The Swiss Population In 2001 Resident population: 7,258,500 Population density: 176 per Km 2 Foreign nationals: 20.1% (~1,460,000) Excess of births over deaths: 13,000 per year [Immigration] – [emigration] = +41,500 per year

Registered Medical Laboratories Primary Care Physicians Swiss Federal Office of Public Health (OFSP) Reporting of positive anti-HCV and HCV RNA tests (mandatory since 1988) Identification from test reporting Further clinical and epidemiological data Cross-checking for duplicates

 Total number of declarations received at OFSP:  all patients = 24,068 (~2,500 per year)  acute hepatitis C = ~600 (~60 per year)  Estimated prevalence (general population, based on a survey on pregnant women):  0.7-1% (50, ,000)  Estimated incidence: new cases per 100,000 per year, mostly (70%) due to IVDU OFSP, 2001 HCV infection in Switzerland based on a mandatory reporting systm

Acute Hepatitis C Declarations Classes of Age

 Intravenous drug use: 68.2%  Blood transfusion: 6.8%  Health care workers : 2.8%  Sexual contact: 2.8%  Contact with anti-HCV+ patients: 1.9%  Unknown: 15.7% Acute Hepatitis C in Switzerland Risk Factors

All Declarations, Classes of Age

The HCV Epidemics in Switzerland: Population-based Studies Study populationHCV+ / total (%) YearReference Blood donors50 / 5,424 (0.9) 1992/ 1997 Zucca et al, 2000 Dentists1 / 1,056 (0.095) 1999Weber et al, 2001 Pregnant women64 / 9,057 (0.7) 1990/ 1991 OFSP, unpublished

 According to official estimates, about 50% of infected patients have been declared to Federal Authorities  Mandatory reporting often concerns diagnoses made well before the declaration  It is likely that more then half of HCV infected patients already know about their own status Indications to Screening for HCV - 1 Swiss Recommendations (OFSP, 2001)

 A general screening policy would be expensive, of limited usefulness, and out of proportion with respect to the expected results Indications to Screening for HCV - 2 Swiss Recommendations (OFSP, 2001) Bull OFSP, 2001;46:877

Indications to Screening for HCV - 3 Swiss Recommendations (OFSP, 2001) Present or former IVDU Individuals transfused with blood before 1992 or with blood derivatives before 1987 Patients under dialysis Children born to HCV-positive mothers HCW after accidental exposure to blood Patients with elevated transaminases

Although the pregnant women study is representative in terms of ethnicity: –females account for only 40% of the HCV infected population –only 2.4% of pregnant women under survey (1.5% of HCV+) were in the >40 y class of age (vs. 39% of OFSP declarations) Official estimates may have underestimated the HCV prevalence in Switzerland The HCV Epidemics in Switzerland How Many Are Infected?

Model predictions (assuming a median 0.75% prevalence according to OFSP estimates) were compared with observed incidence of HCV related deaths and OLT A revised prevalence of 1.25 – 1.75% provided the best fit to the assumed complications Prevalence of HCV in Switzerland SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25

Future complications of a cohort of 77,595 HCV RNA positive patients were evaluated (age distribution was identical to that of the OFSP declarations) In the next 15 to 25 years: –Annual HCC incidence will increase by 70% –HCV-related mortality will increase by 90% –Incidence of HCV-related cirrhosis will decline Predicting HCV Disease Burden (by Prevalence) SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25

Trends in overall and truncated (35-64 y) age-standardised HCC death rates in Switzerland LA VECCHIA et al, Eur J Cancer 2000;36:909 females males females, y females, all ages

Future complications of HCV infection in Switzerland SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25

Antiviral therapy will reduce the annual HCV-related mortality by a mere 5%, since: –According to new estimate, only a minority of patients have been diagnosed (~15%) –Antiviral treatment may cure only 40% of patients Effect of Antiviral Therapy SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25

Annual direct costs for treating complications of HCV will double by 2020 (~32.9 million US $ per year) (vs. 801 million US $ of direct costs of CHD) Indirect costs (loss of productivity) equals 25.9 million US $ per year (1998) Future Costs of Hepatitis C in Switzerland SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25

Current recommendations may help to identify only 50-60% of patients with chronic hepatitis C Extend screening to other groups at risk? Propose anonymous testing/counseling?

The Swiss Population In 2001 Resident population: 7,258,500 Population density: 176 per Km 2 Foreign nationals: 20.1% (~1,460,000) Excess of births over deaths: 13,000 per year [Immigration] – [emigration] = +41,500 per year

Foreign Nationals Living in Switzerland The foreign population is relatively young: –8 persons of retirement age every 100 workers (Swiss nationals: 30 every 100) More than half have been living in Switzerland for >15 years Current net migration is positive, thanks to immigration from non-EU European countries About 80% of foreigners (~1,100,000) are from countries where HCV infection is moderately prevalent and long-standing

Italy Spain other countries former Yugoslavia Germany Portugal Turkey France Austria Switzerland: origin of foreign nationals (1999)

Global Patterns of HCV Infection 3 = Egypt 2 = Spain, Italy 1 = US, Australia WASLEY and ALTER, CDC, 2000

Risk factors for HCV transmission in Italy Blood transfusions2.9 IV drug use 112 Non-disposable needles within the family1.6 Non-disposable needles outside the family3.8 Hospitalization before Hospitalization after Previous tuberculosis3.4 Sexually transmitted diseases1.1 Surgical intervention before Surgical intervention after CHIARAMONTE et al, 1996

HCV Infection in Geneva Risk factors, acute vs. total (%) DELAPORTE, 2001

HCV Infection in Geneva Risk Factors Vs. Geographic Origin DELAPORTE, 2001

 Acute hepatitis C patients are more often young IV drug users, born in Switzerland  Chronic hepatitis C patients are more often of older age, and migrated to Switzeland from countries where the prevailing risk factor for HCV in the past decades was nosocomial / iatrogenic transmission HCV Infection in Geneva

Indications to Screening for HCV Consider to extend screening to: –individuals exposed to non medical, invasive procedures? –individuals exposed in the past to potentially unsafe medical procedures / unsafe injections? –patients with extra-hepatic manifestations possibly linked to HCV?