1. Setting the Scene

2. Non A, non B Hepatitis  Early 1970’s recognised that 2/3 of post transfusional hepatitis were –ve for both Hep A & Hep B Non Hep A and non Hep B divided into:  Enteric form – subsequently HEV  Post transfusional form

3. Post transfusional NANB hepatitis  Short incubation 6 – 20 weeks  Mild < 1/3 jaundiced  Often become chronic  “Saw-tooth” pattern of liver enzymes

4. Experimental  Passaged into chimps  Re-infect with homologous or heterologous Detection of virus  Work for 2 decades unable to detect virus on EM, cell culture or antibody detection Hepatitis C  1989 – Michael Houghton at Chiron using molecular biological techniques

5.  1922 USA  Flame Sterilisation post WW2  Egypt, Italy, S.E.Asia  1960’s  I.D.U. in Vietnam  > R&R at Kings Cross  > Australian IDUs  > Blood Products  Now – I.D.U. ~ 50-75%  B.T.U. ~ 10-15%

6. At the end of 2007, an estimated 207,600 people were living in Australia with chronic HCV infection, including 47,600 with moderate to severe liver disease 88,000 HBV 17,500 HIV National Centre in HIV Epidemiology and Clinical Research 2008. Available at: http://www.nchecr.unsw.edu.au

7.  2.7% of Australian population  5,200 people with chronic HCV  1200 with moderate to severe liver disease

8. Chronic HCV infection Cirrhosis Decompensation Liver disease-related mortality Hepatocellular carcinoma (HCC) 10–20% of patients 5–6%/yr 1. WHO. Hepatitis C Fact Sheet no. 164. 2000 2. Lauer G, et al. N Engl J Med 2001; 345: 41 3. Fattovich G, et al. J Hepatol 1997; 27: 201 4. CDC. Hepatitis C Fact Sheet. 2005 1–4%/yr Progression to cirrhosis can take as little as 5 yrs or as long as >30 yrs 1–5%

9.  Previous and concurrent alcohol consumption (50g daily) 1  Older age at time of infection (>40 years) 1  Male gender 1  Other comorbidities:  HIV–HCV co-infection 2  HIV–HBV co-infection 3  Obesity 4 1. Poynard T, et al. Lancet 1997; 349: 825 2. Di Martino V, et al. Hepatology 2001; 34: 1193 3. NIH. Hepatology 2002; 36: S3 4. Ghany MG, et al. Hepatology 2009; 49: 1337

10. 010203040 0.00 0.25 0.50 0.75 1.00 >50 years 41–50 years 31–40 years 21–30 years <21 years Duration of infection (years) Probability of progression to cirrhosis Adapted from Poynard T, et al. J Hepatol 2001; 34: 730

11. Cirrhosis 11%/yr 2.5%/yr1.1%/yr 40%/yr 0.4%/yr 68%/yr 1.5%/yr 86%/yr HCC Death Buti M, et al. J Hepatol 2000; 33: 651 Death Variceal bleeding Hepatic encephalo- pathy Ascites

12. F0No fibrosis F1Portal fibroses only, no septa F2Portal fibrosis with few septa F3Numerous septa, often with bridging F4Cirrhosis A0No activity A1Minimal activity A2Moderate activity A3Severe activity

13.  Estimated 27,700 people with HCV antibodies have died since early 1960s  HCV-related morbidity:  37,800 quality adjusted life years (QALYs) lost during 2005  Majority of QALYs lost in people with stage 0/1 (77% lost) or stage 2/3 (19% lost) chronic HCV infection  At current treatment rates, the number of people living with chronic HCV and more advanced stage F2/3 liver disease or cirrhosis is projected to increase by around 38% by 2015 Hepatitis C Virus Projections Working Group 2006. Available at: http://www.nchecr.unsw.edu.au

14.  Estimated 27,700 people with HCV antibodies have died since early 1960s  HCV-related morbidity:  37,800 quality adjusted life years (QALYs) lost during 2005  majority of QALYs lost in people with stage 0/1 (77% lost) or stage 2/3 (19% lost) chronic HCV infection  At current treatment rates, the number of people living with chronic HCV and more advanced stage F2/3 liver disease or cirrhosis is projected to increase by around 38% by 2015 “To decrease the number of people living with chronic HCV and stage F2/3 liver disease or cirrhosis, at least a tripling of the number of people receiving treatment would be required” Hepatitis C Virus Projections Working Group 2006. Available at: http://www.nchecr.unsw.edu.au

15. 6% 13% 41% 66% 0 10 20 30 40 50 60 70 IFN 24 weeks 1 IFN 48 weeks 1 IFN+RBV 48 weeks 1,2 PEGASYS+ RBV 48 weeks 3 SVR (%) 1. McHutchison J, et al. N Engl J Med 1998; 339: 1485 2. Poynard T, et al. Lancet 1998; 352: 1426 3. Zeuzem S, et al. J Hepatol 2005; 43: 250 1998 2004 PEGASYS = Peginterferon alfa-2a (40KD) Cure = SVR = sustained virological response = undetectable serum HCV RNA 24 weeks after cessation of therapy; IFN = interferon; RBV = ribavirin.

16. An estimated 3,539 people with chronic HCV infection were prescribed ribavirin and pegylated interferon combination treatment in 2007 This equates to 1.7% of people in Australia living with chronic HCV infection National Centre in HIV Epidemiology and Clinical Research 2008. Available at: http://www.nchecr.unsw.edu.au

17.  Epidemiological and economic evaluation of Hepatitis C treatment uptake in Australia

18.  Aus 11,700; GC 315  Project 11-13% increase in new cases  Liver failure  HCC  Liver related deaths  Liver transplant By 2039

19. If treatment numbers 2 3-7% If treatment numbers 3-4 approx. 20% BUT If treatment numbers halve 41-43% long term liver complications, and 55% total costs

20.  $17K per Q.A.L.Y cf “willingness to pay” threshold $50K per Q.A.L.Y.  Q.A.L.Y. Gains exceed life expectancy gains

21.  In numbers, peak cirrhosis circa 2020 Fibrosis19701989201020202030 FO. 187%42% Cirrhosis (F4) 5%25%37%45%

22.  Hep C is a significant problem & its impact on our society will increase  We can treat this disease  We have the infrastructure (imperfect though it is)  WE CAN DO BETTER

23. HOW DO WE GET OUR MESSAGE ACROSS? A. To the health care professionals B. To the community