Public health challenges for controlling HCV infection (2002)

1. In spite of the advances that have been made in our understanding of hepatitis C virus (HCV) biology, the epidemiology and natural history of HCV infection, and the progress in the primary and secondary prevention of HCV infection that has been made, major public health efforts to prevent and control this infection in the global population are still required.

2. Although the first clinical trials of a therapeutic type against HCV are under way, there is no short-term prospect for the introduction of any kind of vaccine against this virus. The conclusions and recommendations arising from this meeting are made in the context that hepatitis C would not be a vaccine-preventable disease in the foreseeable future.

3. Hepatitis C prevention should be viewed in the context of: (1) Primary prevention of newly infected persons; (2) Secondary prevention of transmission from known infected persons to others; (3) Tertiary prevention of the consequences of chronic HCV infection.

4. Primary prevention should focus on identifying persons at increased risk of HCV infection and providing HCV testing, counselling and health education concerning risk and harm reduction, and substance abuse treatment where appropriate.

5. There is a need for health education and awareness campaigns about HCV to be targeted both to the general public and to health care providers. Only a relatively small proportion of individuals infected with HCV are currently aware of their infection. Moreover, even in 2002, a large number of medical professionals are not sufficiently aware of HCV infection and its implications, and may fail to recognise the disease in their patients. In order to envision appropriate counselling, this lack of awareness by health care professionals of risk factors for infection, diagnostic tests and recent advances in treatment options also needs to be rectified. In short, all health care providers need to be better informed about HCV infection and how to manage and counsel their patients with this infection. Collaboration with patient support groups should be sought and developed.

6. There is a need to identify those infected with HCV to achieve the goals of secondary and tertiary prevention, which includes counselling to reduce the risk of transmission through donating blood, serum, or organs; injecting drug use; and high risk sexual practices. These persons also need medical evaluation for possible treatment in order to prevent progression of their chronic liver disease. They need additional counselling with regard to: (1) Reduction of further liver injury from the consequences of alcohol consumption and co-infection with other hepatitis viruses and HIV; (2) Vaccination against hepatitis A and B, influenza, and possibly against Streptococcus pneumoniae infection.

7. Because of overlapping routes of transmission and populations that are at risk for viral hepatitis, HIV/AIDS, and other sexually transmitted infections, it is important that identification and prevention strategies should be integrated.

8. The problem of identifying all individuals infected with HCV and bringing them under medical attention is compounded by the fact that a large proportion of individuals with HCV infection live in developing and transitional economy countries where resources are scarce, screening of blood and blood products is not performed, the diagnosis of HCV infection is difficult, and treatment is not affordable.

9. There is still insufficient epidemiological data on the prevalence and incidence of HCV infection in many countries. Therefore, further studies, particularly evaluating the general population are warranted in most places. The complexity of reporting highlights the need for organisations such as WHO, CDC, and VHPB to develop guidelines on methods to obtain representative population-based HCV infection prevalence data and case definitions for reporting purposes.

10. Injecting drug use continues to be the source of HCV infections in most developed and some transitional economy countries. Because a high proportion of incarcerated persons have used injection drugs, there is a high prevalence (30-80%) of HCV infection in this population. This stresses the importance of the use of harm-reduction (harm-minimisation) procedures in prisons.

11. To minimise the spread of HCV among intravenous drug users, harm reduction involves more than just needle and syringe exchange. It must also involve swabs, filters, spoons, water, and any other equipment used. One of the major actions recommended is the necessity for needle exchange programmes to be introduced on a far larger scale, including the use of commercially available drug-paraphernalia (e.g., Stericup ). Collaboration with patient support groups should be sought to enhance the impact of prevention programmes.

