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Welcome to the latest edition of the Hepatitis Scotland e-Bulletin.
Further to our joint Welfare Benefits report published in 2012, Hepatitis Scotland and HIV Scotland are working together to collect patients' and services' opinions on Welfare Reform. If you or your service have been affected by welfare reform we want to know how. This will help us to better understand the impact of these reforms and identify where improvements are needed.
If you are living with Hepatitis B, Hepatitis C or HIV and are affected by welfare reforms, fill out the survey here.
If you work for a viral hepatitis or HIV service and have noticed welfare reforms having an impact on service users, fill out this separate survey.
This survey is being conducted against a backdrop of severe criticism of UK Government housing policy by a UN special rapporteur, Raquel Rolnik, particularly the so called 'bedroom tax', as being likely to breach international human rights conventions.
There has also been recent controversy over moves by GPs to either refuse requests for support letters relating to benefit claims and appeals - or to charge for them. GPs say that this is unfunded work and that there has been a 21% rise in requests to verify work capability assessments since January. Previously such charges would have been covered by Legal Aid; however UK Government reforms to Legal Aid mean that this is no longer the case.
The UK Government is currently consulting on the next steps of Legal Aid reform. If you wish to submit to the consultation, visit the Ministry of Justice website.
The 'Glasgow Effect'
Figures released by the Office for National Statistics have shown that Glasgow is the unemployment capital of the UK, and is in the top 5 workless areas of the UK for the 9th consecutive year. 30% of Glasgow households had at least one person aged 16 - 64 who was workless in 2012. The Scottish Index of Multiple Deprivation Report published in December 2012 showed that 49.1% of datazones in Glasgow were among the 20% most deprived areas in Scotland, and 44.4% of Glasgow datazones were among the 15% most deprived areas of the UK.
The recently published Drug Related death figures for Scotland for 2012 show the city had the highest number in the country, with 193 (33%) of 581, with the city also home to 40% of all HCV cases in Scotland.
A US study has found that formal Hepatitis C education for patients and primary care providers improves hepatitis C management, expedites treatment and improves virologic response rates. The study looks at the example of a Hepatitis C education class instituted in San Francisco.
It has previously been shown that Hepatitis C patient education is associated with various positive outcomes, including increased knowledge of the virus, interest in treatment, willingness to accept treatment, increased attendance at liver speciality care and the creation of healthcare efficiencies allowing patients better access to care.
Writing down your emotions has concrete health benefits
A recent piece of research from New Zealand has added to a body of research showing that writing about traumatic experiences and health conditions can have real physical health benefits. A group of elderly people who were asked to do so for 3 days before a skin biopsy saw their wounds heal more quickly.
Previous research has shown HIV patients viral load decrease with immune cell production increasing; as well as having increased the effectiveness of Hepatitis B vaccination by increasing antibody levels generated by the vaccine.
A retired healthcare worker who worked in obstetrics and gynaecological departments in NHS Fife for a short period from March to July 1981 has been diagnosed with hepatitis C infection. As a result, a look-back exercise has been initiated to review patient records and identify individuals who could potentially have been exposed to the virus.
NHS Fife is in the process of reviewing patients' information for the time frame, however, given that this occurred in Fife over 30 years ago, it is proving challenging to source detailed patient records, particularly as names and addresses might have changed. An extensive verification exercise is ongoing. Patients identified as having a risk of exposure will be written to and offered further advice and hepatitis C screening.
Women who are concerned that they might have been exposed to the infection can phone a confidential helpline on 08000 858531. The helpline will be open from 8am to 8pm providing information and advice. Staff can help to arrange counselling and a testing appointment.
The US FDA has approved the addition of boxed warnings and labelling changes to anti cancer drugs Arzerra and Rituxan to reflect their potential for Hepatitis B virus reactivation. The warnings follow 109 reports of fatal acute liver injury related to HBV among patients who received Arzerra or Rituxan from market approval to August 2012, including 32 incidents with sufficient data to link the injury to HBV reactivation.
These drugs, along with other CD20 directed cytolytic antibodies, can induce reactivation of Hepatitis B in patients with previous HBV infection and impaired immune systems.
