely to become infected with the hepatitis C virus. This is why the Hampshire HOPE coalition works closely with Tapestry to support its work.

With the recent DPH alert about hepatitis A, the Northampton Health Department, Hampshire HOPE and other community agencies are joining forces to prevent the spread by holding vaccine clinics. We are working with Tapestry, Medication Assisted Treatment providers, agencies and programs for people who are homeless or with unstable housing to set up a series of free clinics where people will be screened to receive the hepatitis A vaccine, which carries protection for 20 years.

Understandably, there is much confusion among the general public about the three strains of viral hepatitis. In my mind, there are key take-aways: Hepatitis A and B have vaccines that prevent transmission, so people in high risk groups should get vaccinated. While there’s no vaccine for hepatitis C, it is highly treatable with antiviral drugs as long as it is detected early — so screening can save lives.

And for all three types of viral hepatitis, certain basic practices will minimize the risk of transmission, including: hand-washing, proper disposal of needles, not sharing needles or other drug paraphernalia

Thanks to the harm reduction work done by Tapestry, local hepatitis rates are not climbing like those in other parts of the state. This means we have precious time to focus on strategies that will prevent further transmission.

These strategies include public education that aims to reduce stigma so that people at high risk for infection are more likely to seek help. Because syringe access programs like Tapestry’s not only distribute clean needles and properly dispose of infection-laden syringes, they also educate about life-saving harm reduction practices in a non-judgmental way, there are many other positive benefits to the work they do.

By working together, we have a solid chance at preventing a hepatitis uptick from turning into an outbreak, or worse yet, an epidemic.

Northampton Public Health Director Merridith O’Leary is program director for the Hampshire HOPE opioid prevention coalition run out of the city of Northampton’s Health Department. Members of the coalition contribute to a monthly column in this space about local efforts underway to address the opioid epidemic.