Detection and treatment of people with hepatitis C

Advisory report | 05-11-1997

It has now become clear that using medication for the treatment of patients with hepatitis C results in the permanent elimination of the virus and cure in one in four of those treated. Consequently, the question arises of whether it might be desirable or even necessary to trace and treat people infected with hepatitis C virus. Questions on this subject put to the Health Council of the Netherlands by the Minister of Health, Welfare and Sport are answered in this advisory report by a committee set up for that purpose.

The committee concludes:

• - Chronic hepatitis C is a viral infectious disease, which leads to cirrhosis of the liver in at least one in five patients, from within a few years to 20 years of first becoming infected. Prior to cirrhosis, hepatitis C generally produces few symptoms and the same applies to the initial stages of cirrhosis. Cirrhosis may lead to liver failure, and in some cases to liver cancer.
  - Antibodies against hepatitis C virus (HCV) can now be detected in serum with a high degree of sensitivity and specificity. They are an indication of a person having been infected. Of all seropositive individuals, 80 to 85% remain carriers of the virus.
  - The virus is transmitted almost exclusively via blood or blood products.
  - With the introduction of second-generation screening tests for all donations, the likelihood of being infected with HCV via blood products was reduced to practically zero.
  - Except possibly under atypical circumstances, the disease is not transmitted sexually.
  - In the case of simultaneous infection with hepatitis B virus (HBV) or human immunodeficiency virus (HIV) the course of the disease is accelerated. The use of alcohol also accelerates the course of hepatitis C.
  - Treatment with interferon is indicated if a liver biopsy reveals advanced fibrosis, or in the event of extensive inflammation of the liver.
  - Treatment with interferon has to be continued for a year. After three months of treatment, HCV RNA should no longer be detectable in the blood, otherwise it is not useful to continue the treatment. In most cases, the chronic inflammation of the liver has also diminished by this time.
  - Treatment with interferon for one year results in the complete elimination of the virus in 20 to 30% of patients. A considerable improvement in the success rate is anticipated in the near future.
  - With the exception of some special risk groups, the prevalence of HCV infection in the Netherlands is not known. Data from abroad suggests that prevalence among first-generation immigrants may be relatively high.
  - In the Netherlands, people who use drugs intravenously currently account for the group with the highest incidence and prevalence of HCV infection.
  - While patient’s rights dictate that physicians are obliged to spontaneously provide them with information, this does not compel physicians to reveal every last piece of information held on file. Providing the relevant information to a patient who, long ago, was exposed to a very slight risk of HCV infection might be classified as the unrequested provision of information to a symptom-free individual.
  - Where there is a greater likelihood of HCV infection, the obligation to provide the patient with the relevant information remains effective for many years, in view of the severity of hepatitis C.
  - A general lookback (tracing and testing all those who received blood products before 1992) would be inefficient.
  - The registration of blood products administered in hospitals is currently insufficient to enable recipients to be traced. Improvements are required.
  - Practically all active drug users who might qualify for treatment of an HCV infection are already receiving medical treatment in connection with their addiction. In this context, they will already have been tested for HCV infection.
  - The general population lacks adequate knowledge about HCV, the way the infection is transmitted and the resultant occurrence of chronic hepatitis. To tackle the disease properly, it will be necessary to fill this gap.
  - The population includes groups with an increased prevalence of HCV infection, such as those who have had a transfusion or tissue transplant, individuals with tattoos and immigrants. These groups have very little, if any, awareness either of the risks posed by this new infectious disease or of possible treatment. Their ignorance of these facts prevents such individuals from taking responsibility for their own health.
  - The adherence to hygienic measures among non-regular practitioners (tattooing, piercing, acupuncture, ritual treatments) and the effectiveness of the measures are unclear.

The committee recommends the following:

General lookback

A general lookback, i.e., tracing and testing all the people who have been administered blood products in the past, would not be efficient and must therefore not be set as an objective. Because prevalence is low, a lookback would result in a great deal of unnecessary alarm, also among people who cannot recall whether they have ever been treated with blood products. Similar measures in other countries have shown the response is low. People who may have been infected by causes other than a blood transfusion would not be reached. Because the disadvantages of a general lookback exceed the benefits, it could not result in a health care gain and the measure seems inadvisable.

Quality of health care

In connection with the possibility of future, new infections being transmitted by blood, it is important in terms of the quality of health care for hospitals to keep precise records of the origin and use of blood products.

Information on hepatitis C

It is important to inform the general population about this new and sometimes curable disease, and it is especially important to inform people in the risk groups who are not under medical care. People in risk groups should be informed in such a way that they are able to decide for themselves whether they need to contact their GP or the Municipal Health Services in connection with possible HCV infection, and, if necessary, to obtain treatment. These people include everyone who has received blood products or had a tissue transplant, current or past intravenous drug users, immigrants, people with tattoos, and a few other smaller groups. The first group concerns those who received treatment before 1992.

It is advisable to approach immigrants through their own channels, possibly by making use of intermediaries who have first been given the necessary training. The work involved in providing the information should focus on the individual’s culture and should be in line with the provision of general health education.

The provision of education to the general public should be organized so that, where appropriate, it results in a recommendation to contact the GP or Municipal Health Services.

Tracing and treating patients with hepatitis C

Tracing and, where indicated, treating patients with chronic hepatitis C should form part of the medical treatment of patients whose treatment involves an increased likelihood of HCV infection (haemophiliacs, dialysis patients, polytransfusees, patients who have had organ transplants and people with puncture wounds).

People with a chronic HCV infection must be advised to stop their alcohol consumption or cut it down to the minimum, in order to halt the disease’s progress as far as possible.

Expertise promotion

Before activities concerning the public are developed, doctors and GPs must be encouraged to take part in training and refresher courses on diagnostics and advising patients in hepatitis C risk groups. This also applies to information on hygiene presented to those engaged in professions involving an increased risk of HCV transmission (hairdressers, chiropodists, etc.).

Further research

An effective approach to risk groups must be underpinned by insight into the prevalence of HCV infection in the various population groups. This requires epidemiological research.