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

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

HCV : Clinical Hepatocellular Carcinoma (Hepatoma) Normal liver Cirrhosis

HCV : Clinical Ascites Oesophageal Varices

Prevalence of Hepatitis C virus 2001 WHO

WHO RegionTotal Population (Millions) Hepatitis C prevalence Rate % Infected Population (Millions) Africa Americas Eastern Mediterranean Europe South-East Asia Western Pacific Total Prevalence of Hepatitis C Virus

WHO Global Burden of Disease 2000 Cirrhosis (all causes) 785,000 deaths per annum from liver failure (cirrhosis, all causes)785,000 deaths per annum from liver failure (cirrhosis, all causes) HBV 40% HBV 40% HCV 25% HCV 25% Other causes 35% Other causes 35% 600,000 deaths per annum from HCC600,000 deaths per annum from HCC HBV 57% HBV 57% HCV18% HCV18% Other causes 25% Other causes 25%

WHO Global Burden of Disease 2000 Mortality from HBV & HCV 1 million deaths per annum1 million deaths per annum Including deaths from cirrhosis and/or liver cancer Including deaths from cirrhosis and/or liver cancer HBV causes 644,000 deaths per annumHBV causes 644,000 deaths per annum HCV causes 325,000 deaths per annumHCV causes 325,000 deaths per annum

WHO Global Burden of Hepatitis Contaminated Healthcare Injections Population receives 3.4 injections per yearPopulation receives 3.4 injections per year 39.3% with used equipment39.3% with used equipment Worst places are SE Asia and Middle East Worst places are SE Asia and Middle East In 2000, unsafe injections causedIn 2000, unsafe injections caused 21 million HBV infections (32% of new infections) 21 million HBV infections (32% of new infections) 2 million HCV infections (40% of new infections) 2 million HCV infections (40% of new infections) Will cause 73,000 early deathsWill cause 73,000 early deaths

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 Risk Factors Associated with Transmission of HCV

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

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

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

Prevalence of Hepatitis C Antibody (%) Length of Injecting career (years) PHLS Prevalence of antibody to hepatitis C amongst injecting drug users by length of injecting career % HCV

Prevalence of HCV among injecting drug users (Europe)

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 % increase in mortality from HCC Davis et al NEJM 1998 Alter et al NEJM 1999 Deufic et al Hepatology 1999

HCV: Burden of Disease % 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

UK Transplantation for HCV Total HCV recipients

UK Transplantation for HCV Total HCV recipients Total HBV

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

total donors HCV first graft Supply & Demand

total donors HCV first graft HCV regraft Supply & Demand

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

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

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 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 HCV Strategy for England 2002

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

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

How do we compare with other countries? Population HCV Treated 2003 USA273 million Germany82 million France59 million Spain39 million UK60 million2700

Source: CDC Sentinel Counties Study of Acute Viral Hepatitis Surrogate testing of blood donors Anti-HCV test (1st generation) licensed Anti-HCV test (2nd generation) licensed Decline among injecting drug users Decline among transfusion recipients Estimated Incidence of Acute Hepatitis C United States, Cases per 100,000 Year

Time after exposure Hepatitis C Virus Infection Typical Serologic Course Symptoms anti- HCV ALT Normal Titre Titre MonthsYears