Briefing Note: Hepatitis B & Hepatitis C Summary: In Canada, hepatitis B and hepatitis C infections remain serious public health concerns due to high prevalence rates, high health care expenditures and increasing demand for resources for education, prevention, surveillance, care and treatment. Since 2009, the Canadian Coalition of Organizations Responding to Hepatitis B and C ( The Coalition ) has asked federal, provincial and territorial governments to respond by 2012 to 6 National Asks, written and agreed upon in 2008 by a committee of Canadian organizations. Having reviewed the Report Card issued by the Coalition in 2011 to measure government response to the 6 National Asks, and in keeping with the Coalition s belief that it is critical for Canadian governments to adopt a fully- funded, coordinated and comprehensive national strategy for both hepatitis B and hepatitis C, the Coalition recommends that 3 priority areas be addressed as soon as possible by all levels of government with tangible measures at the policy, program and service delivery levels. These priority areas are: Quick Facts: 1. Increasing awareness and preventing hepatitis B & hepatitis C infections among atrisk populations. 2. Improving access to health care and drug coverage. 3. Supporting communities and groups through stable funding for prevention, education, care and support. - Hepatitis B and hepatitis C are life-threatening liver diseases caused by the hepatitis B virus (HBV) and the hepatitis C virus (HCV), affecting approximately 600,000 people in Canada, many of whom are unaware they are infected. 1 - The prevalence of chronic hepatitis B infection in Canada is estimated to range between 0.7% and 0.9%. 2 The prevalence of hepatitis C infection in Canada is estimated to range between 0.8% and 1% and is increasing over time. 3
- Both hepatitis B and hepatitis C are responsible for many cases of cirrhosis, decompensated liver disease and hepatocellular carcinoma, increasing the need for liver transplantation. 4 - Although there is no vaccine for hepatitis C, hepatitis B virus immunization is available for the prevention of hepatitis B infection. 5 - As for hepatitis B treatment, various medications such as pegylated inteferon-alpha-2a, entecavir, lamivudine, telbivudine and adefovir are available according to patient age, the level of viral replication, HbeAg status, inflammation, amino alanine transferase (ALT) levels and risks for cirrhosis and hepatocellular carcinoma (HCC). 6 - The current gold standard of treatment for hepatitis C infection is pegylated interferonα in combination with ribavirin. 7 Combined with interferon injections and ribavirin pills, the latest hepatitis C drugs (boceprevir and telaprevir) are dramatically more effective for people with genotype 1 hepatitis C. 8 Interferon-free, all-oral combinations are likely to follow within the next two to five years. 9 - Overall, hepatitis C costs the Canadian healthcare system about $500 million annually. This is expected to double to $1 billion by 2010. 10 The overall societal costs of not treating infected individuals increase the economic burden of hepatitis B and hepatitis C on Canadian society, with disease progression and hospitalization being the largest cost component throughout the course of disease. 11 - The prevalence of HCV-related sequelae is expected to rise, with the most notable increases for those requiring liver transplants. Priority Areas: Increasing awareness & preventing Hepatitis B & C infections among at-risk populations In Canada, the highest rates of hepatitis C virus infection are reported among people who inject drugs, mostly from sharing used drug-use paraphernalia; the prevalence rate of hepatitis C among people who use drugs is approximately 69%. 12 The reported prevalence rates of hepatitis C among inmates, men who have sex with men (MSM), street youth and the aboriginal population are 28%, 5%, 5% and 3%, respectively. 13 While the prevalence of hepatitis B infection varies depending on population subgroups within Canada, the reported cases of hepatitis B have been decreasing since the introduction of hepatitis B vaccination programs. 14 Individuals who are at increased risk of hepatitis B include MSM, HIV-positive people and recent immigrants. 15 It has been illustrated that it is beneficial to implement a universal hepatitis B virus immunization program in infants for maximized population-level protection and a national immunization registry for evaluation. 16 Many studies indicate that a variety of strategies such as needle distribution and recovery programs, outreach strategies, overdose prevention, methadone use for detoxification and maintenance therapy as well as supervised consumption
and injection sites are safe, inexpensive and effective at preventing transmission of hepatitis B and hepatitis C. 17 Furthermore, sterile ( safe ) prison tattooing programs have been shown to reduce transmissions of hepatitis C infections in federal institutions. 18 Improving access to health care and drug coverage Improved access to health care services in all communities, along with standardization in drug coverage can significantly enhance the quality of life among infected individuals and subsequently reduce health care costs associated with hepatitis B and hepatitis C, which are now both treatable diseases. It has been demonstrated that hepatitis C virus positivity is correlated with increased medical expenditures, and prevention programs to decrease vulnerabilities such as mental health and addiction, as well as hepatitis C treatment are necessary for mitigating medical costs and health outcomes. 19 Also, action directed to reduce stigma and discrimination associated with drug use and hepatitis B or hepatitis C infection is required to improve access to health care for infected individuals and those at increased risk of developing hepatitis B and/or hepatitis C. 20 Other areas where access to health care could be improved include monitoring and shortening the waiting time for specialists and creating a national organ donation procurement program. As for drug coverage, standardization in drug plans and approval processes across the country would result in more consistency in drug coverage and consequently resolve inequities between provinces and territories within Canada. Such standardization would also ensure more timely and coordinated drug approvals for different sub-populations, such as people co-infected with HIV. Supporting communities and groups through stable funding for prevention, education and support Despite the existence of the Hepatitis C Prevention, Support and Research Program launched by the Public Health Agency of Canada in 1999, 21 instability and delays of federal funding have affected the ability of community-based organizations to provide outreach programs (harm reduction and education programs), care and support, all of which are areas embedded in the Program s major long-term goals. Consequently, this lack of funding and human resources has made it difficult for local organizations to reach out to those individuals most at risk. Availability of funding at the provincial and territorial levels varies greatly region to region, resulting in inconsistent service delivery. Furthermore, there is no similar dedicated program to hepatitis B supported by the Public Health Agency of Canada. Recommendations: That the Canadian federal, provincial and territorial governments adopt measures to address the national viral hepatitis epidemic from a public health perspective.
