CHARLESTON, W.Va. — The nation's opioid epidemic has unleashed a secondary outbreak: the rampant spread of hepatitis C.
New cases of the liver disease have nearly tripled nationwide in just a few years, driven largely by the use of needles among drug users in their 20s and 30s, spawning a new generation of hepatitis C patients. Because a treatment that cures the disease costs tens of thousands of dollars, is limited by insurance and Medicaid, and is mostly unavailable to people who are still using illicit drugs, there probably will be financial and public health ramifications for decades to come.
Here in West Virginia, which has the nation's highest rates of overdose deaths and new hepatitis C and hepatitis B infections, public-health officials are attempting to identify as many new hepatitis carriers as possible — and are girding for decades of repercussions.
"If we don't cure a significant number of the people who are injecting, in 20 years from now, the hospitals in this part of the world will be flooded with these people with end-stage liver disease, which has no cure," said Judith Feinberg, a professor of behavioral medicine and psychiatry at the West Virginia University School of Medicine. "I can see it coming at me like the headlights of a train. Just coming, coming, coming, and I'm thinking, 'Doesn't anybody want to jump out of the way?'"
The number of new confirmed hepatitis C cases nationwide rose from 853 in 2010 to 2,436 in 2015, according to the Centers for Disease Control — a 15-year high. But tens of thousands more are believed to have contracted the disease without knowing it.
According to the CDC, 34,000 people were estimated to have contracted hepatitis C in 2015, a number public health officials believe is low. In Massachusetts, officials estimate 300,000 people have the disease — and just half have received a formal diagnosis. Testing for the disease is not widespread, and because it's possible to not display any symptoms, hepatitis C often goes undetected for decades until manifesting in severe, life-threatening liver disease.
"It's the unidentified that scare me," said Rahul Gupta, West Virginia's health commissioner. "What I'm afraid of is that there are people out there not in the medical health care system and they're spreading the disease."
Across the nation, health providers are seeing a cascade of public-health consequences unleashed by the opioid epidemic beyond the significant rise of overdoses: increases in hepatitis B; sexually transmitted diseases including syphilis and gonorrhea; elevated rates of endocarditis, an infection of the heart seen in people who inject drugs; higher rates of emergency room visits for abscesses; and hospitalizations for soft-tissue infections — some that become so severe they require amputations.
Some places are seeing small increases in HIV, and there is a widespread fear that an outbreak like the one in Austin, Ind., where nearly 200 drug users contracted the disease in 2014 and 2015 because of sharing needles, could happen again.
Part of the solution, public health officials believe, is what happened in the wake of Austin: opening syringe exchanges so users can access clean needles. Long controversial, syringe exchanges are becoming more broadly accepted in the wake of the opioid epidemic. In Kentucky, 20 have opened since the state legislature approved them in 2015. In North Carolina, at least 25 have opened since they were legalized last year.
Hepatitis C was once associated with baby boomers — who contracted the disease before the nation's blood supply was screened for it starting in the early 1990s — and with urban drug users. About 3.5 million people nationwide have hepatitis C, three-quarters of them baby boomers. Nearly 20,000 people died of the disease in 2015, the majority of them over the age of 55.
Now, new carriers tend to be young people who use intravenous drugs. Health providers in an array of locations, from rural Tennessee to suburban Boston to Baltimore, are reporting increases in hepatitis C diagnoses.
In West Virginia, the number of new hepatitis C cases is nine times the national average, and Medicaid costs for treating the disease amounted to more than $27 million from 2014 to 2016.
Gupta said West Virginia is seeing major increases in syphilis and gonorrhea cases, which he believes are due to drug use.
"You can have direct consequences of needle injection . . . and consequences of impaired judgment," Gupta said.
West Virginia has aggressively tried to track hepatitis B and C cases, expanding testing at the state's syringe exchanges, jails and prisons. Gupta said one reason the number of hepatitis cases here is so high is probably due to the fact that the state is aggressively seeking them out.
