UNRAVELING MYSTERY OF HEPATITIS C; `SILENT VIRUS' DANGEROUS - BUT NOT HOPELESS.

Byline: Susan Ferraro New York Daily News 

Exciting new therapies and breakthroughs in basic research are bringing hope to patients with hepatitis C, the ``silent virus'' that can derail lives and that leads to death for 8,000 to 10,000 Americans each year.

Although there is no vaccine to combat this quirky and unnerving disease, researchers and doctors are more hopeful than they used to be about treatment. ``We tend to be optimistic,'' says Dr. Ira Jacobson, top liver specialist at New York Presbyterian Hospital/Cornell Medical Center.

``I am hesitant to use the word `cure' in talking about the virus, since viruses have means of hiding out in certain cells of the body, but we really are starting to think that, in patients with prolonged remissions, they may truly be cured.''

It's about time. Identified just 10 years ago, hepatitis C, or HCV, has been with us for many decades, scientists say. Although 15 percent to 25 percent of HCV infections disappear on their own, at least 75 percent of cases become chronic. Today, more than 4 million Americans have the disease - and most are unaware of it.

According to the Centers for Disease Control, about a third of all carriers have no symptoms - ever: HCV can live quietly in the body many years.

``In many instances, it's a silent disease'' until fatigue or liver failure send patients to the doctor, said Dr. Tse-Ling Fong, hepatologist (liver specialist) at Cedars-Sinai Medical Center in Los Angeles.

Like doctors all over the country, Fong said he's seeing more cases of hepatitis C now than he saw 10 years ago. Experts predict that, as the population ages, HCV deaths will triple in 10 to 20 years.

For reasons that remain unclear, most chronic carriers don't become ill until 10, 20 even 40 years after infection. Some 10 percent to 20 percent develop cirrhosis, about 1 percent to 5 percent, liver cancer. Most at risk are men who are drinkers and are over 40 when infected, possibly because of subtle changes in the aging immune system.

For example, Mickey Mantle, who died after a liver transplant for cancer, had HCV. But HCV ``is not a death sentence,'' says Jacobson, although it can scar the liver and do irreparable damage.

The new medical approaches - combination drug treatments and the identification of key viral proteins that, in turn, will lead to even better drugs - promise progress in the battle against HCV. Also, a quiet but significant federal endorsement of support groups signals a new recognition of the tremendous stress that the disease can inflict on its victims.

Like HIV, the AIDS virus, HCV is blood-borne. But it is much more contagious. People who once partied in ways they might not want to explain to their kids today are at risk if they injected drugs or snorted them through a straw even once, experts say. Health workers run an increased risk because of accidental needle sticks.

Blood transfusions before 1992, when researchers developed very good HCV screening methods, sometimes transmitted HCV. The blood supply is safe now, said Dr. Michael Kanter, pathologist and director of the blood bank at Kaiser Permanente Medical Center in Woodland Hills.

``Today, hepatitis C is very, very rare to be transmitted by blood,'' Kanter said. ``One in 200 units in the mid-80s would transmit the disease. Calculated estimates would put it at 1 in 100,000 today. It's been a remarkable decrease over a relatively short period of time.''

Unlike with HIV, intimate sexual contact is not a likely mode of HCV transmission, although it may be possible, experts say. Tattooing and body piercing with unclean equipment are possible but, again, unproven sources of infection. Approximately 10 percent of HCV cases are of unidentified cause.

``Hepatitis C is a democratic disease - it affects everyone, all races, men and women and children,'' says Alan Brownstein, head of the American Liver Foundation in New York. ``It mirrors mainstream America - doctors, lawyers, teachers - not just health workers and illegal drug users.''

In 1974, Dr. Alfred Prince at the New York Blood Center was one of the first to realize that there was a different kind of hepatitis loose. (Not knowing exactly what it was, scientists initially called it ``non-A, non-B hepatitis.'') From the beginning it has been tough to treat.

For end-stage disease, there are liver transplants: HCV is the leading reason for that surgery in the United States. But transplants - for the lucky few who get them - are no sure cure. ``It's a new start, with a liver that is not infected, but the viral disease is more aggressive in immune-suppressed patients after a transplant,'' says Dr. Teresa Wright at the Veterans Affairs Medical Center in San Francisco. ``You don't get another 30 or 40 years.''

In the 1980s, doctors made some progress in the fight against HCV with interferon - a natural protein given by injection that boosts the immune system by blocking the virus as it reproduces. But side effects vary from inconvenient to devastating, and some patients won't - or can't - endure the treatment.

By itself, interferon helps only 10 percent to 15 percent of patients, say experts - crushing news to those who have weathered the side effects. Giving it for a year instead of six months delivers better long-term results, clinicians discovered in the early 1990s, but they needed something more.

