Susan Kreimer

home

authors

susan-kreimer

In the United States, hepatitis C seemed like one those diseases that might be hailed as a success story. Transfusions with unscreened blood products were a major source of infections before a test for the virus that causes the disease started being used in the 1990s. Afterward, infections from transfusions in the United States stopped occurring. Then in the mid-2010s, new medications, such as Sovaldi (sofosbuvir) and Harvoni (ledipasvir and sofosbuvir), that acted directly on the virus, became available. Although their price was a major issue, they were remarkably effective at curing the infection and were a huge improvement over an arduous regimen that many patients had difficulty sticking with.

But as it turned out, it was too soon to celebrate. Hepatitis C virus (HCV) has staged a comeback, largely because of the opioid epidemic and transmission through contaminated needles. The number of acute cases of hepatitis C in the U.S. has more than doubled since 2012, according to the CDC, jumping from 24,700 cases to 57,500 acute cases in 2019. The public health agency says that in 2019, there were 14,242 deaths in the U.S. that listed hepatitis C as the cause of death.

“Chronic HCV infection kills more Americans than HIV and all other reportable infectious diseases except COVID-19,” says David Thomas, M.D., a professor at the Johns Hopkins University School of Medicine who cares for patients with chronic HCV.

Health officials have responded with efforts to make screening for hepatitis C routine. Meanwhile, the prices of the direct-acting antiviral medications have fallen. Even so, states are experimenting with ways to pay for the drugs that lessen the cost burden and may make the medications more readily available.

The hepatitis C virus (HCV) is most commonly transmitted through contaminated blood. Transmission may occur through unscreened blood transfusions and blood products, contaminated injections during medical procedures, or injection drug use. Infection from transfusions and unsafe medical procedures is a problem that haunts healthcare systems in the developing world but not those in richer countries that have taken steps to screen their blood supplies and make medical procedures safer. Sexual transmission is a possibility, but much less likely.

Unlike some pathogens, “this virus doesn’t really come from contact, like when you shake someone’s hand,” says Steven Flamm, M.D., a professor of gastroenterology and hepatology and medical director of liver transplantation at Northwestern University Feinberg School of Medicine in Chicago. “It doesn’t come from sharing forks. It doesn’t come from doorknobs.”

Symptoms of acute infection may include jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and abdominal pain. But in many cases acutely infected individuals have no symptoms.

Over time, HCV infection can lead to fibrosis, which is scarring of the liver. Two or three decades after infection, approximately one-third of people with HCV develop cirrhosis, a late-stage liver disease in which healthy tissue is replaced with scar tissue, resulting in irreversible damage, Flamm says. “Until recent years, hepatitis C was the
No. 1 reason for liver transplantation, not only in the United States but in the Western world,” he adds.

Many states are striving to address HCV through screening and improved access to effective treatment, according to Philip A. Chan, M.D., M.S., an infectious diseases specialist at the Rhode Island Department of Health and associate professor at Brown University. “Routine testing for HCV is key to identifying chronic hepatitis C for treatment and also for preventing onward transmission,” says Chan.

Routine testing in people with risk factors is important, says Chan, because people with chronic hepatitis Cusually don’t have any symptoms that would prompt a clinician to order a test. A crucial step in preventing liver damage and death from HCV is acknowledging that it’s a silent killer, says Neil Gupta, M.D., M.P.H., chief of the epidemiology and surveillance branch in the division of viral hepatitis at the CDC.

The CDC’s new screening guidelines may be helping more people receive an earlier diagnosis. In April 2020 the agency issued an update recommending that all people 18 years or older be tested at least once and that women undergo screening during each pregnancy. The CDC noted, however, that people with ongoing risk factors should be tested more often.

Until that announcement, testing was recommended only for baby boomers. Three-fourths of U.S. adults with hepatitis C are baby boomers, according to the National Institutes of Health. Many of them were infected several decades ago, mainly from blood transfusions, and may not know they’re at high risk for the virus.

Along with baby boomers, adults ages 18 to 36 also have high rates of infection, largely because of the sharing of needles for drug use.

“The epidemics of opioids and heroin use have really fueled the rise in hepatitis C that we are seeing right now,” says Dawd S. Siraj, M.D., M.P.H., a professor in the division of infectious diseases at the University of Wisconsin School of Medicine and Public Health in Madison. Hepatitis C is a disease that affects the marginalized and stigmatized segments of the United States, he notes, including people who are unhoused. Homelessness is a big risk factor in addition to opioid and heroin use.

Educating communities about injection drug use and accessibility of needle exchange programs is helping to flatten the curve of HCV infection. These organized programs enable drug users to replace used needles with sterile ones, says Larry Lutwick, M.D., a retired Mayo Clinic professor who is the moderator of ProMED (Program for Monitoring Emerging Diseases), an online surveillance initiative for infectious diseases throughout the world. “Based on data, this does not lead to increased injection drug use and does decrease the acquisition of HCV and HIV,” Lutwick says.

