September 2012
LEWISHAM JSNA:HEPATITIS C SEPTEMBER 2012
What do we know?
Facts and figures
Key points
- Hepatitis C (HCV) is a blood borne virus that causes inflammation of the liver. In approximately 80% of cases it leads to chronic liver disease, including cirrhosis, and in 1-2% of infection, primary liver cancer.
- Up to 90% of all new cases of hepatitis C in England are acquired through sharing injecting equipment during drug use2.
- It is estimated that there are over 2,000 people in Lewisham infected with HCV.
Definition of Hepatitis C
Hepatitis C (HCV) is a blood borne virus that causes inflammation of the liver. In approximately 80% of cases it leads to chronic liver disease, including cirrhosis, and in 1-2% of infection, primary liver cancer.
The course of the disease
People infected with HCV are often asymptomatic. Reported symptoms are varied and include fatigue, anorexia, nausea, influenza-like symptoms, abdominal pain and jaundice.
Approximately 15-20% of those infected clear the infection naturally within the first 6 months.However another 15-20% of those infected will develop acute hepatitis and 80% of those exposed will go on to develop chronic hepatitis(figure 1).
Figure 1 - Progression of Hepatitis C
Source: South East London Health Protection Unit (2009) Hepatitis C in South East London[1]
Disease progression is slow, often over many decades. The majority of patients undergo asymptomatic acute infection and are simply not aware that they have been infected until symptoms related to liver damage manifest. Some may experience non-specific symptoms (such as lethargy) making prompt diagnosis difficult.Approximately 50-85% of infected patients become chronic carriers.
In chronic carriers, around 15-20% will develop liver cirrhosis after 20 years (30% after 30 years) and each year, up to 5% of this group will develop primary liver cancer.Because the chronic carrier state rarely resolves spontaneously, pharmaceutical treatment to eradicate the virus is essential for these individuals.
Up to 90% of all new cases of hepatitis C in Englandare acquired through sharing injecting equipment during drug use[2].
Routes of transmission in UK
The major route for hepatitis C transmission in England is by sharing equipment for injecting drug use, usually via blood-contaminated needles, syringes and other paraphernalia[3]. It is estimated that up to 90% of all new cases in England are acquired in this way[4],[5].
Blood and blood products have been screened for hepatitis C since 1991. However, some who received blood or blood products before this date have been infected. For example, there is a high prevalence of HCV in people with haemophilia who received clotting factors before 19865.
Less frequently, infection can also occur where blood is transferred from one person to anotherwhen needles are re-used e.g.tattooing, electrolysis or acupuncture procedures5.
Vertical (mother to baby) transmission is estimated to be around 6%. However, this is increased to up to 40% when there is a co-infection with HIV4. There is no firm evidence of additional risk of transmission by breast feeding except perhaps in women who are symptomatic with a high viral load[6].
Sexual transmission occurs at a low rate (approximately 0.2 – 2% per year of relationship) but these rates increase if the index patient is also infected with HIV5.
This assessment will primarily focus on the needs of the injecting drug user (IDU) population in Lewisham, as sharing equipment for injecting drug use is the primary route of transmission of hepatitis C in the UK.
Prevalence
Prevalence rates vary worldwide. It is estimated that approximately 3% (180 million) of the world’s population is affected. The UK is considered to be a country of medium endemicity, where disease prevalence is approximately 1%2.
In the UK, numbers of chronically infected are estimated to be 216,000 and 10,381 new infections were diagnosed in 2010[7].In England,most recent estimates indicate that approximately 160,000 adults are chronically infected with hepatitis C2. The estimated number of infections in Lewisham is around 2,033 individuals[8].
There is no comprehensive national hepatitis C database held. Figures are drawn from various sources including laboratory reports, the National Treatment Agency and the National Unlinked Monitoring survey (UAM) which has 60 participating laboratories across the UK. In South East London, King’s CollegeHospital participates in the programme.
The UAM data offers a valuable guide to local prevalence among injecting drug users (IDUs). In 2010, the infection rate in IDUs in South East London was estimated around73% - an increase from 57% on the previous year (table 1). Possible reasons for this rise were not reported but may be a consequence of more targeted testing or reflect an actual rise in case numbers[9].
