Differences in HCV Infection, and Effects of Treatment, Among Countries

Hepatitis C virus (HCV) infections have developed and spread at different rates in different countries, affecting outcomes of therapy, according to the October issue of Gastroenterology. Specific details of each population must therefore be considered in designing prevention and treatment programs.

Although there are many treatment options for HCV infection, many countries have insufficient public health surveillance systems to track HCV disease, mortality, and access to testing and medical care. This keeps health leaders from realizing the full threat of chronic HCV infection and the potential benefits that accompany testing, care, and treatment.

To fill this information gap, Sylvie Deuffic–Burban et al. created a country-specific Markov model of HCV progression based on published epidemiologic data (on HCV prevalence, screening, genotype, alcohol consumption, and treatments) and mortality reports for 6 European countries. The model was used to predict the incidence of HCV-related cirrhosis and its mortality until 2021 for each country.

From 2002 to 2011, antiviral therapy reduced the cumulative incidence of cirrhosis by 7.1% and deaths by 3.4% overall. Reductions in incidence and mortality values ranged from 4.0% and 1.9%, respectively, in Italy, to 16.3% and 9.0%, respectively, in France (see below figure).

Therapy for HCV infection (of different genotypes), from 2002 to 2011, reduced the cumulative incidence of HCV-related (A) cirrhosis and (B) death in each country.

Their model predicted that from 2012 to 2021, antiviral treatment of patients with HCV genotype 1 infection with protease inhibitor-based triple therapy will reduce the cumulative incidence of cirrhosis by 17.7% and mortality by 9.7%. The smallest reduction is predicted for Italy (incidence reduced by 10.1% and mortality by 5.4%) and the highest is for France (reductions of 34.3% and 20.7%, respectively).

Deuffic–Burban et al. found significant differences in the spread of HCV infection, leading to specific patterns of disease progression among European countries. The total number of patients with cirrhosis (including complications) would peak in Belgium in 2020, in France in 2021, in Germany in 2023, in Spain in 2030, and in the UK in 2033 in the absence of treatment; for Italy, the peak was already reached, in 2008.

The authors explain that the differences in distribution of cirrhosis, over time, are related to patterns of HCV infection. Belgium, France, and Germany have patterns similar to that predicted for the US. In Italy, an intensive epidemic appeared to have occurred during the 1950s and 1960s, mainly from poor hygiene during invasive procedures (surgery, gynecology, dentistry, vaccinations, injection of antibiotics and vitamins), whereas in other countries, the most intensive waves of the epidemic occurred during the 1980s, mainly related to transfusions and intravenous drug use. As a result, in Italy, although antiviral therapy should reduce HCV morbidity and mortality, it will not affect the year or magnitude of the peak; in all other countries, antiviral therapy should affect both.

In an editorial that accompanies the article, John W. Ward, David B. Rein, and Bryce D. Smith say that the model of Deuffic–Burban et al. shows that HCV disease can be averted, and lives saved, when improvements in HCV therapy are accompanied by expanded access to HCV testing, care, and treatment. Although few data are available, the authors estimate that with the exception of France, less than 50% of HCV-infected persons have been tested. The authors propose that increasing HCV testing and treatment could reduce cases of cirrhosis by an additional 26% and hepatitis C-related mortality by an additional 20%.

Limitations of the study, pointed out by Ward et al., include assumptions about past disease incidence, techniques to recreate treatment rates based on data from pharmaceutical sales, and the use of expert opinion in the place of observational data. Compared with other research on chronic, progressive diseases, the field of HCV epidemiology therefore has a long way to go.

Nonetheless, Ward et al. warn that, as for the US, all of these countries (with the exception of Italy) can expect increases in HCV-related cirrhosis into the next 10 years, and in Spain and the UK, for longer. In Belgium, France, and Germany, the epidemics of HCV-related disease are expected to peak within 10 years, leaving little time to expand the capacity for HCV testing, care, and treatment.

The editorial reminds readers that the effects of expanded HCV testing can only be achieved when persons found to be infected with HCV receive appropriate care and treatment. So, regardless of country, policies must be accompanied by resources for a comprehensive set of implementation activities (community education, provider training, laboratory quality assurance, and antiviral therapy).

Read the article online.
Deuffic–Burban S, Deltenre P, Buti M, et al. Predicted effects of treatment for HCV infection vary among European countries. Gastroenterology 2012;143:974−985.e14

Read the accompanying editorial.
Ward JW, Rein DB, Smith BD. Data to guide the “test and treat era” of hepatitis c. Gastroenterology 2012;143:887–889.

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