Although there is no HCV vaccine, the direct-acting antivirals have transformed treatment, so it is easier and more effective.

Until 2014, treatment involved injection of interferon, which was only somewhat effective and resulted in significant side effects. The direct-acting antivirals were pills, not injections, and cured HCV approximately 95% of the time while dramatically decreasing toxicity, says Joseph K. Lim, M.D., a professor and director of the viral hepatitis program at Yale School of Medicine.

For most patients, treatment consists of one to three pills daily for two to three months, Lim says. Afterward, patients still need to be monitored for liver cancer even if they are cured of the infection.

The catch with the direct-acting antiviral medicines has been their price. Lack of access to the curative medications is still an issue in many parts of the world, according to the World Health Organization (WHO).

But Thomas says that “in the United States, the cost of HCV treatments can no longer be an impediment. Prices have dropped considerably, and a complete cure of HCV costs less than a one-year supply of some other widely accepted medications.” But, he adds, “the number of actual prescriptions now is lower than it should be, given that there remain 2 million persons living with a potentially fatal, transmissible and curable infectious disease.”

Louisiana and other states have negotiated “Netflix” subscription plans for paying for the antivirals whereby they pay a set price for an unlimited number of prescriptions. “That type of strategy caps spending for the state and removes the incentive to make treatment hard to get as a way of saving money,” Thomas says.

Articles

Rates dipped in the 1990s, but the opioid epidemic and the contaminated needles associated with it have caused an increase in new acute cases.

Hepatitis C Is Making a Comeback

A new study led by a researcher at the Johns Hopkins Bloomberg School of Public Health in Baltimore suggests that people who vape may be increasing their risk of developing prediabetes, even if they don’t smoke conventional cigarettes.

The data on 600,000 U.S. adults showed that those who inhaled the chemicals in e-cigarettes were more likely to have prediabetes than those who hadn’t engaged in vaping or smoking behaviors.

With e-cigarette use on the rise among youth and young adults, health experts are sounding alarm bells about the potential dangers.

“There is a perception among the younger population that e-cigarettes are a safer alternative,” says 

, Ph.D., a professor of environmental health sciences at Johns Hopkins and co-author of the study published in the 

 “More data is piling up that e-cigarettes are not harmless as they were originally perceived by the users. They do contain many chemicals which have toxic effects.”

Results of the federal government’s 2021 National Youth Tobacco Survey showed that 13.4% (2.06 million ) of high school students and 4% (470,000) of middle schools were current users of a tobacco product and that that e-cigarettes were the most commonly used products. The survey results, 

indicate that 1.72 million high school students use e-cigarettes and 320,000 middle schoolers.

In addition to an elevated risk of prediabetes, lung and heart diseases are major concerns that stem from vaping and smoking, says Biswal, adding that research has linked vaping to erectile dysfunction.

“This study is a good first look at the impacts of vaping and chronic disease development,” says Farah Naz Khan, M.D., a clinical assistant professor in the division of metabolism, endocrinology and nutrition at the University of Washington School of Medicine in Seattle. “More research will be needed to better understand correlation versus causation.” But it is plausible that vaping can affect the development of prediabetes, particularly if a person has other risk factors such as family history, obesity and insulin resistance, Khan says.

Previously, the Surgeon General concluded that cigarette smoking can contribute to the onset of Type 2 diabetes, says Brenna VanFrank, M.D., MSPH, senior medical officer at the CDC’s Office on Smoking and Health.

“Evidence is well established regarding the link between cigarette smoking and inflammation,” VanFrank says. “Cigarette smoke-induced inflammation is a contributing mechanism to a variety of diseases caused by smoking, including cancer, lung disease and cardiovascular disease.”

Cigarette smoking can create low-grade inflammation throughout the body by attacking white blood cells, which protect against invaders and respond to injury. It damages them by activating the release of chemical substances that circulate and localize in tissues, says David C. Christiani, M.D., M.P.H., M.S., a professor at the Harvard T.H. Chan School of Public Health and Harvard Medical School in Boston.

“Animal data and some preliminary human data indicate that vaping can activate some of the same pathways as combustibles, says Christiani, who is also a pulmonologist at Massachusetts General Hospital.

It is still unknown whether prediabetes will develop into full-blown diabetes if a person continues to vape. “This study cannot answer that definitively,” he says.

“However, prediabetes as a condition is linked with adverse health outcomes such as those seen with full-blown diabetes: heart disease, stroke, peripheral vascular disease. So, persistent use will lead to persistent prediabetes, and an elevated risk of these conditions.”

