carlos eduardo brandão, md, phdregist2.virology-education.com/2015/4thlatam/09_brandao.pdfcarlos...
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What are the options in Latin America
Carlos Eduardo Brandão, MD, PhD
Professor Associado de Clínica Médica
Livre Docente em Clínica Médica e Gastroenterologia
Universidade Federal do Estado do Rio de Janeiro
Universidade Federal do Rio de Janeiro
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Approximately 170 million people chronically infected
About 500,000 deaths/year
300,000 liver failure200,000 HCC
Global burden of HCV infection
Lim, et al. Lancet 2012; 380: 2224–2260.
HCV Viremic Infections(Prevalence & Total Infected)
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Total Infected (Viremic)
200K-650K
650K-1.9M
0-200K
1.9M-3.5M
3.5M-9.2M
Prevalence(Viremic)
0.0%-0.6%
0.6%-0.8%
0.8%-1.3%
1.3%-2.9%
2.9%-7.8%
Gower, E., Estes C., Hindman, S., Razavi-Shearer, K., Razavi, H. Global epidemiology and genotype distribution of the hepatitis C virus. Journal of Hepatology 2014.
Argentina
Brazil
Chile
Colombia
CubaDominican Republic
Mexico
Peru
Puerto Rico
Venezuela
HCV Prevalence and Genotype DistributionLatin America
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Total Infected (Viremic)
200K-650K
650K-1.9M
0-200K
Prevalence(Viremic)
0.0%-0.6%
0.6%-0.8%
0.8%-1.3%
1.3%-2.9%
2.9%-7.8%
Gower, E., Estes C., Hindman, S., Razavi-Shearer, K., Razavi, H. Global epidemiology and genotype distribution of the hepatitis C virus. Journal of Hepatology 2014.
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Global Burden of HCV infection
Prevalência da infecção pela Hepatite C e Genotipagem
Distribuição da Faixa etária da infecção
Proporção da população diagnosticada e tratada
No Brasil < 20% diagnosticada e < 1% tratada ao ano
Duração da infecção pelo HCV
Dos fatores de comorbidade
(Álcool, HIV, HBV, Síndrome Metabólica)
Introdução e sucesso das novas modalidades terapêuticas
Bruggmann P, Berg T, Ovrehus AL, et al.. J Viral Hepat 2014; 21 Suppl 1: 5-33
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2,12%2,12%
1,04%1,04%
1,19%1,19%
1,43%1,43%
0,65%0,65%
Sociedade Brasileira de Hepatologia. Revista GED 1999; 18:53-58.
1,173,406 blood donors
14,527 anti-HCV+(1,23%)
HCV in Brazil: studies in blood donors
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0,32
1,05 1,08 1,10
1,611,89 1,79
1,94
0
0,5
1
1,5
2
2,5
10 - 19 years old
20 - 69 years old
1,0
3,2
3
Pereira LMMB, et al. BMC Infectious Diseases 2013, 13:60
HCV in Brazilian Regions: population studyA
nti-H
CV
pos
itive
(%)
Overall anti-HCV+ prevalence: 1.38% ( 2.6 million people) Around 2.1 million viremics (PCR+
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Distribuição etária da população infectada:
Bruggmann P, Berg T, Ovrehus AL, et al.. J Viral Hepat 2014; 21 Suppl 1: 5-33.
Epidemias ‘mais jovens’ (UDIV e migração; fibrose discreta) vs ‘mais idosas’ (nosocomial; fibrose avançada e cirrose)
No Brasil Fibrose significativa (F2-F4) (55%) e prevalência por UDIV (5%) e histórico deTransfusão (15%)
Age Distribution, 2013 Brazil, Egypt, Australia and Turkey
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
% o
f Tot
al H
CV
Infe
ctio
ns (2
013)
Brazil Egypt Australia Turkey
9Razavi H, Waked I, Sarrazin C, et al. The present and future disease burden of hepatitis C virus (HCV) infection with today's treatment paradigm. J Viral Hepat 2014; 21 Suppl 1: 34-59.
