June 2016 | Meitheamh 2016

Integrated Care to Improve Hepatitis C Treatment

Wed, 22 June 16 21:11

HepCare Europe, a European Union-funded initiative which aims to improve the efficacy of Hepatitis C treatment by bringing point of care testing to ‘at risk’ groups and supporting them through their treatment has been formally launched.  The launch took place on 22nd June 2016 at the UCD Catherine McAuley Education & Research Centre at the Mater Misericordiae University Hospital.  Among the speakers were:

  • Prof Walter Cullen, GP & Professor of Urban General Practice, UCD School of Medicine
  • Dr Paddy Mallon, Consultant in Infectious Diseases at Mater Misericordiae University Hospital & Associate Dean for Research & Innovation at UCD School of Medicine
  • Ms Nicola Perry, General Manager, Community Response, Dublin
  • Ms Maura Hiney, Head of Policy, Evaluation and External Relations, Health Research Board
  • Ms Michelle Tait, National Coordinator Hepatitis C Services, Health Services Executive, Mill Lane, Palmerstown, Dublin
  • Ms Mary Day, CEO, Ireland East Hospital Group
  • Prof Jack Lambert, Consultant in Infectious Diseases at Mater Misericordiae University Hospital and Principal Investigator, HepCare Europe.

The innovative multi-country collaboration aims to demonstrate that a targeted community-based intervention can improve the health outcomes of, and reduce the considerable socio-economic burden on a vulnerable group of individuals living with Hepatitis C.

HepCare Europe seeks to improve access to, and effectiveness of, Hepatitis C treatment in Ireland and across the European Union though the use of novel point of care testing and supporting patients through treatment.    The initiative seeks to mobilise primary, secondary and outreach care within the community to reach ‘at risk’ patients including intravenous drug users and the homeless.  These citizens are typically poorly supported in traditional acute hospital settings and do not have the continuity of care necessary to ensure effective clinical intervention.

Funding for HepCare Europe is being provided by the Third EU Public Health Programme (€1.8 million) and Ireland’s Health Services Executive.  The work will be conducted by a consortium involving five institutions across four European countries, and will develop a series of coordinated activities to improve the efficacy of public health policy and intervention in the treatment of Hepatitis C.  The consortium seeks to investigate if focused intervention of ‘at risk’ groups can reduce the socioeconomic burden of Hepatitis C across European member states.

‘Infectious diseases such as Hepatitis C transcend borders and Irish citizens will derive real treatment benefit from projects like HepCare Europe that take a collective approach to developing effective models of care’

noted Graham Love, Chief Executive of the Health Research Board who provide the National Focal Point for the EU Public Health Programme.

‘The HRB is there to assist Irish researchers and policy makers to tap into this European resource’.

Led by Professor Jack Lambert, Consultant in Infectious Diseases at University College Dublin and the Mater Misericordiae University Hospital and Professor Walter Cullen, General Practitioner in Dublin’s North Inner City and UCD Professor of Urban General Practice, the consortium includes clinician scientists from Servicio Andaluz Dde Salud (SAS) in Spain, Spitalul Clinic Dr Victor Babes Bucuresti (SVB) in Romania and both University of Bristol (UoB) and University College London (UCL) in the United Kingdom.

Hepatitis C infection is a major cause of chronic liver disease and death throughout the world with approximately 3% of the world’s population infected with the Hepatitis C virus (HCV).  HCV is transmitted by blood and now occurs primarily through injecting drug use.  Chronically infected people are at risk of progressive liver disease characterised by hepatocellular inflammation, hepatic fibrosis, cirrhosis and hepatocellular carcinoma.  New mobile point of care tests are now available which are highly accurate in diagnosing Hepatitis C and which do not require specialist equipment.  Ultrasonography has emerged as a viable alternative to liver biopsy making the detection of Hepatitis C infection and the progression of liver disease possible outside of acute hospital settings. 

Once detected, patients with Hepatitis C infection can have their viral load dramatically reduced through a course of treatment involving new direct-acting antivirals.  This treatment significantly reduces the risk of secondary infections, extent of liver damage and the need for liver transplantation.  The challenge to successful treatment is the need to maintain medication compliance over an 8 – 12 week period hence this involvement of the primary and community care professionals and peer support.

