May 2, 2002 -- Hepatitis C infection has been called "the silent killer" because millions have the virus and don't know it. New therapies have made it possible to cure more than half of patients with active infection, but a handful of liver experts are now questioning whether too many patients are being treated.
In a personal view essay sure to stir controversy within the hepatitis community, two Italian researchers argue that the virus may be more benign than has been portrayed in the media. They contend that alcohol consumption, and not viral infection, may be the biggest factor in hepatitis C virus (HCV)-related deaths.
"In our opinion, hepatitis C alone cannot be defined as a deadly disease," lead author Sandro Vento, MD, of the University of Verona, wrote in the latest issue of the journal Lancet. "However, when coupled with alcohol consumption, what we believe to be a fairly benign, although chronic, infection can become a serious and potentially life-threatening liver disease."
Vento and colleagues Francesca Cainelli note that infected children tend to have less aggressive disease course than adults. This is true, they say, even when children are infected through blood transfusion, which is associated with a somewhat accelerated progression to liver damage in adults. They suggest this discrepancy might be explained by the fact that children do not drink alcohol.
Some 170 million people worldwide are infected with HCV, and it is estimated that one in five people with active disease will eventually develop cirrhosis of the liver if not treated. In a study released last month, researchers announced that more than 60% of treated patients can now be cured with newly available therapies. Just a few years ago, less than 20% of treated patients cleared the virus.
Verona and Cainelli argue that the heightened media attention has given the public the false belief that HCV infection represents a death sentence and that everyone with the infection needs treatment. People with the virus who have no evidence of progression to liver damage are generally monitored, and treatment is begun when there is evidence of liver inflammation or scarring.
Vancouver hepatitis expert Frank Anderson, MD, says he ends up treating about 20% of the hepatitis C patients he sees.
"Only about a quarter of patients are going to progress to cirrhosis, so you really aren't doing the others a favor if you treat them," he says.
Vento and Cainelli conclude that alcohol consumption as it relates to HCV progression should be "thoroughly investigated," and that patients be "strongly and repeatedly encouraged to abstain from alcohol before beginning the administration of expensive treatments with considerable side-effects, difficult compliance, and often disappointing effectiveness."
While agreeing that alcohol consumption is dangerous for anyone with hepatitis C infection, Anderson disagrees with the Italian authors' contention that it is a major hidden cause of HCV-related liver damage and death.
"Alcohol is a risk factor for progression, but there is no question that hepatitis C progresses in the absence of alcohol consumption," he says. "And there is no question that people with HCV can develop cirrhosis without ever taking a drink."