Table 1. UAM survey data showing sero-prevalence for HCV in injecting drug users in South East London, London and England between 2005 and 2010
2005 / 2006 / 2007 / 2008 / 2009 / 2010Number positive / 141 / 75 / 143 / 96 / 99 / 65
Total tested / 217 / 127 / 211 / 169 / 173 / 89
England / 48% / 46% / 46% / 44% / 49% / Not available
London / 62% / 61% / 65% / 57% / 59% / Not available
South East London / 65% / 59% / 68% / 57% / 57% / 73%
Source: Unlinked Anonymous Monitoring Survey of HIV and Hepatitis in Injecting Drug Users 2011
Within South East London, estimated prevalence is high for the most part with only Bexley being banded in a medium category8. Lewisham is banded as an area of high prevalence for hepatitis C in IDUs, i.e. higher than 50%8.
Trends
Patterns of injecting drug use are changing nationally. The proportion of recent IDUs in treatment has fallen by 9% in the past five years, indicating that new drug users are less likely to inject thanin the past (figure 2)[10].
Figure 2. Reported injecting status of all drug users entering treatment 2005-10
Source: National Drug Treatment and Substance Misuse Agency (2011) Injecting Drug use in England: a declining trend
New (younger) users are less likely to inject than those in the 35-44 year age group and those 40 years or over currently in treatment. This older age group isalso more likely to report current or previous injecting activity10.
Conversely, current levels of hepatitis C transmission among IDUs appear to be higher than a decade ago, as 23% of the recent initiates to injecting participating in the UAM survey were infected in 2010 compared with 12% in 2000 (table 2)8.
Table 2 Proportion of people who inject drugs who are hepatitis C antibody positive 2000-2010 England, Wales and Northern Ireland*
2000 / 2001 / 2002 / 2003 / 2004 / 2005 / 2006 / 2007 / 2008 / 2009 / 2010Current /former injectors / % / 38 / 39 / 42 / 46 / 45 / 45 / 44 / 43 / 43 / 47 / 47
First injected during preceding 3 years / % / 12 / 20 / 16 / 21 / 21 / 18 / 23 / 23 / 24 / 24 / 23
*includes Northern Ireland from 2002
Source: Health Protection Agency (2012) Data tables of the unlinked anonymous monitoring survey of HIV and Hepatitis in people who inject drugs
Sharing injecting equipment is in decline overall but a significant proportion of IDUs continue to share equipment. In 2010, 40% of IDUs had shared injecting equipment compared with 60% in 20005. Sharing equipment continues to be the primary risk factor for acquiring hepatitis C in those who inject drugs.
Morbidity and mortality trends
In the UK, hospital admissions for HCV-related end stage liver disease (ESLD) is rising. Hospital admissions rose from 612 in 1998 to 1, 970 in 2010 (figure 3)2.
Figure 3. Annual number of individuals in England¹, Scotland² and Wales¹ hospitalised with HCV-related ESLD* or HCV-related HCC: 1998-2010
Source: Health Protection Agency (2012) Hepatitis C in the UK
Deaths from end-stage liver disease (ESLD)and in those with HCV mentioned on their death certificates, arealso continuing to rise. Data for the UKfrom the Office for National Statistics show 98 cases were reported in 1996. This rose to 323 in 20102.
Figure 4. Deaths from ESLD* or HCC in those with hepatitis C mentioned on the death certificate in the UK: 1996-2010
Source: Health Protection Agency (2012) Hepatitis C in the UK
All national data sources (hospital admissions for HCV-related end-stage liver disease, liver transplants and deaths) show that HCV-related liver disease is rising. Modelling on current trends anticipates that in 2020, 15,840 individuals will be living with HCV-related cirrhosis or primary liver cancer in England2.
More cases of hepatitis C were reported in men during this period, with a moderate increase in cases reported in women. This may be because a bigger proportion of injectors are men10.
Figure 5: Deaths from ESLD or HCC in those with HCV mentioned on their death certificate in England; 1996 –2011**
Source: Health Protection Agency (2012) Hepatitis C in the UK
What are the key inequalities?
