Chronic viral hepatitis
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7280.219 (Published 27 January 2001) Cite this as: BMJ 2001;322:219All rapid responses
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EDITOR – In their review of chronic viral hepatitis, Ryder and
Beckingham mentioned the prospect of screening at risk groups for
hepatitis C, although from the text their own position on this is unclear.
[1] The recent report from the Wessex Institute for Health Research and
Development concluded that evidence for screening for hepatitis C is
inadequate and as far as I am aware this position has not changed. [2]
Intravenous drug users (IVDU) in particular present difficulties in
patient-led implementation of informed choice, for example with freedom
from the control of methadone prescription, may suffer a less aggressive
course of the illness and on a practical front frequently have abrupt
changes in residence and fail to attend specialist referrals.
It has been argued that screening promotes identification of
asymptomatic young benefiting most from treatment, with interferon-alpha
therapy yielding net saving through delaying the onset of cirrhosis. [3]
Counseling may reduce further transmission and allow more informed choice
regarding detrimental lifestyles and habits. A consequentialistic
approach may be determined by the societal benefits of screening in terms
of decreasing disease incidence or progression.
However, health education programmes and wider introduction of needle
exchange schemes may prove more cost-effective than screening in
preventing spread. [4] Furthermore, current recommendations are for
treatment of moderate or advanced biopsy cases despite evidence for
earlier treatment, while even combination therapy with tribavirin is of
limited effectiveness with possible subsequent virological relapse and any
therapy is contraindicated with ongoing injecting drug abuse. [2]
Asymptomatic carriers have morbidity related to liver biopsies and
interferon-alpha, while a positive hepatitis C result raises personal,
familial and societal concerns with limited knowledge about the disease
restricting relevant counseling, all of which may be fruitless with
ineffective therapy.
The benefits of screening, therefore, are obscured by capricious
treatment and limited knowledge on hepatitis C while the costs of
screening may be better channelled into other preventative and
developmental strategies. Alternatives are to test those more likely to
comply with or respond to therapy, the latter being determined cost-
effectively (e.g. abdominal ultrasound [5]). There is a need for evidence
on the benefits of such proactive testing on selected IVDU and the more
stable non-injectors.
Faisal F. Syed
4th year medical student
University of Manchester, Manchester M13 9PT
faisalfsyed@yahoo.com
1. Ryder SD, Beckingham IJ. Chronic viral hepatitis. BMJ 2001;322:219
-221.
2. Leal P, Stein P. Screening for hepatitis C in intravenous drug
users and genito-urinary clinic attenders. The Wessex Institute for Health
Research and Development, DEC Report 81, March 1998.
http://www.epi.bris.ac.uk/rd.
3. Seymour CA. Controversies in management: screening asymptomatic
people at high risk for hepatitis C. BMJ 1996;312:1347-1348.
4. Allison MC. Controversies in management: screening asymptomatic
people at high risk for hepatitis C: the case against. BMJ 1996;312:1349-
1350.
5. Wedemeyer H, Ockenga J, Frank H, Tillman HL, Schuler A, Caselitz
M, Gebel M, Trautwein C, Manns MP. Perihepatic lymphadenopathy: a marker
of response to interferon alpha in chronic hepatitis C.
Hepatogastroenterology 1998;45:1062-1068.
Competing interests: No competing interests
In their clinical review on chronic viral hepatitis Ryder and
Beckingham1 have included a note in the caption under the first graph
stating that professional tattooing does not carry a risk of transmitting
hepatitis C virus infection.
I have recently accompanied a local environmental health officer on
inspection visits of high street tattoo and body piercing parlours. In
several places tattoo needles and other equipment were not being
adequately sterilised between clients. In one parlour pouched instruments
and body jewellery were being put through a non-vacuum autoclave and the
resulting wet pouches dried on a central heating boiler. In all the places
visited commercial disinfectant solutions were being used in the belief
that they had a sterilising action.
Although the majority of those involved in tattooing and body
piercing were keen to maintain high standards of hygiene a lack of
training and poor regulation mean that many do not. Until this situation
changes professional tattooing and body piercing carry a significant risk
of transmission of blood-borne viruses including hepatitis C virus.
1 Ryder S D, Beckingham I J. ABC of diseases of liver, pancreas and
biliary system. Chronic Viral Hepatitis. BMJ 2001;322:219-221
Competing interests: No competing interests
Hepatitis B, Lamivudine and HIV
We write in response to the clinical review by Ryder SD et al on
chronic viral hepatitis (1). We agree with them that lamivudine has a good
safety profile, and has been shown to be beneficial for patients requiring
treatment for hepatitis B infection. However, lamivudine is also a common
agent used in the management of HIV infection. HIV and hepatitis B share
similar risk factors for acquisition: intravenous drug use, sexual and
vertical transmission. Therefore a significant proportion of patients are
likely to be co-infected (2).
In order to maximise efficacy and reduce the risk of the development
of resistant virus, current guidelines recommend the use of at least 3
antiretrovirals in the management of HIV infection (3). If used in
isolation, lamivudine leads to a rapid multiplication of resistant virus
due to a mutation at position 184 in the reverse transcriptase gene, and
potentially decreases future combination therapies available for that
individual (4).
We therefore feel that it is extremely important in the management of
hepatitis B infection to consider and/or offer an HIV test, prior to
commencing treatment with lamivudine.
References:
1. Ryder SD, Beckingham IJ: ABC of diseases of the liver, pancreas, and
the biliary system: Chronic viral hepatitis. BMJ, 2001 Jan, 322:219-221.
2. Pallas JR et al: Coinfections by HIV, hepatitis B and hepatitis C
in imprisoned intravenous drug users. Eur J Epidemiol 1999 Sep; 15(8):
699-704.
3. Gazzard B, Moyle G on behalf of the BHIVA Guidelines Writing
Committee: 1998 revision to the British HIV Association guidelines for
antiretroviral treatment of HIV seropositive individuals. Lancet 1998 Jul
25; 352(9124): 314-6.
4. Frost SD et al: Evolution of lamivudine resistance in human
immunodeficiency virus type 1-infected individuals: the relative roles of
drift and selection. J Virol 2000 Jul;74(14):6262-8.
Usha Kuchimanchi
Specialist Registrar
Oxford Genitourinary Medicine,
Radcliffe Infirmary,
Oxford.
Guy Rooney
Consultant Physician,
Department of Genitourinary Medicine,
Princess Margaret Hospital,
Swindon.
Competing interests: No competing interests