Hepatitis C and Diving

[blueplanetdiver]

The fall 2017 edition of Alert Diver contains a potentially misleading article on hep c and diving that included insights from Robert Gish. That article replaced an article submitted to DAN that I cowrote with Dr. Gish (an internationally recognized expert on hepatitis). With Dr. Gish's permission, and in hopes of dissipating confusion, here is the previously unpublished piece.

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A ScubaBoard Staff Message...

Text of the article has been removed at the request of the OP and author. The gist of the article is that Hep C is very difficult to transmit in a way that endangers divers and that the disease is often contracted in ways that have nothing to do with drug use and other common “bad” behaviours.

The article will be linked here once it is published.

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[iamrushman]

read and noted....thanks for sharing this important information.

 

[blueplanetdiver]

read and noted....thanks for sharing this important information.

You are very welcome. The Alert Diver article sows FUD and is very disappointing.

 

[blueplanetdiver]

FUD = Fear, Uncertainty, Doubt

 

[drrich2]

and, much more rarely, through sex with an HCV-infected person or

Any thoughts on just what the risk is for transmission via unprotected sexual intercourse? I imagine it's higher when the woman is at risk to contract it from the man, given the degree of fluid exchange. I ask since I was aware sexual transmission was possible, but had not heard it described as rare.

Richard.

 

[JohnN]

Any thoughts on just what the risk is for transmission via unprotected sexual intercourse? I imagine it's higher when the woman is at risk to contract it from the man, given the degree of fluid exchange. I ask since I was aware sexual transmission was possible, but had not heard it described as rare.

Richard.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4659344/

To obtain more quantitative information on sexual transmission risk for the most common sexual partnerships among infected persons, the HCV Partners Study studied monogamous, heterosexual couples in long-term relationships (≥36 months), without confounding exposures such as viral coinfection (HIV or HBV) or both partners having a history of injection drug use (Osmond et al., 2013). Among 500 couples and 8377 person-years of sexual contact, the HCV Partners Study found a low prevalence of HCV infection among partners, with a maximum of 1.2% (95% CI: 0.2%–2.2%) of infections potentially attributable to sexual contact. The maximal incidence of HCV infection was 7.2 per 10,000 person-years (95% CI: 1.3–13.0), and maximal risk per sexual contact was 1 per 380,000 (95% CI: 1/600,000–1/280,000).

 

[drrich2]

Thanks; good to know. Another bit (bold emphasis mine) from the article you linked addresses a follow-up question:

"The frequency and type of sexual contact and protective barrier use were quantified within each interval, allowing us to calculate monthly contact rates by sexual practice throughout the relationship. For vaginal intercourse, couples reported a median of 12 contacts per month, with 83% of couples not reporting frequent condom use. After adjusting for condom use, couples reported >1 million sexual contacts (vaginal and anal), of which 35,000 were vaginal during menses and 8000 anal intercourse."

So, even without condoms (which I don't think health care professionals would generally condone), the transmission rate was surprisingly low.

A lot of Hepatitis C is seen in mental health care patient populations from what I've seen in my workplace; I'm surprised it's as prevalent as it appears to be, in light of the relative rarity of sexual transmission. Of course, methamphetamine has become very prevalent in some areas over the years, and I.V. administration is one of the ways some use it, so needle sharing becomes a concern. I've also heard heroin has made a comeback in recent years.

Oh, another thing from the original post:

And if you test positive for HCV, you can be cured in 8-12 weeks; you can continue to safely dive; and there is no possibility of casually passing your disease on to anyone.

I remember when notice of new treatments able to eradicate Hep. C (at least in some, and a major medical advance) came out; costs were enormous, with some concerned it would either be effectively unavailable to many patients, or an enormous burden on the system. I read of 80 or 90 grand to treat one person.

Wonder what a course of such treatment is running these days, and how commonly health insurance covers it?

Richard.

P.S.: Clean living can cut your risk considerably... Not everyone gets it through illegal and/or immoral activity, but many do. At least now there's better treatment.

 

[drrich2]

Before we take this off into debating value systems/religious views (a move I did not initiate), it's worth being mindful the original post wasn't looking to go in that direction. God was referenced in a belittling fashion; I pointed out that in many cases it is the risky actions of humans that brings the problem.

That said, obviously some people get Hepatitis C in ways they could not have reasonably been expected to prevent. A surgeon or surgical assistant in an operation on a patient with Hep. C gets a needle stick, an infant contracts it from the mother, your sexual partner lied about their sexual history, etc... But what % of cases do such scenarios account for? Since most people don't work in health care, the risk of work-related needle sticks or scalpel cuts seems low for them.

My point is, abstain from needle sharing and risky sexual activity (e.g.: prostitutes, known partners with multiple partners themselves - although the article paints that as less risky than I'd thought), and you can substantially reduce your risk. That's not self-righteous; these options in the context of free will are open to all.

None of this means someone with Hep. C. should be presumed to be a needle-sharing illegal drug user, etc... But if you do that, your risk goes way up.

Richard.

 

[Duke Dive Medicine]

The fall 2017 edition of Alert Diver contains a potentially misleading article on hep c and diving that included insights from Robert Gish. That article replaced an article submitted to DAN that I cowrote with Dr. Gish (an internationally recognized expert on hepatitis). With Dr. Gish's permission, and in hopes of dissipating confusion, here is the previously unpublished piece.

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Diving and Hepatitis C: Know the Facts
Robert Gish MD and C. L. Kutz

You’ve probably seen the television ads aimed at baby boomers. They warn you of your chances of having hepatitis C while advertising drugs that will cure it in 8-12 weeks. You may in fact know you are infected, or a dive buddy may have told you that they have it, confidentially. Confidentially, because there is a lot of shame and discrimination surrounding this disease. Also, from a provider perspective, there is HIPAA, which provides privacy around all health care issues.

