ECMC doctor discusses grant that will help his team to improve access to care and treatment of hepatitis C patients throughout Western New York
By Chris Motola
Q: Erie County Medical Center recently landed the $1.5 million “Eliminating Hepatitis C by Improving Access to Care and Treatment” grant. Tell us about it.
A: We first had this grant going back five or six years when I first got to ECMC. At the time the grant was really focused more on combined hepatitis C and HIV co-infection. This initial aim was to make some advances in treatments for people with both viruses. What happened was hep-C treatments really took off and evolved. The grant came to focus more on hep-C mono-infection, infection with hep-C alone. Hep-C remains a huge problem. New York state put out a new competition for the grant renewal. It’s really evolved over the last few years to focus more on hep-C as a standalone infection.
Q: I always get the hepatitis strains confused. Which one is C again?
A: Hepatitis is pretty much an umbrella term for inflammation of the liver. It can be caused by a number of different things. There’s hepatitis A, hepatitis B and hepatitis C. Hepatitis A and B, we’re able to immunize you and protect you from those. We sometimes see hep-B in patients who were born overseas — it’s still a huge epidemic worldwide. Hep-C is kind of a different thing. It’s a blood-borne virus. Some of the patients born between 1945 and 1965, the baby boomers, were exposed through blood transfusions back in the day. Hep-C didn’t really exist until 1990. We didn’t have adequate testing for it until around 1992.
Q: When you say it didn’t exist before 1990, do you mean it wasn’t identified until then?
A: Right, there was a hepatitis A, hepatitis B and non-A, non-B hepatitis. Eventually they just went with C because it was next in the alphabet.
Q: What is the risk from hepatitis C?
A: There are about 2.5 million people in the U.S. with hepatitis C, but 50% of them don’t know they have it, mainly because they haven’t been tested. And the reason for that is that hep-C is a mostly asymptomatic disease. So it’s replicating in your liver and creating inflammation. That inflammation over time may turn into scarring. By the time you do start manifesting any symptoms it’s late in the disease, when you’ve started to develop so much fibrosis or cirrhosis of the liver. Some people do get symptoms earlier, but they tend to be vague indicators like fatigue and joint pain.
Q: How do you know who to screen?
A: In the old days we used to screen based on risk factors like a history of injection drug use, blood transfusions or non-commercial tattoos. Or, if you’ve ever been on dialysis or accidentally stuck with a needle while on the job. Now, we didn’t do risk-based screening very well in the ‘90s and early ‘00s. The CDC changed the guidelines to not just continue risk-based screenings, but screen everyone born between 1945 and 1965 regardless of risk factors. That helped, but it still didn’t get us to where we needed to be in identification of these patients. So within the past year, the CDC and Preventive Task Force started recommending screening for any adult ages 18 through 79 regardless of risk factor in addition to screening high-risk individuals outside that age group. They recommend screening all pregnant women. The risk of transmission from mother to child is about 6%. The reason so much attention was focused on the baby boomers is because for a long time they were 75% of all patients with hep-C. What we’ve seen is a shift toward patients outside of that cohort to people younger than 40. The curve has changed and is attributed to the injection drug use crisis we have in the country right now. So hep-C is a downstream complication from that. There’re about 50,000 new cases each year, and most of that is attributable to injection drug use.
Q: How treatable is hepatitis C?
A: It’s completely curable. That’s the amazing thing. The therapies have evolved to the point where we give you oral regimens from eight to 12 weeks. The cure rate is about 98%, regardless of comorbidities. The regimen is really well-tolerated, with minimal side effects. This is really exciting for us because we spent so many years with older, injection-based therapies that could only cure about 30-35% of the time. Then the treatments advanced to a 50-75% success rate. Now we’re closing in on 100%.
Q: As far as the injection crisis goes, what’s your program able to do? Or is that outside of its scope?
A: No, actually, ECMC has a globally recognized program. The way we do this is that our hep-C patients who also have addiction disorders can be managed within the walls of our clinic. We recognize that in our younger patients it’s important to deal with both of these disease states. If I just cure the hep-C and don’t deal with addiction process, there’s a chance those patients could become re-infected. So a successful program means managing both of these disease states simultaneously. I’m trained in addiction medicine as well. We have an outreach program with the addiction centers in our area. We work collaboratively to screen patients and link them to care. As a result, we have a very high show-rate in our clinic. We do about 6,000 visits a year. Unfortunately our clinic is as busy as ever. The goal is to eliminate hep-C globally by 2030. The U.S. isn’t on target for that, unfortunately. At our current pace we wouldn’t be able to hit it until 2037 at the earliest. So it’s good news that we’re reaching a lot of folks. But, bad news because it’s a signal that we still have a huge problem with the substance use crisis.
Q: How successful are the addiction interventions typically?
A: It’s an interesting question when people ask about success in this context. I always respond back, “What do you mean by success?” It’s a chronic disease state. You don’t cure it. It doesn’t go away. You manage it much like you would diabetes or hypertension. These require lifelong management. So our cure rate of the hep-C is very high. We do also have a high retention rate for patients who have received the hep-C treatment we still continue to manage them for the addiction. So it really depends on what you consider success to be. Our goals are to make sure they can be productive members of society, take care of their kids, get through school and stay out of the legal system. It’s a really comprehensive thing that doesn’t have an easy metric you can point to.
Name: Anthony D. Martinez, M.D.
Position: Medical director of hepatology at Erie County Medical Center
Hometown: Providence, Rhode Island
Education: Universidad Autonoma de Guadalajara
Affiliations: Erie County Medical Center; University at Buffalo
Organizations: American Association for the Study of Liver Disease; European Association for the Study of The Liver; American Society of Addiction Medicine
Family: Daughter, 11
Hobbies: Rock climbing, mountain biking, hiking, hockey