The Global Burden of Hepatitis C Dr Daniel Lavanchy World Health Organization (WHO) Geneva, Switzerland 3 rd Paris Hepatitis Conference

Global Burden of Disease l For centuries, mankind helpless against infectious diseases l Germ theory & identification of microbes as causative agents led to the development of vaccines and antimicrobials l Optimists at the end of the 19th century predicted eradication of infectious diseases l 1950s, complacency set in with widespread use of penicillin, development of polio vaccines and discovery of drugs for tuberculosis l 1967, US Surgeon General stated that “the war against infectious diseases has been won” l 1981, Richard Krause, director US NIAlD warned that microbial diversity and evolutionary vigor were still forces threatening mankind

Global Burden of Disease

l About 15 million (>25%) of 57 million annual deaths worldwide are estimated to be related directly to infectious diseases l This figure does not include the deaths that occur as a consequence of complications associated with chronic infections, such as liver failure and hepatocellular carcinoma in people infected with hepatitis B or C viruses

End-stage Liver Disease l Cirrhosis > 783'000 deaths / year l Liver cancer > 619'000 deaths / year ~1 of every 40 death worldwide But no good breakdown according to aetiology

Hepatitis C Global Burden WHO estimates: l millions new infections/year l 300'000 deaths annually l million persons chronically infected

Impact of HCC l US national spending each year on HCC – $ 32,907 / case – total annual burden $ million –(Lang et al. 2009) l Interventions to reduce the prevalence of HCC have the potential to yield sizable economic benefits l Screening and treatment programs aimed at reducing viral hepatitis-related morbidity will reduce hospitalization rates

Institute for Public Health, Medical Decision Making and Health Technology Assessment 9 European region Hepatitis C is a major public health problem in the WHO European region, costing twice as many lives and about as many ‘healthy’ live years as HIV/AIDS. Burden of disease caused by advanced disease highlights the potential benefit of antiviral treatment. Varying transplantation and mortality rates suggest inequality of health care services across Europe. Most importantly, the lack of data indicates that hepatitis C still is a neglected disease. What is needed are PUBLIC AWARENESS, coordinated action plans, more and better data.

Global Burden: Basics Global data: l Little more has been done at country level since first WHO estimates in 1997 l 38 different HCV surveillance systems in 27 EU countries (Rantala 2008) l Anti-HCV > RNA positive confirmed in 40-90% –EMCCDA. Annual report 2006

Hepatitis C Incidence

Forecasted cases of hepatitis C for 2001–2040

Health care costs associated with hepatitis C for 2001–2040

Predicted HCV Related Deaths Predictions are difficult, Particularly about the future Yogi Berra

HCV Related Mortality USA Wise, 2008

l Prevalence data still not available in many countries – prevalence studies of the general population needed for an accurate estimate of the rate of infection and the number of individuals chronically infected l Detection of outbreaks of HCV infection difficult l Incidence impossible to measure l Under-reporting (20-50%) l Long-term disease burden outcome not yet known l Heterogeneity in availability/quality of data Global Hepatitis C Epidemic

Summary l Lack of disease burden data l Lack of awareness l Political commitment difficult – Holistic strategy for prevention, control & management of hepatitis A, B, & C (E) l Set clear, quantifiable targets for – reducing incidence and prevalence – reducing morbidity & mortality

Global Public Health Goals l Public recognition as important public health issue l Government lead for a national strategy – for awareness raising, screening, diagnosis, referral and treatment – If public health does not lead, who should lead ? Google ? Industry? Doctors? Rock stars? Media? l Coordinated approach globally – Globally involve advocacy groups, professionals and scientific societies

Conclusions l Heavy global burden – assessment behind schedule – no global data – few good national estimates – WHO work in progress l Standardized approach is essential l Implementation of comprehensive national programs still needed in 2008 = global political agenda with clear targets l Research is necessary to define best practices l Global team effort necessary

Hepatitis C Vaccine l Investigational E1E2/MF59 vaccine (Novartis) l Correlates of protection are complex l Future development ? Urgent !

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