The Hippo


May 25, 2020








Tracking hepatitis C
NH health officials playing catch-up

By Ryan Lessard

 Since health officials began tracking new hepatitis C cases in the state in November, they’ve counted more than 100 — and they believe it’s only the tip of the iceberg.

Clinicians specializing in infectious diseases have previously told the Hippo that hepatitis C cases are exploding in the state, driven by intravenous drug use. It is seen alongside many other types of infections such as bacterial infections in the blood and heart valve infections that are fatal if untreated and sometimes require valve replacement surgery. Left untreated, hepatitis C can cause cirrhosis and liver cancer.
The state Department of Health and Human Services received 194 total reports of suspected hepatitis C cases from November 2016 through March 2017. Of those, 108 have been confirmed, six of which are acute (recent) infections, according to DHHS spokesperson Jake Leon.
Beth Daly, the chief of the infectious disease control bureau at DHHS, said if they extrapolate the national rate of infection for a population the size of New Hampshire’s, one would expect at least 1,078 new infections each year.
So far, the reported numbers are not on track to reach that, since only a tenth of that number was counted in a five-month period, but Daly suspects the numbers are being underreported, which she said tends to happen early on when a new disease reporting requirement is implemented.
“We know we’re missing cases, already. We’re working with providers to get them to report them to us,” Daly said.
In fact, even 1,078 may be a low bar considering the drug crisis in New Hampshire is worse than in most other states, and hepatitis C is commonly spread by intravenous drug users sharing needles. Daly said the state is one of the three states with the highest overdose deaths per capita.
“We are one of the harder-hit states regarding the opioid epidemic,” Daly said.
And hepatitis C cases are unevenly distributed throughout the country. According to the Centers for Disease Control and Prevention, half the states that reported cases had rates below the national rate of .7 cases per 100,000 population while 16 of the 40 states reporting accounted for 76 percent of the total cases reported in 2014.
New treatments
New Hampshire was the last state to make hepatitis C a reportable disease, according to Daly, so public health officials are playing catch-up in an effort to create a clearer picture of the problem. 
Daly said the reason for the change was the emergence of new treatments that can cure the disease and interventions that can help prevent it from spreading. 
One potential intervention strategy currently working its way through the legislature to be legalized is a needle exchange program, which would supply drug users with clean needles in exchange for used ones. Daly said she and others in the department have been supportive of such a measure and would refer users to a needle exchange program if it becomes legal. 
Historically, the best available treatment had been an immune system booster that was very hard on patients, according to Benjamin Chan, the state epidemiologist.
“Up until recently, we did not have great treatment for hepatitis C virus infection,” Chan said.
But in just the past five years or so, antiviral medication has been available to treat hepatitis C, and potentially eradicate the disease from the body. Chan said the antiviral treatment takes about 12 weeks, after which time physicians monitor a patient to make sure the disease doesn’t rebound.
“These have proven to be very, very effective,” Chan said.
The efficacy depends on a number of factors such as past treatment, the genotype of the virus and whether the patient already has cirrhosis of the liver.
Of the 108 confirmed new cases in the state, four people have been treated and cured.
Preventing outbreaks
Having new hepatitis C cases tracked on a regular basis (each new case must be reported within 72 hours) means public health officials will be able to detect any potential outbreaks. 
Daly said it was a matter of luck that during its outbreak in 2012, Exeter Hospital was able to piece together the puzzle and report it to the state.
“If [Exeter Hospital] hadn’t recognized itself that it was an outbreak, we wouldn’t have detected that because hepatitis C wasn’t reportable,” Daly said.
She said it would take time before she was comfortable with the data they’ve collected, at least one year. Until then, the picture is too incomplete to draw any conclusions.
However, there is a small sign that the problem may be worse in New Hampshire than the national average. Daly said a state the size of New Hampshire would normally expect about nine acute cases reported every year. In just the first five months, they’ve already counted six.

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