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CLINICAL REVIEW: S D Ryder and I J Beckingham ABC of diseases of liver, pancreas, and biliary system: Chronic viral hepatitis BMJ 2001; 322: 219-221 [Full text]

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Professional tattooing does carry risk of hepatitis C

John Battersby   (2 February 2001)

Current evidence does not support screening for hepatitis C

Faisal F Syed   (5 March 2001)

Hepatitis B, Lamivudine and HIV

Usha Kuchimanchi, Guy Rooney   (9 March 2001)

Professional tattooing does carry risk of hepatitis C 2 February 2001
John Battersby, Specialist Registrar in Public Health Medicine Suffolk Health Authority Send response to journal: Re: Professional tattooing does carry risk of hepatitis C	In their clinical review on chronic viral hepatitis Ryder and Beckingham1 have included a note in the caption under the first graph stating that professional tattooing does not carry a risk of transmitting hepatitis C virus infection. I have recently accompanied a local environmental health officer on inspection visits of high street tattoo and body piercing parlours. In several places tattoo needles and other equipment were not being adequately sterilised between clients. In one parlour pouched instruments and body jewellery were being put through a non-vacuum autoclave and the resulting wet pouches dried on a central heating boiler. In all the places visited commercial disinfectant solutions were being used in the belief that they had a sterilising action. Although the majority of those involved in tattooing and body piercing were keen to maintain high standards of hygiene a lack of training and poor regulation mean that many do not. Until this situation changes professional tattooing and body piercing carry a significant risk of transmission of blood-borne viruses including hepatitis C virus. 1 Ryder S D, Beckingham I J. ABC of diseases of liver, pancreas and biliary system. Chronic Viral Hepatitis. BMJ 2001;322:219-221
Current evidence does not support screening for hepatitis C 5 March 2001
Faisal F Syed, 4th Year Medical Student University of Manchester Send response to journal: Re: Current evidence does not support screening for hepatitis C	EDITOR – In their review of chronic viral hepatitis, Ryder and Beckingham mentioned the prospect of screening at risk groups for hepatitis C, although from the text their own position on this is unclear. [1] The recent report from the Wessex Institute for Health Research and Development concluded that evidence for screening for hepatitis C is inadequate and as far as I am aware this position has not changed. [2] Intravenous drug users (IVDU) in particular present difficulties in patient-led implementation of informed choice, for example with freedom from the control of methadone prescription, may suffer a less aggressive course of the illness and on a practical front frequently have abrupt changes in residence and fail to attend specialist referrals. It has been argued that screening promotes identification of asymptomatic young benefiting most from treatment, with interferon-alpha therapy yielding net saving through delaying the onset of cirrhosis. [3] Counseling may reduce further transmission and allow more informed choice regarding detrimental lifestyles and habits. A consequentialistic approach may be determined by the societal benefits of screening in terms of decreasing disease incidence or progression. However, health education programmes and wider introduction of needle exchange schemes may prove more cost-effective than screening in preventing spread. [4] Furthermore, current recommendations are for treatment of moderate or advanced biopsy cases despite evidence for earlier treatment, while even combination therapy with tribavirin is of limited effectiveness with possible subsequent virological relapse and any therapy is contraindicated with ongoing injecting drug abuse. [2] Asymptomatic carriers have morbidity related to liver biopsies and interferon-alpha, while a positive hepatitis C result raises personal, familial and societal concerns with limited knowledge about the disease restricting relevant counseling, all of which may be fruitless with ineffective therapy. The benefits of screening, therefore, are obscured by capricious treatment and limited knowledge on hepatitis C while the costs of screening may be better channelled into other preventative and developmental strategies. Alternatives are to test those more likely to comply with or respond to therapy, the latter being determined cost- effectively (e.g. abdominal ultrasound [5]). There is a need for evidence on the benefits of such proactive testing on selected IVDU and the more stable non-injectors. Faisal F. Syed 4th year medical student University of Manchester, Manchester M13 9PT faisalfsyed@yahoo.com 1. Ryder SD, Beckingham IJ. Chronic viral hepatitis. BMJ 2001;322:219 -221. 2. Leal P, Stein P. Screening for hepatitis C in intravenous drug users and genito-urinary clinic attenders. The Wessex Institute for Health Research and Development, DEC Report 81, March 1998. http://www.epi.bris.ac.uk/rd. 3. Seymour CA. Controversies in management: screening asymptomatic people at high risk for hepatitis C. BMJ 1996;312:1347-1348. 4. Allison MC. Controversies in management: screening asymptomatic people at high risk for hepatitis C: the case against. BMJ 1996;312:1349- 1350. 5. Wedemeyer H, Ockenga J, Frank H, Tillman HL, Schuler A, Caselitz M, Gebel M, Trautwein C, Manns MP. Perihepatic lymphadenopathy: a marker of response to interferon alpha in chronic hepatitis C. Hepatogastroenterology 1998;45:1062-1068.
Hepatitis B, Lamivudine and HIV 9 March 2001
Usha Kuchimanchi, Specialist Registrar and Consultant Physician Genitourinary Medicine, Oxford and Genitourinary Medicine, Swindon, Guy Rooney Send response to journal: Re: Hepatitis B, Lamivudine and HIV	We write in response to the clinical review by Ryder SD et al on chronic viral hepatitis (1). We agree with them that lamivudine has a good safety profile, and has been shown to be beneficial for patients requiring treatment for hepatitis B infection. However, lamivudine is also a common agent used in the management of HIV infection. HIV and hepatitis B share similar risk factors for acquisition: intravenous drug use, sexual and vertical transmission. Therefore a significant proportion of patients are likely to be co-infected (2). In order to maximise efficacy and reduce the risk of the development of resistant virus, current guidelines recommend the use of at least 3 antiretrovirals in the management of HIV infection (3). If used in isolation, lamivudine leads to a rapid multiplication of resistant virus due to a mutation at position 184 in the reverse transcriptase gene, and potentially decreases future combination therapies available for that individual (4). We therefore feel that it is extremely important in the management of hepatitis B infection to consider and/or offer an HIV test, prior to commencing treatment with lamivudine. References: 1. Ryder SD, Beckingham IJ: ABC of diseases of the liver, pancreas, and the biliary system: Chronic viral hepatitis. BMJ, 2001 Jan, 322:219-221. 2. Pallas JR et al: Coinfections by HIV, hepatitis B and hepatitis C in imprisoned intravenous drug users. Eur J Epidemiol 1999 Sep; 15(8): 699-704. 3. Gazzard B, Moyle G on behalf of the BHIVA Guidelines Writing Committee: 1998 revision to the British HIV Association guidelines for antiretroviral treatment of HIV seropositive individuals. Lancet 1998 Jul 25; 352(9124): 314-6. 4. Frost SD et al: Evolution of lamivudine resistance in human immunodeficiency virus type 1-infected individuals: the relative roles of drift and selection. J Virol 2000 Jul;74(14):6262-8. Usha Kuchimanchi Specialist Registrar Oxford Genitourinary Medicine, Radcliffe Infirmary, Oxford. Guy Rooney Consultant Physician, Department of Genitourinary Medicine, Princess Margaret Hospital, Swindon.