Key points
-More men report injecting drugs so subsequently, around two-thirds of infections occur in men
-There are wide variations in access to needle exchange schemes and in the number of people who use them and how often
-Little is known how different population groups are affected by hepatitis C
Despite a sound body of evidence showing that treatment is effective, many people with hepatitis C remain undiagnosed and untreated. In England, 48,946 infections were diagnosed by the end of 2005 (about 30% of estimated cases at that point). However, only 12,400 of those infected were treated from 2006 to 2008. There is little evidence available to explain why national treatment rates are low[11].
Estimates for London show that treatment rates in the capital are equally low. The London Joint Working Group for Substance Misuse and Hepatitis C estimate that at least 34,000 Londoners have hepatitis C yet only 800 are treated annually[12].
Intravenous drug use remains the greatest risk factor for acquiring hepatitis C in the UK (about 90% of cases occur in those who currently or previously injected drugs). More men report injecting drugs so subsequently, around two-thirds of infections occur in men10.
In areas of high prevalence, as is the case in Lewisham, half of the IDU population who have been injecting for 5 years will have been exposed to HCV. Therefore the majority of those injecting for more than 5 years will have HCV. Moreover, due to the high prevalence of hepatitis C in IDU populations, those who have recently started to inject are likely to be exposed to HCV fairly quickly8.
Needle exchange programmesare proven to reduce the risk of infection in IDU groupsbutthere are wide variations in the access to needle exchange schemes and in the number of people who use them and how often[13]. Almost a quarter (23%) of respondents to the UAM reported sharing needles and syringes in the previous 4 weeks[14].
As a consequence, NICE recommends collecting information about service users in order to ensure an effective response to the needs of the local population13.At present, there is little information available about the needle exchange service or those who use it locally.
While a small body of information has been collated about the needs of IDUs who have hepatitis C, little work has been carried out to understand how different population groups might be affected by hepatitis C.
Targets and performance
Key points
- in 2010/11 cohort 65% of current or previous injectors entering treatment for substance misuse received a hepatitis C test, compared with 72% in 2009/10.
The revised University of Glasgow smoothed estimate (2009/10) suggests that Lewisham has approximately1,932 opiate and or crack users in the community[15]. This number includes all those estimated to be taking Class A drugs, irrespective of the waythey are taken.
In 2010/11,opiate and crack users (OCU’s) accounted for 1035 of the effective treatment population. This indicates a rate of 54% of estimated prevalence for OCUs engaged in effective treatment.
The National Treatment Agency mandates that 90% of those entering drug treatment programmes,with a current or previous history of intravenous drug use, should be offered a hepatitis C test[16]. The local target set by the Drug and Alcohol Action team (DAAT) is 100%for all clients entering the Lewisham partnership treatment system with a current or previous history of intravenous drug use.
Table 3 Adults entering substance misuse treatment and hepatitis C testing 2010/2011
No of individuals in treatment / No previously or currently injecting / No with a Hep C test / % with a Hep C testEngland / 205127 / 112715 / 67395 / 60%
London / 34061 / 13212 / 7992 / 60%
Lewisham / 1328 / 772 / 499 / 65%
Lambeth / 1872 / 741 / 501 / 68%
Southwark / 1555 / 717 / 529 / 74%
Greenwich / 972 / 471 / 365 / 77%
Source: Q4 Adult substance misuse report 2010/2011
We can see from the table that Lewisham did not achieve its target. Of the 1,328 individuals accessed treatment in 2010/11, 772 were recorded as either currently or previously injecting, andof that cohort 65% (n=499) received a hepatitis C test. This compares with 72% in 2009/10.
In addition, hepatitis B testing (and a course of vaccination) is also offered to all clients commencing treatment and performance is monitored against regional and national averages.
There is no national or local target for those presenting at their general practice surgeries.
National and local strategies
Key points
-The national strategy emphasises increased awareness of HVC and enhanced surveillance and testing
-Fully integrated care pathways should be developed and commissioned
-Clinical networks should be established to support the process
Over the last decade, several national policy documents have detailed a number of key issues forto consider when planning and delivering hepatitis C services2,[17],[18],[19]In essence, these key themes are:
Raising awareness and harm reduction
Increasing awareness of hepatitis C in both the general population and amongst risk groups is essential to encourage more at risk people to come forward for testing and treatment.
