Assoc. Yordan Genov is one of the leading hepatologists in Bulgaria, head of the hepatology department at the Gastroenterology Clinic of Tsaritsa Joanna University Hospital - ISUL. On the occasion of the European Hepatitis B, C and HIV Testing Week from November 17 to 24, we collected questions from hepatitis C patients and asked them on their behalf to Prof. Genov
Prof. Genov, is it possible to prove at least approximately when a person contracted hepatitis C?
- No, because the rate of development of the disease is different for different people. I am often asked this question by patients. There are different thoughts behind it. Some patients know when they have had a drug injection in the past. Other patients know when they have been in contact with a hepatitis C patient, and still others know when they have been in contact with a blood product from a hepatitis C patient through a blood transfusion, or when they have been pricked by a needle or sharp instrument used by a hepatitis C patient. The last mode of infection is characteristic of he althcare workers. They are at constant risk, especially those practicing speci alties associated with more invasive actions on patients.
Is there a guarantee that a person cannot get infected with hepatitis C during manipulation at a dentist?
- In general, dental procedures are not a risk factor for contracting hepatitis C. But any invasive procedure on the human body with an instrument that may have previously been in contact with a patient with hepatitis C carries a risk of infection.
Are the so-called “brain fog” and intestinal discomfort included in the symptoms of hepatitis C disease?
- One of the symptoms of chronic hepatitis C infection is cognitive impairment. This means more and more difficult memorization over time, a reduced capacity for learning, for intellectual production, for communication, for work related to mental load, and with easier fatigue from intellectual load. So brain fog may be synonymous with the cognitive impairment associated with hepatitis C. It is important to know that once the infection is cured, the cognitive impairment resolves relatively quickly. In a considerable part of the patients, an improvement in cognitive functions was observed already during the treatment.
As for abdominal discomfort, it is not a characteristic symptom of chronic hepatitis C infection by itself. Unless it is associated with advanced liver disease.
How much are the new medications that revolutionized the treatment of hepatitis C, and how much of them does the He alth Insurance Fund pay for?
- There are several generations of new medications. Some of them failed to establish themselves in the treatment of hepatitis C because it turned out that their effectiveness was not high enough and they were not broad-spectrum. A trend in Europe and North America, as already in Asia and Australia, since the beginning of 2017 is to use pangenotypic medications - maybe with one medication
to affect all genotypes of the virus
of hepatitis C, to be easy to take - once a day, one to three tablets, to have no side effects and not too expensive. At the moment, the most important medicines for the treatment of hepatitis C are available in Bulgaria, but the He alth Fund still does not reimburse the latest ones that entered clinical practice last year and this year. In 2017, the best pangenotypic medication for the treatment of hepatitis C for patients with compensated liver cirrhosis entered into use in Europe and America. It consists of two molecules and is called mavired. We also do not yet have a pangenetic drug available for the treatment of hepatitis C in decompensated liver cirrhosis. But we are doing our best to have these two drugs in our clinical practice from 2018. The use of all old narrow-spectrum drugs that act only on one subgenotype of the virus, which require long-term treatment of patients and expensive preliminary tests for subgenotype of the virus and for resistance, must be stopped. The price of new medicines in both Europe and America is not higher than the old ones. Even in most cases it goes below them. So for me personally, it is unwarranted to continue the use of these narrower spectrum drugs. They are more expensive for the he alth insurance system, for the hospitals, because they have to do genotyping, and also for the patient, because he has to attend more frequent check-ups during the treatment and afterwards.
Is there any possibility for the patient to buy the latest medicines himself, if he is able to pay or if he makes a donation campaign?
- There is no point in anyone looking for a way to buy them. Because all the responsible people in the National He alth Service, who deal with the expensive treatment of viral hepatitis, together with the 12 treatment centers in the country, have tried to ensure that all patients have unlimited access to the medicine they need.
Assoc. Jordan Genov
Do new drugs have side effects?
- New medications have a small number of side effects with a weak manifestation. This allows patients to be treated at home without the risk of reducing their ability to work and without having to go to hospital to treat any side effect. The best treatment nowadays in hepatology is the treatment of hepatitis C with the new drugs.
To how many patients per month does the He alth Insurance Fund issue the drug?
- This year there was a plan to give treatment to several hundred people, but towards the end of the year
The he alth fund will have already reimbursed the treatment
to over thousands of people with hepatitis C. Unlike another time when they accused the He alth Insurance Fund of doing something to the detriment of patients, now it really works in their service. It was only in February that there were some strange events and the treatment was stopped temporarily. There was an idea to give the most expensive medicine possible. It was not clear what exactly was going on. But since March, things have gone in the right direction - patients will receive the best treatment for them. It even turned out that it was not as expensive as it was circulated until then. There are no restrictions on receiving hepatitis C medication, but there are rules according to which they are dispensed, and all of them are based on medical expediency - the patient's condition, his additional diseases, the genotype of the virus. Let all patients arm themselves with patience. They were infected with hepatitis C a few years ago or decades ago, but they all want to get treatment right away. Eventually everyone will get treatment, but it can't be done in a month and it doesn't have to be. Let no one worry that they will not get treatment in one month, but in two or three months.
