Volume 65 - 2002 - Fasc.2 - Symposium
Why a Belgian hepatitis C day ? (1)
Hepatitis C is a major health care problem affecting 3% of the world population and 100,000 people in Belgium. This prevalence is 10 times higher than that of HIV (1,2) and recent data from France (3) reveal that, actually, patients with hepatitis C have a 2.5 higher risk of death due to their disease than those suffering from AIDS. If no action plan is organized on a national basis by the various actors of health care, we will have to face, given the present trends, a dramatic increase of the bur- den of hepatitis C in the next 15 years, due to the com- plications of cirrhosis and hepatocarcinoma, leading to significant morbidity and mortality and increase of the indications for liver transplantation. This will of course be accompanied by an increase of the health costs whereas organized and planned strategies focused on prevention, screening of high risk groups, optimal and early management of patients who can benefit the most of the antiviral treatment (which can now cure the dis- ease in 50 to 60% of the cases) have been demonstrated to be cost-effective (4).
Hepatitis C virus : the burden of the disease
Chronic hepatitis C infection affects approximately 3% of the world population and is responsible for a large proportion of patients with cirrhosis, end-stage liver diseases, hepatocellular carcinoma and for those who are candidates for liver transplanta- tion or die of liver-related complications.
The health care burden of this infection, whose epidemic peaked in the 1980s, is expected to significantly increase in the next 15 years in the absence of an organized national strategy.
On the other hand, hepatitis C infection can be easily diagnosed with third generation enzyme immunoassay and indications for molecular biology-based assay are well defined. Composite scores and non-invasive markers of fibrosis may in the future replace liver biopsy which is still recommended in the presence of chroni- cally elevated transaminases and indications for antiviral treat- ment. (Acta gastroenterol. belg., 2002, 65, 83-86).
HCV day : conclusions and requests of the Belgian Association for the study of the liver
The first Belgian HCV Day, held in Brussels on November 26, 2001, was as a success. About 200 parti- cipants were present and information related to hepatitis C, requests of the BASL and requests of the patients' associations published in the white book were largely diffused by the medical and general press.
The main regret is the low rate of participation of general practitioners and the total absence of politicians at this meeting.
Risk factors for hepatitis C : past, present and future
Patients at risk for hepatitis C (HCV) are those exposed to a major risk factor (i. e. blood transfusion prior 1990, and intra- venous drug abuse), and those exposed to a minor risk factor (sex- ual, mother-to-infant transmission, household contact, nosocomial contamination). The present paper aims to review the current and past modes of transmission of the virus C. (Acta gastroenterol. belg., 2002, 65, 87-89).
Economic evaluation for hepatitis C
This paper describes the methods used in economic evaluation and illustrates the challenges of assessing the cost-effectiveness of new interventions in Hepatitis C (HCV), where the impact of interventions needs to be assessed over the patient's lifetime.
This paper provides an example of an economic evaluation in HCV using a model estimating the cost-effectiveness of combina- tion therapy (CMB) for patients with mild HCV. The preliminary results from the model suggested that for 1000 cases with mild dis- ease CMB lead to 55 fewer deaths from liver disease compared to no treatment, an average gain of 1.2 life years. Although CMB lead to additional costs of 14,882 EURO's, the cost-effectiveness ratio was 8,490 EURO's per Quality Adjusted Life Year (QALY), which suggests the intervention is relatively cost-effective. The sensitivity analysis showed that the cost-effectiveness ratio was sensitive to the effectiveness of the intervention, and the progression rates between mild disease and cirrhosis.
A large UK study is collecting data on the effectiveness of CMB for patients with mild disease, and the costs and quality of life for patients at different stages of HCV. These data will be used to improve the projections of the model. In general, economic evalu- ations can provide information to help decide where priorities lie both in HCV, and other disease areas. (Acta gastroenterol. belg., 2002, 65, 104-109).