The consortium believes substantial socioeconomic benefit will accrue to the State through this focused intervention. The HepCare Europe pilot project is designed to evaluate the efficacy of this approach and help build the necessary knowledge base and evidence to support a role out of this strategy across the European Union. 

About HepCare Europe

HepCare Europe comprises six strategic initiatives designed to demonstrate the effectiveness of a community-based intervention.

  • HepCheck seeks to identify patients not accessing care by using point of care HPC oral rapid test in hard to reach settings (homeless, in shelters, prisons, etc.) and identify the factors associated with treatment discontinuity.
  • HepLink seeks to develop an integrated model of HCV care involving 24 GP practices to reach approximately 240 ‘at risk’ patients.
  • HepEd will develop and implement a multidisciplinary inter-professional education resource for healthcare professionals on Hepatitis C care.
  • cHepFriend recognises the importance of peer support to ensure treatment adherence and will recruit, train and support credible advocates to support the clinical care team.
  • HepCost will assess the cost-effectiveness of the specific case-finding interventions across different EU countries to inform the development public health policy in member states.
  • The above actions will be coordinated (HepCoord) under the direction of Principal Investigator, Prof Jack Lambert and his team at the Mater Misericordiae University Hospital.

In addition to the principal investigators, Irish collaborators in this project includes Dr Austin O’Carroll of the Merchant’s Quay and Safety Net Primary Care Services in the Dublin, Dr Stephen Stewart, the Mater Misericordiae University Hospital, Dr Eoin Feeney and Dr Diarmaid Houlihan  at St Vincent’s University Hospital and Dr Des Crowley of HSE Addiction Services. Other agencies involved in the project include Community Response, HIV Ireland and the Ireland East Hospital Group.

Consortium Partners

  • University College Dublin School of Medicine (UCD), Ireland
  • Servicio Andaluz Dde Salud (SAS), Spain
  • Spitalul Clinic Dr Victor Babes Bucuresti (SVB), Romania
  • University of Bristol (UoB), United Kingdom
  • University College London (UCL), United Kingdom 

About Hepatitis C

Hepatitis C infection is a major cause of chronic liver disease and death throughout the world with approximately 3% of the world’s population is infected with the Hepatitis C virus (HCV).  Hepatitis C infection is caused by an RNA virus that was first identified in 1989.  There are six distinct but related genotypes and multiple subtypes have been identified. In Western Europe genotypes 1a and 1b are most common, followed by genotypes 2 and 3. 

HCV is transmitted by blood and now occurs primarily through injecting drug use, and less frequently through sex with an infected partner, occupational exposure, and mother to infant transmission. In some cases no risk factors can be identified.  Transfusion-related HCV infection is rare now since the introduction of routine screening of blood for HCV antibodies in the early 1990s. 

Acute HCV infection, in general, is relatively mild with only 20%-30% of infected people developing symptoms or clinically evident acute infection.  In most people who become infected with HCV, viremia persists, that is, virus continues to be present in the circulation. Chronic HCV infection is marked by persistence of HCV RNA for at least 6 months after onset of infection. Spontaneous resolution after 6 or 12 months of infection is unusual. Between 55% and 85% of those infected develop chronic infection, the lower end of the range being accounted for mainly by women, particularly young women.  Spontaneous resolution of chronic Hepatitis C is relatively rare, but can occur. 

Chronically infected people are at risk of progressive liver disease characterised by hepatocellular inflammation, hepatic fibrosis, cirrhosis and hepatocellular carcinoma (HCC). These complications develop only in a proportion of patients and only after many years or decades of infection. It has been estimated that up to 20% of chronically infected individuals will develop cirrhosis of the liver over a 20 to 25 year period. Approximately 3% to 4% of patients with cirrhosis will develop HCC per year. Factors that have been shown to be associated with progression of liver fibrosis include older age at infection, male sex, genetic factors, metabolic factors (steatosis, diabetes and obesity), co-infection with human immunodeficiency virus (HIV) or Hepatitis B, duration of infection, and alcohol intake.