The good news is that quitting smoking decreases markers of inflammation, according to the 2020 Surgeon General’s Report on Smoking Cessation. Yet VanFrank notes that “airway inflammation may persist for months to years after quitting.”

Khan adds that “the best way to try to prevent further inflammation is to stop the offending factor, whether that is smoking or vaping. This can prevent further inflammation from developing, but it is unlikely to reverse any damage that has already occurred.”

Still, Biswal says prediabetes is reversible with lifestyle management. He recommends “doubling down on public health measures to prevent the initiation and use of e-cigarettes, at least among youth.”

A Johns Hopkins study found an association between use of e-cigarettes and  prediabetes. More research is needed to tease out the possible causal elements of the association. Meanwhile, a federal government survey found that 1.72 million high school students and 320,000 middle schoolers are current users of e-cigarettes.

Study Links Vaping and Prediabetes

Many individuals with multiple sclerosis (MS) may have weak bones that predispose them to fractures, suggesting that bone health monitoring is important for people with this disease of the central nervous system, a new meta-analysis has shown.

Osteopenia — the medical term for bone mineral density that is lower than normal — affected 43% of MS patients included in the meta-analysis, which included 29 studies, six conference papers and almost 14,000 study subjects.

The meta-analysis also found that about 17% of MS patients have osteoporosis, which is characterized by lower bone density that osteopenia, so bones are even more fragile and susceptible to fracture.

The prevalence of osteoporosis/osteopenia in patients with multiple sclerosis (MS): a systematic review and meta-analysis

“It’s helpful for clinicians to have a systematic review and meta-analysis demonstrating the prevalence of osteopenia and osteoporosis in the MS population,” says Julie Fiol, M.S.W., BSN, RN, MSCN, associate vice president of healthcare access at the National Multiple Sclerosis Society. “Hopefully, this helps raise awareness of the need for appropriate screening.”

Researcher have identified several factors that may make MS patients prone to developing osteopenia and osteoporosiss: prolonged, MS-related motor disability that diminishes mechanical loading of bone, vitamin D deficiency and the use of corticosteroids to treat MS relapses.

“Mobility impairment is a risk factor for decreased bone density, and it is also a risk factor for falls,” notes Fiol. “If someone with decreased bone density falls, they are more prone to bone fractures, which leads to further impaired mobility and other complications. “People with MS, even those with mobility impairment, should be encouraged to exercise regularly, particularly to engage in weight-bearing exercise, she adds.

Lead author Mohaddeseh Azadvari of the Department of Physical Medicine and Rehabilitation at Imam Khomeini Hospital in Tehran, Iran, sifted through studies published up to March 2021. The research included in the meta-analysis was published between 2004 and 2020.

Azadvari and his colleagues said that additional research would be necessary to further elucidate the occurrence of osteoporosis and osteopenia in MS patients. Res

Other research has drawn a connection between MS and vitamin D deficiency. A link between MS and low vitamin D levels would fit with the fact that MS is more common in northern latitudes. Vitamin D production relies on skin exposure to sunlight, so people residing farther away from the equator are at higher risk of deficiency.

Fiol recommends that clinicians measure vitamin D level with a blood test and recommend supplementation when appropriate. A bone density scan also can be performed, especially for those with risk factors, such as mobility impairment and frequent corticosteroid use.

Beyond that, “people should ensure they are getting adequate calcium intake in their diet or supplement if needed,” she says. “Limiting alcohol intake and smoking cessation can also improve bone health.”


A recent meta-analysis shows that a large proportion of people with multiple sclerosis have osteopenia or osteoarthritis. Lack of mobility and vitamin D deficiencies may play a causative role.

Fractures Should Be Concerning to Clinicians Caring for Patients With MS

Since its inception, magnetic resonance imaging (MRI) has been lauded for its ultra-sensitivity in identifying plaques in the brain and spine of patients with multiple sclerosis (MS). In the years since, it has become vital for diagnosing MS, in addition to gauging response to treatment or disease progression.

But despite the capabilities of standard MRI — equipped with conventional 1.5-, or 3-tesla (T) magnetic field strength — the technology isn't sensitive enough to detect all the components of this neurodegenerative disease in which the body's immune system attacks the fatty protective myelin sheath surrounding nerve fibers.

Now, a new study published online Jan. 4 in the journal 

 found that high-resolution MRI of neurochemicals termed MR spectroscopic imaging  at 7.0 T can help visualize pathologic findings beyond the lesions in participants with multiple sclerosis. It detected MS-relevant neurochemical changes in the normal-appearing white matter and cortical gray matter of the brain that were associated with patients' disability.

The research was led by Eva Heckova, Ph.D., a postdoctoral researcher in the High Field MRCentre at the Medical University of Vienna in Austria.

"If the results are confirmed in further clinical longitudinal studies, MR spectroscopic imaging could become a standard imaging tool for initial diagnosis, for disease progression and therapy monitoring," Heckova says.

