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Hepatitis C: A 20-Year Debt Comes Due
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Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States. A National Health and Nutrition Examination Study indicates that 3.9 million Americans –about 1.8% of the population–have been infected.1,2 The chronic liver disease caused by HCV infection can be indolent and asymptomatic for years. In about 20% of those with chronic infection, cirrhosis develops after a period of 20 years or more. About 1% to 4% of these patients develop hepatocellular carcinoma annually. The infection currently kills at least 10 000 to 12 000 people in the United States every year.3,4
The good news is that the incidence of new HCV infections has been steadily decreasing–from about 230 000 new cases per year in the 1980s to 38 000 cases per year in the 1990s and to 25 000 cases in 2001.2,5 This decline reflects the improved screening of blood donors and also the safer needle-use practices among injection drug users, most likely due to human immunodeficiency virus education programs.5 Unfortunately, there are still millions of aging and currently asymptomatic individuals who acquired HCV from the 1960s to the 1980s. In many of these baby boomers, chronic infection is likely to lead to clinical liver disease over the next decade causing an increase in the morbidity and mortality associated with viral hepatitis. The nation‛s debt of HCV infection is coming due.
For clinicians and decision makers in managed care settings, this impending upswing of symptomatic HCV infections should prompt renewed attention to education of staff and patients alike. Existing protocols for HCV screening and prescribing may require revision. In particular, pharmacy programs aimed at maintaining drug adherence and managing side effects with innovative dosing programs will be critical. Health plans will incur significant costs if patients discontinue drug therapy because of side effects and then restart therapy.6 Compliance programs involving nurses and pharmacists can help patients anticipate and manage the side effects and thereby reduce overall drug costs.
As managed care organizations fine-tune their HCV guidelines to reflect the coming epidemic of HCV liver disease, the need for flexibility and individualized management will remain crucial. Hepatitis C disease is not just a liver disease. It is also a disease with significant psychiatric and hematologic aspects. It is a cause of cancer. It is not a single unchangeable virus; it is an array of at least 6 different major genotypes of virus, all with a propensity to mutate. It is a disease that frightens and confuses many patients. The societal implications of HCV infection are complex. And it is a disease for which the best treatment approaches are still evolving.
N Engl J Med.
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2. Centers for Disease Control and Prevention. Division of Viral Hepatitis. Disease burden from viral hepatitis A, B, and C in the United States. August 2002.
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3. National Institutes of Health. Consensus Development Conference Statement: Management of Hepatitis C: 2002—June 10-12, 2002. 2002;36:S3-S20.
4. National Institutes of Diabetes and Digestive and Kidney Disorders, National Institutes of Health. Chronic Hepatitis C: Current Disease Management. NIH Publication No. 03-4230, February 2003. www.digestive. niddk.nih.gov/ddiseases/pubs/chronichepc/index.htm. Accessed November 14, 2003.
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5. Williams I. Epidemiology of hepatitis C in the United States. 1999;107:2S-9S.
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6. Reed C. Use guidelines to control hepatitis C costs. 2003;8:3.
