From the end of 2015 to 2016, mass infections of hepatitis C occurred at three hospitals. Before these incidents, chronic hepatitis C had not been a major disease in Korea. Around the same time, new medicines with sharply improved cure rates were released, but they remained largely unknown because of high prices and the low attack rate of hepatitis C in Korea.
However, the mass infection increased the awareness of the importance of prevention and treatment of hepatitis C, as well as issues concerning disposable syringe use. Reflecting the mounting public concern about the disease, the government included, with unusual swiftness, its treatments in the health insurance coverage, and the National Screening Program for the Transitional Ages.
Along with policy changes, the trend of its treatment also rapidly shifted in the clinical field, from interferon-oriented cure to direct acting antivirals (DAA).
It is against this backdrop Korea Biomedical Review talked with the experts in Korea and the United States to hear their views on recent changes in the treatment of Hepatitis C. First, KBR met with Jun Dae-won, professor of the Department of Gastrointestinal Internal Medicine at Hanyang University Seoul Hospital, to hear his views about the changes in Korean society and treatment trends after the incidents of mass infection.
Question: Although the mass infection of hepatitis C was an unfortunate incident, it has reportedly raised public awareness of the disease. Do you feel this in clinical settings?
|Professor Cheon Dae-won of Hanyang University College of Medicine explains about the influence the mass infections of Hepatitis C last year has exerted on the Korean society and the new treatment trends, during a recent interview with Korea Biomedical Review at his office.|
Answer: From the standpoint of medical workers, it is true that public awareness has been raised, but I felt a lack of follow-up measures, such as an investigation of infection routes, public relations activities to prevent the disease and education for medical staff.
The recent incidents of mass infection resulted from inappropriate measures by some medical workers, but the public’s general distrust of the healthcare system and medical staff has been growing along with the fear of infection in hospitals. As the heightened awareness of the disease cannot last long, the government needs to take proper measure to help people shape the correct perception of it.
For example, hepatitis C can be transmitted through various routes, but there is an acute shortage of education and PR activities about it. The most common infection routes in Korea are transfusion and tattoos. In this country, however, there is a low percentage of people who get tattoos compared with other countries, including the United States. Infections by transfusion do not often occur, either.
In most cases, hepatitis C is transmitted through direct and indirect contacts with an infected person, but there are no reliable data regarding infection routes for hepatitis C beyond unofficial sporadic analyses or medical journal articles. It is necessary to grasp more reliable and concrete infection routes on the national level.
Q: Hepatitis C has been included, if provisionally, in the National Screening Program for the Transitional Ages, pushing up popular expectations about higher diagnosis rate. There are two conflicting opinions on this: Some suggest it be included in national screening program not only for those in the transitional ages but all people. Others express doubts about the need to include it in the national testing program given its low incidence, criticizing the ongoing move as a populist policy.
A: I believe the whole nation should receive screening because Hepatitis C is an infectious disease and can be completely cured. As the expense of screening and treatment can be costly, however, there should be more cost-benefit analyses.
The U.S. government discovered hepatitis C incidents increased in particular years and decided it would be beneficial at a national level to invest in testing and treating people born in those years. Similarly, such a rational judgment is needed on social and economic costs.
I think Hepatitis C is an infectious disease and ultimately curable one, and therefore the government should conduct tests on as many people as possible. However, it would better fit the society’s advantage if the government, after assessing it from social and economic aspects, targets high-risk groups based on their birth yeas and residences, and provide extensive supports for them.
Q: Why do you think the prevalence of Hepatitis B is decreasing while hepatitis C is increasing? Can the prevalence of HCV be due to the emergence of hidden patients amid the growth of awareness and change of policy?
A: Personally, I think the prevalence rate of Hepatitis C itself is rising. It is the most prevalent type of hepatitis in most of the developed countries, including the United States and Japan. Although developed countries are highly interested in infectious diseases and control them quite successfully, the prevalence rate of this disease is always higher than 2 percent. It also means there are many cases of nosocomial and iatrogenic infection, including tattoos, piercing and surgical procedures at medical institutions. Other infectious diseases that transmit through other routes, such as contaminated water and sexual intercourses, decline as a nation develops and its sanitary conditions improve, but iatrogenic infections seldom decrease despite national development.
