Prevention of HCV infections in Switzerland

1. Prevention of HCV infections in Switzerland Virginie Masserey Spicher, MD Head Vaccination Programmes and Control MeasuresSection Communicable Diseases Division Project KIK 35 - Warsaw 11 October 2012

2. Prevention and control of communicable diseases in Switzerland Federalepidemiclaw (1970), revised 2012: responsibilities • FederalAuthorities: • Surveillance • Notification systems • National ReferenceCenters • Objectives, strategies, recommendations • Advisory expert groups • National Programs • Coordination • Cantonal Authorities: • Implementation of prevention and control measures

3. Anti-HCV prevalence in Switzerland • General population: • 1990ies: 0.7-1% (up to 1.3-1.8% ?) • Approx. 55 000-78 000 persons HCV-infected • Population of injecting drug users (IDUs): • 1990ies: 56-82% (today: up to 75% ?) • Patients under haemodialysis: • 1999: 5.1% • Pregnant women: • 1990/1991: 0.7% Source: specialstudies

4. HCV prevalence in Switzerland • Blood donors (2004-08): • Yearly mean of 23 715 first-time blood donors: • 18 HCV-positive tests/year (0.08%) • Yearly mean of 373 000 blood donations: • 20 HCV-positive tests/year • Since 1999: Nucleic Acid Amplification screening for HCV Source: National Reference Center for Infections through Blood and Blood Products

5. HCV notifications in Switzerland Notifiable disease in Switzerland since 1988: • Laboratories report positive tests: • Anti-HCV confirmed by immunoblot • HCV RNA • HCV Ag • Physicians report: • Clinical manifestations, likelyexposure / riskfactors • Classification: acute / chronic / unclassifiable • Investigations / look-backs if indicated

6. Total reportedso far: app. 45’000

7. Acute HCV infections in Switzerland • Number of reported cases: • 2005-10: yearly mean of 57 cases (range: 39-74 cases) • Estimated incidence: x 4-5 = 3-4 / 100’000 inhab. • Case characteristics: • Male proportion: 71% • Age peaks: 20-34 years olds • Reported risk factors: • Intravenous Drug Use (IDU): app. 70% • HCV infections in the medical setting: • Since 1997: 10 infected HCWs after needle stick injury

8. Swiss Needle-stick Surveillance → 2008 Mandated by SFOPH to National Reference Centre for AccidentalExposure to Blood and Body Fluidsin Healthcare Institutions • National needlestick surveillance since 1989 • Voluntary reporting system • Reporting of accidental exposures of HCW to blood/body fluids • if HBV, HCV or HIV-positive index patients • if HIV-post exposure prophylaxis initiated • Annual feedback report to participating institutions • Bi-annual publication of results

9. Evolution of reports 1989 – 2008 of blood and body fluids (BBF) exposures Estimated underreporting Swiss hospitals: 20% (housekeeper), 50% (nurses), 80% (physicians) Luthi JC et al. Schweiz Med Wochenschr.1998 * 2008: data collection for six month only

10. Location of exposures Operating theatre Trend  Exposures and Profession Female 70% / Male 29.4% Nurses 54.3% RN 76.8% Students 6.3% Physicians 31.4% Surgeons 45.6% Anesthesiologists 6.8% Students 16.6% Housekeeping 3.4% Lab-personal 2.6% Others 8.3% Doctors (Surgeons) Trend  Location of exposures andaffected professional groups 2001 - 2006n = 6795

11. Occupational exposure and burden of HCV Number of HCV-positive source patients of reported BFF and of acute Hepatitis C infection among the general population in Switzerland between 1989 and 2008* 1994: start HCV status survey index Number HCV-infection general population Number of Hepatitis C + Source patients Occupational acquired HCV-infections * 2008: data collection for six month only

12. Current method and reporting system • National needlesticksentinel surveillance since 2009 • Selected group of primary care hospitals • Reporting of all exposures to blood/body fluids • New standards entry form (comparable to the EPINet™ form) • Documenting incidence rates per occupied beds, per HCW and per surgical procedures (operating theatres) • Annual feedback report to participating institutions

