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Why hepatitis C is getting younger

"This is a one-month supply," said Jameson Danielson, who works at the Rural AIDS Action Network in Duluth. He's referring to the boxes of syringes given out free to drug users in the area to help prevent the spread of Hepatitis C from unclean needles and practices. Bob King / rking@duluthnews.com1 / 5
Clients who stop by the Rural AIDS Action Network at 18 W. First St. are given a kit that includes a 10-pack of syringes, small cotton balls for filtering their drug, a tourniquet (blue band), a tube of sterile water for mixing the drug, a cooker for cooking the drug and an alcohol pad. Bob King / rking@duluthnews.com2 / 5
A sharps container is available for clients to dispose of used needles and other drug-related paraphernalia. Bob King / 3 / 5
Jameson Danielson, who works for the Rural AIDS Action Network, displays the clean syringes given out to drug users. Bob King / rking@duluthnews.com4 / 5
With the widespread use of fentanyl cut into more traditional drugs, drug users can get free fentanyl test strips to find out if their drugs contain fentanyl. Bob King / rking@duluthnews.com5 / 5

The two women showed up at the Rural AIDS Action Network office in downtown Duluth, one providing moral support for the other.

Both were in their 20s, executive director Mary McCarthy said. The woman who hadn't been feeling well was encouraged by her friend to take advantage of free, confidential testing at the office for hepatitis C. To help assuage her friend's fears, the other woman agreed to be tested, too.

Both tested positive.

"That was challenging for staff because they were in their 20s, and they knew it was going to have a longer-term impact," McCarthy said.

It's becoming an increasingly plausible scenario, according to those tracking the potentially dangerous liver disease that's spread from human to human through blood.

"Initially it was more middle-aged people that had been exposed from blood transfusions and maybe service-related," said Sherry Johnson, a nurse practitioner with St. Luke's Infectious Disease Associates. "And now I would say that maybe 25 percent of the people I see are middle-aged and older, and otherwise they're younger."

Sherry JohnsonHepatitis C long has been the province of baby boomers, so much so that the U.S. Centers for Disease Control and Prevention recommends everyone born from 1945 to 1965 be tested for the virus. It's prevalent in that age range because that generation was young at a time when there was less awareness of the dangers of blood-borne pathogens, said Genny Grilli, an epidemiologist for the Minnesota Department of Health. Before 1992, hepatitis C was mostly spread through blood transfusions and organ transplants, according to the CDC. It also could be spread through contact with blood during military service, Grilli added.

But for a younger generation, there's a different source.

"Without a shadow of a doubt, it's all recreational drug use," Johnson said.

The median age of people living with hepatitis C in Minnesota was still 58 in 2017, according to health department data. But Grilli noted that sharp rises occurred for new cases involving people in their teens, 20s and 30s.

"We're diagnosing more and more of the young population," she said.

According to the CDC, widespread screening of the blood supply in the U.S. has virtually eliminated blood transfusions and organ transplants as a source of infection for hepatitis C. Today, most who become infected do so by sharing needles or other equipment to prepare or inject drugs, the CDC confirms.

100,000 syringes

That means the modest storefront on West First Street occupied by the Rural AIDS Action Network is on the front line for the battle against hepatitis C. Along with the agency's four other Minnesota offices (Grand Rapids, Mankato, Moorhead and St. Cloud), the Duluth location provides new sterile syringes and other supplies in exchange for used syringes.

During the first six months of the year, the Duluth office gave out 100,000 syringes, McCarthy said. The office served more than 1,500 different individuals during that time, she said.

It's not a perfect one-for-one exchange; 92,000 used needles were brought in. Some people claim their needles were stolen, McCarthy said.

"That's not unlikely," she said. "There's a secondary market going on."

It can't be concluded that every one of those 100,000 syringes given out was used to inject an opioid. Some may want the syringe to inject steroids, or hormones, McCarthy said.

Some may merely be injecting water.

"We've got people that may be abstinent from their drug of choice," she said. "But they're still really connected to the act of injecting."

Whatever the needles are used for, if they're shared they can be a source of hepatitis C. And it's not just the needle, McCarthy said. If the surface where the drug is prepared has been used before without being properly cleaned, it also can be a channel for infection.

Hepatitis C is "an incredibly virulent virus," she said. HIV "pretty much dies" when it hits the air. But hepatitis C, if a surface isn't properly cleaned, will remain infectious for three weeks or longer.

Because of that, McCarthy recently has been advocating giving people their syringes and supplies in a paper bag. The recipient can be counseled to use the bag as a surface when preparing the drug.

'Three to five a day'

The Rural AIDS Action Network ordinarily doesn't give out more than 10 syringes, McCarthy said, to match that pharmacy access law that limits individuals to 10 unused needles. But judgment calls are made for exceptions in some cases, she said, such as for someone coming from a considerable distance.

How long 10 needles will last, if each is used just once, depends on the individual and the drug used, McCarthy said.

"I would say, again, depending on their drug of choice, they may use three to five a day," she said.

Drug users in the Duluth area may be injecting more often than they did in the past, McCarthy said. That's because most of what is being distributed as heroin is actually fentanyl. The latter is not only more dangerous, but it also requires more frequent doses because the high doesn't last as long.

"So my concern with that is ... they're going to be injecting more times a day than they would have historically," McCarthy said.

The purpose of providing clean needles is harm reduction, which means providing the safest possible conditions for people who are going to use drugs anyway. McCarthy said she sees her role more as disease management rather than advocating immediate abstinence.

"Sobriety is a spectrum," she said. "And if we get nailed down into: It's got to be abstinence starting from this point on till forever, I think that we minimize people's success."

'Very life-changing'

The acute form of hepatitis C can cause a flu-like illness, abdominal pain, diarrhea or no symptoms at all, Johnson said. In the chronic form, it may be hidden for years or decades but eventually lead to cirrhosis of the liver of cancer of the liver. "It can be a very life-changing, life-ending disease," she said.

If discovered, hepatitis C is highly treatable, Johnson said, with a medication regimen that is completed within months. But it's expensive: as much as a thousand dollars a day. Even someone with good health insurance will need to demonstrate that they aren't a risk for being reinfected, Johnson said.

She has that policy as a health professional as well.

"My criteria as a provider will be to be reasonably sure that candidates for treatment will be pretty committed to sobriety," Johnson said. "So they've completed their drug treatment program. They are willing to submit to drug screening."

There's no vaccine to prevent hepatitis C, Johnson said. Nonetheless, she said, it could be avoided if drug users didn't share needles.

It's also important for people at risk to be screened for hepatitis C, she said. That's one reason she's a fan of the Rural AIDS Action Network.

"There are so many more people out there that just really don't seek treatment or they don't know they have it," Johnson said. "So that's why places that do screening, like the needle exchange, are good because it's anonymous and it's easy for people to do."