Tackling hepatitis C: a tale of two countries

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The Lancet, Volume 377, Issue 9773, Pages 1227 - 1228, 9 April 2011

doi:10.1016/S0140-6736(11)60485-6 Cite or Link Using DOI

Tackling hepatitis C: a tale of two countries

Hepatitis C remains underdiagnosed and undertreated in parts of the UK.

asks whether the National Liver Strategy for England will deliver what

Scotland is already achieving.

20 years after the hepatitis C virus was identified, mortality and

hospitalisations are steeply rising in the UK as people infected 20—30 years ago

develop end-stage liver disease and hepatocellular carcinoma. At least 250 000

people in the UK might have the infection, mostly undiagnosed, and more likely

to present with advanced disease.

Graham , professor of hepatology at Queen 's University, London, UK,

has “no doubt that more people are being diagnosed with an increase in awareness

and testing, but still we are way behind Europe and the rest of the developed

world in diagnosing patients and our flow through from diagnosis to treatment is

still woefully inadequate”. , who also works as a clinician in east

London, tells The Lancet that “treatment services in general are very poor

throughout the UK”; he fears that excellent treatment performance and high

standards of care are found in few services.

Injection drug use is the main, but not sole risk factor, for contracting

hepatitis C, hence the infection is stigmatised and misunderstood in the general

population. Prevalence among people who inject drugs is about 50%, yet local

provision of testing and treatment varies widely in this often marginalised and

unheard of group, despite clear evidence of its usefulness to reduce disease

burden and ongoing transmission.

Moreover, treatment and testing are inextricably linked. “If you have a good

treatment service, then GPs [general practitioners] become aware that their

patients are being cured and that drives them to find the virus and refer

patients on”, explains. “If treatment is available at a very low level,

GPs stop referring patients because they see nothing happens.” But if specialist

services are poorly resourced, then consultants have to place severe

restrictions on who gets treatment, he says.

These disparities are increasingly seen now at country level, because action to

tackle the virus has widely differed especially between the UK countries

Scotland and England, which have similar high prevalence epidemics compared with

other countries in the UK and much of the developed world.

England launched a national hepatitis C strategy in 2002 and then an action plan

in 2004. This plan, say critics, had few outcome measures, no clear timetable,

no attached financing, and the political environment, which focused on priority

setting at local National Health Service (NHS) level, was such that the

government would not stipulate what was required of local clinical services.

“There were absolutely no levers whatsoever to have this actioned. The result is

that largely it hasn't been”, says Gore, chief executive officer of the

Hepatitis C Trust, which has been campaigning for 10 years for England to

develop an actionable plan.

Scotland launched its two-phase action plan in 2006. The 3-year first phase was

completed early so that progress and outcomes of the second phase (2008—11) have

now been reported for 2 years. From 2007 to 2009, Scotland had a 34% increase in

new diagnoses, and a further increase is expected as a consequence of

professional and public awareness campaigns, which began early in 2010. Testing

has also been enhanced by the roll out of dried blood-spot collection by finger

prick, which allows sampling in non-clinical settings.

Development of clinical services has doubled the number of patients started on

treatment in 2007—09, while treatment of prison inmates has increased six times.

Provision of clean injecting equipment has increased several times since

guidelines were approved in 2009. This year, the governance structure and

data-generating initiatives now in place will further monitor progress and

outcomes. In April, the plan will become part of the Sexual Health and

Blood-Borne Virus Framework.

The Scotland Hepatitis C Action Plan “is regarded globally as a model of good

practice”, says Gore, who is also president of the World Hepatitis Alliance. To

make progress in England, says, Scotland's example “shows how a

government-supported initiative can produce enormous dividends in numbers

diagnosed and numbers treated”. Gore concurs: “what we in England need to learn

is to have outcome measures as a key part of a strategy, to put some money

towards it, and to have a clear timetable.” Scotland's total investment in the

action plan is about £43 million.

