Hepatitis C: Hidden Harm Friday 21 st March, 2014 Dublin

1. Hepatitis C: Hidden HarmFriday 21st March, 2014Dublin Hepatitis C – A Public Health Issue Joe Barry, TCD

2. Hepatitis C virus (1) • Virus first identified in 1989 • Routine screening of blood started in 1991 • Many people were infected through contaminated blood/blood products prior to this • Most new cases in developed countries are in injecting drug users • Hepatitis C can also be transmitted sexually and from an infected mother to her baby – but these routes are less common • Most cases are initially asymptomatic or mildly symptomatic • 55-85% of those infected develop chronic infection

3. Hepatitis C virus (2) • Chronic infection can lead to chronic liver disease, cirrhosis, liver failure and liver cancer (usually over 20-30+ years) • >170 million people chronically infected worldwide • No vaccine available • Standard treatment: • Combination therapies using interferon and new antiviral drugs have steadily improved the rate of cure (sustained virological response) in the last decade. • Treatment success rate of up to 80% depending on various factors.

4. Worldwide prevalence hepatitis C infection (source: WHO)

6. Strategy Main WG – membership (1) • Joe Barry, TCD (Chair) • Jean Flanagan, Hepatitis C liaison service, HSE North Dublin • Walter Cullen, UCD • Helena Irish, Hepatitis Service, SJH • Julian Pugh, Coordinator Drugs Treatment Services, HSE • Shay Keating, Hepatitis C Service, Drug Treatment Centre Board • Taru Burstall, Community Sector • Lelia Thornton, Specialist in PH Medicine, HPSC • Anna Quigley, Community Sector • Colm Bergin, Infectious Disease Consultant, SJH • John Moloney, Patrick Street Clinic, Addiction Service, HSE DML

7. Strategy Main WG – membership (2) • Jack Lambert, Infectious Disease Consultant, Mater/Rotunda Hospitals • Patricia Ramshaw, HSE West • Lesley O’Sullivan, Addiction Services, HSE DNE • Ger Power, Addiction Services, HSE DML • Maurice Farnan, Area Operations Manager, Drug Service, HSE DML • Margaret Bourke, GP Coordinator, HSE DML • Eddie Ward, Health Promotion, HSE DML • Ruadhri McAulliffe, Uisce • Emily Reaper, UISCE • Sinead Donohoe, Registrar in PH Medicine, Dept of PH, HSE

8. Strategy Main WG – membership (3) • Aiden McCormick, Consultant Hepatologist, SVUH • Des Crowley, GP Coordinator, HSE North Dublin • Susan McKiernan, Consultant Hepatologist, SJH • Naomi Glover, Hepatitis C liaison service, HSE North Dublin • Bobby Smyth, Adolescent Addiction Psychiatrist, HSE DML • Paul Kavanagh, Dept of PH, HSE East • Mary O’Shea, Dublin Aids Alliance • Louise Mullen, Dept of PH, HSE East • Jeff Connell, NVRL, UCD

9. Strategy Surveillance Subgroup - membership • Lelia Thornton, Specialist in PH Medicine, HPSC (Chair) • Joe Barry, TCD • Niamh Murphy, Surveillance Scientist, HPSC • Orla Ennis, Surveillance Scientist, Dept of PH, HSE East • Julie Heslin, Specialist in PH Medicine, HSE South East • Suzie Coughlan, Senior Clinical Scientist, NVRL, UCD • Sinead Donohoe, Specialist Registrar in PH Medicine, Dept of PH, HSE East

10. Strategy Education and Prevention Subgroup - membership • Maurice Farnan, Area Operations Manager, Addiction Service HSE DML (Chair) • Julian Pugh, Coordinator Drugs Treatment Services (Prisons), HSE • Eddie Ward, Health Promotion, HSE DML • Bobby Smyth, Adolescent Addiction Psychiatrist, HSE DML

11. Strategy Treatment Subgroup - membership • Shay Keating, Hepatitis C Service, Drug Treatment Centre Board (Chair) • Jack Lambert, Infectious Disease Consultant, Mater/Rotunda Hospitals • Margaret Bourke, GP Coordinator, HSE DML • Sinead Donohoe, Specialist Registrar in PH Medicine, Dept of PH, HSE • Helena Irish, Hepatitis Service, SJH • Susan McKiernan, Consultant Hepatologist, SJH • John Moloney, Patrick Street Clinic, Addiction Service, HSE DML • Colm Bergin, Infectious Disease Consultant, SJH • Des Crowley, GP Coordinator, HSE North Dublin