MR spectropic imaging allows for assessment of brain metabolism and is of keen interest in MS, where MRI showing merely structure cannot adequately shed light on microscopic components of disease activity.

The study recruited 65 participants with MS and 20 age- and sex-matched healthy controls, with an average age of 32, between January 2016 and December 2017. Metabolic ratios were obtained in white matter lesions, normal-appearing white matter and cortical gray matter regions.

MR spectroscopic imaging at 7.0 T permitted visualization of brain metabolic alterations, particularly those related to neuroinflammation, which cannot be visible with conventional T1- or T2-weighted MRI.

“Seven-tesla MR spectroscopy offers improved signal-to-noise ratios and improved spectral resolution compared with lower field strengths, such as 3.0 and 1.5T,” Peter B. Barker, D.Phil., professor of radiology and oncology at the Johns Hopkins University School of Medicine in Baltimore, wrote in an editorial accompanying the trial’s results.  “As a result, more compounds can be detected with higher accuracy. However, before these improvements can be realized in practice, many engineering challenges have to be overcome ...”

The National Multiple Sclerosis Society expressed optimism that this trial could pave the way toward better diagnostic tools. "We find this research finding to be intriguing and encourage the research team to continue to explore the utility of this approach in the diagnosis of MS,” says Julie Fiol, the society's associate vice president for healthcare access.

New technology detects changes in the brain beyond the lesions seen with normal MRI scans.

Study: High-resolution MRI Permits Visualization of Metabolic Change in the Brain  Related to Inflammation in MS Patients

 may be the main cause of multiple sclerosis (MS), a progressive and incurable neurological disease afflicting 2.8 million people worldwide, a new study reveals.

Results of the study — led by researchers at the Harvard T.H. Chan School of Public Health — were published online in

To explore the potential link between EBV and MS, the Harvard researchers evaluated more than 10 million young adults on active duty in the U.S. military, measuring EBV antibodies in blood serum samples stored by the Department of Defense. They identified 955 service members diagnosed with MS. Those infected with EBV after joining the military had a heightened risk of developing MS compared to those who did not contract the virus.

As a chronic inflammatory disease of the central nervous system, MS wreaks havoc on the myelin sheaths, insulating layers of fatty tissue that safeguard neurons in the brain and spinal cord. EBV is a herpes virus that triggers infectious mononucleosis and continues to lurk inside the body for life. The exact mechanism by which it could cause MS remains unclear. 

Substantiating EBV’s causal role in MS has been fraught with challenges, partly because EBV infections are so common. About 95% of adults get infected with the virus, yet only a tiny fraction of people ever develops MS. Moreover, the onset of MS symptoms occurs, on average, a decade after EBV infection, and some studies have found that MS develops 30 years after the EBV caused mononucleosis, says 

, Sc.D., a senior research scientist at Harvard public health school and one of the study’s two senior co-authors.

“We can consider EBV necessary to developing MS, but there need to be other mitigating factors, such as a genetic predisposition,” says Munger. Cigarette smoking, vitamin D deficiency and obesity, particularly early in life, could play a role in whether EBV infection leads to MS.

The researchers suspect that that the time lag between EBV infection and MS onset could stem, in part, from the MS symptoms not occurring during the initial pathophysiology. Another factor may be that the relationship between viral infection and the immune system may evolve, with the latent infection reactivating due to persistent stimulation.

There are antiviral medications that can help control infection, but no drugs for MS that specifically target EBV. The researchers expressed hope for development of an EBV vaccine or EBV-specific antiviral drugs — and an EBV vaccine may be in the works. In early January, Moderna launched early-stage clinical trials in humans to test an mRNA vaccine against the EBV virus. The company expects to assess the vaccine’s safety and dosage in about 270 participants.

“Moderna is committed to developing a portfolio of first-in-class vaccines against latent viruses for which there are no approved vaccines today,” Stéphane Bancel, the company’s chief executive officer, said in a prepared statement.

If the trial shows that the experimental vaccine is safe and has some efficacy, the same mRNA technology underpinning Moderna’s COVID-19 vaccine could be applied to develop to EBV vaccine.

“A vaccine against EBV may result in the prevention of the majority of MS cases,” Munger says.

A longitudinal study of 10 million people in the U.S. military shows the link. The researchers say genetic predisposition, other factors are likely needed for the viral infection to cause multiple sclerosis.

Susan Kreimer

Articles

Hepatitis C Is Making a Comeback

Study Links Vaping and Prediabetes

Fractures Should Be Concerning to Clinicians Caring for Patients With MS

Study: High-resolution MRI Permits Visualization of Metabolic Change in the Brain Related to Inflammation in MS Patients

Harvard Researchers Identify Epstein-Barr Virus as a Cause of MS