Last December, the Food and Drug Administration approved the use of ribavirin, another sophisticated anti-viral drug, in combination with interferon. Together the two drugs increase sustained remissions almost threefold - 38 percent of patients taking the combo therapy for a year had very good results, compared with 13 percent for those on interferon alone, Jacobson says.

Also, lab scientists working with HCV have ``identified the viral proteins, elucidated their structures, and are trying to develop prototype drugs,'' Jacobson says, to kill the virus by inhibiting its proteins.

Dr. Michael Lai, a molecular virologist at the University of Southern California, spends his days trying to solve the mystery behind the virus's resistance to interferon therapy.

``By developing potential targets for anti-viral agents, hopefully we can develop more drugs that can lead to a cure for hepatitis C,'' Lai said.

It doesn't hurt, he added, that more researchers are studying HCV now and government funding is increasing as public awareness of the disease spreads.

``Compared to two, three years ago, the pace of progress is much, much faster,'' Lai said.

Ultimately, what will work best, and in which combinations, remains unclear, but scientists also are working with different forms of interferon, as well as exploring the possibility of treating the virus on a molecular level. Researchers now calculate patients' viral loads, too, which helps doctors chart their responses to the drugs.

And they have identified six genotypes, or strains, of HCV. Though the one that infects 70 percent of U.S. patients is also the most resistant to drug therapy, Jacobson says, there is ``a feeling now that we may be able to start custom-designing our therapy, based on (these) virologic parameters.''

That doesn't make it easy. Jacobson says treating HCV patients is ``labor-intensive,'' because patients are so individual in their response to both virus and treatments. ``This is not a matter of giving a prescription for penicillin and patting patients on the back,'' he says. ``Treatments must be individualized, all various factors considered - if they have symptoms, how long they have had the disease, what the liver biopsy looks like. All factors must be taken into consideration, and all patients deserve a detailed evaluation and consultation.''

Given the wildly different realities of the disease, the Centers for Disease Control - in an unusual move - now recommends that new HCV patients consider joining a support group. Doctors, hospitals and HCV organizations often provide contacts or assist in forming groups.

``Only a small fraction of people who are infected are going to develop serious, life-threatening disease,'' says Dr. Celso Bianco of the New York Blood Center. ``But people who are infected don't know which way they are going to go, and this is very anxiety-producing.''

- Daily News Staff Writers Betty Kwong and Carol Bidwell contributed to this story.

Understanding the strains of hepatitis

Hepatitis is inflammation of the liver. In addition to hepatitis C, there are four other known strains:

A is caused by a virus in tainted food (or, rarely, a medicine that disagrees with a body that causes a ``toxic'' hepatitis reaction that is not viral).

B can be chronic.

D is a co-infection with B.

E can cause A-like epidemics in underdeveloped countries.

Hepatitis C symptoms: None, or they can develop decades after infection. Often, symptoms resemble the flu - loss of appetite, nausea, vomiting, fever, extreme fatigue, weakness. There may be abdominal pain.

- New York Daily News

Blood primary mode of transmission

Hepatitis C is not spread by everyday social contact such as touching, sneezing and coughing, closed-mouth kissing, holding a child, or sharing a bathroom or meal. Unlike HIV, unsafe sex is not considered a likely form of transmission.

But because the hepatitis C virus is in the blood of infected persons and is highly contagious, the American Liver Foundation and other experts warn against using something that may have someone else's blood on it - for example, razors, nail clippers or scissors; toothbrushes or Water Piks; tattoo needles; body-piercing implements; and IV drug needles.

- New York Daily News

Where to obtain information on HVC 

Many organizations provide help and information on hepatitis C. Here are a few:

American Liver Foundation, or ALF, funds research, does advocacy at the federal level, publishes newsletters, and has a patient resource list for doctors and support groups. Call toll-free at [phone] or [phone]. Or try its Web site at http://www.liverfoundation.org/

Latino Organization for Liver Awareness provides bilingual educational support. Call toll-free at [phone].

American Digestive Health Foundation publishes HEAL (Hepatitis Education & Advocacy for Life) with ALF. Call [phone]. Or, try the Web site at http://www.gastro.org/adhf.html

Hepatitis Foundation International, [phone].

Centers for Disease Control, [phone].

- New York Daily News

CAPTION(S):

2 Photos, 4 Boxes

Photo: (1--Cover--Color) Computer graphic representation of the hepatitis C virus courtesy of Amgen Inc.

Courtesy of Amgen Inc.

(2) no caption (Blood)

Box: (1) HEPATITIS C

Knight Ridder Tribune

(2) Understanding the strains of hepatitis (See text)

(3) Blood primary mode of transmission (See text)

(4) Where to obtain information on HVC (See text)