Hepatitis C: an Australian snapshot
How many people in Australia have hepatitis C?
At the end of 2005, there were an estimated 264,000 people in Australia who had contracted hepatitis C virus (HCV), including:- 154,000 with early liver disease;
- 38,000 with moderate liver disease;
- 5,300 with cirrhosis of the liver; and
- 67,000 with HCV antibodies but without chronic HCV infection.
An estimated 9,700 new HCV infections accumulate annually (2005) — that’s about 27 new infections each day across Australia.
About 89 per cent of these new infections occur through blood-to-blood contact between people sharing equipment used for injecting illicit drugs. About 7 per cent occur among immigrants to Australia (through medical procedures and other transmission routes in their countries of origin), and about 4 per cent involve other routes such as unsterile tattooing and body piercing.
There have been over 225,000 notifications of HCV-positive diagnoses between 1990 and 2005. Men comprise 65 per cent of the diagnoses; women 35 per cent. About 65 per cent of people diagnosed are in the age range 20-39 years.
Of all the people in Australia estimated to have HCV, about 39,000 people are yet to be diagnosed.
How is hepatitis C transmitted?
Hepatitis C is transmitted via blood-to-blood contact. About 82 per cent of existing infections occurred as a result of people sharing equipment used to inject illicit drugs.About 11 per cent of existing cases are believed to involve immigrants who contracted hepatitis C (also called hep C) in their countries of origin through unsterile medical procedures or other means.
About 7 per cent of current cases involved people having blood transfusions or blood products prior to 1990 — when screening by Australian blood banks was introduced, or through other blood contact risk behaviours, including:
- unsterile tattooing and body piercing;
- transmission from mother to baby;
- unsterile skin penetration equipment, including barbers’ clippers and razors;
- needlestick injuries;
- possible blood-to-blood contact during sex; and
- possible household transmission through shared toothbrushes or razors.
Hep C is not transmitted through sharing crockery, cutlery, toilet or laundry facilities. For hepatitis C to be transmitted, the blood of a person who has hep C needs to get into the bloodstream of another person.
Prisoners are at particular risk of new infection or re-infection with HCV because rates of prevalence (existing infections) and incidence (new infections) within corrective services establishments are vastly higher than in the broader community.
What does hep C do?
The hepatitis C virus causes inflammation of the liver. Usually, a person’s immune response does not initially clear hep C, nor does it protect against re-infection.There is no vaccine to protect against hepatitis C infection.
What’s the likely outcome of infection?
Very few people will show any outward signs of illness soon after infection, as acute symptoms are rare. Unless they have an HCV antibody blood test, most people will not know for many years that they have hep C.About 75 per cent of people who contract HCV will develop chronic (long term) infection.
Of 100 people with chronic HCV infection who remain untreated, and after 20 years of infection:
- 45 would not develop serious liver damage;
- 47 would develop progressive liver damage, which may be only mild or moderate;
- 7 would develop cirrhosis of the liver; and
- one would develop liver cancer or liver failure.
If the same group of 100 people were followed up for a further 20 years (40 years of infection in total):
- 45 would still have not developed serious liver damage;
- 31 would have remained as having mild to moderate liver damage;
- 20 would have developed cirrhosis of the liver; and
- 4 would have developed liver failure or liver cancer.
Hep C symptoms and their effects
Typical symptoms include debilitating fatigue, nausea and abdominal pain. People with significant illness are often unable to carry out ordinary, everyday functions, including employment and home duties.Other common symptoms include joint and muscle pain, general malaise, weight loss, hormonal irregularities in women, flu-like symptoms and depression.
Hep C infection is now the most common reason for liver transplantation in Australia. Because HCV circulates in the bloodstream, the new liver will become infected.
History and treatments
Earliest evidence of HCV comes from blood samples stored in the 1940s. The virus has been transmitting widely via blood-to-blood contact since the early 1970s, yet was identified as a distinct virus only in 1989. Prior to that it was known as non-A, non-B hepatitis.Current treatment involves combination therapy (pegylated interferon injections and ribavirin tablets). Response is related to a person’s hep C genotype (subtype). HCV genotypes 2 and 3 have been shown to have a higher sustained response rate (approximately 80 per cent) than genotype 1 (approximately 50 per cent).
A sustained response is where no presence of the virus can be detected immediately after therapy, and also at 6 months after treatment ceases. Recent research shows that 99 per cent of people maintain their viral clearance for at least 4 years and it is believed their response will last indefinitely.
Many people with HCV report benefits received from complementary or alternative therapies. Proven efficacy is hard to establish, given limited research in the area. However, one Australian scientific trial of Chinese herbal therapies showed some optimistic results and evidenced the need for further research.
