Hepatitis C: A New Look at the Affected Population

   

It is estimated that over 5 million people in the US are living with the hepatitis C virus (HCV) 1 and up to 75% are not aware they are infected2 . As of 2007, more people in the US die from chronic hepatitis C infection (15,106 deaths) than HIV (12,734 deaths). Hepatitis C is a curable disease, and HCV-related deaths are potentially preventable if people are identified and receive appropriate care before they develop liver failure or liver cancer. 3

   

    HCV is unusual in that it disproportionately affects baby boomers -- 82% of people infected with HCV were born from 1945 through 19654,5 (Figure). A majority of these people acquired HCV in the 1960s through 1980s, so they have lived with HCV for 20 to 40 years. The risk of cirrhosis, liver failure and liver cancer increases with longer duration of infection. In fact, HCV-related cirrhosis is projected to increase from 25% to 37% over the next decade, peaking at over 1 million cases by 2020 if there are no changes in screening, diagnosis, and treatment. 6     Baby boomers (1945-1965) account for 82% of HCV cases in the US5
        Vertex
        Figure adapted from Pyenson B. et al. 4     The CDC is evaluating new HCV screening guidelines that would recommend a one-time anti-HCV antibody test for everyone born from 1945 through 1965. It is estimated that an additional 121,000 deaths could be averted with the addition of age-based screening compared to current risk-based screening. 3 Moreover, two recent studies have shown that birth cohort screening for HCV infection is cost-effective and comparable to screening for cervical cancer or hypertension. 3,7
       
        HCV is a hidden epidemic. Most people are not aware of having been infected with HCV, do not have symptoms that bring them to medical attention for chronic hepatitis, and often lab abnormalities, such as mild elevation of liver enzymes, are attributed to other causes. In fact, only 15% of people infected with HCV have persistent ALT elevation.8 By the time these people present to medical attention with signs of liver disease, they may have developed severe complications, such as liver failure or liver cancer that can lead to liver transplant or death. We have a window of opportunity to identify people living with HCV before they develop severe complications.    
       
        In order to make an impact on this epidemic, people need to be tested for HCV while they are asymptomatic. Groups with a higher prevalence of HCV than the general population include3, 9,11

     
               
  • People born from 1945 through 1965
  •            
  • African Americans
  •            
  • Recipients of blood products or solid organ transplants before 1992, or clotting factor before 1987
  •            
  • Individuals with unexplained abnormal liver enzyme tests, even once (eg, current or past elevated ALT)
  •            
  • Individuals with past or current injection or intranasal drug use (even once many years ago)
  •            
  • Individuals engaging in high risk sexual activity
  •            
  • HIV-infected individuals
  •        
     


        Everyone who has a positive anti-HCV antibody test needs to have an HCV RNA (“viral load”) test to confirm that they have chronic infection.(Click Here to download screening algorithm) About 25% of people who have anti-HCV antibodies will have spontaneously cleared their infection in the past, and are not chronically infected12 . People who have detectable HCV RNA need to be referred to health providers who have experience taking care of people with HCV. 
       
        Vertex
       
        An average PCP has approximately 40 patients infected with HCV in his/her practice1,13 . This number may underestimate practices in urban areas, since these have a higher prevalence of people with HCV infection. 14,15Primary care physicians are the front line to identify patients with HCV infection. Timely identification and appropriate diagnosis are critical first steps to curing HCV patients. PCPs can play a key role in preventing avoidable deaths by providing prompt referrals to specialty providers experienced in treating HCV (See list of resources below). 
        Camilla Graham, MD
        Vice President, Global Medical Affairs
        Vertex Pharmaceuticals Incorporated
       
       
        Resources:
        – AASLD( http://aasld.org/PATIENTS/Pages/PhysicianReferralService.aspx)
        – ACG (http://patients.gi.org)<http://patients.gi.org/) 
       
        – AGA ( https://secure.gastro.org/GILocator/locator.asp)
       
       
        References:

 
       
                       
    1. Chak E. et al. Hepatitis C virus infection in USA: an estimate of true prevalence.
                      Liver Int. 2011;31:1090-1101. ( http://www.ncbi.nlm.nih.gov/pubmed/21745274)
    2.    
     