Thousands of people each year stream into West Virginia Health Right's free clinic for clean needles, medication and, staffers hope, a hepatitis C test.
About half of the clinic's clients have hepatitis C, chief executive Angie Settle said, discovered through a rapid-results test the clinic offers. The clinic, which sends mobile dental units around the state to offer free dental care, has started sending staff along to test people for hepatitis C.
William Turley was high when he let his friend plunge her used heroin-filled needle into a vein running through his left hand. When they sobered up, she told him she had hepatitis C. He got tested here and it came back positive. He was in such disbelief he asked for a second test, which confirmed the result.
"I never thought that I would catch it," said Turley, 49. Very few drug users talk about the disease, he said. "You hear about AIDS. You never hear about hepatitis C."
Turley said he is focused on getting sober so he can be cured. West Virginia Health Right is one of the few places that gives patients the drugs that will help without cost — but treatment does come with conditions.
Drug companies require patients to be sober to access the medication, Settle said. And many states, including West Virginia, require Medicaid patients to have an advanced form of the disease and be sober before approving treatment. A six-month course of the drugs used to cure hepatitis C can cost upward of $100,000. In Louisiana, Health Secretary Rebekah Gee is considering asking the federal government to intervene to cut the price.
"A lot of the state Medicaid treatment restricts access," said Laura Fanucchi, an assistant professor at University of Kentucky HealthCare. "A lot of physicians don't think that's the best approach because it limits access to the most vulnerable populations."
Hepatitis C is particularly worrisome because it is 10 times more contagious than HIV. While HIV can be spread by sharing needles, hepatitis C can be contracted at any point during the injection process, including by using a drug cooker or tourniquet that has another person's blood on it, said Shruti Mehta, deputy chair of the department of epidemiology at the Johns Hopkins Bloomberg School of Public Health. The disease also is spread through sexual contact, though the rate of transmission is not as high as blood-to-blood contact.
Mehta said hepatitis C rates also are spiking among inner-city drug users. She studies a cohort of about 5,000 injection drug users, and about 60 percent of them have contracted hepatitis C.
"It's a disease of long-term consequences that people don't understand," she said.
Officials are increasingly concerned that some of those consequences could manifest themselves for decades. The prevalence of hepatitis C among women who gave birth from 2009 to 2014 increased 89 percent, according to a study by Vanderbilt University and the Tennessee Department of Health. West Virginia has the highest rate of births to infected mothers, with 22.6 per 1,000 live births. The disease can be passed to an infant during birth, and about 6 percent of babies born to infected mothers contract the disease.
Stephen Patrick, an assistant professor of pediatrics and health policy at Vanderbilt University School of Medicine and a co-author of the study, said there is no treatment for the disease during pregnancy and that babies cannot be tested for hepatitis C until they are 18 months old. Only about 16 percent of infants receive follow-up testing, he said. Hepatitis C is also not a routine test administered to pregnant women.
Soon after finding out she was pregnant, Sarah Farrugia went to the doctor, who drew blood and diagnosed her with the disease.
Farrugia, 27, of Maine, had injected heroin for about five years. She stopped using drugs after meeting the man who is now her husband and got pregnant a few months later.
She was shocked but not surprised because of her past drug use. She was glad to know that there is a cure.
"But of course there's the other layer of it: What does this mean for my child?" she asked.
Farrugia gave birth to a healthy baby boy and nursed him for a year, even though doctors warned the baby had a small chance of contracting the disease through breast milk.
Farrugia planned to start the drugs used to cure hepatitis C when she was done nursing her son, but she became pregnant again. Her son tested negative for hepatitis C. She will have her daughter, who will turn 1 in December, tested when she is 18 months old. Farrugia wants to start the drug regimen when she is done nursing, noting that her viral load is low and that she feels good about her prognosis.
She believes that drug use needs to be less stigmatized and that people need to start talking more about hepatitis.
"When I would be worried about using someone else's needles, it was because I didn't want to contract HIV or AIDS," she said. "I didn't think about other things."