Awareness of how to prevent new infections should be supported by the provision of a broad range of services to minimise the on-going transmission of hepatitis C including education and needle exchange services.
Enhanced surveillance and testing programmes
Hepatitis C surveillance should be strengthened wherever possible and universal testing initiated in high risk groups. These high risk groups are previous or current IDUs or those who share drug paraphernalia.
Integrated care pathway
Work with services that provide hepatitis C tests and treatment (in both primary and secondary care) to develop and commission a fully integrated care pathway.
Services should be accessible to those who need them and integrated into the wider health economy. Integrated pathways of care for patients with hepatitis C have been shown to help to resolve variations in access and provision of treatments across the country. Currently over 78% of primary care trusts have developed such a pathway.
Clinical networks
Local clinical networks should be established to provide an ongoing forum for professional discussion and service development.
Commissioning
Encourage the development of locally enhanced services for hepatitis C in areas where the population includes a higher than average number of people at increased risk.
What works?
Key points
-Harm reduction services are important in reducing the rate of spread of HVC
-Comprehensive testing is need to assess those at risk
-Antiviral treatment is effective in many cases, though has side effects. Those co-infected with HIV respond less well.
The key elements of an effective hepatitis C programme are;
providing effective harm reduction services (i.e. education and needle exchange services)12
providing a comprehensive testing programme for those at 19,[20]
Receiving anti-viral treatment[21],[22],[23]
Harm reduction and needle exchange services
A key aim of needle exchange services is to reduce the transmission of blood-borne viruses and other infections caused by sharing injecting equipment and other drug paraphanalia3.
NICE guidance details that needle exchange programmes should also aim to reduce other harms caused by injecting drugs. Ensuring good access and responding to service users’ needs are key components of a good service12.
Services should be readily accessible and include:
- advice on safer injecting practices
- advice on how to avoid an overdose
- information on safe disposal of injecting equipment
- advice on opioid substitution programmes
- support to stop injecting
- access to blood-borne virus testing, vaccination (for hepatitis B) and treatment
services
In addition, the programme should collect and analyse data about the prevalence and incidence of intravenous drug use in the area,about service users, andabout how the service is used. This data should help to monitor if the programme meets the health needs of IDUs and the local community12.
Testing
Improving surveillance for hepatitis C is a theme in the literature and a key recommendation from national guidance documents. Many individuals are not aware that they have a hepatitis C infection and untreated individuals act as a reservoir for onward transmission of the virus. Because of this, a system of targeted testing for high risk groups should be in place,2,19.
Treatment
There is no vaccine available for hepatitis C. Standard treatment to date has been a combination of two antiviral drugs, interferon and ribavirin, given to either eradicate or greatly reduce viral replication, thus reducing further liver damage.
Treatment courses last 24 or 48 weeks and individuals are usually managed on an outpatient basis16. Standard anti-viral treatment is effective in eradicating hepatitis C in approximately 50 - 70% of those infected. Treatment success is dependent upon a number of factors:
- Genotype: there are 6 genetic types of HCV known as genotypes. Genotype 1 is most common in the UK accounting for 40-50% of all infections. Genotypes 2 and 3 make up another 40-50%.
- Around 75-85% of those with genotypes 2 or 3 respond well to treatment in contrast with those with genotype 1 (at around 40 - 50%).
- Those co-infected with HIV can progress to chronic disease more quickly and respond less favourably to conventional treatments.
- Those recently infected fair better than those with chronic infection. However, there is strong evidence that those with chronic infection do benefit from antiviral therapy 3,17.
NICE guidance recommends thatall individuals with hepatitis C infection should be considered for treatment. This includes those with mild to chronic infection and those co-infected with HIV. It also includes those who have had previous unsuccessful treatment programmes with combination therapy21.
NICEapproved two additional antiviral drugs, boceprevir and teleprevir, for the treatment of hepatitis C in April 2012.Clinical evidence is encouraging and demonstrates a much higher success rates (up to 70%) for treatment in those with genotype 1 as well as providing shorter treatment times for those who respond well22,23. Success rates treating genotype 1 using conventional combination therapy is approximately 40 – 50%21.
This new regime offers effective treatment to a large group of people in whom established treatment programmes have had limited success.
Current activities and services