Back in 1995, three MD's (Gitlin, Nolte, and Weiss) associated with Emory
University School of Medicine in Atlanta decided to do a little experiment
in their spare time. They took the liquid that barbers use to "sterilize"
their equipment, and spiked it with a patient's blood, which had been
declared HCV positive by PCR. They tested the liquid after 3 hours, and
again after 6 hours. Not pleased, they tested again a week later. Those
little critters were still alive and kicking after their week-long swim.
(No one asked them about their sex drive, however.) This study brings to
mind a number of questions: How safe is a shave at the local barber? How
are manicure tools dealt with when the cuticles bleed, or a client is cut?
What about tattoo and body piercing salons? Do beauticians have
autoclaves, like the dentists? We must become aware of these issues, in
order to make policy changes possible. Here in Victoria, most tattoo salons
use new needles for each client, and many display certificates of approval
by various agencies. Reputable piercing salons often use the earring to do
the piercing, rather that using needles. I called a couple of tattoo salons
listed in the phone book. Both numbers were no longer in service. I saw a
couple of ads that stated the business in question was certified by some
association, but when I looked up the association in the phone book, I
couldn't find any listing. I did talk to one business. The man on the
phone was very pleasant, and said that their business is certified by the
Center for Disease Control, as well as the Canadian Association of
Professional Tattooists (CAPT). He stated that they manufacture their own
needles, and that they put them through several steps, including an
autoclave and 2 hours of ultrasound. He says they never reuse needles. The
moral of this story: Please check out these salons completely. Don't be
afraid to ask. The reputable businesses are proud to show clients their
sterilization techniques.
HepC BC
Can your family catch hepatitis C from your tears? Probably not, but there
are studies out there that have detected the hepatitis C virus (HCV) in
tear fluid. A French study appeared this last March in the Journal of
Medical Virology that says their findings "suggest that tear fluid may
transmit HCV but the source of HCV RNA in this fluid needs to be better
understood." The virus was detected in the tears of 5 out of the 51
patients with Hep C that they tested.
Similar studies were done in Hamburg, Germany, and published in medical
journals [J Clin Microbiol 33: 2202-2203, 1995, and Microbiol Immunol 38:
157-158, 1994], where all their samples tested positive for HCV. They
state, "Remarkably, we regularly found greater amounts of amplification
products in tear fluid and eye swabs compared to plasma using the same
conditions for sample preparation."
What about transmission by tear fluid from patient to patient in a medical
setting, such as during tests for glaucoma? I interviewed a local
ophthalmologist, and he told me that he was very careful, and sterilized
the instrument that actually touches the eye with alcohol. There are
studies, however, that indicate that only heat can kill HIV, one of which
was published in the September 1996 issue of Nature Medicine. It seems
that HCV is not so contagious as HIV, but even harder to kill. The
effectiveness of alcohol as a means of killing HCV remains in
question.
A study was done in Atlanta, GA [Ann Intern Med 126(5): 410-411 (1997)]
that indicates that disinfectants used by barbers still contained HCV after
7 days. In an article written by Gurevich, et. al. [J Hosp Infect, Apr
1996], speaking of disinfection practices in dentistry, the authors state,
"some of the liquid chemical products used were not suitable for
sterilizing instruments, and 12% of respondents used incorrect contact
times." It seems that there are insufficient studies at this time to really
say. The ophthalmologist I talked to mentioned that there is equipment here
in town that checks for glaucoma without direct contact with the eye. It
might be a good idea to talk to your eye doctor before your next
examination, to find out what kind of equipment is used for the glaucoma
test. Personally, I want to avoid passing on hepatitis C, and I also want
to avoid being infected with other viruses.
Speaking of eye doctors, there are eye conditions related to hepatitis C or to interferon treatments of which your doctor may not be aware. Hep C-caused problems may include:
Mikuliez's syndrome
corneal ulceration
Mooren's corneal ulcersand
dry eyes (sicca or Sjogren's syndrome).
