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Hepatitis C- Global and National Perspective

Hepatitis C- Global and National Perspective. Dr Allister Grant Consultant Hepatologist University Hospitals Leicester NHS Trust. 20 Clear the HCV. 80 Develop Chronic Hepatitis. 20 No Harmful Effects. 60 Signs/symptoms. Age Gender Alcohol. 20% at 20yrs 50% at 30yrs. Liver Failure.

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Hepatitis C- Global and National Perspective

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  1. Hepatitis C- Global and National Perspective Dr Allister Grant Consultant Hepatologist University Hospitals Leicester NHS Trust

  2. 20 Clear the HCV 80 Develop Chronic Hepatitis 20 No Harmful Effects 60 Signs/symptoms Age Gender Alcohol 20% at 20yrs 50% at 30yrs Liver Failure CIRRHOSIS 3.9% pa Liver Cancer 1.4% pa HCV- Natural History 100 Infected Transplantation

  3. Cirrhosis Normal liver Hepatocellular Carcinoma (Hepatoma) HCV : Clinical

  4. HCV : Clinical Ascites Oesophageal Varices

  5. Prevalence of Hepatitis C virus 2001 WHO

  6. Prevalence of Hepatitis C Virus

  7. WHO Global Burden of Disease 2000Cirrhosis (all causes) • 785,000 deaths per annum from liver failure (cirrhosis, all causes) • HBV 40% • HCV 25% • Other causes 35% • 600,000 deaths per annum from HCC • HBV 57% • HCV18% • Other causes 25%

  8. WHO Global Burden of Disease 2000Mortality from HBV & HCV • 1 million deaths per annum • Including deaths from cirrhosis and/or liver cancer • HBV causes 644,000 deaths per annum • HCV causes 325,000 deaths per annum

  9. WHO Global Burden of HepatitisContaminated Healthcare Injections • Population receives 3.4 injections per year • 39.3% with used equipment • Worst places are SE Asia and Middle East • In 2000, unsafe injections caused • 21 million HBV infections (32% of new infections) • 2 million HCV infections (40% of new infections) • Will cause 73,000 early deaths

  10. Risk Factors Associated withTransmission of HCV • Injecting drug use • Transfusion or transplant from infected donor • Hemodialysis (yrs on treatment) • Accidental injuries with needles/sharps • Sexual/household exposure to anti-HCV-positive contact • Multiple sex partners • Birth to HCV-infected mother

  11. UK HCV Prevalence <1% IV Drug Use Blood Donation 200,000 Migration

  12. Laboratory reports of infection Renal Failure (<1%) Vertical (<1%) Sexual (1.5%) Other (2.4%) Blood transfusion (1.4%) Blood product Recipients (1%) Injecting Drug users (92%) Risk factors (where reported) PHLS

  13. Injecting Drug Use and HCV Transmission • Highly efficient • Contamination of drug • paraphernalia, not just needles • and syringes • Rapidly acquired after initiation • 30% prevalence after 3 years • >50% after 5 years • Four times more common than HIV

  14. Prevalence of antibody to hepatitis C amongst injecting drug users by length of injecting career 100 75 50 Prevalence of Hepatitis C Antibody (%) % HCV + 25 0 0-2 3-5 6-8 9-11 12-14 15+ Length of Injecting career (years) PHLS

  15. Prevalence of HCV among injecting drug users (Europe)

  16. HCV: Burden of Disease Perspectives for the next 15 years 65% increase in cirrhosis 68% increase in hepatocellular carcinoma 279% increase in decompensated liver disease 528% increase in need for liver transplantation 150-200% increase in mortality from HCC Davis et al NEJM 1998 Alter et al NEJM 1999 Deufic et al Hepatology 1999

  17. HCV: Burden of Disease 30-50 % of the newly diagnosed chronic liver disease 30% of cirrhosis 60% of HCC 30% of the indications for liver transplantation Charlton et al Hepatology 1999 Terrault et al AASLD 2000 EASL Consensus 1999

  18. UK Transplantation for HCV recipients Total HCV

  19. UK Transplantation for HCV recipients Total HCV Total HBV

  20. Birmingham Transplants for HCVUK-born versus OS-born 76/145 (52%) UK born Number of transplants ’90 ’91 ’92 ’93 ’94 ’95 ’96 ’97 ’98 ’99 ’00 ‘01 Year

  21. Supply & Demand total donors HCV first graft

  22. Supply & Demand total donors HCV first graft HCV regraft

  23. Supply & Demand totalHCV total donors HCV first graft HCV regraft

  24. HCV Strategy for England 2002 • Aims To prevent new cases of Hepatitis C Identify those already infected Offer access to trained specialists & Access to treatment via coordinated pathways

  25. HCV Strategy for England 2002 Targeting injecting drug users- Improving needle exchange Harm minimisation info Education- before injecting starts Improving treatment for drug dependency Targeting of prisons and young offenders institutions

  26. HCV Strategy for England 2002 Education in schools HCV Awareness campaign Education for primary care health professionals Good practice guidelines (piercing/ tattooing) Increasing HCV testing and treatment

  27. National Plan for Liver Services AIM- Establish commissioning of Hepatology services across the UK for the four components of liver services • Viral Hepatitis • Complications of Cirrhosis • Liver tumours • HPB surgery Provide a framework for the delivery of the hepatitis C Action Plan

  28. “Government to demonstrate greater urgency” “A proactive screening programmeis needed especially amongst at risk groups” “…lack of funds should never be an excuseto deny or delay treatment for Hepatitis C.” “Hepatology should be given a higher priority in the NHS” “All prisoners should be screened on entry to and exit from prison” “The awareness campaign directed at the general public and target groups is far too low-key”

  29. How do we compare with other countries? Population HCV Treated 2003 USA 273 million 126 300 Germany 82 million 17 300 France 59 million 14 700 Spain 39 million 16 200 UK 60 million 2700

  30. Estimated Incidence of Acute Hepatitis C United States, 1982-1993 25 Surrogate testing of blood donors Anti-HCV test (1st generation) licensed 20 15 Cases per 100,000 Anti-HCV test (2nd generation) licensed 10 5 Decline among injecting drug users Decline among transfusion recipients 0 1983 1987 1993 1989 1985 1991 Year Source: CDC Sentinel Counties Study of Acute Viral Hepatitis

  31. Hepatitis C Virus Infection Typical Serologic Course anti-HCV Symptoms Titre ALT Normal 6 1 2 3 4 0 1 2 3 4 5 Months Years Time after exposure

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