Did the worst cases go through the treatment, with the severe complications?
- Yes, these patients were a priority group. Their treatment began in 2016, and a majority of patients received it, but not all. Unfortunately, patients with decompensated liver cirrhosis still emerge. But there is no delay in treatment. All will be covered.
I should point out that hepatitis C medications interact with other medications. And because patients with hepatitis C also have concomitant diseases, before starting treatment, possible drug interactions must be carefully evaluated.
How long after infection with hepatitis C do complications occur?
- Hepatitis C progresses relatively slowly. It takes decades - two or three - to reach cirrhosis of the liver. Some people do not develop cirrhosis at all.
The disease progresses faster,
if, in addition to the hepatitis C virus, there are other factors that damage the liver. These are alcohol use, smoking, hepatitis B virus added to hepatitis C virus.
People should know that smoking is a serious factor in the progression of liver disease. On the other hand, the progression of the disease is slower and the risk of complications is lower if you drink coffee regularly. One of the certain things in hepatology is that the daily use of two or three coffees a day (preferably schwarz or black coffee, but espresso is also possible) slows down the development of the disease in the liver, the development of fibrosis in general and reduces the risk of developing primary liver cancer.
Are there any symptoms to think about chronic hepatitis C infection?
- Primary infection with the hepatitis C virus in the majority of people does not produce symptoms and this is a big problem for diagnosis. And already chronic, the infection rarely produces symptoms, so it can go unnoticed. But between 50 and 76% of patients with chronic C virus infection have non-liver symptoms. The hepatitis C virus is special. It mainly affects the liver, but also other organs and systems. Extrahepatic manifestations of chronic C-virus hepatitis may persist for decades. They may be associated with damage to the central nervous system, those infected may suffer from depression, experience easy fatigue during mental and physical exertion, have rashes and itching, various manifestations on the part of the circulatory system - most often an inflammation called vasculitis. These people have kidney diseases more often, more often they reach the end stage of chronic kidney failure. One type of glomerulonephritis is associated with hepatitis C. Ischemic strokes, coronary events, and a number of other rarer manifestations in young people are associated with this infection, but which disappear when the infection is cured.
Is it possible to have liver enzymes within the normal range and at the same time have hepatitis C?
- Quite possibly a very long time after infection
absent any symptoms,
a and no changes in laboratory parameters. This creates conditions for errors in the medical network. It is known that the patient has antibodies against the hepatitis C virus, but at the same time has normal liver enzymes. And they tell him that he is a carrier of the virus, but without being sick. This is not true. There is no correlation between the level of enzymes in the blood and the degree of liver damage. Someone may have normal liver enzymes but already have cirrhosis. Therefore, anyone with hepatitis C antibodies should be referred for follow-up testing at one of the major centers dealing with the treatment of viral hepatitis.
How many liver biopsies have you done in your long-term practice and are they necessary for diagnosis?
- I've probably done between 4,000 and 5,000 biopsies. Liver biopsy is done for a number of diseases. One of them still continues to be hepatitis C. But with this disease, the biopsy examination will soon disappear, not because the biopsy is superfluous, but because there is a possibility with the current medications in Europe, which I hope will soon enter Bulgaria as well, that the treatment will not be appoint according to the degree of inflammation and fibrosis of the liver, but only on the basis of whether the liver disease is compensated or decompensated. If the liver disease is compensated, the patient receives his medication, with which in eight weeks he is cleared of the hepatitis C virus with a probability of 97 to 100%. If the disease is decompensated, the patient receives a different treatment, but there is still no need for a biopsy. At this stage, there is still a need for it, because depending on the degree of fibrosis of the liver, the duration of treatment is determined, and to some extent - the type of medication.
Very often patients are afraid of the word biopsy, but there is nothing scary about it. Liver biopsy is performed under ultrasound guidance with automatic devices of very small diameter. A microscopic amount of material is taken from the liver and there are no serious complications, no pain.
Liver biopsy will continue to be a very important investigative method in all liver tumors and in other virus-related diseases, with non-steatic viral hepatitis likely to be the major liver disease in the coming years. So a histological examination will still be done, which gives the most information about what is going on in the liver. At the moment, in the clinic, we have the latest generation apparatus for measuring liver stiffness, with which elastography is performed. We also have two more ultrasound machines that can also do elastography, and we expect to receive a fourth machine soon. This test is also painless and safe.
For a year and two months, we also have the newest laboratory for virological diagnostics in the country, which is staffed by highly qualified specialists. The favorable attitude of the National Assembly and the help of the Ministry of He alth contributed to its construction. We rely a lot on this laboratory because we are constantly flooded with patients from all over the country and abroad.