Rare complications found associated with interferon therapy were:
vascular retinopathy
optic neuropathy
retinal haemorrhages
cotton- wool spots and retinal artery
or vein obstruction.
If you are having vision problems,it may be a good idea to check with your local support group for materials to take with you to your appointment.
Joan Diemecke
HepC BC
By Darlene Morrow, BSc
The transmission of HCV can occur via improper
handling and cleaning of dental instruments. Although the risk
is small it is a proven source of infection (1, 2). Therefore
it is our responsibility to help our dentists and to see that
our HCV stops with us and is not passed on.
Dentristry has come a long way and is doing
many things to prevent the spread of infectious diseases. However
the HCV transmission occurs through blood and equipment not viewed
as a risk may in fact be harbouring the virus. Next time you
go to the dentist make a note of everything he/she touches with
their gloved hands. The gloves could have your blood on them.
How is the dentist going to clean the areas he touched?
Step one: A number of studies have shown
that only heat is effective at killing the HCV (3, 5). That means
the autoclave must be used. Chemical cleaning agents are not
effective when used alone. According to Chris Martin, a spokesperson
for the American Dental Association 90% of North American dentists
use the autoclave. That means 10% are not (5).
Step two: Where possible disposable units
should be used. This includes the sterile cartridges for the
local anaesthetics and the needles, scalpel blades and discs for
cutting tooth material, dental burrs and brushes, and the metal
bands that are used to help form the matrix to place restorations
which can cut into the gums causing bleeding. One study in the
UK showed that of the "disposable" items that were reused
by some dentists a full 50% did not autoclave between patients
(1).
Step three: All permanent handpieces should
be covered with a baggie. This baggie will catch the blood splattered
by the high speed drill and then can be removed and properly disposed
of. The blood can combine with the lubricant and be very difficult
to remove otherwise (1, 4). In one study examination of 328 samples
collected from work benches, air turbine handpieces, holders,
suction units, forceps, dental mirrors and burs showed that 6.1%
were positive for HCV RNA (6).
Other areas of concern: The water coolant
that is used for the scaling and the high speed drill can become
contaminated with bacteria. This is a concern for immunocompromised
patients and neither chlorination nor charcoal filtration reliably
decontaminates the water (1).
HCV RNA has been found in saliva. There is
one record of transmission through a human bite. Did the saliva
carry the virus or was there blood involved? To date the transmission
via saliva is not believed to be possible.
So the next time you see your dentist make
sure they are wearing gloves, a mask, eye goggles and share the
information you have learned here about baggies covering handpieces.
Ask them if they would like information about the transmission
of HCV in dentistry. We would be very happy to mail them an information
packet.
HepC BC
Tylenol and HCV: How Can We Protect Ourselves?
Many people with HCV are required to take 2 extra strength Tylenol before
their interferon shots. The Tylenol helps to alleviate the flu-like side
effects. However, Tylenol is a liver toxic substance. As little as 12g of
Tylenol is able to produce liver failure in some people. That's 24 500mg
tablets in a healthy individual. That's just to show you how toxic it can
be. So how can people with HCV protect themselves from the liver damaging
effects of Tylenol?
Dr. Alistair J. Makin and associates at King's College Hospital in London
looked at over 560 patients with acetaminophen-induced liver failure. This
study appeared in Gastroenterology 1995;109:1907-1916. The doctors
credited an improved survival to prompt initiation of N-acetylcysteine
(NAC) therapy and greater availability and success of liver
transplantation. NAC is an amino acid. You can buy it in the health food
stores in 500mg capsules. It has proven so effective at preventing Tylenol
induced damage to the liver that a company in Europe is in the process of
forming a Tylenol combined with NAC.
Another study titled "Protection From Acetaminophen Induced Liver Damage By
The Synergistic Action Of Low-doses Of The Poly(Adp-ribose)
Polymerase-inhibitor Nicotinamide And The Antioxidant N-acetylcysteine Or
The Amino-acid L-methionine" by Kroger H, Deutsch Rheumaforschungszentrum
Berlin, Monbijoustr 2, D-10117 Berlin, Germany (GENERAL PHARMA- COLOGY 1997
FEB;28(2): 257-263) looked at the various methods of protecting the liver.