 

 

 
       
           
    1. Institute of Medicine. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C. Washington, DC: 
                      The National Academies Press; 2010. ( http://www.iom.edu/Reports/2010/Hepatitis-and-Liver-Cancer-A-National-Strategy-for-Prevention-and-Control-of-Hepatitis-B-and-C.aspx)
    2.    
     
 

 

     
               
                       
    1. Rein DB. et al. The cost-effectiveness of birth-cohort screening for hepatitis c antibody in U.S. primary care settings. 
                      Ann Intern Med. 2012;156:263-270. ( http://www.ncbi.nlm.nih.gov/pubmed/22056542)
    2.              
           
     

 

     
               
                       
    1. Pyenson B. et al. Consequences of Hepatitis C Virus (HCV):
                      Costs of a Baby Boomer Epidemic of Liver Disease. New York, NY: Milliman, Inc; May 18, 2009. Milliman report was commissioned by Vertex Pharmaceuticals.
                      ( http://publications.milliman.com/research/health-rr/pdfs/consequences-hepatitis-c-virus-RR05-18-09.pdf)
    2.              
           
     

 

     
               
                       
    1. Smith BD. et al. Hepatitis C virus antibody prevalence, correlates and predictors among persons born from 1945 through 1965, United States, 1999-2008 [AASLD abstract 394].
                      Hepatology. October 2011; 54(4):554A. ( http://onlinelibrary.wiley.com/doi/10.1002/hep.24666/pdf)
    2.              
           
     

 

     
               
                       
    1. Davis GL. et al. Aging of hepatitis C virus (HCV)-infected persons in the United States: a multiple cohort model of HCV prevalence and disease progression.
                      Gastroenterology. 2010;138:513-521. ( http://www.ncbi.nlm.nih.gov/pubmed/19861128)
    2.              
           
     

 

     
               
                       
    1. McGarry LJ. et al. Economic model of a birth cohort screening program for hepatitis C virus.
                      Hepatology. 2011 doi: 10.1002/hep.25510. [Epub ahead of print]. (http://www.ncbi.nlm.nih.gov/pubmed/22135116)
    2.              
           
     

 

     
               
                       
    1. Inglesby TV. et al. A prospective, community-based evaluation of liver enzymes in individuals with hepatitis C after drug use.
                      Hepatology. 1999;29:590-596. ( http://www.ncbi.nlm.nih.gov/pubmed/9918940)
    2.              
           
     

 

     
               
                       
    1. Centers for Disease Control and Prevention. Hepatitis C FAQs for the Public. 2009. 
                      http://www.cdc.gov/hepatitis/c/cfaq.htm#cFAQ08. 
                      Accessed April 11, 2012.
    2.              
           
     

 

     
               
                       
    1. O’Shea RS. Hepatitis C. Cleveland Clinic Foundation. 
                      http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/hepatitis-C. 
                      Accessed April 11, 2012.
    2.              
           
     

 

     
               
                       
    1. Centers for Disease Control and Prevention. 2010. The ABCs of Hepatitis. 
                      http://www.cdc.gov/hepatitis/Resources/Professionals/PDFs/ABCTable_BW.pdf.
                      Accessed April 11, 2012.
    2.              
           
     

 

     
               
                       
    1. Ghany MG. et al. Diagnosis, management, and treatment of hepatitis C: 
                      an update. Hepatology. 2009;49:1335-1374.
                      ( http://www.ncbi.nlm.nih.gov/pubmed/19330875)
    2.              
           
     

 

     
               
                       
    1. Ferrante JM. et al. Family physicians’ knowledge and screening of chronic hepatitis and liver cancer. 
                      Fam Med. 2008;40:345-351. 
                      ( http://www.ncbi.nlm.nih.gov/pubmed/18465284)
    2.              
           
     

 

     
               
                       
    1. The National Minority Quality Forum. Hepatitis C Index. www.maphepc.com. 
                      Accessed April 2012. Index project supported by Vertex Pharmaceuticals.
    2.              
           
     

 

     
               
  1. The US Census Bureau. www.census.gov. Accessed April 2012.
  2.