Today in Italy the infection mainly affects a part of the population that is difficult to intercept. Being able to reach it could allow a decisive step forward
By 2030, the World Health Organization calls for the eradication of hepatitis C, a liver infection affecting over 70 million individuals worldwide. An asymptomatic disease, which occurs when very advanced and can lead to cirrhosis, liver cancer and cause other complications in the liver. Thanks to the new direct-acting antivirals it can be cured with 95% effectiveness. But the problem with this infection is finding it. Today in Italy hepatitis C mainly affects a part of the population that is difficult to intercept: by drug users intravenously to the prison population, passing through all those individuals who do not attend recovery centers but carry on risky behaviors. The Government has allocated over 70 million to step up the screening campaign, but without an adequate treatment path, there is a risk of not achieving the precious goal of 2030.
How the infection turns out
People discover the infection randomly, perhaps after having blood tests that document the alteration of liver function indices. About 15% of those who contract Hcv recover spontaneously – explains the professor Claudio Mastroianni, Director of Uoc Infectious Diseases of the Policlinico Umberto I in Rome and elected president of Simit, the Italian Society of Infectious and Tropical Diseases – while in 85% of cases hepatitis becomes chronic. Of these, about 15-20% of cases develop liver cirrhosis, of which 2-3% per year can develop liver cancer. Hepatitis C is transmitted through contact with blood and mucous membranes, unsafe sexual intercourse, exchanging needles or syringes, performing tattoos or piercings without the application of correct hygiene rules, accidental exposure to infected blood by health professionals.
What treatments are available
There is no specific vaccine or prophylaxis
. The only preventive tools are the reduction of risk factors and behaviors. Before the arrival of direct-acting antivirals, they were used to treat hepatitis C therapies with pegylated interferon in combination with ribavirin, which had limited efficacy of around 50%. The new antivirals are 95% effective and have been present in Italy since 2014. As these are curative therapies for the infection, the use of these drugs decreased over time: as reported by recent analyzes carried out by Iqvia, a provider of technologies and information in the health sector, in the last 5 years there has been a decrease of 21% in the doses sold. Degrowth tells us that all diagnosed people are being treated therefore, every year, fewer drugs are used as the population affected by the infection is covered.
How many healthy carriers are there in Italy
This it does not mean that the disease is disappearing but that diagnosable people are only being treated. Which are only a part of the existing ones. According to the Aifa registers for the monitoring of anti-Hcv drugs, patients treated with innovative drugs are approximately 227,789 (as of 27 September 2021). But according to several estimates, people who have hepatitis C without knowing it could be about 400 thousand. There are populations that have remained on the fringes and that can represent important reservoirs of the virus, such as prisoners, drug addicts and migrants. Because of this the penitentiaries and the SerD they are points of reference for intercepting these subjects. And with the arrival of the pandemic it is likely that the estimate of the undeclared is to be revised upwards. A survey carried out in 2020 byItalian Association for the Study of the Liver (Aisf) in fact, it highlighted a drastic reduction in outpatient hepatology activities and antiviral treatments.
How the potential infected are traced
In Italy the strategy to trace potential infected from Hcv is based on one graded screening, which identifies the young populations (born between 1969 and 1989) at risk of transmission and also extends to key populations already mentioned (prisoners, subjects who frequent the SerD, people with risky behaviors). The people at risk are not only those who attend these centers – he explains Marco Riglietta, deputy director of the Scientific Committee of FederSerD, the Italian Federation of Operators of Departments and Addiction Services – but all drug users who use needles or inhale drugs. It is difficult to test at SerD because so many do not show up for the appointment. But the point is not so much screening, but all patient management. Case managers are needed who follow the person, from when the appointment is made, to when he takes the test and receives, if positive, therapy. Inside the HAND project (Hepatitis in Addiction Network Delivery, a project promoted by various associations in the field of infectious disease and addiction: Simit, FederSerd, Sipad, Sidt, ed) we carried out a screening campaign that lasted a month: when patients came to the SerD to collect their drugs, we offered them the opportunity to take the test. So we managed to intercept them.
The situation in prisons
Unlike the SerD, in prisons the situation seems to be more under control: In Lombardy – specific Roberto Ranieri, infectious disease specialist and responsible for the penitentiary health of the region – the Hcv test is done in 60-70% of the population prison. The point why not all doctors can prescribe antiviral drugs. This is likely to create bottlenecks with high numbers of requests compared to doctors who can make prescriptions. And it hinders the linkage to care, the path that leads the patient to receive the drug. One of the most effective ways to disseminate screening could be to support them in the tests for Covid-19, or administer them when vaccinating against Covid, or on any other occasion when a patient undergoes an examination or a visit to the hospital.
The sustainability of screening
Screenings, done right, could avoid substantial costs for the National Health Service: According to some analyzes —explains Francesco Mennini, professor of Health Economics and Microeconomics at the Tor Vergata University of Rome and Kingston University of London and president of Sihta, Italian Society of Health Technology Assessment – for a thousand patients diagnosed and treated, in 20 years they would go to prevent over 600 unfortunate clinical events, starting with liver cancer episodes, with a savings for the NHS of over 65 million euros. And as for the use of direct-acting antiviral drugs, Mennini’s team estimated that investments in these treatments could be recovered in just five and a half years.
November 11, 2021 (change November 11, 2021 | 20:14)
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