Hepatitis C: The Uncounted Disease Part Two

Hepatitis C presents public health officials with a puzzle. Which tactic should take priority? A – go to places where you find the people most likely to have the virus, or B -- find the people most likely to become sick from the virus in the next ten years? The two groups are not the same.

The state has chosen option A with a focus on substance abusers, HIV clinics and prisons. When pressed on the point, State Epidemiologist, Jose Montero is quite clear about where the problem lies.

CUT Would you say that most of the people walking around infected today are in the IV drug or prison community? Based on national data, yes.

National reports do find that 60% of new cases come from intravenous drug use. That's generally thought to explain in large measure the prevalence of the virus among drug addicts and prisoners. But the data do not support the conclusion that most of the people with the virus are IV drug users.

Nationally, the number of people with the virus outnumber all IV drug users ten to one.

Kevin O'Conner with the Centers for Disease Control says there's good reason to give a lot of thought to taking a broader view of who is at risk.

CUT: There was a lot of transmission in the 70's and 80's which leave us with a large group of people that have been exposed and may have chronic liver disease as a result of that exposure. So a lot of what we do is try to identify people who have been exposed for a long time and try help them avoid complications.

The CDC encourages states to both prevent the spread of the virus and reduce its impact. O'Conner says it's easy to go after what he calls the low-hanging fruit – the people engaged in high risk behaviors, like injecting heroin. But the people who don't fit that description are much more difficult to find and they are the source of the skyrocketing impact of the disease.

In New Hampshire, NHPR found that hospital charges for patients with the disease grew by leaps and bounds – nearly an 800% increase in seven years.

Most of those people have one thing in common – they got a blood transfusion or some blood product before 1992. That was the year that testing of the blood supply began.

Contaminated blood put many unlikely people at risk.

CUT 6:12 I was on my back. I didn't even feel like I could raise my knees because I could feel the bullets passing over.

In 1966, Howard was a 21-year-old private in the 101st Airborne Division in Vietnam. He was on his way back from a night ambush when his unit came under fire.

CUT 7:39 I was one of the first to get hit. They only had my helmet and shoulders to aim at. It came in the top of my arm, it shattered my bone, saved my life, worked as a shield.

At a field hospital, Howard received the first of several transfusions. It is the only explanation he has for how he became infected with Hepatitis C. He returned from Vietnam, got married and became a salesman of fire alarm systems. Today, he is 60, a slender man with graying brown hair – he calls himself just an Average Joe. His treatment for Hepatitis C was exhausting, but successful

Studies at VA hospitals have found that 8% of Vietnam Era vets have Hepatitis C – that's four times more likely than in the general public. The VA has moved more aggressively than any other government agency to track down the virus. Dr. Johann Rothwangl and Nurse Marie Gavin run the hepatitis program at the Manchester VA.

CUT: 21:35 If someone comes in here from the Vietnam era he automatically gets offered to get tested for Hep C (Marie) This the brochure that the physicians use the first risk factor is Vietnam Era vet.

But Nurse Gavin is quick to point out, it wasn't just blood transfusions that produced infections in Vietnam.

CUT 25:08 From having a husband who was in Vietnam who swears he never did IV drugs and I believe that, he could not believe the number of his friends and co-workers who did. It was the only way they could get through the day. So, as much as the veterans don't want to admit that they did IV drugs over there, I guess it was pretty rampant.

Clinicians talk about the mental wall that people put up around drug use in the distant past. They don't think of themselves as drug users today and they have no desire to open the door into those memories. Add to that the general stigma attached to viral hepatitis and it becomes even more difficult to uncover the tens of thousands of people in New Hampshire who are walking around with the virus and have no idea of their infection.

To get over that hurdle, some New England states have launched broad public information campaigns. This ad ran in Massachusetts.

PSA CLIP "I had a C section before 1992, the blood supply is safe but I had my operation it was a totally different story. It was one time, one needle. If you are at risk, get tested, protect your health –fade

That ad had its roots in a look back program launched by the Red Cross in the mid-1990's. That was an effort to reach donors and blood recipients. Paul Loberti with the Rhode Island Health Department says that study prompted many health officials to re-think their assumptions about Hepatitis C.

CUT :43 I think what struck all of us was that we were looking at an epidemic was not exclusive to injection drug users, although it was high, we were seeing other things happening in RI as well as across the country. For example, a significant group of individuals was women who had C-sections and hadn't realized that having that would put them at risk for Hep C.

To find the largely unsuspecting carriers of Hepatitis C requires the help of doctors' offices statewide. States like Rhode Island, Massachusetts and Maine have done extensive outreach to front line health care practitioners. New Hampshire has not. In general, it is several years behind its regional neighbors.

In 2000, Maine set Hepatitis C as its number one infectious disease priority. Paul Kuehnert, Director of Public Health Emergency Preparedness, says the virus was costing the state Medicaid program at least 10 million dollars a year. Early detection seemed like a fiscally responsible strategy.

CUT We have 20,000 people. If we invest money up front, identify those folks as early as possible and get them into less expensive care, even though we may be spending more money up front, we'll save money in the long run.

New Hampshire's former state epidemiologist says there's no proof that such interventions save money. But Keuhnert says it's hard to see how it wouldn't.

Maine set a goal of identifying 7 thousand cases by the year 2010. It was part of the state's plan, Healthy People 2010.

New Hampshire has its own Healthy People 2010 plan. It has no mention of Hepatitis C.

For NHPR News, I'm Jon Greenberg