The author found that the combination of NAC and methionine provided 100%
protection for the liver! The methionine can be found in the form of
S-Adenylose Methionine or SAM.
You may recall that Dr. Bayley suggested this compound to aid people with
HCV in the detoxification of the liver. So the best thing that you can do
is take your Tylenol with NAC and SAM. In fact, these compounds are great
help for your liver, and aid in the daily detoxifying.
HepC BC
By Darlene Morrow, BSc
"Morbid Prognostic Features in Patients With Chronic Liver
Failure Undergoing Nonhepatic Surgery" by Henry E. Rice,
MD; Grant E. O'Keefe, MD; W. Scott Helton, MD; Kaj Johansen, MD,
PhD in Arch Surg. 1997;132:880- 885
The authors looked at nonhepatic (not related to the liver disease)
surgery. They found that there was a significant increase in death
due to the surgery. The surgeries were not for the hepatitis
but were related to other problems. The surgeries included abdominal,
heart by- pass, orthopaedic and miscellaneous. 28% of the people
died within 30 days. Child classification and Pugh score failed
to predict 30-day mortality. They found that an international
normalised ratio greater than 1.6 and encephalopathy were associated
with a greater than 10- and 35- fold increased mortality risk,
respectively. They concluded that nonhepatic surgery confers a
substantial mortality risk in patients with chronic liver failure.
From this study I think that we can safely
say that any type of elective surgery is something that people
with HCV should think very seriously about. Certainly those people
that suffer from encephalopathy should not undergo any surgery
that is not absolutely necessary.
HepC BC
VIRAL HEPATITIS IN OLDER ADULTS
J Am Geriatr Soc 45 (6): 755-763 (Jun 1997)
Marcus EL, Tur-Kaspa R/Acute Geriatric Department,
Sarah Herzog Memorial Hospital, Jerusalem, Israel.
The objective of this paper is to review the
epidemiology, manifestations, therapy, and prevention of viral
hepatitis in older people and to discuss issues of prevention
and management. In developed countries a significant portion of
the adult population is not immune to Hepatitis A virus (HAV).
Morbidity and mortality from HAV infection increases with age.
A safe and effective hepatitis A vaccine is available and health
authorities should consider immunization early in life and for
healthy adults as well as for potential high risk groups such
as nursing home residents. Acute hepatitis due to Hepatitis B
virus (HBV) is rare in older people and is usually a mild disease.
Most older patients with chronic HBV infection who suffer from
advanced liver disease have no evidence of ongoing viral replication.
Therefore, they are not candidates for interferon therapy. Those
with evidence of ongoing viral replication and compensated liver
disease should be offered interferon or be included in clinical
trials with new antiviral drugs such as lamivudine. Since the
response rate to hepatitis B vaccination decreases with age, developing
vaccines with greater immunogenicity is crucial. Hepatitis C virus
(HCV) is the most frequent cause of acute viral hepatitis in older
people. Acute hepatitis C is usually a mild disease in this age
group. Because many older patients with chronic HCV infection
have compensated liver disease, they could benefit from antiviral
therapy. In light of the low response rate to interferon in older
patients with chronic hepatitis C and the side effects of the
drug, interferon therapy should be reserved for those with the
best chance of response. "Combination" antiviral therapy
should be on trial for older patients with chronic HCV infection
who do not respond to interferon. The recently discovered RNA
virus, Hepatitis G (HGV), has been associated with liver disease
in older people. It's role in the pathogenesis of liver injury
remains to be elucidated.
