An SVR is a SUSTAINED Viral Response

[19Dragon52]

Wow jb!

Always something new to learn.  Thanks for your input!  Say, "Hi' to Pixie for me...would you?

Sincerely.....

[Pancho and Lefty]

Joy,

The lack of professionalism in the medical 'industry' in incredibly low these days. A professional treats all blood as if it might be infected with something potentially harmful.

It's thought I've carried hep C over 40 years, and, as far as I know, never infected anyone. I was every bit the risk for 2/3's of my life that I am today. Having people suddenly freak is simply their reaction to their fears.

Are you aware you don't have to tell anyone?

Peace

[joycemc]

Max~

I was required by the surgeon's office to have blood work done that included a Hep C antibody test.  I tested positive, as I knew I would, so I was asked to get medical clearance from the doctor who had treated me for the HCV, before I could have my surgery.

Are you sure that people are not required to disclose HCV infection?  Even my dentist has (or had, the last I knew) a patient information form that asks if the patient has ever been diagnosed with hepatitis C...

[willy]

Thanks for addressing this issue.  My question is: how does a person sufficiently prove the absence of HepC when a blood test reveals the HC virus antibody?

Here is my story:  Before a recent elective cosmetic surgery procedure, I disclosed that I had been cured of hepatitis C.  I provided the surgeon's office with a note of clearance from the doctor who had treated me, and a copy of the sensitive PCR results from blood work done seven months following the completion of my treatment.

(I had been a genotype B, with EVR).

A few days after the surgery, while removing my stitches, the nurse asked: "So what are your thoughts on the status of your blood?"
Me: "I'm sorry. I don't quite know what you mean...."
Her: "You know, the Hep C.  I got a needle prick during your surgery, so I just wanted hear what you think...."

I tried to reassure her that I was virus free, but I was mortified that she had concerns that I might have infected her, and I was upset that the clearance and verification that I had provided must have been insufficient.  Moreover, I worried that maybe my HCV had come back since I had the PCR at the end of last summer.  Maybe I did, indeed, infect her!

Should the doctor who treated my hepC be ordering a PCR every few years?  Should excellent liver enzymes help to verify the absence of the virus? How could that very uncomfortable conversation have been avoided?

Thanks for your response(s)

Joyce,  I'm glad that you asked the question and I think it's a great question. 

First, I'm going to get off track and digress from your question.  I may end up splitting this portion of the thread off in a bit so that we can have a seperate thread which addresses your question.  Then again; I may not since it still kinda pertains to the origional notion.  Sometimes IF other people are looking for such information we might choose a topic name for the thread that helps other people find the discussion, such as;
"HCV transmission after SVR", "Can you transmit if you are SVR?"  "HCV Transmission Post SVR"

You get the point.

Answering the question is kinda hard.  There may not be solid data on the topic.  Wanswers there are may be unclear, unproven, theoretical and a source of contention; not all will agree. (IMHO)

The "old school" answer is that once you SVR you don't have any virus in your blood.  You simply cannot transmit what you do not possess.  In a sense....this answer my serve as "truth" and my be pretty accurate.  I don't think it is totally 100% accurate however.  It may be that there are exceptions to it in certain circumstances.

Some of the newer thought on the question may hinge on certain "facts" or what are currently thought to be facts.  I may not be relating them 100% accurately but I hope to get the concept accross.

1)  Current PCR's are not 100% accurate; therefore we cannot truely and accurately say that people are "virus free" since we cannot prove it.  Many of the early PCR's were only acurrate down to 600ml/iu yet doctors willingly pronouced some people virus free, undetectable or "cured"

2)  They are finding that even post TX and post SVR that HCV RNA is commonly found in blood or tissue.  It is even thought to replicate.  And yet there appears to be some mechanism which either keeps it in check, keeps it from rapidly reproducing, mutating around the bodies defenses. Perhaps it cannot relicate as well, perhaps the body has learned to keep it in check.  Some people might consider it a remission since generally speaking the virus doesn't go back to chronic or acute phase.  It's confusing.  Neither are they absolutely clear of the virus and yet they remain undetectable, don't seem to get sick and generaly speaking do not (and maybe cannot) re-infect people.

3)  Some people and studies suggest that even after SVR that for some people an "occult infection" exists.  They cannot tell that thru PCR's but rather from continuing symptoms which suggest that some form of infection still exists.  Generally speaking I don't think that this is well proven or widely experienced, and yet there still is a body of evidence which exists on it that seem to validate some aspects of the claims.  If one thinks back to the days that HCV didn't exist.  All that they had was a name for something they could tell was out there but didn't yet have a means for proving it's existence.  That was back when HCV was called "non-A and non-B hepatitis".