England's action now depends on the forthcoming National Liver Strategy, which

is currently in development by the Department of Health and the national

clinical director for liver services, Lombard of the Royal Liverpool

University Hospital NHS Trust, Liverpool, UK. Lombard has spent the past 12

months working with government policy officials, patient and professional

groups, the National Institute for Health and Clinical Excellence, and industry

“to develop an understanding of how to tackle the escalating burden of liver

disease in England”. Through the strategy, expected in autumn, “we want to

transform outcomes for people with liver disease and the various underlying

conditions that lead to liver disease”, he says.

Government commitment to tackling liver disease, including hepatitis, is clear

by inclusion of chronic liver disease in outcome frameworks for the NHS and

public health, says Lombard, and the National Liver Strategy must link in with

the government's vision for the NHS and for public health, published in the

white papers Liberating the NHS and Healthy Lives, Healthy People. “Across liver

disease, there are significant numbers of patients who need help in their

lifestyles to achieve optimum benefit from such a programme. This is an area

where we need to do more work with key partners and different agencies”, he

says.

“The temptation is going to be to focus very much on alcohol with obesity next

as big headline problems”, Gore tells The Lancet. He would like hepatitis C to

be the primary focus of strategy: “Out of the main causes of liver

disease—alcohol, obesity, and viral hepatitis—hepatitis C is the one bit that is

actually solvable in a reasonable amount of time. We could all but eradicate

hepatitis C in England within the next 30 years, and make a huge dent in the

prevalence in a reasonably short time, if there are clear directions to local

NHS on how to go about it in a way that is easy to action.”

Alcohol and obesity must be part of the National Liver Strategy,

comments, “but the half million or so people with viral hepatitis deserve a very

significant place. There are very large numbers of people infected, the disease

burden in terms of cancer and transplantation is huge, and it's a tractable

problem where we have solutions”. Conversely, he says, reducing problem drinking

requires strategies that are more social than medical, to tackle marketing and

availability of alcohol.

Broadly speaking, there is consensus on hepatitis C, “that we need to identify

patients earlier”, says Lombard. “Key to this is the need to engage with and

up-skill primary and community care services to help us to do this. We also need

to do more work with those areas and populations identified as having a higher

prevalence of hepatitis C such as drug treatment units, prisons, and within some

ethnic groups…many more patients could be treated and prevented from progressing

to advanced liver disease if we can achieve this”, he tells The Lancet.

With a new NHS structure and government looking for savings across the board,

Gore wonders what will be the levers and incentives to increase testing and

treatment. Without safeguards, he says, GP consortia might fail to prioritise or

even reduce testing and commissioning of the expensive recommended treatments,

with concomitant effects on specialist care. England already ranks second lowest

of 14 comparable countries in use of drug treatments, while about a third of

patients referred to hospitals in 2009 were not offered treatment, according to

the 2010 audit report from the All-Party Parliamentary Hepatology Group and the

Hepatitis C Trust.

Amid this uncertainty, the clinical outlook for patients is about to change

radically, with the launch of new drugs boceprevir and telaprevir expected

within 1 year. When added to existing treatments, these drugs can increase

response rates from 40% to 70% in patients with genotype 1 virus and greatly

reduce treatment times. “This will transform the picture, both for those who

have failed to respond to previous treatment and for naive patients”, says

, but could “expose some terrible holes in our service provision”, he

warns.

Lombard acknowledges that “some patients who have not responded to treatment

programmes in the past may benefit from the availability of newer treatments in

the future”. However, he urges, “we need to understand better, and explain

better, which particular patients will benefit and what services are needed to

treat them”, especially given future financial pressures, and the need to

optimise efficiency in services.

Globally, Gore describes the increasing awareness of viral hepatitis B and C

infection, as raised last year in a World Health Assembly resolution. July 28

will be the first annual WHO-supported World Hepatitis Day, and WHO is currently

drafting a global viral hepatitis strategy. In January, the US Institute of

Medicine released a report that recommends steps to improve awareness,

recognition, and surveillance, plus integration of care services, to tackle

hepatitis B and C in the USA. comments that, “the message from Scotland

is absolutely clear. If you set clear targets and you nominate individuals with

clear tasks, action happens. If you set rather vague, pious wishes, nothing

effective will take place.”