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The Swiss Population In 2001 • • • • • Resident population: 7,258,500 Population density: 176 per Km2 Foreign nationals: 20.1% (~1,460,000) Excess of births over deaths: 13,000 per year [Immigration] – [emigration] = +41,500 per year Registered Medical Laboratories Cross-checking for duplicates Reporting of positive anti-HCV and HCV RNA tests (mandatory since 1988) Swiss Federal Office of Public Health (OFSP) Identification from test reporting Further clinical and epidemiological data Primary Care Physicians HCV infection in Switzerland based on a mandatory reporting systm Total number of declarations received at OFSP: all patients = 24,068 (~2,500 per year) acute hepatitis C = ~600 (~60 per year) Estimated prevalence (general population, based on a survey on pregnant women): 0.7-1% (50,000 - 70,000) Estimated incidence: 5 - 15 new cases per 100,000 per year, mostly (70%) due to IVDU OFSP, 2001 Acute Hepatitis C Declarations Classes of Age 250 200 150 100 50 0 0-19 20-29 30-39 40-49 50-59 60-69 >70 Acute Hepatitis C in Switzerland Risk Factors Intravenous drug use: 68.2% Blood transfusion: 6.8% Health care workers : 2.8% Sexual contact: 2.8% Contact with anti-HCV+ patients: 1.9% Unknown: 15.7% All Declarations, Classes of Age 6000 5000 4000 males females 3000 2000 1000 0 <20 20-29 30-39 40-49 50-59 60-69 >70 The HCV Epidemics in Switzerland: Population-based Studies Study population HCV+ / total (%) Year Reference Blood donors 50 / 5,424 (0.9) 1992/ Zucca et al, 2000 1997 Dentists 1 / 1,056 (0.095) 1999 Weber et al, 2001 Pregnant women 64 / 9,057 (0.7) 1990/ 1991 OFSP, unpublished Indications to Screening for HCV - 1 Swiss Recommendations (OFSP, 2001) According to official estimates, about 50% of infected patients have been declared to Federal Authorities Mandatory reporting often concerns diagnoses made well before the declaration It is likely that more then half of HCV infected patients already know about their own status Indications to Screening for HCV - 2 Swiss Recommendations (OFSP, 2001) A general screening policy would be expensive, of limited usefulness, and out of proportion with respect to the expected results Bull OFSP, 2001;46:877 Indications to Screening for HCV - 3 Swiss Recommendations (OFSP, 2001) • Present or former IVDU • Individuals transfused with blood before 1992 or with blood derivatives before 1987 • Patients under dialysis • Children born to HCV-positive mothers • HCW after accidental exposure to blood • Patients with elevated transaminases The HCV Epidemics in Switzerland How Many Are Infected? • Although the pregnant women study is representative in terms of ethnicity: – females account for only 40% of the HCV infected population – only 2.4% of pregnant women under survey (1.5% of HCV+) were in the >40 y class of age (vs. 39% of OFSP declarations) • Official estimates may have underestimated the HCV prevalence in Switzerland Prevalence of HCV in Switzerland • Model predictions (assuming a median 0.75% prevalence according to OFSP estimates) were compared with observed incidence of HCV related deaths and OLT • A revised prevalence of 1.25 – 1.75% provided the best fit to the assumed complications SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25 Predicting HCV Disease Burden (by Prevalence) • Future complications of a cohort of 77,595 HCV RNA positive patients were evaluated (age distribution was identical to that of the OFSP declarations) • In the next 15 to 25 years: – Annual HCC incidence will increase by 70% – HCV-related mortality will increase by 90% – Incidence of HCV-related cirrhosis will decline SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25 Trends in overall and truncated (35-64 y) age-standardised HCC death rates in Switzerland females males females, 35-64 y females, all ages LA VECCHIA et al, Eur J Cancer 2000;36:909 Future complications of HCV infection in Switzerland 500 450 400 350 300 250 200 150 100 50 0 HCC dec-CIRRH DLD OLT 1998 2005 2010 2015 2020 2025 2030 SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25 Effect of Antiviral Therapy • Antiviral therapy will reduce the annual HCV-related mortality by a mere 5%, since: – According to new estimate, only a minority of patients have been diagnosed (~15%) – Antiviral treatment may cure only 40% of patients SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25 Future Costs of Hepatitis C in Switzerland • Annual direct costs for treating complications of HCV will double by 2020 (~32.9 million US $ per year) (vs. 801 million US $ of direct costs of CHD) • Indirect costs (loss of productivity) equals 25.9 million US $ per year (1998) SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25 Current recommendations may help to identify only 50-60% of patients with chronic hepatitis C • Extend screening to other groups at risk? • Propose anonymous testing/counseling? The Swiss Population In 2001 • • • • • Resident population: 7,258,500 Population density: 176 per Km2 Foreign nationals: 20.1% (~1,460,000) Excess of births over deaths: 13,000 per year [Immigration] – [emigration] = +41,500 per year Foreign Nationals Living in Switzerland • The foreign population is relatively young: – 8 persons of retirement age every 100 workers (Swiss nationals: 30 every 100) • More than half have been living in Switzerland for >15 years • Current net migration is positive, thanks to immigration from non-EU European countries • About 80% of foreigners (~1,100,000) are from countries where HCV infection is moderately prevalent and long-standing Switzerland: origin of foreign nationals (1999) other countries 243,350 28,100 Austria 60,500 France 80,200 Turkey 87,200 Spain 104,100 Germany former Yugoslavia 337,600 136,400 Portugal Italy 329,150 anti-HCV positive (%) Global Patterns of HCV Infection 50 3 = Egypt 40 30 20 2 = Spain, Italy 10 1 = US, Australia 0 0--9 10--19 20--29 30--39 40--49 50+ age group (years) WASLEY and ALTER, CDC, 2000 Risk factors for HCV transmission in Italy • • • • • • • • • • Blood transfusions IV drug use Non-disposable needles within the family Non-disposable needles outside the family Hospitalization before 1970 Hospitalization after 1970 Previous tuberculosis Sexually transmitted diseases Surgical intervention before 1970 Surgical intervention after 1970 2.9 112 1.6 3.8 2.1 0.9 3.4 1.1 0.8 0.5 CHIARAMONTE et al, 1996 HCV Infection in Geneva Risk factors, acute vs. total (%) acute total IVDU 79.4 48.7 Sexual contact 22.1 13.0 Contact with HCV-positive patient 8.8 8.4 Health care worker 2.9 2.2 Transfusions 1.5 9.6 Other 1.5 4.4 Unknown / no information 11.6 51.7 DELAPORTE, 2001 HCV Infection in Geneva Risk Factors Vs. Geographic Origin IVDU Others 60.7 39.3 Europe 45 55 Africa 7.7 92.3 Americas 38.5 61.5 Asia 28.6 71.4 Unknown 29.8 70.2 Total 48.7 51.3 Switzerland DELAPORTE, 2001 HCV Infection in Geneva Acute hepatitis C patients are more often young IV drug users, born in Switzerland Chronic hepatitis C patients are more often of older age, and migrated to Switzeland from countries where the prevailing risk factor for HCV in the past decades was nosocomial / iatrogenic transmission Indications to Screening for HCV • Consider to extend screening to: – individuals exposed to non medical, invasive procedures? – individuals exposed in the past to potentially unsafe medical procedures / unsafe injections? – patients with extra-hepatic manifestations possibly linked to HCV?