SO  IF some aspects of infection still exist post TX and post SVR in theory one could transmit....something. 
1)  If it were de-activated HCV it still might not be an issue and may not replicate
2)  Since SVR generally means a virtually free of the virus the amount of HCV present might be very slight.  It might not be in the blood, but in the tissue making it even harder to transmit.
I believe that since there are many people who have SVR'ed there would probably be more data on people infecting others if it could be easily done.  I don't think there is much data out there however.
3)  Whatever there is in the blood it will be in very low barely percepible quantities making transmission very difficult.

It could be one of those things where technically it could be possible but in actual practice it doesn't seem to happen, or at least enough to show up and be readily detected.

I read that a conventional needle stick injury transmits 0-10% of the time.  I would venture that if the so called infected party were an SVR post infected person that the chances would be diminished by a factor of 100-1000.  The chances of a needle stick would be very slight but that a transfusion from person to person could in theory transmit something.  This is the reason that we are not allowed to donate blood even after we clear.

I hope this helps.  I also hope that it helps allay the fear.  Many people would simply tell you that you can't transmit what you no longer have.

best,
Willy

[Rainbow]

Willy:

I'm with you.  You can't get infected by something that's not there.  I've certainly never seen any cases of people getting infected by someone who got SVR.

Plus, transmission from needle sticks seems to depend on how high the viral load is and the type of needle.  In other words, the risk is higher if you get stuck with a needle used to start an IV....because blood goes inside the needle, that's how you know you're in the vein....vs a needle used to give an injection which may have some blood on the tip, but not inside the needle. 



HCV Transmission and Occupational Exposure

A matched case-control study involving five European countries evaluated risk factors for transmission of hepatitis C virus (HCV) to healthcare workers following occupational exposure. A total of 60 healthcare workers who underwent seroconversion subsequent to percutaneous exposure to HCV were compared with 204 healthcare workers who had been exposed to HCV but did not experience seroconversion. Placement of hollow-bore needles into the veins or arteries of patients with HCV, deep injury and male gender were identified as multivariate risk factors for transmission of HCV. Unmatched univariate risk analysis showed that the risk of transmission was 11-fold greater when the source patient had a viral load >6 log10 copies/mL compared with a source patient who had a viral load ≤4 log10 copies/mL. Study investigators conclude that these findings call for “widespread adoption of needlestick-prevention devices in healthcare settings, together with other preventive measures.”

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16231252&query_hl=5 




But....why don't we ask the experts    This comes from a group of docs and NP's that treat HCV....Someone asks.....


Q.  "Has anyone seen any articles or statements stating that if a patient is HCV negative (after successfully being treated for HCV) he/she is no longer contagious? "


A.  "It is my understanding that a patient will always be HCV Ab positive, but if his HCV RNA <50 IU/mL or the TMA test is negative, the patient is not considered "viremic." I will look for articles confirming this."

(that sounds good....but then somebody else ruins a perfectly good answer  )

A.  "I would like to point out the recent Care & Counsel listserve posting from 2/8/06 called "HCV and Elective Cesarean Section," which says, "While most transmissions occurred among mothers who were viremic, a few cases occurred from nonviremic mothers."

http://www.projectsinknowledge.com/cc3/index2.cfm?id=301


So we ended up back where we started, didn't we?


P.S.  Hospitals have guidelines for needle sticks.  They include asking the patient for permission to get a blood sample and test for HIV, Hep B and C.  Free of charge to the patient, of course.  On someone with previous SVR, perhaps you could do a qualitative PCR to check for recent infection.   

[Pancho and Lefty]

Willy and everyone,

I'd like to stir this thread back to the surface since actually achieving SVR may be a possibility.

I'm going to see my GP next week for what would normally be my yearly checkup. I could ask him to do a PCR (I'll be about 9 wks post tx)

I know SVR can't be established until after 24 wks. So, are there any advantages to being able to say I'm SVR? Would that allow me to not mention HEP C on a job application? Would I be more likely to be accepted by a health insurance provider? If I was asked by anyone about my health status could I not mention hcv? (I've read that labs will always test positive for hcv antigens.

Anybody know of other situations being SVR might be a factor? It's not so much that I'm impatient, it's that my situation will change and I might not be five minutes walk to a doctor four months from now. Big thing is I can see the doc for a $5 copay until the end of month. I'm being reviewed this month and that could change.

