July 7, 2006 For nearly four years, a researcher in Washington, D.C., has been working toward tracking how servicemembers respond to treatment for the "silent disease" hepatitis C.
Dr. Maria Sjogren, a retired Army colonel and hepatologist, which is a doctor who specializes in treating liver disease, has enrolled 90 active-duty servicemembers in her study at the Walter Reed Army Medical Center. The virus, which affects the U.S. military at similar rates as the civilian population, causes tiny scars to form in the liver and can prevent blood from flowing freely through the liver. The disease has earned its silent reputation because 80 percent of the people who have it have no symptoms.
While working at her clinic at the military hospital, Sjogren noted that at least half of her patients tested positive for the hepatitis C virus. She then started wondering about how servicemembers were faring with treatments and how the disease affected the quality of their lives. From the start, Sjogren wanted to answer specific questions for servicemembers who have Hepatitis C: What happens to these people over time? How does it affect their quality of life? What happens when you treat them?
"We just don't know what the impact of hepatitis C is. The rate of hepatitis C has been studied in the military but not the outcomes," she said. "Nobody has talked to them as a research population ... and captured the story the way we do."
Sjogren's research endeavors were funded by a grant from the DoD's Peer Reviewed Medical Research Program. Congress created the program in 1999 to promote research in health issues the military faces. Since its inception through 2005, the program has spent almost $300 million to fund nearly 200 projects in a range of medical topics, including combat casualty care and technology and infectious disease research like Sjogren's.
Once members from any of the military services were diagnosed as positive for the hepatitis C virus, their doctors told them about Sjogren's study so they could learn more about joining it. If they decided to participate, Sjogren's team performed a liver biopsy, if one hadn't already been done, to see how advanced the disease was. At the end of four years, a second biopsy was taken.
"It's the only way to establish the progression of the disease," Sjogren said.
Her patients, ranging in age from 18 to the upper 50s, mostly come from the Northeast because of its proximity to Walter Reed. Thirty percent of the study volunteers had minimal liver disease, Sjogren said. Of the 70 percent with more advanced liver disease, 15 to 20 percent had cirrhosis, a condition in which scar tissue replaces healthy tissue, blocking the flow of blood through the organ and preventing it from working as it should. Cirrhosis is the twelfth leading cause of death by disease, killing about 26,000 people each year, according to The National Digestive Diseases Information Clearinghouse Web site.
Sjogren's clinic provided treatment to "just about everybody unless they have very minimal disease or liver damage," she said. "We may not offer them treatment because chances are that person's disease may not progress."
The standard treatment--24 to 48 weeks of a once-a-week injection with interferon and several pills of ribavirin each day--are what Sjogren speculated would cause a decrease in quality of the volunteers' lives. "The medications are tough to take," she said.
On initial questionnaires, study volunteers reported that they were depressed; anxious about their health, families, and careers; and having trouble sleeping. Once treatment began, however, they reported that their quality of life had improved.
"We've been very surprised. When we asked the patients why (they felt better), they said, 'I'm doing something for my infection,'" Sjogren said.
Another factor that may have calmed study volunteers is the patient education Sjogren's staff offers. "Sometimes they don't fully understand hepatitis C, and the patients are very anxious. They think they have HIV or something that's going to kill them overnight," she said. "We like to talk to the patient and put them at ease, and say 'Look this is the story, let's work together.'"
Having the disease doesn't end a military career. Military members who have it can still deploy, though not while they're undergoing treatment because it's so intensive. "When we have patients in treatment we've asked for deployment delays," she said. "To date they have not denied us once."
According to a 1999 Defense Department report to Congress, military personnel today are at a lower risk of hepatitis C infection because of the screening that's done before they enter the military and while they're serving. Routine, random drug screening is also believed to keep rates lower than the civilian population.
One offshoot of Sjogren's research has been discovering how military members contracted the virus. Hepatitis C is typically transmitted through IV drug use and blood transfusions that were given before 1990 because a good screening tool wasn't available prior to then. The servicemembers Sjogren treats most often report that they contracted it through blood products because they were transfused at an earlier time or because they used IV drugs before they joined the military. Her patients have also listed skin piercings or tattoos as the possible source of their infection.
"Military people (46 percent) have more tattoos than civilian population, but the link between tattoos and HCV (hepatitis C virus), although it exists theoretically, has not been proven," she said. Currently no data exist in the United States indicating that people who have had tattoos are at increased risk for hepatitis C infection; however, the Centers for Disease Control and Prevention is currently conducting a large study to evaluate tattooing as a potential risk, according to its Web site. Of the 90 volunteers enrolled, six have completed the study and 74 are still active. Ten volunteers either dropped out of the study or died.
"We are marching toward the end (of the study), and we have about a year and a half until we see the last of the visits," Sjogren said, adding that she's been pleased with the results so far. "We had a spectacular treatment success with this group of people, about 70 percent. I'd like to know why we had such success because nobody has these rates of success."
For more information on the DoD's Peer Reviewed Medical Research Program, go to http://cdmrp.army.mil.
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