Promote campaigns encouraging communities, including baby boomers and immigrants, to get tested for hepatitis B and hepatitis C. Develop a universal neonatal hepatitis B virus immunization program for maximized population-level protection and a national immunization registry for evaluation. Endorse and implement supportive measures that reduce harm for people at risk, especially those who inject drugs and federal inmates. Develop broad-based prevention programs to reduce vulnerabilities and programs to identify and treat hepatitis C virus-infected individuals who are unaware of their infection. Standardize drug plans and approval processes to eliminate inequities between provinces and territories across Canada. Promote the continuity and expansion of funding to community-based organizations to ensure adequate interventions regarding prevention, education, care and support for both hepatitis B and hepatitis C. References 1. Public Health Agency of Canada (PHAC). (2012). Hepatitis. Retrieved from http://www.phacaspc.gc.ca/hep/index-eng.php. 2. PHAC. Hepatitis B: Get the Facts. 2010. Retrieved from http://www.phac-aspc.gc.ca/hcai-iamss/bbp-pts/hepatitis/hep_b-eng.php. 3. Centre for Communicable Diseases and Infection Control, Infectious Disease Prevention and Control Branch, PHAC (2010). Hepatitis C in Canada : 2005-2010 Surveillance Report (pp. 1-42). 4. Ibid. 5. PHAC. (2012). Hepatitis. Retrieved from http://www.phac-aspc.gc.ca/hep/index-eng.php. 6. PHAC. (2008). Brief Report : Hepatitis B Infection in Canada. 7. PHAC. (2009). Management and Treatment of Chronic hepatitis C. Retrieved from http://www.phac-aspc.gc.ca/hepc/faq-eng.php#d1. 8. Bacon, B. R., Gordon, S. C., Lawitz, E., et al. (2011). Boceprevir for previously treated chronic hepatitis C virus genotype 1 infection. The New England Journal of Medicine, 364(13), 1207-1217. 9. Sharma, P., & Lok, A. S. (2011). Interferon-free treatment regimens for hepatitis C: are we there yet? Gastroenterology, 141(6), 1963-7.
10. Joint Advisory Committee of the Health Canada/CIHR Research Initiative on Hepatitis C. Hepatitis C As A Roadmap For Integrated Communicable Disease Prevention And Control: A Strategy For The Renewal Of The Health Canada/Canadian Institutes Of Health Research (CIHR) Research Initiative On Hepatitis C. Ottawa: 2005. 11. Krajden, M., Zagorski, B., Alvarez, M., et al. (2010). Health care costs associated with hepatitis C : A longitudinal cohort study. Canadian Journal of Gastroenterology, 24(12), 717-726. Jacobson, I. M., McHutchison, J. G., Dusheiko, G., et al. (2011). Telaprevir for previously untreated chronic hepatitis C virus infection. The New England Journal of Medicine, 364(25), 2405-16. McHutchison, J. G., Manns, M. P., Muir, A. J., Terrault, N. A, et al. (2010). Telaprevir for previously treated chronic HCV infection. The New England Journal of Medicine, 362(14), 1292-303. Poordad, F., McCone, J., Bacon, B. R., et al. (2011). Boceprevir for Untreated Chronic HCV Genotype 1 Infection. The New England Journal of Medicine, 364(13), 1195-1206. Zeuzem, S., Andreone, P., Pol, S., et al. (2011). Telaprevir for retreatment of HCV infection. The New England journal of medicine, 364(25), 2417-28. 12. Centre for Communicable Diseases and Infection Control, Infectious Disease Prevention and Control Branch, PHAC (2010). Hepatitis C in Canada : 2005-2010 Surveillance Report (pp. 1-42). 13. Ibid. 14. PHAC. (2008). Brief Report : Hepatitis B Infection in Canada. 15. Ibid. 16. Mackie, C. O., Buxton, J. a, Tadwalkar, S., & Patrick, D. M. (2009). Hepatitis B immunization strategies: timing is everything. CMAJ : Canadian Medical Association Journal - Journal de l Association medicale canadienne, 180(2), 196-202. 17. Canadian Nurses Association (CNA). (2011). Harm Reduction and Currently Illegal Drugs. 18. Bonnycastle, K. D. (2011). The Social Organisation of Penal Tattooing in Two Canadian Federal Male Prisons: Locating Sites of Risk for Empirically-Based Health Care Interventions. The Howard Journal of Criminal Justice, 50(1), 17-33. 19. Krajden, M., Zagorski, B., Alvarez, M. (2010). Health care costs associated with hepatitis C : A longitudinal cohort study. Canadian Journal of Gastroenterology, 24(12), 717-726.
20. Centre for Communicable Diseases and Infection Control, Infectious Disease Prevention and Control Branch, PHAC (2010). Hepatitis C in Canada : 2005-2010 Surveillance Report (pp. 1-42). 21. PHAC. (2011). Hepatitis C Prevention, Support & Research Program. Retrieved from http://www.phac-aspc.gc.ca/hepc/prsp-ppsr-eng.php.