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Eradicating infectious diseases – could hepatitis C be next?

Recent history shows that the combination of medical advances and well-coordinated global public health campaigns can eliminate deadly pathogens. Smallpox was officially declared eradicated in 1980; annual polio case numbers have fallen by over 99 per cent since 1988, and it now exists only among the world’s poorest and most marginalised communities. Is the hepatitis C virus next on the list?

What is hepatitis C?

Hepatitis C is a viral infection that can lie dormant for decades, then cause liver inflammation and serious disease. Many people with hepatitis C experience few symptoms; others feel varying degrees of fatigue (often dismissed as part of ageing); 15–20 per cent develop cirrhosis of the liver 20 or more years after infection; and a small number of people may suffer liver failure or develop liver cancer.1

Hepatitis C affects 130–150 million people worldwide, and up to half a million people die each year from liver diseases related to the virus.2 An estimated 230,000 Australians are living with hepatitis C;3 most (but certainly not all) have contracted it through unsafe injection of illicit drugs such as heroin and methamphetamine. The long-term healthcare costs associated with untreated hepatitis C infection in Australia run into billions of dollars.

Hepatitis C in western Victoria

While usually regarded as a problem for urban or metropolitan communities, injecting drug use has been occurring and spreading hepatitis C in western Victoria for many years. Epidemiologists from the Burnet Institute interviewed dozens of Western District drug users in the early 1990s, and found many had been injecting for a decade or more.4 Although their hepatitis C prevalence was relatively low, the incidence of infection (the number of new infections per 100 people per year) was much higher in methamphetamine injectors in the Western District than in Melbourne, implying that prevalence was rising.

Illicit drug injecting and hepatitis C in regional Victoria has not been studied since the mid-1990s, but the rise in the use of crystal methamphetamine (‘ice’) across Victoria in recent years suggests that the problem is pervasive. A crude estimate can be derived by applying the national prevalence of hepatitis C infection to Western Alliance’s regional population.5 This calculation indicates that nearly 7000 western Victorians are living with the disease and are at risk of the health complications mentioned above.

New treatments offer a solution

New drugs listed on the Pharmaceutical Benefits Scheme (PBS) on 1 March this year offer the nearest thing yet to a cure for hepatitis C infection – and even hold out the prospect of eradicating the virus in Australia.

In a farsighted and economically pragmatic move, the Australian government is spending $1 billion over the next four years on new, direct-acting antiviral treatments. These new treatments are available to anyone aged 18 years or over, regardless of the severity of their liver disease or whether they have previously injected or continue to inject drugs. This unrestricted treatment access, which is not the case in most countries, makes the elimination of hepatitis C from Australia a real possibility.

Direct-acting antivirals are more effective and have fewer side effects than previous treatments. The cure rate is over 90 per cent, and they require the person to undergo treatment of only 8–12 weeks of once-daily tablets. By way of comparison, the older, largely interferon-based treatments are debilitating, cure only 50–80 per cent of patients (depending on hepatitis C genotype) and require weekly dosing for 24–48 weeks.

Eliminating hepatitis C

In an ABC interview in March 2016, Professor Margaret Hellard of the Burnet Institute stated that, thanks to the PBS listing of the new direct-acting antivirals, ‘Australia has the ability to eliminate [hepatitis C] as a public health threat over the next 10 to 15 years.’ She noted that ‘the next hurdle will be to ensure our health systems and services are set up well to ensure people can access the therapies in a timely way. That will be our challenge in the next six to 12 months.’

Professor Hellard’s comments echoed those of Helen Tyrrell, CEO of Hepatitis Australia, who earlier this year had pointed out that ‘… there are many people in Australia with hepatitis C who really don’t know that these medicines are available yet. They were probably diagnosed decades ago, years ago when treatments really weren’t that acceptable.’6 Ms Tyrell said that people living with hepatitis C need to be educated about the new treatments, and that new models of care must shift treatment out of hospitals and into the community.

Raising awareness

Insufficient community awareness of hepatitis C in regional Victoria has been identified as a problem. At a forum on hepatitis, held in Warragul in late 2015, Associate Professor Ben Cowie, from The Peter Doherty Institute for Infection and Immunity, said hepatitis C is being diagnosed at a greater rate in regional and rural Victoria than in Melbourne. He described the reasons for this as multiple and varied, but stated that ‘there’s a real lack of community awareness and lack of knowledge among healthcare workers about how much viral hepatitis is around.’

Professor Cowie added, ‘We should be concerned about this because liver cancer, which is predominantly caused by viral hepatitis in Australia, is the fastest increasing cause of cancer deaths in Australians … All of those deaths are preventable through early diagnosis and treatment.’

What can we do?

The message for the western Victorian healthcare sector is clear. It is likely that several thousand people in the region have the hepatitis C virus and can benefit from the new direct-acting antivirals. All general practitioners can prescribe them. Leaders in the sector need to assess and (if necessary) raise the awareness of clinical and other front-line workers about the new hepatitis C antivirals; strive to inform potential recipients about the new drugs; and above all, ensure the region has sufficient capacity to prescribe and deliver hepatitis C antiviral therapy as needed.


References

  1. Hajarizadeh B, Grebely J and Dore GJ (2013) Epidemiology and natural history of HCV infection, Nature Reviews. Gastroenterology and Hepatology, 10(9): 553–62.
  2. Shepard CW, Finelli L and Alter MJ (2005) Global epidemiology of hepatitis C virus infection, The Lancet Infectious Diseases 5: 558–67.
  3. Sievert W, Razavi H, Estes C, Thompson AJ, Zekry A, Roberts SK and Dore GJ (2014) Enhanced antiviral treatment efficacy and uptake in preventing the rising burden of hepatitis C-related liver disease and costs in Australia, Journal of Gastroenterology and Hepatology 29(S1): 1–9.
  4. Aitken CK, Brough R and Crofts N (1999) Injecting drug use and blood-borne viruses: A comparison of rural and urban Victoria, 1991–1995, Drug and Alcohol Review 18(1): 47–52.
  5. The Australian Bureau of Statistics gives population estimates for four regions that roughly correspond to Western Alliance’s footprint, but also include Mildura, Echuca and other regional centres and rural areas in north-western Victoria.
  6. Swann, Norman: Hepatitis C treatment coming to PBS. 22 February 2016.

For more information

  • Better Health Channel: quality-assured and reliable, up-to-date, locally relevant and easy to understand health and medical information.
  • Country Awareness Network (Victoria): resources, advocacy, referral and education for country people infected with and affected by hepatitis C.
  • Hepatitis Victoria: the peak not-for-profit community organisation working across the state for people affected by or at risk of viral hepatitis.