Hepatitis C Hepatitis CDiagnosisLong-term risksTreatmentHep C action plan Hepatitis CWorldwide 300 million people are infected with Hepatitis C. In NZ population 0.45% of the population is positive for Hepatitis C antibodies This is approx. 50,000 individuals - 20 - 30,000 people are still unaware of the diagnosis and need to be found so that treatment can be given to prevent severe liver disease in the future The infection affects ethnic groups in NZ in equal proportions (in contrast to Hepatitis B). Hepatitis C is usually acquired without any symptoms (no hepatitis illness). A "carrier state" does not exist (in contrast to Hepatitis B) >75% have a history of intravenous drug use. This may be only 1-2 episodes of use at a teenage party. Promoting the use of clean needles for people using injectable drugs is important to reduce new infections. If people using injectable drugs are not already receiving assistance, they should be referred to community alcohol and drug services (CADS) and a local needle exchange service. 5% have a history of blood transfusion prior to 1992 (before routine testing of blood was commenced). 5-10% have other risk factors. Unsterile tattooing. There are high rates in prison inmates (presumably related to i.v drug use). Migrants from countries with high rates (due to re-using unsterilised needles). Regions with high HCV prevalence include Eastern Europe, the Middle East, North Africa, Western and Central Sub-Saharan Africa, Central Asia and the Indian subcontinent 5-10% have no identifiable risk factors. People cannot develop immunity to HCV. Therefore, anyone who has eradicated HCV infection either spontaneously or following antiviral treatment may be re-infected. Lifestyle Issues If you are considering treatment you will need to prepare for the possible impact on your lifestyle and relationships. You could also require time off work to deal with side effects and/or need to arrange a flexible work schedule with your employer. Personal relationships may come under pressure from mood altering side effects and disruptions to routine. A big part of preparing for treatment is preparing those who will support you so they can help you through this time. What about alternative / complementary treatments? There is much interest in alternative treatments such as homeopathy, herbal medicine, dietary changes, and various therapies to decrease stress. Overall the results are disappointing. It is important to be open and frank with your GP or specialist so that appropriate decisions are made. The current treatment is so effective with very little risk that there is no need to delay treatment or consider "natural" alternatives The best “alternative” treatment is to: Stop alcohol. Lose weight. Have a balanced diet (low fat, fresh fruit and vegetables). However there is minimal evidence to support any other sort of dietary restriction and no evidence for any herbal treatment. Fatty liver has a negative influence on the outcome of Hepatitis C. Therefore weight loss, a low fat diet and regular exercise and minimal or nil alcohol intake are all helpful measures in a more holistic approach because of a reduction in the degree of fatty liver. Useful links New Zealand Hepatitis C support group www.hepc.org.nz Hepatitis C Council of NSW (factsheets and FAQ are excellent) www.hepatitisc.org.au American Liver Foundation< www.liverfoundation.org How is the infection diagnosed? Most people have no symptoms although tiredness is common Tests may be taken because of concerns about having a risk factor for infection. Alternatively liver enzyme tests may have been done as part of routine blood tests and then subsequent tests reveal Hepatitis C. A few people present with the long-term complication of cirrhosis or liver cancer. They have had the virus for 30 years but have had no symptoms until serious problems have developed. Tests for the virus. The Hepatitis C antibody test is a screening test. The presence of Hepatitis C antibody does not suggest any immunity – it suggests the presence of the virus. There are false positive results. The confirmatory test is the Hepatitis C PCR. This is a direct test for virus in the blood and is very accurate. There are also false negatives for the antibody test therefore if you have a risk factor then the PCR test is required to be sure that you do not have the virus. Further tests of the virus were required before starting treatment but this is not relevant with new highly effective treatments that are equally successful for all genotypes. In New Zealand the most common genotypes are 1a, 1b and 3. Tests of the viral load – i.e how much virus is in the blood - also rarely required now. Previously this test was helpful for planning type and duration of treatment and also during the course of treatment to determine likelihood of success. What is the risk of cirrhosis or liver cancer? The overall risk of developing cirrhosis is 1% per year.The risk is significant after 20 years of infection. The date of infection may not be known but can be estimated if due to intravenous drug