13. Per 100 occupied beds Incidences of exposures sentinel hospitals 2010 → Benchmarking Benchmark: Perry J et al. EPINet 2007 Per 1000 operations Benchmark: Myers DJ et al. InfectControlHospEpidemiol 2008

14. Safety Devices Reduction of exposures 13.4 to 7.3 exposures per 100‘000 MendelsonMH InfectControlHospEpidemiol. 2003

15. Safety Devices Exposures per 100’000 used devices before and after introducing Safety Devices in a Swiss University Hospital 2008 / 2010 / 2011 In-dwelling catheter Wing Steel needle Capillary lancets  2008  2010 ▲ 2011 Reduction significant (p=<0.01): In-dwelling catheter and Wing Steel needle http://www.europeanbiosafetynetwork.eu/

16. Recommendations for operating theatres Usage of ‘blunt-needles Sewing-techniques ‘In-between-depots’ of used instruments Recommendations for general wards Safe disposal of equipments Avoidance of recapping Use of safety devices Offering information/educational courses Guidance to students Increase use of safety devices Consequences healthcare exposures

17. Primary HCV prevention in Switzerland • Safety of blood products • Hospital hygiene: standard precautions, etc. • Good practice in piercing and tattoo studios • Behaviour prevention in targeted populations: • Population groups with ongoing HCV transmission: • IDUs • MSM, especially HIV-infection • Persons with high-risk sexual behaviour • Health-care workers • Antiviral therapy ? (Martin et al. J Hepatol 2011;54:1137-1144) • Reduce reservoir

18. Secondary HCV prevention • Targeted populations: • Population groups with ongoing HCV transmission • Health-care workers • General population • Approx. half (?) of the infected people are unaware of infection • Future challenges of HCV infection: • Peak in the number of patients with cirrhosis/ cancer/ waiting for liver transplant not yet reached ! • Targetedearlytreatment

19. Treatment of Acute Hepatitis C Current: No post exposure prophylaxis establised after HCV exposure Outlook: “In summary, early treatment of acute hepatitis C with interferon alfa-2b alone prevents the development of chronic HCV infection in most patients”. Treatment ofacutehepatitis C withinterferon alfa-2b. Jaeckel E, et al. N Engl J Med. 2001 Nov 15;345(20):1452-7

20. Swiss Policy Drugs and Addictions Four pillarpolicy: • Prevention • Therapy • HarmReduction • Repression and Regulation of Market Infodrog: Swiss Office for Coordination of Addiction Facilities, mandated by the SFOPH → National awarenesscampaign hepatitis C 2009 - 2012

21. Objectivesofthehepatitis C Campaign • Reducing the number of hepatitis C infections among Drug Users • Improving access to HCV testing and treatment for Drug Users • Continuous transfer of knowledge concerning hepatitis C to experts dealing with addiction and to Drug Users

22. Elements ofthehepatitis CCampaign • Provision of Prevention Material for Drug Users and Addiction Specialists • Training of Addictions specialists and Drug Users • Supporting of Projects in the Field of Addiction

23. Supported Projects • Screening ofPatients in addictionscenters Clinica Luganese Moncucco, TI, 2010-2011 • Studyof the PrevalenceofHepatitis C, B and HIV amongdrugusers Ingrado und Antenna Icaro, TI, 2011-2012 • Testing and Treatment in a drugconsumptionroom City of Zürich 2010 – 2012 • Build-upof a qualitycircleforSpecialists in DiseasesoftheLiver & Gastroenterology, Family Doctors, AddictionsSpecialists HepnetZurich

24. Challenges HCV in IDU • Barriersto Treatment for Drug Users • High Chargesfor Treatment • Lack ofscreening and treatment in thesubstitutioncentres and in theprisons • Insufficient Data about HCV-Prevalence and Transmisson and Treatment of Hepatitis C

25. National HIV/Aids Program 1981 1987 1993 1999 2004 2011 1981: First AIDS case in Switzerland (retrospectively diagnosed) 1987: First “Response against AIDS-Epidemic” concept in Switzerland 1993: HIV-Prevention in Switzerland: Goals, Strategies, Measures 1999: HIV and AIDS, National Program 1999-2003 2004: National HIV&AIDS Program 2004-2008 (extended for 2 years) 2011: National HIV and other sexually transmitted infections Program 2011-2017