The FDA have recommended that cancer patients are screened for HBV before treatment with either drug is initiated and consult with hepatitis experts in the event that a patient may be at risk of HBV reactivation while on either medication.
This Medscape article, from their Seminars in Liver Disease series, looks in detail at available research into anti-viral therapy for mothers with chronic Hepatitis B during pregnancy. The article points out that the management of chronic HBV during pregnancy is a challenging area, and that despite standard immunoprophylaxis a significant number of infants born to highly viremic mothers remain infected with HBV. Emerging data suggest that anti-viral therapy in the third trimester can prevent immunoprophylaxis failure.
A systematic review of the features of Hepatitis B during pregnancy is provided, including risks of vertical transmission and evidence based data on anti-viral use during pregnancy. They then propose an algorithm to assess the need for anti-viral therapy and monitor mothers with chronic Hepatitis B.
The authors conclude that the use of anti-viral therapy to prevent mother to child transmission deserves further exploration and requires universal implementation because the success of such interventions may contribute significantly in achieving the goal of global eradication of Hepatitis B.
C-section reduces risk of Hepatitis B transmission during childbirth
A recent study has shown that there is significantly reduced risk of mother to child transmission of Hepatitis B with Cesarean section over vaginal delivery.
A review of reviews has been published in the International Journal of Drugs Policy, to assess the effectiveness of interventions to prevent Hepatitis C and HIV in people who inject drugs. Among the main conclusions were that harm reduction initiatives reduce injecting risk behaviour with particularly strong evidence for opiate substitution therapy and needle and syringe programmes. However, it found comparatively little review level evidence regarding effectiveness of these interventions in preventing Hepatitis C infection among PWID.
Independent Expert Review of Opiod Replacement Therapies in Scotland
This review was commissioned by the Scottish Government and tasked with examining current evidence on the use of methadone and other opioid replacements, and making recommendations aimed at ensuring that where ORT is used, it is being used as effectively as possible. It also looked at access to other treatments.
It concluded that ORT, in particular methadone, is supported by a strong evidence base, that local services are largely providing it in accordance with national guidance and its use should continue in Scotland. However, it also concluded that ORT must be one of a full range of treatment options across the country ranging from community to residential rehabilitation, and services should become more aspirational in relation to supporting individuals’ recovery.
This review was published shortly before the release of the latest Scottish Drug Related Death figures for 2012. Overall, drug deaths were down by 3 from 584 in 2011 to 581 but this was still the second highest number ever recorded. Heroin and/or morphine related deaths went up from 206 deaths to 221, while deaths where methadone was implicated dropped from 275 to 237.
Fatalities among those aged 35 and over numbered 364 (63%) of the overall number.
2010 Global Burden of Disease Due to Illicit Drug Use
The Lancet Journal have also recently published the findings of the 2010 Global Burden of Disease study as applying to illicit drug use and dependence. Not surprisingly, Hepatitis C and HIV transmission due to injection drug use accounted for a significant amount of disease burden. Countries with the highest rate of burden included the US, UK, Canada, Australia and Russia.
English Police Chief calls for and end to the war on drugs and advocates heroin prescription
Mike Barton, Chief Constable of Durham Police, has said that current drug laws are failing, putting billions of pounds into the hands of organised crime, criminalising people with addiction and furthering the spread of HIV and Hepatitis C.
He said, "Not all crime gangs raise income through selling drugs, but most of them do in my experience. So offering an alternative route of supply to users cuts their income stream off. What I am saying is that drugs should be controlled. They should not, of course, be freely available. I think addiction to anything – drugs, alcohol, gambling, etc – is not a good thing, but outright prohibition hands revenue streams to villains. Since 1971 [the Misuse of Drugs Act] prohibition has put billions into the hands of villains who sell adulterated drugs on the streets.
"If you started to give a heroin addict the drug therapeutically, then we would not have the scourge of hepatitis C and Aids spreading among needle users, for instance. I am calling for a controlled environment, not a free-for-all."
Unlike the criminals who supply drugs, Barton said that addicts "must be treated and cared for and encouraged to break the cycle of addiction. They do not need to be criminalised."
Read full Guardian article here.