PMID: 9180674, MUID: 97324569
HepC BC
This column is a response to requests for a personal classified
section in our news bulletin. Here is how it works: To place an
ad: Write it up! Max. 50 words. Deadline is the 15th of each
month and the ad will run for two months. We'd like a $10 donation,
if you can afford it. Send checks payable to HeCSC Victoria Chapter,
and mail to R. Hicks, Box 263-453 Head St., Victoria, BC V9A
5S1. Give us you name, tel. no., and address. To respond to an
ad: Place your written response in a separate, sealed envelope
with nothing on it but the number from the top left corner of
the ad to which you are responding. Put that envelope inside
a second one, along with your check for a donation of $2, if you
can afford it. Mail to the same address as above.
Disclaimer: R. Hicks and/or HeCSC cannot
be held responsible for any interaction between parties brought
about by this column.
Ad no. 1
Life should be an adventure. If you are female, 35/40ish,
know how to sail or would like to learn, and love life, I live
on a comfy sailboat with a spectacular view of Victoria Harbour.
I am trim, fit, and my mom says I'm handsome. Let's talk about
the possibilities!
Ad no. 3 SF/S/ND 5'5",
110 lbs., Canadian, seeks Lady/Gent. 55-65, honest, with good
sense of humour, needed for companionship. I am a single lady
who enjoys camping, travel, nature, as well as music, cooking,
garden, etc. Will answer all positive replies. Life is worth
living even with Hep C.
Ad no. 4 SWM Italian, 33yrs. Life's too short to be alone. If you are a female 25/34 looking for love, understanding, and a shoulder to cry on, I'm here. I love all music, esp. country, horseback riding, walks along the lake late at night looking at the stars and dream. Once in a lifetime opportunity.
HepC BC
Schering-Plough
Announces Phase III Results for INTRON(R) A Plus Ribavirin in
Treating Hepatitis C
09:04 a.m. Sep 22, 1997 Eastern
MADISON, N.J., Sept. 22 /PRNewswire/ -- Schering-Plough Corporation (NYSE:
SGP) today announced results from two pivotal Phase III clinical studies
showing that INTRON(R) A (interferon alfa-2b) plus oral ribavirin
combination therapy versus INTRON A alone resulted in a 10- fold increase
in the number of patients showing eradication of detectable (HCV- RNA
(qPCR)- negative)* hepatitis C virus in patients who had relapsed after
prior alpha interferon treatment. Detailed data from these Phase III
studies will be presented at the American Association for the Study of
Liver Diseases meeting in Chicago on Nov. 10 by the study investigators.
"Based on these encouraging results, we are moving quickly to compile the
data from these studies and hope to file an NDA (New Drug Application) with
the Food and Drug Administration by the end of this year, to be followed by
a Health Registration Dossier (HRD) in Europe next year," said Jonathan R.
Spicehandler, M.D., president of Schering-Plough Research Institute.
* (HCV-RNA (qPCR)-negative) is defined as <100 copies of hepatitis C viral
RNA as measured by the National Genetics Institute assay. SOURCE
Schering-Plough Corporation
Copyright 1997, PR Newswire
HepC BC
From: Health Canada
"It's Your Health" series
Moulds and mycotoxins
Moulds are organisms capable of growing on many substances, according
to varying conditions of temperature and moisture. Some moulds
are useful to man. Carefully cultivated varieties enhance the
flavour of Camembert, and give blue and Roquefort cheeses their
marbled appearance and characteristic tang. Probably the most
famous beneficial mould is a Penicillium. The discovery of its
ability to kill harmful bacteria led to the development of antibiotics
and a whole new era in the treatment of disease. However, many
moulds are a nuisance because they spoil food, clothing and leather,
and cause extensive food crop losses in the form of blights and
rusts. In addition, some moulds may pose a health hazard by producing
substances called mycotoxins. Mycotoxins (mycos is Greek for mould)
are undesirable chemical compounds produced by some species of
mould under certain temperature and moisture conditions. Mycotoxins
are persistent substances and may remain in a product even after
the moulds which produced them are killed. The illness, disease
or condition resulting from the intake of mycotoxin- contaminated
food or feed is called mycotoxicosis. In the past, scattered
outbreaks of mycotoxin poisoning in man and animals were recorded.