26. HIV-Infections in Switzerland 1000 Heterosexual contacts 900 Homosexual contacts 800 IDU 700 Others 600 500 400 300 200 100 0 89 91 93 95 97 99 01 03 05 07 09 1st decade: 81-90 Year of test

27. HIV-Infections in Switzerland 1000 Heterosexual Contacts 900 Homosexual Contacts 800 IDU 700 Others 600 500 400 300 200 100 0 89 91 93 95 97 99 01 03 05 07 09 2nd Decade: 91-00 Year of test

28. HIV-Infections in Switzerland 1000 Heterosexual Contacts 900 Homosexual Contacts 800 IDU 700 Others 600 500 400 300 200 100 0 89 91 93 95 97 99 01 03 05 07 09 3rd Decade: 01-10 Year oftest

29. Sexuallytransmittedinfections (STI): 2010 Rise of new Chlamydia cases, especially among young people Rise of Gonorrhea cases among (young) gay men and other MSM Rise of Syphilis cases among (gay) men, yet not only young people Suspected rise of LGV cases among gay men and other MSM Riskof sexual transmission of HCV among gay men

30. The Swiss National HIV and STI Program (NPHS)2011-2017General principles of the program • Prevention through protective measures (safer sex) • Vaccination (when vaccines are available and recommended, HPV, forms of hepatitis) • Early detection (including individual counselling for clarification of the risk) • Correct treatment at the right time.

31. Principal goals per intervention axes

32. Priorities in the launching of the Swiss National HIV and STI Program 2011 - 2017 • Gay men and other men who have sex with men. • People living with HIV and their partner(s). • Migrants, Sex workers, Prison inmates, Injecting drug users. • General population (LOVE LIFE)

33. Identifying persons with HCV infection • Screening of specific populations • Voluntary testing requested by the person concerned • Health-care provider initiated testing based on identified risk-factors in patients • Screening recommendations: • Screening for HCV infection in blood donations and transplant donors • HCV testing recommendations: • Since 1993 • Based on riskfactorsandclinicalsignsorsymptoms

34. Identifying persons with HCV infection • Swiss Experts in Viral Hepatitis (SEVHep) & SFOPH (2012): • Promotion of health-care provider initiated testing based on identified risk-factors in patients • Review of the patient’s history by a (primary) health-care provider, in order to:  Determine if a person is at risk for being chronically infected or becoming infected with HCV  If necessary, to test for HCV infection  If indicated, to refer to medical care and case-management  Decision based on a variety of risk factors and clinical signs or symptoms of hepatitis (Submitted)

35. Summary and conclusions • Instead of a single national program or strategy, • HCV preventionisintegrated in several programmes and recommendations • Situation ismonitored, and subject of research (e.g. cohortstudies) • Focus on IDU and chronic infections: • prevention, testing and treatmentstrategies

36. Thankyou www.bag.admin.ch virginie.masserey@bag.admin.ch

38. Material for Addiction Specialists • The Manual “Prevention & Therapy” • The Brochure: “A Summary of Key Facts” • The DVD “Hepatitis C: Prevention for Drug Users” • The Website www.hepch.ch • Training Material

39. Material for Drug Users • Flyers • Information Leaflets • The Brochure: “A Summary of Key Facts” • The DVD “Hepatitis C: Prevention for Drug Users” • Give-Away Articles

40. Training • Medical introductionto Hepatitis > Hepatitis A,B,C > Prevention / saferuse > Therapyof Hepatitis C > Useofthe material ofthecampaign • Presentationofcampaign’s material • Viewingofthemovie «Preventionfor Drug Users» • Discussion

41. Vaccination / PEP Avoidance of contact Personal protection equipment Organisational changes (e.g. patient/nurses ratio) Safety Devices Substitutes of infectious material? Prevention of occupational infections Infection Exposure / Contact Infectious Material

43. Fretz et al. Swiss Medical Weekly 2012; submitted 15.05.12.