A study published in HIV Medicine has shown that a quarter of HIV-positive people in the EuroSIDA cohort with chronic Hepatitis C co-infection have received treatment for Hepatitis C. Treatment rates increased between 1998 and 2007 but then dropped.
It noted concern that only 36% of treated patients had significant fibrosis of the liver, while 22% of patients with severe fibrosis were still waiting to start treatment. People in Southern Europe and gay men were most likely to start HCV treatment.
Guidelines recommend that HIV/HCV co-infected people should start treatment for HCV if they have significant liver fibrosis (stage F2 or above). Those with a well controlled HIV infection should also be prioritised for HCV treatment. This has been supported by recent research published in the Clinical Infectious Diseases journal and other research showing that therapeutic education and HIV treatment adherence support has a major influence in timely HCV therapy.
A Spanish study published in the Journal of Acquired Immune Deficiency has also shown that HIV/viral Hepatitis co-infected people with decompensated cirrhosis are at higher risk of liver cancer than those with compensated cirrhosis.
Another recent study from Canada has shown that smoking marijuana does not accelerate progression of liver disease in HIV/HCV co-infected people. Previously it had been linked to liver fibrosis in cross sectional studies.
Recent research from Singapore has given hope for new personalised HIV, Hepatitis B and Hepatitis C treatment that could use a patients own blood to treat the infection.
The team at SICS led by Prof Antonio Bertoletti has discovered that monocytes, a type of white blood cell that can activate an immune response, are able to capture the virus in chronically-infected patients and use the captured virus to boost the patient's own immune response.
This could lead to personalised vaccines, also making vaccine production simpler and less costly. The research team say that vaccines produced this way could increase accessibility to treatment.
A billboard advertising campaign encouraging people to get tested for Hepatitis C has been launched in Greensboro, North Carolina. The billboards read: "Born from 1945 - 1965? CDC recommends you get tested for Hepatitis C."
In 2012 the US CDC officially recommended that those from the 'baby boomer' generation be tested for Hepatitis C due to the experimental drug use of the era and the fact that many blood transfusions were dangerous. The CDC has said that more than 3 million people in the United States have Hepatitis C and don't know it yet.
View news report on billboard campaign.
The CDC has conducted a survey on Hepatitis C testing as part of their ongoing Chronic Hepatitis Cohort study. 45% of respondents accessed initial Hepatitis C testing only when they started experiencing symptoms of the illness making this the single largest reason people were accessing testing.
They say that this adds further support to their decision in 2012 to recommend a one off Hepatitis C test to those born between 1945 and 1965. Once a person experiences symptoms of the virus it means that it has begun to damage the liver, with most people not experiencing any symptoms for many years after infection. That situation is undesirable because it could mean that the liver is seriously damaged or that treatment is less likely to be successful.
The survey is subject to some limitations and cannot be generalised across the country.
'Ever injected? Get tested!"
The national Big Red C campaign in Scotland around World Hepatitis Day also sought to target those who may have experimented with drugs many years ago, particularly injection drugs, and not be aware that they may have been at risk of contracting Hepatitis C. Bus and pub washroom advertisements bearing the slogan 'Ever injected? Get tested! Hep C. It can be cured' appeared in Glasgow, Edinburgh, Dundee, Aberdeen and Lanarkshire. An estimated 18,000 people in Scotland are infected with Hepatitis C but don't know it yet.
Both campaign focus on the importance of getting tested if you have been at risk from contracting Hepatitis C and emphasise the fact that Hepatitis C can be cured.
You can find out more about Hepatitis C, the risks and information on where to access testing by visiting either www.hepcscot.org or www.hepatitisscotlandc.org.uk.
An international conference in Munich this month has highlighted Scotland’s world-leading role in the prevention and treatment of Hepatitis C. At the 3rd symposium of the International Network on Hepatitis in Substance Users, key experts praised Scotland’s coordinated strategies that have lead to an increase in numbers cleared of the virus and a reduction in overall Hepatitis C prevalence. A first morning plenary address by Scotland’s Professor Sharon Hutchinson highlighted the current success of the national Hepatitis C strategy and sparked significant interest and discussion amongst the gathered experts.
Professor Greg Dore, from the University of New South Wales said, "Scotland leads the world with a targeted, effective and well funded HCV action plan. It is the first country to demonstrate that through enhanced HCV prevention strategies and improved HCV treatment uptake that population HCV prevalence can be reduced."