Personal and social costs
Because of the relatively recent identification of hepatitis C, healthcare worker knowledge, including that of general practitioners, can be limited. Levels of discrimination and stigmatisation, from both healthcare workers and the general public, are high. Ignorance, and misplaced fear of infection, are potential causes for this discrimination. The fact that the risk behaviour that most commonly leads to hep C infection — injecting drug use — is an illegal behaviour, adds another level of stigmatisation for all those affected.On initial testing, during ongoing monitoring and during treatment, levels of support for people affected by hepatitis C are inadequate. Personal costs, through inability to work, relationship breakdown or through discrimination, stigmatisation and vilification are great.
A government-funded inquiry into hepatitis C-related discrimination was undertaken by the Anti-Discrimination Board of NSW in 2001. Its report, C-CHANGE, notes that hepatitis C is a highly stigmatised condition and that discrimination against people with hepatitis C is rife, particularly in the healthcare setting.
Economic costs of infection
Economic studies estimate both the direct and indirect costs of hepatitis C. Direct costs are those associated with action taken to tackle specific aspects of the disease, and include research, prevention, diagnosis, treatment and palliation. Indirect costs are related to loss of workplace production resulting from premature death and ill health.
Looking at lifetime costs (direct and indirect) per person infected with hepatitis C is alarming. Combining the lifetime average treatment cost per case of hep C (being $13,000) and the indirect costs per case (being $33,600), gives a conservatively estimated cost of hep C infection of $46,600 per person.
Using this figure, the 197,000 people (to end of 2005) already living with hep C represent a $9.2 billion cost to our health care system.
Additionally, each year, the estimated 9,700 new cases of HCV occurring in Australia would annually add $452 million in lifetime costs to our health budget.
Needle and syringe programmes (NSPs) have been shown to be effective in reducing hep C prevalence rates in people new to drug injecting. It has been estimated that NSPs prevented 21,000 hep C infections (from 1991 to 2000). In preventing these cases, NSP has saved an estimated $783 million in lifetime hep C treatment costs.
Government responses
In November 1998, the Standing Committee on Social Issues tabled its report Hepatitis C: The Neglected Epidemic in the NSW Legislative Council, following its public inquiry. It found unanimously that hepatitis C is a disease that was largely neglected by decision makers, health planners, the media, healthcare workers and the community in general. It found that there was no overarching policy to guide and direct the control, treatment and prevention of hep C. It found that the impact of hepatitis C is enormous. The social impact of the disease is ‘profound and touches every facet of life’.The Federal government has developed a formal hepatitis C strategy (most recently, 2005/2008) and funds one-off and ongoing research, education and prevention projects through various Commonwealth/ State funding mechanisms.
The NSW State government has developed a formal hep C strategy (most recently, 2000/2003) and an NSP policy (2006) It is currently reviewing hep C care and treatment services (2007). These initiatives have been put in place to better guide the state-wide delivery of services that reduce transmissions and reduce the negative social and economic impact caused by HCV infection.
Key challenges include ensuring that sufficient ongoing funding from Federal and State and Territory governments is applied to meet identified needs, and that evidence-based approaches to drug policy and law reform are considered in order to make a significant impact on HCV transmission reduction. Under the current national harm minimisation drug policy, only 3 per cent of government expenditure on drugs is for harm reduction programmes, and the vast majority is spent on law enforcement and customs (56 per cent), prevention education (23 per cent) and drug treatment/ rehabilitation (17 per cent).
References/ recommended reading
Hepatitis C Virus Projections Working Group: Estimates and Projections of the Hepatitis C Virus Epidemic in Australia 2006, Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis (Hepatitis C Sub-Committee), October 2006.HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia: 2006 Annual Surveillance Report, National Centre in HIV Epidemiology and Clinical Research, 2006.
HIV/AIDS, hepatitis and sexually transmissible infections in Australia: Annual report of trends in behaviour 2006, National Centre in HIV Social Research, 2006.
What is Australia’s ‘Drug Budget’? The policy mix of illicit drug-related government spending in Australia, Moore, TJ. Monograph No. 01: DPMP Monograph Series, Turning Point Alcohol and Drug Centre, 2005.
Return on investment in needle and syringe programs in Australia, Commonwealth Department of Health and Ageing, 2002.
C-CHANGE, Report of the enquiry into hepatitis C-related discrimination, Anti-Discrimination Board of NSW, November 2001.
Estimates and Projections of the Hepatitis C Epidemic in NSW, National Centre in HIV Epidemiology and Clinical Research and AIDS and Infectious Diseases Branch, NSW Health Department. Draft: August 1999.
Economic analyses relating to hepatitis C, Alan Shiell (Chapter 7: 83-96) in Hepatitis C: a review of Australia’s response, prepared by David Lowe and Ruth Cotton for the Commonwealth Department of Health and Aged Care, January 1999.
Hepatitis C: The Neglected Epidemic, Inquiry into hepatitis C in New South Wales. Parliament of NSW Legislative Council Standing Committee on Social Issues, November 1998.
Last Reviewed: 01 May 2007
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