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Home > HSE publishes hepatitis C strategy.

Long, Jean (2013) HSE publishes hepatitis C strategy. Drugnet Ireland , Issue 44, Winter 2012 , pp. 16-17.

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The Health Service Executive published the hepatitis C strategy in September 2012.1 The strategy contains updated epidemiological information on hepatitis C and details of new direct-acting antivirals. 

The Hepatitis C Strategy Working Group summarised the epidemiology of hepatitis C, which is a disease of the liver caused by a virus identified in 1989. This viral disease is spread from person to person through contact with infected blood or other body fluids. Unsterile injection equipment and infected blood or blood products are the major risk factors for the transmission of the virus. There are usually no symptoms associated with the acute and early chronic stages of hepatitis C disease.  Chronic infection occurs in 70%–80% of adults who are infected with the virus. Symptoms of chronic infection may include: ongoing flu-like symptoms, joint pains, abdominal pain, loss of appetite, altered bowel habit, mood swings and/or an inability to sleep. Complications of chronic hepatitis C include liver cirrhosis, liver failure and liver cancer. There are six genotypes for hepatitis C; treatment outcomes are dependent on genotype and other factors. In Ireland injecting drug users are likely to have genotypes 1 or 3.2 Certain factors have been identified as increasing the severity of the disease and these are alcohol intake, co-infection with HIV or hepatitis B, super-infection with hepatitis A and older age at infection.
 
The working group reviewed the effectiveness of treatment and reported that hepatitis C can be treated with a combination of two or three anti-viral agents. The medication used to treat this disease includes pegylated interferon, ribavirin and more recently (in the USA) the addition of telaprevir or boceprevir. The addition of either telaprevir or boceprevir to the existing treatment (pegylated interferon and ribavirin) increases the success of the treatment for those with genotype 1. When treated with a combination of the three anti-viral agents, 80% of the hepatitis C genotype 1 patients are likely to experience sustained viral clearance, compared to 50% when only the two drugs (pegylated interferon and ribavirin) were used. There are contra-indications to hepatitis C treatment which include pregnancy; severe depression or other mental illness; renal disease; autoimmune disease; and end-stage liver cirrhosis.
 
The working group reported that the prevalence of hepatitis C among those infected through injecting drug use or the administration of blood and blood products was high. For injecting drug users the prevalence was between 62% and 81% prior to 2003 while 1,700 people were infected through blood and blood products. The prevalence in the general population is unknown but was 0.02% among blood donors between 2007 and 2010 and was 1% among attendees at antenatal clinics. There are only two historic studies that examined the incidence of hepatitis C among drug users. One study estimated the incidence of hepatitis C among 100 injecting drug users attending treatment in Dublin between 1992 and 1998 who had an initial negative test and a repeat test within nine months.3 The authors reported that the incidence of hepatitis C was 66 per 100 person years. A later study reported an incidence of 24.5 per 100 person years among a sample (358) of opiate users (including some non-injectors) attending treatment in the former South Western Area Health Board in 2001/2002.4 Comparisons between these studies are difficult as it is not possible to ascertain the proportion of non-injectors in the sample surveyed in the later study. Studies in Ireland identify homeless people, prisoners and asylum seekers as being high-risk populations for hepatitis C, largely because a high proportion of prisoners and homeless people inject drugs. The working group reports that asylum seekers often come from countries where hepatitis C is endemic.
 
There were 2,800 discharges from acute hospitals with a principal diagnosis of chronic viral hepatitis C between 2005 and 2010 and there were 1,193 discharges with a principal diagnosis of primary liver cancer. There were 703 cases of hepatocellular carcinoma registered by the National Cancer Register Ireland between 1994 and 2010. The NCRI estimates that 30% of hepatocellular carcinoma cases were hepatitis C positive. The liver transplant unit at St Vincent’s University Hospital reported that 42 (13.5%) of 311 liver transplant cases between 2000 and 2006 had hepatitis C.
 
The new national hepatitis C strategy makes 36 recommendations: 8 covering surveillance; 14 on education, prevention and communication (through 6 overarching themes); 6 on screening and testing; and 8 on treatment (through 7 overarching themes).
 
