Q: Why are baby boomers considered at high risk for hepatitis C?
The Centers for Disease Control and Prevention (CDC) estimates the number of undiagnosed cases of chronic hepatitis C virus (HCV) infections in the United States to be approximately 3.2 million (CDC, 2012). Individuals born from 1945 to 1965 (the baby boom years) account for nearly three fourths of these infections (CDC). The highest risk population for HCV infections are those who have used intravenous (IV) drugs or received blood transfusions before 1992 (Jemal & Fedewa, 2015). Lesser risk factors include tattoos, nasal drug use, and high-risk sexual behaviors. In fact, most of the baby boomers who have been positive for years will have spouses who test negative. The lack of identification and treatment of infected individuals is concerning for healthcare providers, who may be exposed to HCV. The highest risk for transmission for the home care clinicians is accidental needle-stick exposure.
HCV infection rates peaked in the mid-1970s when IV drug use in the United States was likewise at its highest point (Jemal & Fedewa, 2015). By the early 1990s, HCV transmissions via blood transfusion and IV drug use underwent a sharp decline. During the 2000s, HCV infection rates decreased by 90% (CDC, 2012). In 2012, the CDC published "Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945-1965" in the agency's Morbidity and Mortality Weekly Report. Current screening recommendations include HCV antibody testing, which reflects prior and current infections. Quantitative polymerase chain reaction testing needs to be performed to assess for active infection if antibody testing is positive. Patients who have had long-standing HCV infection, those who consume alcohol regularly, and those with fatty liver disease are at higher risk for developing hepatocellular carcinoma (HCC) (Axley et al., 2018; Starbird et al., 2018), and will need long-term HCC surveillance. This includes annual testing for alpha-fetoprotein tumor marker and performing ultrasound.
Unfortunately, many individuals infected with HCV have no signs or symptoms of the illness and are unaware that they are infected. A majority of those infected with HCV have normal lab tests and normal imaging. Therefore, most people do not know they have HCV infection until advanced liver damage is identified during routine blood tests. This is why it is often called a silent epidemic. As this is the age of many patients who receive home care, it is important to encourage and promote a one-time screening of all baby boomers to effectively identify individuals infected with HCV.
Older adults who know they are infected with HCV may assume treatment is expensive, not covered or not well tolerated, and may choose not to seek care. Primary care providers may also be uninformed of screening guidelines, available treatments, efficacy, and affordability. Prior treatments for HCV included pegylated interferon and ribavirin that were lengthy, labor-intensive, poorly tolerated, and low rates of sustained virological response (Pourmarzi et al., 2019). Treatment of HCV improved dramatically with the development of direct-acting antivirals (DAAs) (Pourmarzi et al.). The newest treatments are pangenotypic, have fewer side effects, shorter duration of treatment, and sustained virological response in excess of 90% (Pourmarzi et al.).
Different models for caring for the patient with HCV have been explored including primary care models, hepatology clinic-based models, and models that pair HCV clinics with substance abuse clinics. Home care models utilize collaboration with healthcare management systems in cooperation with a hospital-based liver clinic (Pourmarzi et al., 2019). The home care clinician can be a vital part of continued treatment compliance by patients with HCV. Education, treatment navigation, and reminders for medication compliance and follow-up care are some of the opportunities for advocacy by home care clinicians. Research from Starbird et al. (2018) demonstrated that a nurse case management intervention can have success for HCV patients to complete treatment plans. Currently, there are three DAAs that are pangenotypic for HCV patients. Sofosbuvir/velpatasvir (Epclusa) is a one-tablet daily regimen taken with or without food for 12 weeks. Glecaprevir and pibrentasvir (Mavyret) is a three-tablet daily regimen with food for 8, 12, or 16 weeks depending on disease severity. Sofosbuvir/velpatasvir/voxilaprevir (Vosevi) is a one-tablet daily regimen with food for 12 weeks (American Liver Foundation, 2017).
Baby boomers receiving home care services are a vulnerable population at risk for HCV infection. HCV is a significant concern in this generation as they have often been infected for more than 3 decades raising concerns for evolving liver damage and HCC. The recommendation for diligent screening in this population has been made, and large numbers of patients are being identified every day. New treatments are safe, efficacious, and well tolerated with cure rates >90% even when patients have prior attempts at treatment. The new DAAs are also well covered by insurance and are accessible. Home care clinicians can play an integral role in advocacy for this patient population by encouraging screening and follow-up care as well as medication compliance, education, and HCC surveillance.
Teen e-Cigarette Use Doubles Since 2017
NIH: Data from the 2019 Monitoring the Future Survey of eighth, 10th and 12th graders show alarmingly high rates of e-cigarette use compared to just a year ago, with rates doubling in the past two years. University of Michigan scientists who coordinate and evaluate the survey released the data to The New England Journal of Medicine to notify public health officials working to reduce vaping by teens. The new data show a significant increase in past month vaping of nicotine in each of the three grade levels since 2018. In 2019, the prevalence of past month nicotine vaping was more than 1 in 4 students in 12th grade; 1 in 5 in 10th grade, and 1 in 11 in eighth grade.
"With 25% of 12th graders, 20% of 10th graders and 9% of eighth graders now vaping nicotine within the past month, the use of these devices has become a public health crisis," said Dr. Nora D. Volkow. "These products introduce the highly addictive chemical nicotine to these young people and their developing brains, and I fear we are only beginning to learn the possible health risks and outcomes for youth."
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