Q: It seems a matter for consideration that the prevalence rate of hepatitis C is still high in developed countries despite their efforts for preventing and treating the disease. Perceptions about tattoos, for instance, have changed much over the past decade or so, haven’t they?
A: Risk factors for hepatitis C include not only body tattoos but also piercings and eyebrow tattoos as well. The ear piercing is so common here that we can hardly find women who have not gotten their ears pierced. This means the population with the risk of hepatitis C may be higher than 70 percent in Korea.
Q: Are there any research results about infection routes conducted in the U.S. or Japan?
A: Many researchers are working on this matter but still haven’t identified exact routes. Hepatitis C is transmitted through indirect and unexpected routes rather than direct and primitive ways like blood contact.
When mass infection occurred in Korea, people denounced individual doctors. This kind of response cannot ensure progress. Rather, we should investigate the causes of incidence based on self-examination and data sharing, and use this to take action against recurrence.
Despite thorough investigation and verification of the incident, there is a lack of policy alternatives. If the government has no alternatives amid the loss of trust in medical workers and national system, it is highly likely to lead to its recurrence. Incidents like mass infections are not mistakes of some individuals but accompany social responsibility, which calls for national soul searching.
Q: New medicines for hepatitis C with sharply improved cure rates have been released recently, and will do so in the future, too. As it is often necessary to prescribe them in combination with one another, some general practitioners complain that these are too complicated to prescribe.
A: Compared with interferon used for treating hepatitis C in the past, current treatment options have significantly advanced. First, DAA showed the cure rate of 95 percent or higher, compared with the existing interferon that showed the cure rate of a mere 60-percent range for patients with chromosome type 1, called the “SVR (Sustained Virologic Response) 12” treatment performance. Second, new DAA medicines substantially reduced the side effects of interferon, such as hair loss and depression. Third, DAA has shortened the therapeutic period from one year to three to six months. DAA medicine is a much better option than interferon regarding cure rate, healing time, and side effects except for cost.
Treatment of genotype-1b patients using peginterferon alpha and ribavirin (IFN+RBV) only reached an SVR of 62.7 percent. Of those, patients of genotype 1b who also had cirrhosis only showed an SVR of 20.8 percent, and had high risks of side effects or complications. On the other hand, the DAA formulation Daklinza and Sunvepra therapy yielded an SVR12 of 95.6 percent during an analysis of clinical trials on six Asian patients. It also reached an SVR12 of 94.3 percent, according to an investigation by the Korean Association for the Study of the Liver.
Q: You are not using interferon any longer, are you?
A: No. We will not be using interferon anymore. Until recently some had thought genotype-3 patients would have to continue treatment using the interferon-ribavirin combination, but the continual development of new drugs has solved the problem. The treatment of genotype three patients using the Daklinza+Sovaldi therapy maintains an SVR12 of about 90 percent. Interferon and ribavirin have exhausted their potential regarding HVC.
Q: New medications are flooding the market in addition to Daklinza+Sunvepra therapy.
A: So many drugs have been released that some people compare the present to the period of warring states in ancient China. Every medication has its advantages and disadvantages. They’re nearly identical in efficacy and differ only slightly based on compatibility when used alongside immunosuppressants, used on nephrology patients, and by genotype.
From the perspective of medical workers, we’re waiting for the Hepatitis C equivalent of medications like Baraclude or Viread, which can be used on all Hepatitis B patients. Since many medications are undergoing clinical trials, we expect a Pan-genotype medication with a short treatment period of eight weeks within three years, will win the approval soon.
Q: Do the new HVC medications pose any risk of resistance?
A: We can’t say they are completely free from such a possibility. Treatment grades have improved markedly but not reached 100 percent, so there some 5 percent or so of failure rate with some of them developing instances of tolerance. We have yet to come up with follow-up researches concerning alternative treatments, either. Figuring out how to treat patients for whom current antiviral agents don’t work remains another task to tackle.
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