The recommendations for ensuring accurate surveillance are:
·         Ensure laboratory requests for hepatitis C serology contain patient identifiers and clinician details.
·         Encourage clinicians to notify newly diagnosed cases of hepatitis C and provide relevant information where possible.
·         Commence enhanced surveillance (including the collection of risk factors) for newly diagnosed cases of hepatitis C
·         Establish a national register of patients diagnosed with hepatitis C
·         Commence appropriate public health follow-up on newlynotified cases of hepatitis C
·         Estimate the prevalence of hepatitis C and identify risk factors among the general population
·         Complete a modelling exercise to estimate future disease burden and aid service planning
·         Conduct follow-up studies amongst injecting drug users to identify seroconverters so as to measure incidence rate.
 
The recommendations for maximising prevention and ensuring clear and accurate information are:
·         Treat existing drug addiction among injecting drug users.
·         Prevent transition from smoking heroin to injecting heroin and encourage current injectors to move to treatment or harm-reduction approaches.
·         Improve provision of harm-reduction materials through nationwide access to and uptake of comprehensive set of materials and appropriate communications with respect to language, literacy and accuracy.
·         Ensure staff and peer-educators are recruited to pre-agreed standards and have appropriate training and materials to provide accessible and accurate information.
·         Plan and implement a campaign to raise awareness amongst those who may previously have been diagnosed with hepatitis C or who may have been at risk of infection in order that they consider accessing new treatment options.
·         Regulate services that provide body-piercing, tattooing and permanent make-up.
 
The recommendations for ensuring screening and diagnosis are available to the appropriate risk populations in a timely manner are:
·         Improve availability of and access to facilities for screening, testing and diagnosis available in primary and community care services with adequate and timely laboratory facilities.
·         Enhance prison-based services with respect to risk assessment, screening and follow up.
·         Offer and promote screening for hepatitis C and other blood-borne diseases to those who attend services such as needle-exchange programmes and other harm-reduction services.
·         Continue targeted antenatal screening for those with risk factors for hepatitis C infection and consider the evidence for introduction of universal screening at regular intervals.
·         Ensure the NVRL provide previous tests results to medical practitioners who ascertained the patient’s consent.
·         Establish guidelines on hepatitis C screening for individuals from endemic countries or new entrants to the Irish healthcare system.
 
The recommendations for ensuring that evidence-based hepatitis C treatment and other supports are available to patients in a timely manner are:
·         Ensure governance, evidence-based protocols and review is available to diagnose people with hepatitis C and treat if required.
·         Develop, implement and evaluate a treatment model appropriate to the prison setting on a national basis.
·         Establish a postgraduate diploma in hepatitis C management for physicians and nursing staff.
·         Undertake a formal assessment of the needs of individuals infected with hepatitis C, other than through contaminated blood and blood products, through an increased number of clinical nurse specialist posts and subsequent needs assessments.
·         Develop a role for general practitioners (with special qualifications) to monitor hepatitis C treatment in primary and community care in consultation with other appropriate medical specialists.
·         Provide patients, particularly those with chaotic lifestyles and other social problems, with practical supports to enable them to attend for and adhere to treatment.
·         Provide interventions to assess and if necessary reduce alcohol intake in patients with hepatitis C.
 
 
1. Hepatitis C Strategy Working Group or HSE National Social Inclusion. (2012) National Hepatitis C Strategy 2011–2014. Dublin: Health Service Executive.  www.drugsandalcohol.ie/18325
2. Conroy A, Coughlan S, Dooley S and Hall WW (2003) Prevalence of hepatitis C genotypes in Ireland. Irish Journal of Medical Science, 172(2, Supplement 1): 15.
3. Smyth B, O'Connor JJ, Barry J and Keenan E (2003) Retrospective cohort study examining incidence of HIV and hepatitis C infection among injecting drug users in Dublin. Journal of Epidemiology and Community Health, 57(4): 310–311.
4. Grogan L, Tiernan M, Geoghegan N, Smyth B and Keenan E (2005) Bloodborne virus infections among drug users in Ireland: a retrospective cross-sectional survey of screening, prevalence, incidence and hepatitis B immunisation uptake. Irish Journal of Medical Science, 174(2): 14–20.

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