Professor Markus Backmund, a German expert and Deputy Chair of the INHSU said “Scotland is a very good example of how adequate investment in prevention strategies works and how better treatment can be provided. Scotland’s plan treats hepatitis as an illness and does not discriminate regarding the method in which it is acquired. This is a key step that is informing other national strategies for treating this illness, an infection that often affects the most marginalised and deprived populations in western countries”.
Professor Sharon Hutchinson, from Glasgow Caledonian University and Health Protection Scotland, said “Scotland’s Action Plan on Hepatitis C is regarded globally as a model of good practice. It is evident that a considerable amount of progress has now been made in preventing the spread of infection, and in the treatment of those already infected. Nevertheless, HCV remains a serious public health problem, affecting thousands of people inScotland, and as such efforts absolutely need to be maintained.”
Hepatitis Scotland was represented at the conference by their Lead Officer, Leon Wylie, who said, “It was very exciting to see the effect that Scotland’s success had on the delegates. Throughout the two days I was continually asked about how we (Scotland) progressed such a world leading program. It is plain to see that the successScotlandhas had will inspire other countries to initiate similar programs, leading to less people in the world being affected by Hepatitis C. It is vital thatScotland’s government continue to invest in such a successful and world leading program”.
New drug may combat diabetes and non alcoholic fatty liver disease
Research published in the Journal of Gastroenterology has shown that Obeticholic Acid may help to combat diabetes and non alcoholic fatty liver disease (NAFLD). In a phase 2 trial it increased insulin sensitivity and reduced markers of liver inflammation and fibrosis in patients with type 2 diabetes and NAFLD.
Interestingly there is an ever increasing body of evidence that Vitamin D supplementation exhibits many of the same properties as this new drug in terms of limiting fibrosis and increasing insulin sensitivity.
View e-bulletin 21 article and research on Vitamin D.
View e-bulletin 17 article and research on Vitamin D.
View e-bulletin 13 article and research on Vitamin D.
Text messaging cuts new diabetes cases by 40%
Research published in the Lancet has shown that text messaging is an effective intervention in lifestyle modification and helped to cut new diabetes cases among Asian Indian men.
Exercise, diet and Hepatitis C
The World Hepatitis Alliance have posted a video on Youtube with some advice on how you can exercise to combat fatty liver disease, diabetes and slow progression of liver disease.
A US study has found that Hepatitis C anti viral therapy leads to future savings in healthcare costs.
Chronic Hepatitis B patients treated with Besifovir have experienced outcomes to entecavir recipients in phase 2b trials conducted in Asia, but often required carnitine supplementation.
Researchers concluded, “With its high potency (comparable with entecavir), its effectiveness in lamivudine-resistant patients and its absence of renal toxicity up to 48 weeks of treatment, besifovir (taken together with carnitine supplement) is a potential alternative agent for the treatment of CHB.”
Medivir and Daewong have abandoned development of lagociclovir valactate (MIV-210), a Hepatitis B compound. Medivir said that although it had shown competitive antiviral activity, like other drugs in it's class it doesn't completely eradicate Hepatitis B.
The British Medical Association have rejected UK Government plans to charge migrants for access to healthcare. The BMA also raised concerns that patients with serious health conditions may not present to a GP, possibly leading to their condition worsening and leading to more expensive emergency care; or to the spread of infectious diseases to a wider population. A UKBA consultation closed at the end of August.
In Scotland, the Scottish Public Services Ombudsman have upheld a complaint made by the family of a woman diagnosed with Hepatitis C at an Ayrshire and Arran hospital. The Scottish Public Services Ombudsman pointed out that viral hepatitis is a condition which is exempt from payment by overseas visitors.
Hepatitis Scotland has teamed up with Patient Opinion to provide a platform for viral hepatitis patients to talk about their experiences, either positive or negative, of healthcare services. The responses you give are then fed back to the appropriate NHS people to make a positive difference to health services in this country.
If you would like to submit a story about the healthcare you have received, then visit our website where you can fill out the Patient Opinion questionaire.
View the latest Patient Opinion newsletter here.