Impact of hepatitis C virus infection on the aetiology of cirrhosis and hepato- carcinoma in three affiliated hospitals in southern Belgium
In a consecutive series of 411 patients with cirrhosis attending the outpatient liver clinics of 3 general hospitals located in the southern part of Belgium, hepatitis C virus infection accounted for 20% of the cases, far behind alcohol (63%). However, in a consecu- tive series of 57 hepatocarcinoma superimposed on cirrhosis, hepatitis C virus infection was the main aetiological factor accounting for 44% of the cases. (Acta gastroenterol. belg., 2002, 65, 80-82).
National campaign against hepatitis C in France (1999-2002)
Since 1988, several measures have been applied in France to control HCV infection. HCV seroprevalence in the adult popula- tion is estimated at 1.1% (500 000 to 650 000 persons) and the number of chronically infected at 400 000 to 500 000 persons. In 1994, most of them might not be aware of their infection. Blood products administration and injecting-drug use are identified as the main transmission routes.
The national hepatitis C plan (1999-2002) was based on scien- tific data and developed after a consensus conference and several expert consultations. It involves six programs and quantified objectives : prevention of new infections, enforcement of screening access ; improvement of care management ; implementation of a surveillance system, clinical research and evaluation. Specific financial supports were attributed for the implementation of the plan. The 2001 progress report confirmed a major increase in national and regional actions.
In 2000, considering the high proportion of persons still un- aware of their infection (at least one third) and the increase of treatment efficacy, the target population of the screening strategy was considerably extended after scientific analysis. A national con- sciousness-raising campaign directed at general practitioners was launched in June 200O.In 2001, a media campaign directed to the general population was developed, in newspapers and on radio stations. Since the end of 1999, a national toll free phone number provides information to the public. In order to improve access to screening, a new regulation added HCV testing to the missions of anonymous and free HIV testing centres, as well as of family plan- ning centres. The hepatitis C prevention strategy is still included in a national public health program and improved in view of its renewal. (Acta gastroenterol. belg., 2002, 65, 87-112-114).
Issues in managing patients with chronic hepatitis c in public hospitals
Public hospitals in Belgium are taking care of a disfavoured people such as drug addicts, alcoholics, patients with low income and people referred by refugee centres. Many of these patients are at risk of hepatitis C. The medical and paramedical staff is facing numerous problems in taking care of these patients. Requests of hepatologists from public hospitals are a more effective psycho- social management, an increase of the framing in these hospitals, and a more rapid process of reimbursement of medication for treatment of hepatitis C, allowing to treat the patients according to international standards. (Acta gastroenterol. belg., 2002, 65, 101-103).
Treatment of hepatitis C : impact on the virus, quality of life and the natural history
Results of treatment for chronic hepatitis C have improved sub- stantially during the last decade. Combination treatment with interferon alpha 3 MU tiw and ribavirin 1000-1200 mg daily dur- ing 24 to 48 weeks leads to sustained virologic response (SVR) in approximately 40% of patients, two to three times more than interferon alpha monotherapy. It was considered standard thera- py at the EASL Consensus Conference of February 1999. Recently, results have been published on treatment with pegylated interferons alone and in combination with ribavirin. Pegylated interferon treatment leads to almost doubling of SVR rate as com- pared with standard interferon monotherapy. Combination of pegylated interferon alpha with ribavirin is most promising, lead- ing to a SVR rate of 54 to 56%. It is to be expected that this treat- ment will become the new standard. Selected patients with geno- type 2 or 3 have now a SVR rate of almost 80%. Response to treat- ment also leads to significant improvement of quality of life and survival, probably by reducing the risk of developing hepatocellu- lar carcinoma. Recent data suggest that early interferon alpha treatment of patients with acute hepatitis C largely prevents thde- velopment of chronicity. (Acta gastroenterol. belg., 2002, 65, 90-94).