12. Distribution of Strategy Recommendations • Surveillance 8 • Prevention 14 • Screening/testing 6 • Treatment 8

13. Implementation Committee – membership • Joe Barry, TCD (Chair) • Lelia Thornton, Specialist in PH Medicine, HPSC • Michele Tait, National Hepatitis C Coordinator, HSE • Ruadhri McAulliffe, Uisce (Union for improved services, communication and education) • Margaret Bourke, GP Coordinator, HSE DML • Suzanne Norris, SJH, Chair of Irish Hepatitis C Outcomes Research Network (ICORN) • Diane Nurse, Lead National Planning Specialist-HSE National Social Inclusion Office • Ruth Armstrong, Project Manager - Health Promotion & Improvement - HSE • Vivienne Fay, Area Operations Manager, Addiction Service, HSE DML

14. ToR – Implementation Committee • Oversee and monitor implementation of recommendations of the HSE National Hepatitis C Strategy. • Facilitate communication and provision of information throughout the health services and wider community in respect of progress made on implementation of recommendations, identification of emerging issues, and other matters • Update recommendations in light of new evidence • Develop and encourage synergies across the Hepatitis C sector

15. Surveillance and Screening subgroup membership • Lelia Thornton, HPSC (Chair) • Elizabeth Keane, Director of PH, HSE South • Jeff Connell, National Virus Reference Lab • Shay Keating, National Drug Treatment Centre • Niamh Murphy, Surveillance Scientist, HPSC • Fionnuala Cooney, HSE East • Orla Ennis, HSE East • Joanne Moran, NVRL and HSPC • Chantal Migone, SpR in Public Health • Eve Robinson, SpR in Public Health

16. Surveillance priorities for 2014 • Development of national hepatitis C screening guidelines • The national hepatitis C screening guidelines will be developed according to the approach recommended by the National Clinical Effectiveness Committee (NCEC). A formal “Notice of intent to develop clinical guidelines” has been submitted to NCEC. It has been accepted and published on NCEC website. A provisional project plan and timeline has been developed. The guidelines will cover what population groups should be offered testing, in what settings, at what frequency, by what type of test. • Population Prevalence project – determining current prevalence and assessing need for and options for a seroprevalence study • Work is currently focused on exploring ways to establish prevalence of hepatitis C in IDUs, based on screening carried out in drug treatment clinics and exploring the different options for a seroprevalence survey.

18. Epidemiology of hepatitis C in Ireland • Hepatitis C became notifiable in 2004 • 2004-2012: 11,568 cases notified, mean annual number: 1,285 • Crude notification rate in 2012: 24.4/100,000 • Likely to include some cases diagnosed before 2004 and not previously notified, and some duplicates (as full names not always provided) • 65% of cases notified 2004-2012 were male • The median age at notification 2004-2012 was 34 years • Risk factor data collected since early 2007 – data available for 55% of cases notified between 2007 and 2012 • 77% were injecting drug users

19. Number or notifications hepatitis C 2004-2012, by sex and mean age

20. Most likely risk factor (%) for cases of hepatitis C notified in 2012 (where data available, n=651, 63%)

21. Education, Prevention and Communication subgroup • Ruth Armstrong, Project Manager Alcohol, HSE • Gail Hawthorne, Hepatitis C Liaison Nurse CNS, HSE • Kenneth Hartnett, Service User Representative Forum (SURF) • Nicola Perry, Manager, Community Response Ltd • Susan Donlon, Coordinator Prevention Education and Training, Dublin Aids Alliance • Sarah O’Brien, Health Promotion Information, Social Marketing and Advocacy, HSE

24. Education, prevention and communication priorities for 2014 • To provide clear, consistent and updated advice on the transmission risks of hepatitis C through the development of an education and awareness week in July 2014 • To collate and review existing informational and educational material to identify gaps in information and advice on hepatitis C

25. Challenges • Cuts in Services • Stigma • Asymptomatic infection • Absence of IT in drug services

26. Opportunities • Good structures • Health Identifier Bill • New treatment options • Awareness potential