Prevalência da Hepatite C no Brasil HCC, Cirrose Descompensada e Transplante, 1950-2030 Brasil
10Razavi H, Waked I, Sarrazin C, et al. The present and future disease burden of hepatitis C virus (HCV) infection with today's treatment paradigm. J Viral Hepat 2014; 21 Suppl 1: 34-59.
HCV Treatment Rate
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Total Viremic HCV InfectionsCountries Responsible for 80% of Global Infections
12Gower, E., Estes C., Hindman, S., Razavi-Shearer, K., Razavi, H. Global epidemiology and genotype distribution of the hepatitis C virus. Journal of Hepatology 2014.
Treatment Rate by Country, 2013
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Razavi H, Waked I, Sarrazin C, Myers RP, Idilman R, Calinas F, et al. The present and future disease burden of hepatitis C virus (HCV) infection with today's treatment paradigm. J Viral Hepat 2014;21 Suppl 1:34-59.
Hatzakis A, Chulanov V, Gadano AC, Bergin C, Ben-Ari Z, Mossong J, et al. The present and future disease burden of hepatitis C virus (HCV) infection with today's treatment paradigm – J Viral Hepat 2014. Submitted for publication 30 July 2014.
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Taxa de tratamento e número de tratados
Gore et al., Journal of Viral Hepatitis, 2014, 21 (Suppl. 1), 1–4
15Adapted from Dore GJ, et al. Journal of Viral Hepatitis, 2014, 21 (Suppl.
Estimated HCV prevalence, diagnosis and treatment rate for several countries (2013)
12,000/yr (0.6%)
300,000(15%)
1%
0.3%
70%
Trea
tmen
t rat
e pe
r yea
r
Percent of the infected population diagnosed
5.2%
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Brazil: more than 2 million people with
chronic HCV infection
‒ Less than 15% diagnosed
‒ Less than 10% treated
‒ Less than 5% cured
‒ Less than 1% treatment rate
But to achieve an SVR, first you have to find and treat the infected patients
Bruggmann, et al. Journal of Viral Hepatitis, 2014, 21, (Suppl. 1), 5–33
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Outcome 2013 2030 Variation (%)
Total no. of HCV 1.940.000 1.250.000 ↓ 35
HCC 9.710 18.900 ↑ 95
Liver related deaths 9.000 16.620 ↑ 85
Decompensation 27.500 45.000 ↑ 95
Compensated cirrhosis 222.000 323.000 ↑ 65
Razavi, et al. Journal of Viral Hepatitis, 2014, 21, (Suppl. 1), 34–59
Estimated HCV disease burden in Brazil: (2013 vs 2030)
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Year People treated
2007 6,533
2008 8,626
2009 8,224
2010 11,628
2011 11,505
2012 12,491
2014 15645
2014* Telaprevir (2600)Boceprevir (840)
Source: Programa DST/AIDS/Hepatites - 2014
HCV treatments per year in Brazil (including re-treatment and co-infection)
Only about 0.5% of all HCV infected patients are treated every year
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Terapia Tripla no Brasil PegIFN/RBV e TelaprevirSVR24 por histórico de tratamento anterior
Ferreira, P; Brandão-Mello et al., 2014
Sem tratamento anterior (n=19)
Recidivantes do tratamento
anterior (n=31)
Respondedores parciais prévios
(n=15)
Respondedores nulos prévios
(n=28)
2020
Outcome 2004 2006 2021
Total no. of HCV 575600 586800 647600
HCV Incidence 13700 14302 18700
Liver related deaths 10700 11000 19000
Treated patients 600 900 ?
Treatment rate (%) 0.10 0.15 ?
Kershenobich, et al. Liver International, 2011
Estimated HCV disease burden in Argentina: (2004 vs 2021)
212121
Outcome 2004 2006 2021
Total no. of HCV 982700 1002900 1227600
HCV Incidence 29000 31044 47700
Liver related deaths 24800 25300 37000
Treated patients 1400 3300 ?
Treatment rate (%) 0.14 0.33 ?
