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Improving identification and awareness of hepatitis C

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According to a report from the Hepatitis C Trust (2005), the UK has the worst record for treating hepatitis C in Europe. The report highlights that only 1-2 per cent of hepatitis C cases in the UK are identified and treated with National Institute for Health and Clinical Excellence-approved drugs (NICE, 2004; 2000), compared with France where 13 per cent of those infected receive treatment.


VOL: 101, ISSUE: 42, PAGE NO: 23

Terry Hainsworth, BSc, RGN, is clinical editor, Nursing Times

According to a report from the Hepatitis C Trust (2005), the UK has the worst record for treating hepatitis C in Europe. The report highlights that only 1-2 per cent of hepatitis C cases in the UK are identified and treated with National Institute for Health and Clinical Excellence-approved drugs (NICE, 2004; 2000), compared with France where 13 per cent of those infected receive treatment.



The Hepatitis C Trust is calling for the government to take urgent action to improve awareness, diagnosis and treatment of hepatitis C.



Hepatitis C infection
Hepatitis C is a viral infection of the liver. It is a major cause of acute hepatitis and chronic liver disease, including cirrhosis and liver cancer (World Health Organization, 2005). The virus is primarily spread by direct contact with blood. The major causes of infection worldwide are unscreened blood transfusions and reuse of needles and syringes that have not been sterilised, including needle-sharing among drug users. Sexual and mother-to-child transmission have been widely documented (WHO, 2005).



In England the most common route of infection is through injecting drug users sharing contaminated needles or other injecting equipment (Department of Health, 2004). Most people who become infected are not aware of it at the time. Those with chronic infection may have no symptoms, which is why hepatitis C is known as the silent epidemic. Where symptoms occur, they can include:



- Mild to severe fatigue;



- Loss of appetite;



- Weight loss;



- Depression or anxiety;



- Poor memory or concentration;



- Pain or discomfort in the liver.



About 80 per cent of patients develop chronic infections. Cirrhosis develops in about 10-20 per cent of those with a chronic infection, and liver cancer develops in 1-5 per cent over 20-30 years (WHO, 2005). About 15 per cent of liver transplants in England are undertaken because of liver damage caused by chronic hepatitis C infection (DoH, 2004).



No vaccine is available and, although moderate to severe disease can be treated in up to 55 per cent of cases, the medications are too costly for widespread use in developing countries (WHO, 2005). Therefore, from a global perspective, screening of transfusion blood products, effective sterilisation processes and health education are important for prevention.



The WHO (2005) estimates that globally 170 million (three per cent of the population) are chronically infected with hepatitis C and that 3-4 million people are newly infected each year.



The estimate for the general population in England is approximately 250,000 people or 0.5 per cent. However, the majority of them are undiagnosed (DoH, 2004) so there are relatively large numbers of people who do not know they are infected.



Information collected and published by the Health Protection Agency shows an increase in hepatitis C cases in England and Wales (Table 1) (HPA, 2005).



HPA surveillance and other studies into hepatitis C prevalence show that infection occurs countrywide, with higher levels in inner-city areas. This is thought to reflect a higher concentration of injecting drug users in inner cities (DoH, 2004).



The prevalence of hepatitis C in injecting drug users accessing health services is estimated at 38 per cent. It is thought that this figure could be higher in long-term drug users, those no longer in contact with services and homeless drug users.



UK management
Early detection and appropriate treatment can cure or stabilise up to 80 per cent of patients (Hepatitis C Trust, 2005). However, in the UK there are high numbers of undiagnosed cases and, in the next 5-10 years, illness and death due to hepatitis C is likely to increase (DoH, 2004).



The growing public health concerns regarding hepatitis C were identified in 2002 in the chief medical officer’s infectious diseases strategy for England, Getting Ahead of the Curve (DoH, 2002a) and the Hepatitis C Strategy for England (DoH 2002b). To support these documents the Hepatitis C - Action plan for England (DoH, 2004) has been developed as a framework for implementation.



The plan covers four key areas of action:



- Surveillance and research;



- Increasing awareness and reducing undiagnosed infections;



- Development of services for assessment and treatment in primary care and NHS hospital trusts;



- Hepatitis C prevention.



Management in France
The number of patients in France infected with hepatitis C who receive treatment is at least five times higher than in the UK. France has achieved a significant reduction in deaths from liver disease over the last decade (Hepatitis C Trust, 2005).



They have made this progress by:



- Having a government advocate for action on hepatitis C;



- Establishing an effective hepatitis C virus network;



- Setting clear targets for detection;



- Having a clear strategy with dedicated funding;



- Creating an adequate surveillance system to determine the extent of the problem and measure the impact of interventions;



- Running annual media awareness campaigns;



- Anonymous testing at a number of centres, such as family planning clinics, drug clinics, universities and prisons;



- Including patient organisations at all stages of strategy development and implementation.



The result of these measures and adequate investment in hepatitis C services in France has doubled detection in 10 years. In 1994 24 per cent of those infected knew they had the condition; this has increased to 56 per cent. Patient awareness in France is four times higher than in the UK.



These improvements in detection and awareness have enabled France to significantly reduce deaths from liver disease (Hepatitis C Trust, 2005).



The main differences in approach between France and the UK are that France has set clear targets for detection and runs regular media awareness campaigns. The Hepatitis C Trust (2005) has drawn up recommendations, based on the measures in France, as priorities for hepatitis C control in the UK. These are:



- Improve the clinical infrastructure for delivery of care through priority investment;



- Set targets for proactive screening of at-risk individuals, referral and management;



- Increase public awareness of the risk factors and consequences of the disease;



- Improve referral to specialist services;



- Offer more immediate treatment for those identified as being infected.



If these actions are adopted, detection rates for hepatitis C will increase and awareness of this serious infection will improve. This should reduce morbidity and mortality.



- This article has been double-blind peer-reviewed.



For related articles on this subject and links to relevant websites see

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