However, these incidents were isolated and were usually linked
with unusual circumstances involving consumption of poorly stored
grains. The view that mycotoxins did not constitute a general
health hazard changed in 1960, when an outbreak of Turkey-X disease
killed more than 100,000 turkey poults in England. The mysterious
Turkey-X outbreak was traced to imported peanut meal contaminated
by the mould Aspergillus flavus, which is capable of producing
several mycotoxins called aflatoxins.
Aflatoxin toxicity
The discovery of aflatoxins renewed scientific interest in mycotoxicosis
and led to the development of improved methodologies for detecting
and isolating mycotoxins. Further studies revealed that aflatoxins
were acute poisons at high concentrations, and also were potent
liver carcinogens when fed to experimental animals at low levels
over long periods of time. In addition, epidemiological studies
in Southeast Asia and Africa have shown that liver cancer is
significantly higher among certain human population groups who
consume diets high in aflatoxins, although other factors such
as local diseases may influence this incidence.
Food susceptible to aflatoxins
Certain crops grown in warm, humid climates are susceptible to
mould contamination which can result in the production of aflatoxins.
These crops include corn, tree nuts and peanuts. Aflatoxins are
rarely found in Canadian field crops because of our climate.
Reducing levels in food products
Since moulds are a naturally occurring crop problem, it is not
possible to eliminate traces of aflatoxin entirely from food
products. However, contamination can be minimized by careful storage
and handling of the crops after harvest, and by rigorous inspection
of products before they are offered for sale. Of all mycotoxins,
aflatoxins are the most studied and regulated. Reduction of aflatoxin
levels in food products is the shared responsibility of the grower,
distributor and food processor. The Health Protection Branch has
an active program aimed at further reducing aflatoxin levels in
foods sold in Canada. Because of the popularity of peanuts and
peanut butter, the presence of aflatoxins in these vulnerable
foods is of particular concern. In accordance with the Canadian
Food and Drug Regulations, the maximum tolerated level of aflatoxins
in nuts and nut products sold in Canada is 15 parts per billion.
Aflatoxins and peanut products
Peanuts consumed in Canada are primarily imported from other countries,
mainly the USA. Peanuts and peanut butter are checked for aflatoxin
contamination at many points during the manufacturing and marketing
process. In the United States, the Department of Agriculture analyzes
every lot of raw peanuts to ensure that peanuts sold for human
consumption do not contain excessive amounts of aflatoxins. Each
lot of peanuts imported into Canada from the United States is
accompanied by a certificate of analysis. Peanuts grown in Canada
are regularly monitored for aflatoxin contamination. No detectable
levels have been found to date in the domestic peanut crop. The
Canadian food processors are responsible for ensuring that each
shipment of peanuts is of an acceptable quality before processing
it. Peanuts of acceptable quality are then roasted. This has been
shown to destroy approximately half of any aflatoxin in the nuts.
After roasting, the nuts are sorted to remove damaged or discoloured
kernels, which are likely to contain most of any aflatoxin residues
present. Peanut processors also analyze samples of finished peanut
butter for aflatoxin residues to ensure that they do not exceed
the standard set out in the Food and Drug Regulations. Inspectors
of the Health Protection Branch inspect peanut processing plants
to assess manufacturing procedures for reducing aflatoxins in
the finished product. The inspector will identify any specific
weakness in a firm's quality control program and will advise the
plant managers on any need for improvement. Inspectors obtain
samples of peanut butter for analysis from every manufacturing
plant in Canada. Enforcement action, including product recalls,
is initiated when a batch of market-ready peanuts, peanut butter
or other nut products is found to contain excessive amounts of
aflatoxins.
Safety tips for the consumer
Throw away all food contaminated with mould. This is a good rule
to follow to avoid mycotoxin intake in general. Do not eat shrivelled,
discoloured, mouldy or damaged nuts of any variety. Do not allow
peanut butter or other foods susceptible to mould growth to stand
uncovered for long periods of time. Store in a cool dry place
to avoid mould contamination.
HepC BC