Kershenobich, et al. Liver International, 2011
Estimated HCV disease burden in Mexico: (2004 vs 2021)
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HCV Treatment Rate
How to implement better strategies to increase treatment rate?
How to increase screening?How to increase diagnose?
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Impact of 3 different ways to manage HCVEstimates for Brazilian pts.
Strategy 1(no change)
Strategy 2(IFN‐free: ↑ SVR & pts eligibility)
Strategy 3(Strategy 2 plus↑ no. of treated pts )
Patients treated/year 11,700 11,700 118,700 (2021)Treatment rate (%) 0.6 0.6 9.1
Mean SVR (%) 43 90 90
New cases diagnosed/year 10,000 10,000 119,000 (2020)
Treatment elegibility (%) 60 95% 95%
Age for treatment (years) 15‐69 15‐69 15‐74
Stage for treatment (Metavir) ≥F2(G1); ≥F1(G2,3) ≥F2(G1); ≥F1(G2,3) ≥F0 (all genotypes)
Reduction in mortality rate ‐ 5% 70%Reduction in HCC cases ‐ 5% 75%Reduction in decompensation ‐ 10% 80%Reduction in HCV infections ‐ 5% 90%
Wedemeyer, et al. Journal of Viral Hepatitis, 2014, 21, (Suppl. 1), 60–89
24Wedemeyer, et al. Journal of Viral Hepatitis, 2014, 21, (Suppl. 1), 60–89
Brazil: comparison among strategies 1, 2, 3 Reduction in HCV infections Reduction in liver-related deaths
Reduction in HCC Reduction in cirrhosis
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Estratégia de rastreamento
Wedemeyer, et al. Journal of Viral Hepatitis, 2014, 21, (Suppl. 1), 60–89
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Estimated age related distribution of HCV in Brazil vs. selected countries in 2013
Razavi, et al. Journal of Viral Hepatitis, 2014, 21, (Suppl. 1), 34–59
Baby boomer strategyis not appropriate for Brazil
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Estimated age related distribution of HCV in Brazil vs. selected countries in 2013
Razavi, et al. Journal of Viral Hepatitis, 2014, 21, (Suppl. 1), 34–59
Baby boomer strategyis not appropriate for Brazil
Brazil should test people born between 1950 and 1980
28Wedemeyer, et al. Journal of Viral Hepatitis, 2014, 21, (Suppl. 1), 60–89
Birth-cohort testing strategy to detect >75% of HCV pts. in several countries
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What are the options in Latin America
Países de América Latina que utilizam boceprevir e telaprevir:
Argentina, Brasil, Colômbia, Peru, Venezuela
Países de América Latina que somente utilizam o telaprevir:
Costa Rica, México, Santo Domingo
Países de América Latina que analisam a introdução dos novos DAAs:
Argentina, Brasil, Chile, Cuba, México
Países de América Latina que possuem um programa para as hepatites:
Argentina, Brasil, Chile, Colômbia, Costa Rica, Cuba, México
http://hepato.com/p_geral/023_geral_port.php#sthash.thJ4Tmyc.dpuf
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What are the options in Latin AmericaSummary
A Epidemiologia da infecção pelo HCV é diferente entre os países daAmérica Latina
A carga de doença varia consideravelmente entre os países, nadependência da faixa etária, duração da infecção pelo HCV, dosfatores de comorbidade e da estratégia de tratamento antiviral
O número de pacientes diagnosticados e tratados é baixa (<10%:<1%)
Vários fatores socioecônomicos contribuem para as taxas de RVScomo doença hepática avançada, falta de infraestrutura de acesso aodiagnóstico e tratamento;população marginalizada e efeitos colateraisdo atual tratamento
Estratégias que combinem o emprego de medicações de alta eficáciae segurança aliada ao aumento nas taxas de rastreamento, diagnósticoe tratamento são imperiosas para reduzir o impacto causado pela HCV
Wedemeyer, et al. Journal of Viral Hepatitis, 2014, 21, (Suppl. 1), 60–89