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Epidemiology of HCV in Europe
Dr D Lavanchy
Dr D Lavanchy of the WHO reviewed the prevalence of hepatitis C virus
(HCV) infection in Europe, making estimates based on published evidence,
and concluded that hepatitis C is a public health problem for this geographical
region, as well as the world in general.
Using stringent criteria for making the estimates, including age, sex,
and geography, 3 per cent of the world’s population may be infected
with hepatitis C virus. In Western Europe, on the other hand, only France
has a prevalence greater than (>) one per cent. In contrast, the prevalence
in Romania is the highest in Eastern Europe at 4.9 per cent. Of 31 European
countries (East and West) reporting HCV infection, the total prevalence
appears to be 1.2 per cent, as a best estimate. However, there are six
different HCV genotypes that can be present in different populations within
a single country. Thus overall prevalence for a particular country may
be misleading.
Significantly, HCV still appears to be spreading. In Egypt, no decrease
in prevalence is expected until 2005 to 2015. Prevalence ranges from 18
to 35 per cent in different parts of the country.
The Hungarian perception of hepatitis C management
Dr A Pár
Dr A Pár, Pécs, Hungary, explained that there is a one
per cent prevalence of hepatitis in his country, which translates into
100,000 individuals, 20,00 of whom will have chronic disease, and 6,000
of whom need antiviral treatment.
The main sources of infection are via blood transfusion, major surgery,
and unknown sources. Although 10 per cent of infections are found in health
care workers, there is no evidence of vertical transmission of HCV.
During the past five years approximately 1000 patients with HCV in 16
designated centres have received treatment, and which has mainly been
with interferon (IFN) a-2b. Some patients who failed with IFN monotherapy
have also received combination treatment with ribavirin and IFN. Predictors
of response to therapy have been identified, including time from transfusion,
serum ferritin, serum HCV RNA, previous HBV infection, fibrosis in liver
biopsy, and HLA DR3. Treatment with IFN has shown a trend in improvement
in hepatitis C patients.
Why to treat patients with chronic hepatitis C – the benefits
of IFN treatment
Dr Stefano Hadziannis
Dr Stefano Hadziannis, Athens, Greece, made a strong case for the treatment
of chronic hepatitis C with IFN, despite its (traditionally) modest success
rate. There are probably 170 million people in the world who are infected,
and 33 per cent will develop cirrhosis after 21 years, and one to two
per cent hepatocellular carcinoma after 29 year. Since HCV is usually
contracted in early life, it is a significant threat to survival.
Although the goal of therapy is eradication of the infection and cure
of the disease, treatment that changes the unfavourable clinical course
is still justifiable. Treatment with IFN has led to different responses
in different patients. The best response is sustained, where HCV RNA levels
have fallen and aminotransferase enzymes (ALT levels) normalise and remain
so six months after therapy termination. On the other hand, relapsers
have initial good response to therapy, but their HCV RNA and ALT levels
increase again after therapy is ended.
Longer duration of IFN therapy has increased the rate of sustained response,
and combination therapy with ribavirin has achieved a rate of 40 per cent
of patients. However, this dual therapy is not yet licensed in Europe.
New strategies of treatment are being evolved, including longer and more
frequent IFN treatment, which may increase the success rate even further.
A relevant consideration as well is that IFN treatment is more cost effective
than several other common procedures, such as therapy for hypertension
and screening blood products for HIV.
Who not to treat for chronic hepatitis C?
Dr M Manns
Dr M Manns, Hanover, Germany, suggested a number of patient groups who
might not benefit from IFN treatment. He reminded the audience that the
decision to treat depended on probable outcome, disease stage, viral and
host factors influencing response to treatment, and the risk of side effects.
Those with normal ALT levels or decompensated cirrhosis should not be
treated, and neither should those of advanced age ( 60 years), and those
infected with HIV with a high viral load. Drug and alcohol abusers would
not benefit from treatment, and neither would those with a history of
cardiac disease or suffering from haemoglobinopathies. A low HIV viral
load ( 1 million) and a CD4 cell count of
500 per cubic mm would justify treatment, although the increasing
number of long term survivors may bring about further refinements.
Finally, Dr Mann said that the benefits of treatment in children and
liver transplant patients had not been established.
Management of hepatitis in Romania
Dr A Streinu-Cercel
Dr A Streinu-Cercel, Bucharest, Romania, described the diagnosis and
treatment of hepatitis C in the country with the highest prevalence of
this disease in all Europe. At present, 169 serotyped patients have been
treated with IFN, and factors found to influence the success of therapy
included age, dose, (3 or 6 MU), and duration of therapy. He stated that
the response to therapy was good, although the treatment is expensive.
The response was also improved by ribavirin, in combination with IFN.
He strongly supported therapy for chronic hepatitis C.
In a summary of this session, given by Dr N Naomov, London UK, it was
stated that there are approximately 900,000 people with hepatitis C in
continental Europe. Successful treatment is possible, as shown by those
who have remained virologically free and biochemically normal, 10 years
after ending their therapy. Improvement in the success rate is continuing,
and now treatment can be more tailored to the individual, and various
indicators are available for who not to treat. Finally, patients who are
difficult to treat should be referred to appropriate clinical centres,
and should be included in clinical trials.
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