Hepatitis C Virus - (Virtually)
All Patients Should Be Treated
Douglas
R. LaBrecque, MD
Chronic Hepatitis
C: Epidemiology and Economic Burden
I will be discussing the data which I believe indicate that
virtually all hepatitis C (Hepatitis C Virus) patients should be treated.
Before discussing the controversial aspects of this topic,
however, I will discuss the facts, just the facts, about which
there is little disagreement.
Slide 1. Worldwide Prevalence
This slide depicts a recent map of the worldwide prevalence
of Hepatitis C Virus infection. The prevalence of infection is greater than
10% in those areas shown in red, which include areas of Asia,
South America, and Africa. Much of the map indicates that
between 2.5% and 10% of the population are chronically
infected. The Centers for Disease Control (CDC) estimates that
1.8% of the US population is currently infected.
One point eight percent of the US population equates to
approximately 4 million US citizens and there are 170 million
individuals infected worldwide. Approximately 30,000 new
infections occur each year in the United States. Approximately
20% of these individuals will progress to develop cirrhosis
over the following 20 years. Eight to 10,000 individuals die
each year in the United States from Hepatitis C Virus complications. This
occurs at a rate of 2% to 5% per year once the patient
develops cirrhosis and the risk of developing hepatocellular
carcinoma (HCC) is 3% to 7% per year after the development of
cirrhosis. Overall, 35% to 40% of all liver transplants
performed in the US and Europe are performed for Hepatitis C Virus.
Slide 2. Estimated Hepatitis C Virus Incidence, United States, 1982-1996
This slide demonstrates that the incidence of acute Hepatitis C Virus in
the United States fell between 1982 and 1996. During that time
there were improved diagnostic tests for Hepatitis C Virus and yet the
incident rate fell despite our improved ability to diagnose
the disease. This was due to a decline in the disease among
transfusion recipients and a decline among injection drug
users. Because of this there is great hope that there will
eventually be a corresponding fall in liver disease related
deaths due to this decreased infection rate as well as the
development of improved selective treatments.
However, when I add the prevalence of Hepatitis C Virus to this graph,
you will note that the prevalence has continued to increase
despite the decreased infection rate due to the chronic nature
of Hepatitis C Virus infection and the body's inability to rid itself of the
virus on its own. This emphasizes the need for an effective
therapy.
Death rates due to Hepatitis C Virus are expected to increase over the
next 20 years. Estimates of death rates may underestimate the
actual death rate because of underreporting of liver disease
and underreporting of deaths due to liver disease on death
certificates and in other databases (Wong et al. Am J
Public Health. 2000;1990:1562).
Healthcare costs for Hepatitis C Virus include managing patients'
symptoms, managing other organ involvement, treating Hepatitis C Virus with
antiviral agents, and managing end-stage liver disease as well
as the cost of liver transplantation. Wong and coworkers
estimated that the annual US healthcare cost for Hepatitis C Virus will
exceed $1 billion by the year 2008 and continue to increase up
to at least the year 2015 (Wong et al. Am J Public Health.
2000;1990:1562).
Leigh and colleagues, using a more inclusive method of
estimating costs, arrived at a dramatically higher figure and
estimated the yearly cost of Hepatitis C Virus in the United States had
already exceeded $5 billion in 1997 (Leigh et al. Arch Int
Med. 2001;161:2231).
Slide 3. Costs of Medical Care (year)
This cost is comparable to what we spend on asthma care in
this country and of the diseases listed on this slide, Hepatitis C Virus is
the only one whose morbidity and mortality are predicted to
increase 2- to 3-fold over the next 20 years.
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