France led the world in the proportion of its hepatitis C
patients who received treatment in 2010, but some countries in southern and
eastern Europe had treatment rates that were almost tenfold lower, according to
research presented last month at the International Liver Congress in Amsterdam.
However, European epidemiologists and physicians cautioned
that the results should be treated as indicative rather than hard estimates,
and that far more research is needed into hepatitis C prevalence in order to arrive
at reliable estimates of treatment need in the European region.
The study, carried out by the Center for Disease Analysis in
Colorado, USA, sought to develop estimates of the number of people who received
treatment with pegylated interferon and ribavirin in 2010. This was the last
year in which all European countries had access to a comparable regimen for the
treatment of hepatitis C. In 2011, the HCV protease inhibitors telaprevir (Incivo) and boceprevir (Victrelis) began to become available in
some European countries following European marketing approval.
The study compared treatment rates in 22 European countries
(Austria, Belgium, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Netherlands, Norway, Poland, Portugal,
Romania, Russian Federation, Slovakia, Spain, Switzerland, Sweden and the
United Kingdom) using data supplied from a variety of sources including key
opinion leaders and national surveys, as well as international databases on
pharmaceutical sales. The Baltic states and Ukraine were excluded due to a lack
of robust data on drug purchases.
Treatment rates were calculated using the following
parameters:
- Estimates of the total number of units of
pegylated interferon and ribavirin sold in each country between 2004 and 2010,
adjusted for probable use in hepatitis B treatment.
- Estimates of chronic, viremic hepatitis C
infections for each country, derived from calculations of global burden
published in the journal Liver International in 2011.
- Country-specific genotype distribution, used to
adjust the duration of treatment (the higher the prevalence of
difficult-to-treat genotypes, the fewer patients would be treated with a given
volume of interferon, because treatment courses would last for 48 weeks rather
than 24 weeks).
- The proportion of patients who were estimated to
complete a full course of treatment and the average duration of treatment of
all patients who started treatment.
Estimates of HCV prevalence remain the subject of
controversy among public health specialists and epidemiologists owing to a lack
of robust national surveys.
Session chair Prof. Daniele Prati warned that some estimates
of HCV prevalence in Italy are questionable. In particular, he warned, they may
over-estimate prevalence through reliance on population surveys which
over-represent southern Italy and older populations. Both these populations had
a higher HCV prevalence.
Epidemiologist Prof. Matthew Hickman of Bristol
University voiced similar concerns about the United Kingdom. “The bound of
uncertainty for the United Kingdom alone might be anywhere between 100,000 and
500,000 – that’s just one country,” he said.
Homie Razavi of the Center for Disease Analysis defended the
prevalence estimates, pointing out that they were based on the best available
data, identified through a systematic
review of the published literature on HCV prevalence.
Taking into account these uncertainties, some clear European
trends were evident nevertheless.
While the total number of patients treated had grown substantially
between 2004 and 2010 in the United Kingdom, Russia and Romania, Germany and
Spain, the number of patients treated had fallen in Italy and France. This,
said Homie Razavi, indicated that liver specialists had already begun 'warehousing' patients in anticipation of the availability of more effective
hepatitis C treatments in the future. This trend was already evident by 2008,
he said.
The rate of hepatitis C treatment within the viremic
population differed enormously between some countries in northern and western
Europe and most countries in southern and eastern Europe. Whereas an estimated
6.7% of French hepatitis C patients underwent treatment in 2010, only 0.8% of
Italian patients were treated in the same year. Even if the prevalence of
hepatitis C in Italy and France were the same, the treatment rate in France
would still be several times higher than in Italy.
The treatment rate was also very low in Poland (0.4%),
Romania (1%) and Russia (0.3%), perhaps due to the cost of treatment. Yet it
was also substantially lower in Belgium (1.1%), Finland (1.1%) and Ireland
(1.5%) when compared to Germany (4.3%), Sweden (4.3%) and the United Kingdom
(3.4%), suggesting that resource allocation for hepatitis C treatment in countries at similar levels of economic development remains highly variable.
Prof. Daniele Prati cautioned that any comparison of treatment
rates needed to take into account two factors: the age distribution of the
viremic population, and the proportion of people in the population who had
already experienced failure of a treatment regimen and who were waiting for new
treatment.
HCV epidemics in eastern Europe may be 'younger' than in
northern Europe and the Mediterranean. More recently infected people may not
need treatment yet. On the other hand, high rates of HIV/HCV co-infection in
eastern European populations, particularly in Russia, could diminish this
difference, by causing rapid progression of liver disease.
Similarly, even though almost twice as many people received
treatment in Italy in 2004 compared to France, with the gap disappearing by
2010, a very high proportion of these patients and those treated in subsequent
years would have to fail treatment for this argument to explain the difference
in treatment rates between Italy and France.