Friday, October 24, 2014

More HCV screening, better treatments should curb infection rate, researchers find

Model Predicts Sharp Decline in Hep C Burden
October Issue:Gastroenterology & Endoscopy News 
by Monica J. Smith

More screening, better treatments should curb infection rate, researchers find
by Monica J. Smith

The public health burden posed by chronic infection with the hepatitis C virus (HCV), which claimed more lives in 2007 than HIV and is associated with an annual cost in the United States of about $6.5 billion, may be greatly diminished by 2036, according to a recently published computer simulation study (Ann Intern Med 2014;161:170-180).

Significant changes have occurred since the release of prior predictive analyses that were limited to the scenario of treatment with peginterferon and ribavirin (PEG-RBV) in an HCV screening-free setting, or that evaluated only the cost-effectiveness of new drugs.

The launching of direct-acting antiviral medications in 2011, the increasing availability of oral drug therapies, the continuing development of new drugs that increase sustained virologic response rates with fewer adverse effects, and the Centers for Disease Control and Prevention (CDC) recommendation for a one-time HCV screening of all people born between 1945 and 1965 may have a profound effect on the burden of the infection in the United States.

“We anticipated that the HCV burden would go down, but we wanted to quantify how quickly that would drop,” said Jagpreet Chhatwal, PhD, assistant professor of health services research at the University of Texas MD Anderson Cancer Center, in Houston, who helped conduct the study.

To predict the effect these recent developments may have on chronic HCV infections and associated outcomes, including cirrhosis, hepatocellular carcinoma, the demand for liver transplants and liver-related mortality, Dr. Chhatwal and his colleagues at MD Anderson and the University of Pittsburgh developed an individual-level state transition model capable of simulating the HCV-infected population spanning a 50-year range, from 2001 to 2050.

The model simulated the current clinical practice: treatment with PEG-RBV or protease inhibitor–based triple therapy before 2014, then with sofosbuvir- and simiprevir-based therapies and new drugs as they develop. The model also acknowledged one-time birth-cohort screening starting in 2013.

The researchers validated their model using several sources: the National Health and Nutrition Examination Survey 2003-2010 report, data from the CDC, a multicenter follow-up study of individuals with advanced fibrosis and earlier studies. Their model predicted a decrease in the number of chronic HCV cases from 3.2 million in 2001 to 2.3 million in 2013 in the general population, noting that screening baby boomers should identify nearly 490,000 cases over the next decade. One-time universal screening, on the other hand, could identify nearly twice as many.

“We should not be limiting ourselves to screening baby boomers, but explore other screening policies,” Dr. Chhatwal said, adding that expanding screening would require an evaluation of the effects of broader screening and of its cost-effectiveness. “We could look at geography, if the disease burden seems more prevalent in some areas, or by other settings. For example, there is a high prevalence of HCV among prison inmates; screening that population could be a very efficient and cost-effective way to reduce disease burden.”

The model also predicted that the availability of the most recently approved therapies for HCV could prevent a substantial number of HCV-related outcomes, reducing the number of new cases of cirrhosis by 124,200, the number of cases of hepatocellular carcinoma by 78,000, the number of liver-related deaths by 126,500 and the number of liver transplants by 9,900.

Type 1 Strain Accounts For Nearly Half of Cases

Of HCV’s six genotypes, type 1 appears to be the most prevalent, affecting more than 83 million people worldwide, according to the findings of one of the largest prevalence studies to date (Hepatology 2014 July 28. [Epub ahead of print]).

To estimate trends in genotype prevalence, researchers in the United Kingdom reviewed 1,217 studies reporting HCV genotypes. The studies, published between 1989 and 2013, represented 117 countries and about 90% of the global population. The researchers also used prevalence estimates generated by the World Health Organization’s Global Burden of Disease project.

Their analysis showed that genotype 1 made up 46% of all HCV cases. Genotype 3 accounted for 30%, with genotypes 2, 4 and 6 making up 23%, and genotype 5 making up less than 1%.

The authors noted that although genotype 1 is the most common, non–genotype 1 HCV cases account for more than half of all cases and are generally less well served by advances in vaccination and drug treatment.—M.S.

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