Viral Hepatitis Clinical Research Program The Kirby Institute for infection and immunity in society The University of New South Wales UNSW Sydney Australia The broad patterns of HCV morbidity and mortality across the world What is the anticipated pattern in Iran ID: 810630
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Behzad Hajarizadeh, Jason Grebely, Gregory DoreViral Hepatitis Clinical Research ProgramThe Kirby Institute for infection and immunity in societyThe University of New South Wales (UNSW), Sydney, Australia
The broad patterns of HCV morbidity and mortality across the world. What is the anticipated pattern in Iran?
Slide2OutlineHCV transmission routs and population at risk
Increasing burden of HCV mortality: highlighted or missed?
HCV prevalence across the world
Liver fibrosis progression in chronic HCV infection
Major determinants of current and projected burden due to HCV
Broad patterns of HCV morbidity and mortality across the world
How will new treatments affect HCV burden?
HCV age-specific prevalence in Iran
Anticipated pattern of HCV morbidity and mortality in Iran
Slide3Increasing burden of HCV mortality: highlighted or missed?Ly K, et al. Annals of Internal Medicine. 2012
Annual age-adjusted mortality rates from HBV, HCV and HIV infections in the United States
Fauci
, A &
Morens
, D. NEJM 2012
Slide4HCV distribution across the world
Gravitz
L. Nature. 2011 ; Lavanchy D. Liver International. 2009 ; GBD. J
Clin
Pharm. 2004 ; WHO. Weekly
Epi
Record. 1999
Global pr. :
2-3%
30-170 million
people infected
Slide5Liver fibrosis progression in chronic HCV infectionGrebely J & Dore G. Semin
Liver Dis. 2011
HCV-related mortality and morbidity is mainly due to cirrhosis and
hepatocellular
carcinoma (HCC)
Risk of HCV-related cirrhosis increases exponentially by duration of infection
There are various factors associated with a higher risk of fibrosis progression
Slide6Current and projected HCV-related burden reflects temporal HCV incidence and prevalence, HCV disease progression co-factors and HCV treatment uptake.Given slow progression of liver fibrosis, the temporal incidence of HCV is the main determinant of the future burden.
Mathematical models have been used to define trends in incidence, which rely on the assumption that current age-specific prevalence reflects the cumulative risk of acquiring infection.
Major determinants of current and projected burden due to HCV
Slide7Broad patterns of HCV morbidity and mortality across the worldFirst pattern
HCV is endemic; High prevalence in all age groups; High incidence
Africa, South Asia, South-East Asia
Second pattern
Low overall prevalence; Low incidence; High prevalence in elderly
Japan, Southern Europe
Third pattern
Low overall prevalence; Low incidence; High prevalence in middle age
The United States, Australia, Northern and Western Europe
Slide8HCV pr.: 14.7%HCV pr. increases with age
50–59 years age group
M: 46%
F: 31%
HCV inc.: 7/1000 p/y, corresponding to 500,000 new cases per year.
HCV incidence and age-specific prevalence in Egypt
Guerra J, et al. J Viral Hep. 2012
Miller FD & Abu-
Raddad
LJ. Proc Nat
Aca
Sci. 2010
Slide9HCV is endemicPr. is high in all agesInc. is high
HCV-related mortality is projected to be 2.5 fold higher in 2020 compared to 1999
More than 20,000 HCV-related deaths occurring in 2020
HCV-related mortality in Egypt
Deuffic-Burban
S, et al. J Hep. 2006
Slide10HCV prevalence: 1.0-1.9% HCV incidence: 1.9 per 100,000 p/y (blood donors)HCV pr. is strongly related to age; exponential increase in over 55 yrs
People aged 40 to 69 years account for 86% of infections.
Major HCV spread occurred in the distant past (1920s and 1940s [WW II])
HCV incidence and age-specific prevalence in Japan
Tanaka J, et al.
Intervirology
. 2004 ; Tanaka J, et al.
