Epidemiology of Hepatitis C Infection - Viral Hepatitis Prevention ...

Epidemiology of
Hepatitis C Infection
Pablo Barreiro
Service of Infectious Diseases
Hospital Carlos III, Madrid

Worldwide Prevalence of Hepatitis C
10%
No data available
WHO. Wkly Epidemiol Rec. 2000.

Hepatitis C in Figures
• Worldwide prevalence ≈ 3% (170 M people) 1
• Rate of chronification 75–85% 2
• Rate of cirrhosis
10% in 20 years
20% in 30 years 2
• Liver mortality (cirrhosis) 1–5% / per year 3
• Hepatocarcinoma in cirrhotics 1–4% / per year 2
1. WHO. Hepatitis C. Fact sheet no. 164. 2. CDC. MMWR. 1998.
3. CDC. Hepatitis C slide kit. September 25, 2000.

Distribution of Hepatitis C Genotypes
1a, 1b
2a, 2b,
3a
1a, 1b
2a, 2b, 2c,
3a
4
4
1b,
3a
2a
1b,
6
1b
1a, 1b,
2b, 3a
5a
3b
1b,
3a
Fang et al. Clin Liver Dis. 1997.

Distribution of HCV Genotype
in the US
Genotype 2, 3
22%
Genotype 4, 5, 6
4%
Genotype 1
74%
Alter et al. N Engl J Med. 1999; Blatt et al. J Viral Hepatitis. 2000.

HCV Prevalence by Selected Groups, US
Hemophilia
Injecting drug users
Hemodialysis
STD clients
Gen population adults
Surgeons, Nurses, PSWs
Pregnant women
Military personnel
0 10 20 30 40 50 60 70 80 90
Average Percent Anti-HCV Positive
Centers for Disease Control and Prevention

Prevalence of Hepatitis C
by Age & Ethnicity, in the US
7
HCV-Ab positive (%)
6
5
4
Blacks
3
2
1 Whites
0
6–11 12–19 20–29 30–39 40–49 50–59 60–69 =70
Age group (years)
Hispanics
Adaptado de Alter. N Engl J Med. 1999.

Estimated Incidence of Acute HCV, U.S.
New Infections/100,000
140
120
100
80
60
40
20
0
N~240,000/yr
Decline in
transfusion recipients
≠
Decline in injection
drug users
N~30,000
1960 1970 1980 1989 1991 1993 1995 1997 1999 2001 2003
Year
Centers for Disease Control and Prevention, 2005
Armstrong GL. Hepatology 2000;31:777-82
Alter MJ. Hepatology 1997;26:62S-65S

Prevalence of Hepatitis C in Spain
Area Population (n) Prevalence* Author Year
Cataluña General (2,154) 2.6% Sola 2002
La Rioja Urban (890) 2% Sacristán 1996
Galicia General (1,170) 1.6% Riestra 2001
Murcia General (2,203) 1% Gª-Fulgueira 1996
Zamora General (675) 0.7% Chimeno 2001
Alicante Drug addicts (832) 82% Esteban 1997
Madrid Immigrants 8.8% López-Velez 2003
Spain Estimated 2%
*according to HCV-Ab positivity
Around 70% of HCV-Ab positive are HCV-RNA positive

Prevalence of HCV infection
in the United States
3,5
Risk factors
3
%
2,5
2
*
* *
*
1,5
1
0,5
0
Gender Socioeconomic Education Race
males / females low-medium / high low / high others / white
*p

Prevalence of HCV infection in the US
6
5
Other risk factors
*
*
Odds Ratio
4
3
2
1
*
>2
>50
*
0
*p

Exposures not associated with
acquiring HCV infection
Exposure Cases Controls
(previous 6 months) (n=148) (n=200)
Medical
procedures 30.4% 29.5%
Dental work 24.3% 23.5%
Health care work
(no blood contact) 4.1% 5.0%
Ear piercing 2.7% 3.0%
Tattooing 0.7% 0.5%
Acupuncture 0 1.0%
JID 1982;145:886-93; JAMA 1989;262:1201-5.

Overlapping HCV & HIV epidemics
HIV
Hep C
40 40 million
175 million
10 10 million

HCV and HIV routes of transmission
Percutaneous
Injection drug use
Transfusion, Transplant
Therapeutic
Occupational
Permucosal
Sexual
Occupational
Vertical
Centers for Disease Control and Prevention

HCV and HIV in Figures in the US
HCV
HIV
Incidence 1-3 40,000 40,000
Prevalence 1, 3, 4 2.7 M 0.94 M
Deaths/year 1, 2, 5 8,000–10,000 15,000
1. CDC. Viral hepatitis C fact sheet. 2. CDC. HIV/AIDS Surveillance Report. 2001. 3. CDC. Viral hepatitis C
fact sheet. 4. UNAIDS/OMS. AIDS epidemic update. 5. CDC. Viral hepatitis B frequently asked questions.