Of course, I'd like to hear any opinions you all might have.

peace,

Max

[MissyMouse]

I know SVR can't be established until after 24 wks. So, are there any advantages to being able to say I'm SVR? Would that allow me to not mention HEP C on a job application? Would I be more likely to be accepted by a health insurance provider? If I was asked by anyone about my health status could I not mention hcv? (I've read that labs will always test positive for hcv antigens.

Anybody know of other situations being SVR might be a factor? It's not so much that I'm impatient, it's that my situation will change and I might not be five minutes walk to a doctor four months from now. Big thing is I can see the doc for a $5 copay until the end of month. I'm being reviewed this month and that could change.

Max,

I think the biggest advantage of being able to say you are SVR is for your health.   As far as telling a prospective employer, you NEVER have to disclose Hep or any other medical status unless it will prevent you from performing the job for which you are applying. 

As far as health insurance,  that's not going to be an easy task but it is possible, especially since your liver damage is not advanced.  I do know that Kim/RuThere has looked into getting health insurance since her COBRA will run out next year and she's finding that even though she is SVR, no one will insure her with Stage 3 liver disease.  You really should not try to hide the fact that you have had HCV on an insurance application.  If they asked you a direct question to that affect on the application and IF you don't answer honestly, they could nail you for fraud.  You will indeed always test positive for the HCV antibody.

Here's wishing you SVR!

Mouse

[robin]

This is such an interesting thread and one that will be for debate, I imagine, for a long time. One thing that struck me is that I was also involved in a blood transfer issue, during my TIPS procedure, the surgeon actually cut himself with a scaple. They KNEW I had HCV and still this happened. Since transplant, I wear a medic-alert necklace which lists in order: Liver Transplant Recipient, Immunosuppressed, HCV Positive. That way, I feel that I've done my part to inform the medical community if I would become injured or ill and not be verbally responsive. BTW...I signed all consents for testing for any communicable diseases after my surgery mishap with the scaple. I feel that even if you are SVR, those who medically treat you have the right to be informed. HIPPA laws would prevent them from sharing the information with anyone else.

Missy made an excellent point on the insurance. If you say you do not or have not had Hep C or liver problems, it can give the company valid grounds to drop you from coverage, if they found out. Now, they may never find out but it would stink to get dismissed if you discovered you were going to have some extensive needed coverage due to liver disease.

Question...isn't there a current proposal that an insurance company has to give insurance to one, even if they have been uninsured or have pre-existing conditions and they can't exclude paying on pre-existing or is that only in AR?

Keep your spirits high...robin

So...SVR doesn't mean CURE. Right?
 
   

[MissyMouse]

Robin,

I couldn't get  insurance after I treated for Leukemia.  Back then Florida did have a law that stated if you got 3 turn down letters from insurance carrier, the State of Florida plan had to pick you up.  You still have to pay for the coverage but it was there.   It's been so long since I went through that I have no clue if that coverage is still available here.

Mouse
P.S.  I do let the medical community know about my HCV but will never, ever again let another prospective employer know.

[mindy]

Wow, congratulations to all our members who have gotten posiistive results, this post just gave me alot more
reason to continue to push for treatment.  I forgot to tell everyone, you know my genotype is 1A, the hardest to beat
but I just found at that I am at grade 2, what does that mean?  What does the grade mean is it that I am almost at stage 2?  mindy

[DougV]

Mindy,

Staging is the amount of fibrosis (excess and non-functional connective tissue).  There are two scales but most commonly this is 0 for no fibrosis, to 4 for cirrhosis.

Grade is the amount of inflamation, or swelling if you will, and represents activity level, also confusingly done from 0-4.

Staging does go in order, but grading does not.  Grading can go up and down at any time or stay the same regardless of stage.  It varies according to immune response, diet, exercise, medications, alcohol use, other disease issues, and so on.  Staging generally only goes down if the cause of damage is removed.

The lower the grade the slower the progression of stage, for the most part.  And this is where you can impact disease progression.  A healthy low fat diet with plenty of protein, weight kept down to normal BMI range, exercise, rest, being careful with medication and avoiding it wherever possible, and of course avoiding alcohol and tobacco entirely  (alcohol as it damages the liver and tobacco as it damages the bodies ability to heal) can reduce the inflamation and thus slow or even halt progression of staging.

So no, grade two does not mean you are around the corner from the next stage, but honestly you may or may not ge.  There is also some subjectivity involved.  Give slides of a liver biopsy to three different pathologist and you are likely to get three slightly different stages and/or grades.

Doug