Intervirology
. 2008
Slide11HCV-related HCC incidence in JapanTanaka H, et al. Ann Intern Med. 2008
High HCV prevalence in elderly
Peak HCV incidence occurred several decades ago
Low current HCV prevalence, and incidence.
HCC incidence peaked in late 1980s to early 1990s and has been decreasing afterwards.
Trends in age-standardized incidence of HCC in Osaka, Japan, 1981–2003.
Slide12HCV prevalence:1.8% in 1988-19941.6% in 1999-2002
Peak prevalence shifted from 30-39 yrs in 1988-1994 to 40-49 yrs in 1999-2002
Major HCV spread occurred in the recent past:
High incidence in the 1970s and early 1980s
Rapid decline from the mid-1980s
.
HCV incidence and age-specific prevalence in the USA
Armstrong GL, et al. Ann Intern Med. 2006 ; Williams IT, et al. Arch Intern Med. 2011 ; Armstrong GL, et al. Hepatology. 2000
Slide13HCV prevalence: 1.4%Peak prevalence is 30-39 yrs, at least 10 yrs younger than in the US.
HCV incidence increased throughout the 1980s and 1990s with a decline from 2000, initially related to a heroin shortage.
HCV incidence and age-specific prevalence in Australia
The Kirby Institute. Annual Surveillance Report 2012 ;
Razali
K, et al. Drug and Alcohol Dependence. 2007 ; Amin J, et al.
Comm
Dis
Int. 2004
Slide14HCV-related cirrhosis and HCC in the USADavis GL, et al. Gastroenterology. 2010
Low prevalence and incidence
Relatively higher prevalence in middle age
Is following Japanese profile, but with a time lag of 20-30 years.
Number of cirrhosis is increasing steadily to a peak level of 1.4 million in 2020
HCV-related HCC should peak in 2019 at 14,000 per year.
HCV-related mortality is increasing with 280,000 liver-related deaths within 2020-2029
Slide15Schematic presentations of various patterns of age-specific prevalence of HCV infection and incidence of HCV-related advanced liver disease in four representative countriesPatterns of age-specific HCV prevalence and HCV burden
Slide16How will new treatments affect HCV burden?The sustained virological response (SVR) increased from 55% with
pegylated
-interferon (PEG-IFN) and
ribavirin
(RBV) to 70% in the era of PEG-IFN, RBV, and a protease inhibitor (genotype 1 only)
IFN-free agents will be available by 2018, with SVR equals to 90%.
In 2005, 3% of patients in Europe and the US received treatment, with treatment uptake increasing by only 0.5% per year .
Slide17HCV distribution in Middle-East and EMRO countries
Slide18HCV age-specific prevalence in Iran
Merat
S, et al.
Int
J
Inf
Dis. 2010
Poorolajal
J, et al. J Res Health Sci. 2011
Ansari-
Moghaddam
A, et al. Hepatitis Monthly. 2012
HCV prevalence: 0.5-1%
Age specific prevalence:
Peak pr. in young or middle age
No constant increase with age
Limited data of HCV incidence
Newly diagnosed HCV cases:
Blood donors: 0.8-1.9/1000 p/y ; relatively steady trend
Surveillance: 5-8/100,000 p/y in one province; relatively steady trend
Khedmat
H, et al. Hepatitis Monthly. 2009
Amini
Kafi
-Abad S, et al. Transfusion. 2009
Slide19Anticipated pattern of HCV morbidity and mortality in Iran Given high coverage of HBV vaccination in infants and also implementation of catch-up HBV vaccination programs among adolescent, HCV seems to emerge as the leading cause of chronic viral liver disease in the future.
Age-specific prevalence of HCV in Iran is more close to that in the US Australia, and Western Europe than the regional countries. Then it is anticipated that the profile of HCV-related burden in Iran is more or less similar to the Western countries (maybe with a time lag of 10-20 yrs).
More data needed to identify the profile of HCV-related burden in Iran.
Data registry in MOHME has potentials to collect required data for modellings but needs modifications.