Danta M. CROI 2006 (abst 86)

Acute hepatitis C outbreaks in HIV+ MSM, UK
Median number of different patners (12 months)
30
25
*
20
Number
15
10
*
Cases (n=59)
Controls (n=121)
5
0
Partners
One-night stands
*p

Acute hepatitis C outbreaks in HIV+ MSM, UK
Group sex risk factors
% participating (12
months)
100
90
80
70
60
50
40
30
20
10
0
*
Group sex
*
Receptive UAI
*
Insertive UAI
Receptive fisting
*
Insertive fisting
*
Drugs
*
Cases (n=52)
Controls (n=63)
UAI: unprotected anal intercourse; *p

Prevalence of Chronic Viral Hepatitis
in HIV Infected Patients
2,168 patients at the Hospital Carlos III Cohort
59%
HCV alone
HBV alone
HCV+HBV
HCV+HBV+Delta
None
36%
1%
1%
3%
Castellares, et al. J Hepatol (submitted)

Mean progression to cirrhosis
among HIV+ is 25 years
3-fold faster in HIV pos than in HIV neg
Fibrosis Grades
(METAVIR Score)
4
3
2
1
HIV+ (n = 122)
Controls (n = 122)
0
0
10
20
30
40
Duration of HCV Infection (years)
Benhamou et al. Hepatology 1999
Soto et al. J Hepatol. 1997;26 :1-5

Fibrosis in Patients with Chronic
Hepatitis C and Elevated ALT
80
70
60
50
40
30
20
10
0
HIV negative (n=476)
HIV positive
(n=914) by biopsy
(n=408) by elastometry
F01 F2 F3 F4
Metavir Score
1
Forns et al. Hepatology 2002; 36: 986-92
2
Martin-Carbonero et al. CID 2004; 38: 128-33

Risk of Cirrhosis and ESLD
in HIV/HCV vs HCV alone
Study N RR of Cirrhosis
(95% CI)
RR of ESLD
(95% CI)
Makris et al. 138 3.9 (1.4-10.8)
10.8) 4.21 (0.96-18.41)
Soto et al. 547 1.94 (0.92-4.1) --
Pol et al. 514 2.6 (1.1-5.9)
--
Benhamou et al. 244 1.46 (0.76-2.83) --
Eyster et al. 156 -- 3.2 (0.6-17)
Telfer et al. 255 -- 21.4 (2.6-174.5)
Lesens et al. 134 -- 7.4 (2.2-25.5)
25.5)
Graham et al. 1,988 2.07 (1.4-3.07)
6.14 (2.86-13.2)

Prevalence of Cirrhosis According
to Liver Condition in HIV Infected Patients
2,168 patients at the Hospital Carlos III Cohort
Cirrhosis (%)
[95% CI]
80
70
60
50
40
30
20
10
0
No. of
patients
8.3
[7.2-9.5]
19.2
[16.4-21.9]
6.1
[0.5-11.7]
41.7
[13.8-69.6]
66.7
[44.9-88.4]
All HCV HBV HCV+HBV HCV+HBV
+Delta
2,168 777 54 12 18
16.5
[13.5-19.6]
Alcohol
1.1
[0.5-1.8]
None/
Unknown
574 1,055
Castellares, et al. J Hepatol (submitted)

Chronic Hepatitis C: Mortality and Cumulative Costs
Estimates for 2010–2019 in the US
Deats related
Deaths due to CHC
Cost
165,900
27,200
$10,700 M
Wong et al. Am J Public Health. 2000.

Impact of Chronic Hepatitis C in
Coming Years (19982008)
Liver transplant
528%
Liver
decompensation
Liver related
deaths
223%
279%
Hepatocarcinoma
68%
Liver cirrhosis
61%
0 100 200 300 400 500 600
Increase in 10 years (%)
Davis et al. Hepatology. 1998.

Liver Transplant in the US
HCV related
Other causes
3500
3000
No. of patients
2500
2000
1500
1000
500
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Calendar year
Kim. Hepatology. 2002.

Chronic Hepatitis C
•Widely distributed
•Significantly prevalent in Western countries
•Frequently associated to HIV infection
•Source of clinical complications and mortality
•Impact on the health care system on the rise
in coming years