use.The risk is higher is the virus is acquired later in life (for example from a blood transfusion at the age of 50 years).Alcohol intake significantly increases the risk of cirrhosis.If there is cirrhosis the risk of serious life-threatening complications is 5% per year and the risk of developing liver cancer is 3% per year. General advice The risk of passing on the infection is very low.It is important to stop or least markedly decrease alcohol intake.Vaccinate against Hep A and B.Treatment cannot be started if still using intravenous drugs. You must be stable on a methadone program for at least 6 months.What is the risk of sexual transmission of Hepatitis C?The likelihood that somebody with the virus could have passed it on to a sexual partner is worrying for many people. Should you tell past sexual partners of your Hepatitis C status? How should you discuss the topic with your current sexual partner? These are all are difficult issues to deal with.Hepatitis C is thought to be a blood borne virus that can only be passed on if the infected blood of one person gets into the bloodstream of another. Sexual transmission of hepatitis C is very uncommon. Current treatment for Hepatitis C Previous results from treatment were poor but there have been significant advances. In June 2016 PHARMAC announced funding for direct-acting antiviral drug therapies for New Zealanders living with the hepatitis C virus. From July 2016, Harvoni and Viekira Pak for hepatitis C infection were fully funded (some with access criteria) through a hospital specialist. This was a major advancement in the treatment of hepatitis C, with cure rates of more than 90% with as little as 12 weeks oral treatment. Since October 2016, all prescribers including general practitioners have been able to prescribe Viekira Pak and Viekira Pak-RBV - available for genotype 1 only. On 17 December 2018 PHARMAC announced their decision to fund a new treatment for people with hepatitis C to commence from 1 February 2019. This treatment is a potential cure for people with chronic hepatitis C infection regardless of the type or genotype This treatment (known as Maviret, Glecaprevir with pibrentasvir) has fewer side effects and fewer interactions with other medicines than the previous funded treatments and is a simpler treatment – once-daily dose (three tablets) for a minimum of 8 weeks. This treatment is for all patients with hepatitis C except for advanced cirrhosis It would be ideal for all patients to have a Fibroscan to check for liver fibrosis and cirrhosis before starting treatment. If this is not available so estimation of the risk of cirrhosis can be made by clinical assessment and a scoring system based on blood tests Ledipasvir + sofosbuvir is subsidised for patients who meet Special Authority criteria, including patients with advanced liver complications, e.g. decompensated cirrhosis or awaiting a liver transplant. Applications for subsidised ledipasvir + sofosbuvir are likely to be made in secondary care and will be reviewed by the PHARMAC Hepatitis C Treatments Panel. Treatment should be deferred if pregnant or breast-feeding Patients with a combination of Hepatitis C and HIV need specialist management Your doctor will need to review your current medication to make sure there are no drug interactions Follow-up after completing treatment There should be a follow-up blood test 12 weeks after completing treatment. This is the Hepatitis C PCR test - this is a very accurate measure of treatment success Over 98% of people will have long term success with Maviret. If treatment with Viekira Pak failed then Maviret can be given with the expectation of excellent results. Treatment for failures to Maviret requires specialist input. There are several options and funding is yet to be determined The NZ Government has launched a National hepatitis action plan to eliminate Hepatitic C by 2030 FROM THE REPORT JULY 2021 It is estimated 35-40% of the 40,000 people with Hepatitis C are unaware of the diagnosis Modelling using estimated data for the New Zealand population has suggested that we will need to treat more than 7 percent of people with chronic hepatitis C each year to meet the WHO target to eliminate hepatitis C. Between February and December 2019, 3,362 New Zealanders were treated with Maviret; however, numbers of those treated have been dropping since that time. This is likely in part due to services being impacted by COVID-19. To meet the treatment numbers required to achieve elimination, health service providers need to more effectively identify people who need treatment, and better link people to health services and treatment. A robust and functional hepatitis C register that enables monitoring, surveillance and linkage to care was identified as a key part to eliminating hepatitis C in New Zealand. Currently, New Zealand has no single national registry of cases of hepatitis C. Ideally, such a registry would: • enable surveillance and monitoring of disease incidence and prevalence • link all diagnosed cases of hepatitis C (acute or chronic) to treatment.