As a diver and DAN reader, you should know the facts about chronic infection with hepatitis C virus (HCV), and whether it affects your diving lifestyle.

According to a recently released (Jan. 2017) Viral Hepatitis Action Plan prepared by the Office of HIV/AIDS and Infectious Disease Policy (OHAIDP), Office of the Assistant Secretary for Health, and other U.S. health agencies, “an estimated 4.4 million Americans from all walks of life are living with chronic viral hepatitis infection and are at increased risk for liver disease, liver cancer, and death. In 2012, hepatitis C-related deaths surpassed deaths from all other reportable infectious diseases combined and continued to rise in 2013 and 2014, killing more Americans each year.” The Centers for Disease Control and Prevention (CDC) estimates that 75 percent of U.S. citizens infected with hepatitis C are baby boomers, many of whom don’t know they have it because the disease can be asymptomatic for decades. Thus the CDC recommends that all persons born from 1945 through 1965 should be tested. Others who should be tested include people with elevated liver tests, persons who have ever injected illegal drugs (even if it was just once many years ago), recipients of blood transfusions or solid organ transplants prior to July 1992, recipients of clotting factor concentrates made before 1987, anyone who has had blood exposure via sharps, health care workers who have been stuck by a needle contaminated with HCV-positive blood, all persons with HIV infection, and anyone born to an HCV-positive mother. (Further guidelines are at HCV FAQs for Health Professionals | Division of Viral Hepatitis | CDC)

Although knowing that millions of people have hepatitis C and the majority don’t know it is frightening, it is imperative that you understand that hepatitis C is NOT casually transmitted. Transmission can occur through blood-to-blood contact via contaminated blood products, needle sharing, medical sharp devices, tattooing, and, much more rarely, through sex with an HCV-infected person or from mother to child. The current medical literature does not indicate transmission in any other manner.

A person with hepatitis C is under no obligation to tell a friend or dive buddy that they have hepatitis C. In fact this type of health care information is protected by HIPAA. The current drugs prescribed for the cure pose no adverse affects specific to a diver. And so unlikely is casual transmission of hepatitis C that the “CDC's recommendations for prevention and control of HCV infection specify that persons should not be excluded from work, school, play, child care, or other settings on the basis of their HCV infection status. There is no evidence of HCV transmission from food handlers, teachers, or other service providers in the absence of blood-to-blood contact.”- From HCV FAQs for Health Professionals | Division of Viral Hepatitis | CDC. This expert, Dr Gish, believes this applies directly to HCV and diving medicine.

Shared equipment environments such as dive shops, aquarium dive programs, and university dive programs pose no disease transmission risk to divers. Furthermore, bleach solutions are often used to sanitize equipment; bleach kills HCV. HCV requires directly blood to blood exposure to pose any risk of transmission.

So let’s look at an unlikely scenario: You have to practice using alternate air sources with someone with cracked, bleeding lips who also happens to have hepatitis C (he doesn’t know). Assuming he unwisely gets in a pool while actively bleeding from a wound, you are in no danger of becoming infected by HCV by either being in the pool with him or from sharing air via an octo. There is no blood-to-blood contact occurring, and furthermore, the virus will not survive for any significant time in salt or chlorinated water.

Sadly, factual awareness of hepatitis C is low among the general public and medical professionals. As a result, there is fear, stigma, and discrimination surrounding this disease, preventing many people from getting tested and linked to care, and also obtaining proper advice.

This shouldn’t be the case. If you are a baby boomer or have the other indications mentioned here, get tested. And if you test positive for HCV, you can be cured in 8-12 weeks; you can continue to safely dive; and there is no possibility of casually passing your disease on to anyone.

Also keep in mind that several federal laws protect people with viral hepatitis, including the Americans with Disabilities Act (ADA).

There is a plethora of online information available by searching for “CDC” and “hepatitis C”. You can also improve your understanding by taking a free online course about hepatitis C at Robert G. Gish Consultants, LLC

Thank you for this. There is some misinformation out there about Hep C and it's nice to see myth-busting like this.

I'd like to offer a couple of additional thoughts. First, though the reported side effects of ledipasvir/sofosbuvir (the most recent therapy that Richard referred to) appear to be minor and there are few reported drug-to-drug interactions, it might be better said that there are no known adverse effects on divers as the drugs have not been specifically tested in this area.

Second, HCV transmission has been associated with sharing personal items such as toothbrushes and there are rare incidences of seroconversion after exposure of mucous membranes to blood (ref: https://www.ncbi.nlm.nih.gov/pubmed/29097105; Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis), so although the risk of contracting HCV from sharing a regulator with an HCV-infected individual is extremely low, there is evidence to suggest that the risk is not zero.

Best regards,
DDM

 

[blueplanetdiver]

Thanks for pointing this out. Buddy breathing is definitely a controversial topic. Probably best to not even engage in it!

See this article by Buddy Breathing: Is it Time for Change? | Scuba Diving News + Gear + Resources // Dive Training Magazine
and in particular, this paragraph:
It’s one of the few techniques in which the incompetence of one diver can actually threaten the life of another. More than once, poor buddy breathing performance has resulted in two victims. In formulating my opinion on the matter, I have been influenced most by what I believe is simple common sense and experience. In the absence of true objective, scientific inquiry into out-of-air emergency responses, there really are no other guidelines to aid us in making a decision. Based on my assessment of the issue, I have concluded that buddy breathing – the practice of sharing a single regulator among two divers – should be abandoned as an emergency procedure for recreational scuba divers. Alternate air source use should be adopted as the only method of sharing air in an emergency.