Management of hepatitis C virus infections in intravenous drug users
Intravenous drug use is a major route of hepatitis C virus (HCV) transmission. In Belgium, more than 70% of the intra- venous drug users (IVDUs) are HCV seropositive. In the past, medical treatment of HCV-positive IVDUs has been controversial. However, current studies support that the anti-HCV therapy of IVDUs should be the same as in other HCV-infected patients. In prison populations, HCV screening and therapy has to be per- formed. Patients should be counseled about the benefits of alcohol abstinence, should be educated about safer injection techniques to avoid reinfection, and should be vaccinated to avoid hepatitis A or B co-infections. Treatment of HCV infections should not be with- held from patient populations with complicated social problems. Physicians should rather develop individual treatment and follow- up plans in order to optimize compliance in IVDUs. (Acta gas- troenterol. belg., 2002, 65, 99-100).
What can be done in Belgium for fighting against hepatitis C ?
Belgium is a federal country with three regions and three communities. Competences of Regions are based on territories, while competences of communities are based on language-speaking. Health care is paid and managed by the federal administration of Public Health and Social Affairs as well. Preventive care, such as vac- cinations and screening, are performed by the communi- ties. A perverse side-effect of this repartition is that, if prevention avoids mortality and costs, benefits and return are for the federal administration. Thus, benefits of prevention are not fully perceived as they should be. Nevertheless, the federal government now assists com- munities in prevention programs such as screening of breast cancer or childhood vaccination.
Hepatitis C in children and adolescents : mode of acquisition, natural history and treatment
Hepatitis C is nowadays mainly acquired in childhood through vertical transmission, while transfusion or surgery related conta- mination is no more significant. The risk of maternal transmission is related to presence and amount of maternal HCV RNA at the time of delivery. Infection rate is higher in children form HIV pos- itive mothers, and higher if they are themselves co-infected with HIV. Breast milk feeding is not a risk factor, and there is so far no argument to propose cesarean delivery to HCV positive mothers. Treatment with interferon alone is poorly efficient, although pedi- atric studies remain scarce. Combination treatment using Ribavirin plus interferon, or Ribavirin + pegylated interferon yield a higher success in eradicating viral infection in adults. These treatments can be considered for children in selected cases. (Acta gastroenterol. belg., 2002, 65, 95-98).
Epidemiology of hepatitis C in Belgium : present and future
Based on currently available epidemiological data, Belgium appears to belong to the low endemicity countries for hepatitis C, with an estimated annual incidence of 3/100,000 clinical cases ; a survey among the Flemish population showed an overall sero- prevalence of 0.87% (1993-1994). There was no statistically signif- icant difference in anti-HCV prevalence between men and women. A significant increase of the anti-HCV prevalence with increasing age was observed. In the French Community there was an overall seroprevalence of 0.6%.
Developing surveillance for hepatitis C has proven to be diffi- cult, since it requires confirmation tests. Techniques detecting hepatitis C antibodies in saliva will replace the need for serum samples, making prevalence studies more accessible. (Acta gas- troenterol. belg., 2002, 65, 78-79).
Health strategy on HCV in the Netherlands
The current basis for the health care policy on hepatitis C in The Netherlands is an advisory report of the national Health Council, published in 1997.
The Council confirmed that : Chronic hepatitis C (HC) is to be considered as a serious disease ; the hepatitis C virus (HCV) can be detected easily and accurately ; transmission of HCV occurs mainly via blood ; the prevalence of HC is low in The Netherlands and comparable to or somewhat lower than other countries in Northern Europe ; treatment is possible and worthwhile ; patients have the right to be provided spontaneously with relevant infor- mation ; the general population lacks adequate knowledge about the essentials of HCV infection, preventing them from taking ade- quate measures for their own health.
Cost-effectiveness of peginterferon alfa-2b plus ribavirin compared to interferon alfa-2b plus ribavirin as initial treatment of chronic hepatitis C in Belgium
Initial therapy with peginterferon alfa-2b and rib- avirin results in a higher sustained virological response but is more expensive than interferon alfa-2b and rib- avirin.
The objective of the analysis was to examine the cost- effectiveness of peginterferon alfa-2b combination therapy versus interferon alfa-2b combination therapy for treatment naïve chronic hepatitis C patients in Belgium.