12. Evidence-based information on nosocomial infections dramatically proves the impact of unsafe injection procedures, and the resulting high chronic HCV infection rates. In some countries unsafe injection techniques are now the predominant mode of acquisition of HCV infection. Particularly important in this regard are the following:

• Using only sterilised medical equipment. Unsafe medical injections may be eliminated by: (1) Changing behaviour among patients and health care workers to decrease injection overuse and improve injection safety; (2) Providing access to necessary equipment and supplies.
• Applying proper management of sharp waste.
• Recent literature has stressed that in haemodialysis units, in particular, recommended procedures are not being carried out adequately, and hand-washing techniques remain faulty.

13. Multidose vials are also a cause of nosocomial transmission of HCV. Therefore:

• Single-dose vials should be used wherever possible. If multidose vials must be used, the septum should always be pierced with a sterile needle, and a needle must not be left in place in the stopper.
• Each injection should be prepared in a clean designated area where blood or body fluid contamination is unlikely.

14. Other routes of infection, such as through sexual activity or intra-familial transmission, play a much lesser role in spreading HCV.

15. Testing for HCV:

• Of all patients with persistently raised serum ALT levels,15% prove to be chronically infected with HCV. It is recommended that individuals with persistently raised serum ALT levels that are unexplained should be tested for HCV. Screening of the whole population is, however, not recommended.
• Patients with defined extrahepatic manifestations of HCV should be tested for the virus.
• It is self-evident that testing for HCV should be undertaken only if appropriate counselling can be given and appropriate treatment is available.

16. Disease progression - Controversy still exists over the proportion of patients acutely infected with HCV who progress to cirrhosis. Hospital-based data on patients with symptomatic chronic HCV infection give far higher rates of progression to cirrhosis than do analyses of all patients infected with the virus. When patients in the Irish outbreak of HCV infection caused by  contaminated anti-D immunoglobulins were followed-up, only 2% developed cirrhosis, and in other large-scale studies in children with posttransfusion HCV infection and in intravenous drug users less than 5% progressed to cirrhosis.

17. In order to reduce the morbidity and mortality caused by HCV infection, the objective of treatment should be:

• Cure by completely eliminating HCV and normalising serum ALT levels. If this is not possible, the objectives should be to:
  - Stop disease progression;
  - Improve quality of life;
  - Reduce transmission of the virus;
  - Reduce the pool of chronic carriers.

 18. Despite a greater awareness of HCV infection, earlier diagnosis through improved laboratory techniques, and the recent introduction of more effective treatment, the overall outcome of HCV infection has not improved appreciably in recent years.

19. Treatment of chronic HCV infection with interferon does result in viral clearance in some patients, and in others it slows down progression to fibrosis. More recently, controlled trials have demonstrated that combined treatment with pegylated interferon and ribavirin has produced a greater number of sustained responses, depending on the genotype of the virus. Higher response rates are obtained with 6 months of treatment in patients with genotypes 2 and 3. Treatment of persons infected with genotype 1 produces less encouraging results and there is also the need to treat for 12 months.

20. Treatment of acute community-acquired HCV infections in younger patients appears to have a higher success rate with respect to viral clearance and progression to chronic infection. If confirmed, early treatment with interferon alone or in combination with other drugs should reduce the burden of HCV disease.

21. In spite of the advances in the treatment of HCV infection, given the fact that the majority of patients infected with this virus are not under medical care, the overall impact of therapy on the number of patients who are chronically infected with HCV is relatively small.

22. The VHPB aims to contribute to the prevention and control of hepatitis C by: (1) Raising awareness among health care providers and policymakers of the public health significance of hepatitis C; (2) Informing them about the risk of HCV transmission through blood or blood products, injecting drug use, and high-risk sexual practices; (3) Stressing the potential impact of preventive strategies, including the effect on the prevalence of other infectious diseases such as hepatitis B and HIV/AIDS; (4) Collecting and collating epidemiological data on hepatitis C, especially in Europe.

References 

Viral Hepatitis Prevention Board. Public health challenges for controlling HCV infection. Viral Hepatitis Prevention Board meeting, Geneva, Switzerland, May 13-14, 2002. Viral Hepatitis 2002; 11.1.