Hepatitis C Screening in der Schweiz Philip Bruggmann Chefarzt Innere Medizin, Arud Zentren für Suchtmedizin, Zürich Präsident SEVHep (Swiss Experts in Viral Hepatitis) WHO: die stille Epidemie. Momentum Therapie Revolution, Momentum PH Bedeutung

Wieviel Prozent Ihrer Patienten sind HCV Ak positiv? <0.1% 1 % 5% 20% 50%

HCV in der Schweiz anti-HCV Prävalenz Schweiz: ca 1.3 % (BAG Bulletin 1998; Sagmeister 2002) Ca 50% der Betroffenen sind nicht adäquat getestet (Fretz, 2013; Schulthess , 2011) As in other countries, the BAG used the anti-HCV prevalence in blood donors and pregnant women to estimate the prevalence of hepatitis C at 0.5±1% in the 1998 Swiss population, translating into 35 000±70 000 persons who were HCV infected in 1998 [17]. When applied in the United States, prevalence estimates based on a similar approach underestimated the prevalence actually observed when screening was applied to a representative sample of the US population

HCV Testen HCV Antikörper HCV RNA (Viruslast) Genotyp Normale Transaminasen schliessen HCV oder HCV induz Cirrhose nicht aus

HIV/Hep B/Hep C Sterblichkeit Ly, Annals Int Med, 2012

HCV Prävalenz und assozierte Gesundheitskosten HCV prevalence peaked in 2003, at 88,600 (41,500-98,500) viremic cases There were 82,700 (37,200-93,400) viremic cases in 2013, and by 2030, there will be 63,200 (25,900-71,800) viremic cases Annual HCV-related healthcare costs (excluding treatment costs) were estimated at CHF 89.6 M (CHF 43.3 M – CHF 191.1 M) in 2013 Costs are expected to peak in 2030 at CHF 118.7 M (CHF 43.9 M – CHF 282.9 M Bruggmann et al, abstract EASL 2014

HCV Gesundheitsbelastung: heute und morgen In 2013, advanced stage disease accounted for 12% of total HCV cases, or approximately 10,180 cases By 2030, there will be 15,500 advanced stage cases (25% of total cases), of which, 2,530 will be decompensated cirrhosis or HCC cases (4% of total cases as compared with 2% in 2013) 04/02/2014 Bruggmann et al, abstract EASL 2014

Szenario hohe Heilungsraten 380 650 580 400 740 670 Increasing SVR, in conjunction with 2013 treatment rates of 1,100 patients annually, will decrease HCC and liver-related mortality by 10%, to 670 cases and 580 deaths, by 2030 Additionally, total viremic infections will decrease by 7%, or 4,510 infections from 2012-2030, as compared with the base case by 2030 An estimated CHF 94 M in healthcare cost savings (excluding treatment costs) was projected 04/02/2014 Swiss Manuscript Scenario Bruggmann et al, abstract EASL 2014

Szenario erhöhte Heilungs- und Behandlungsrate 650 400 380 130 740 160 150 120 A scenario to treat 3,940 patients (≥F2) by 2018 will decrease HCC cases and liver-related mortality by 80%, to 150 cases and 120 deaths, by 2030 The proposed scenario would require the diagnosis of 4,740 new viremic infections annually by 2020 (as compared with 1,050 in 2013) Expanding treatment access to ≥F0 patients would require treatment of 6,320 annually by 2018 to achieve the same reduction in HCC cases and liver-related mortality An estimated CHF 735 M and CHF 742 M in healthcare cost savings (excluding scenario and treatment costs) was projected for the scenario treating 3,940 ≥ F2 patients and 6,320 ≥ F0 patients, respectively 04/02/2014 Swiss Manuscript Scenario

Wen testen Sie auf Hepatitis C? Erhöhte Leberwerte Alkoholiker Iv Drogenkonsum Ältere Italiener Homosexuelle Männer Dialysepatienten In den 60er Jahre geborene

Aktuelle Teststrategie Schweiz HCV Screening: nur für Blutprodukte Risikostratifiziertes Testen: Fretz et al , SMW 2013

Hepatitis C nach Alter und Geschlecht Chronic hepatitis C prevalence >65 jährige machen nur 16% aller Hepatitis C Betroffenen aus Das mittlere Alter von HCV Patienten ist 47 Männer sind häufiger betroffen Chronic hepatitis C infectedpopulation

Hepatitis C nach Geburtsjahr Random screening would require >100 anti-HCV tests (in addition to further confirmatory tests) to find one current HCV case, while screening in the 1949-1978 cohort (36-65 years of age) could find one case per 59 persons screened. Screening in the 1949-1978 cohort would cost CHF 1,890 (USD $2,110) per positive diagnosis, as compared with a CHF 2,790 ($3,115) cost for random screening. Mittleres Geburtsjahr= 1966 >50% zwischen 1954 – 1973 geboren >70% zwischen 1949 – 1978 geboren

Number needed to screen Birth cohort Swiss Population (in millions) Chronic Hepatitis C Number of persons necessary to screen to find one CHC case Cases % of Total Prevalence Prior to 1928 0.20 1,300 1.7% 0.64% 155 1929 - 1933 1,400 1.8% 0.70% 143 1934 - 1938 0.26 2,200 2.8% 0.84% 118 1939 - 1943 0.32 3,200 4.1% 0.98% 102 1944 - 1948 0.44 4,400 5.7% 1.01% 99 1949 - 1953 0.47 6,300 8.2% 1.34% 75 1954 - 1958 0.50 8,500 11.0% 1.71% 59 1959 - 1963 0.60 10,400 13.4% 1.74% 57 1964 - 1968 0.68 11,100 14.3% 1.65% 61 1969 - 1973 0.62 10,300 13.3% 1.68% 60 1974 - 1978 0.52 8,100 10.4% 1.56% 64 1979 - 1983 0.51 5,300 6.8% 1.03% 97 1984 - 1988 2,900 3.8% 0.59% 170 1989 - 1993 0.48 0.29% 343 1994 - 1998 0.45 500 0.7% 0.12% 833 1999 - 2003 0.39 200 0.2% 0.04% 2,351 2004 - 2008 0.37 - 0.1% 0.01% 8,980 2009 - 2013 0.0% 0.00% 96,397 Random screening would require >100 anti-HCV tests (in addition to further confirmatory tests) to find one current HCV case, while screening in the 1949-1978 cohort (36-65 years of age) could find one case per 59 persons screened. Screening in the 1949-1978 cohort would cost CHF 1,890 (USD $2,110) per positive diagnosis, as compared with a CHF 2,790 ($3,115) cost for random screening.

1955-1975? BAG

Zusammenfassung Testraten sind ungenügend in der Schweiz Hepatitis C ist ein relevantes, zuwenig beachtetes Public Health Thema Testraten sind ungenügend in der Schweiz Jahrgang 1949 bis 1978 als Risikofaktor Auf nationaler Ebene: zusätzliche Teststrategie in gesamtheitliche nationale Hepatitis Strategie einbetten

Herzlichen Dank für Ihre Aufmerksamkeit! p.bruggmann@arud.ch www.arud.ch