Epidemiology of HCV in Europe

International Conference Reporter from

11th World Congress of Gastroenterology (WCOG)

Vienna, Austria

Sept 11, 1998

Epidemiology of HCV in Europe

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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