Case finding strategies for hepatitis C infection

Hepatitis C virus infection (HCV) is a viral liver disease affecting approximately 3% of the world’s population and 0.1 to 0.4% of the population of the Netherlands. HCV infection can lead to liver cirrhosis and liver cancer. In addition to the severe burden of disease, the failure to find and treat those infected at an early stage also leads to a considerable economic burden on society. Since treatment success rates have improved substantially in the past years, long term complications can now be largely prevented. Consequently, the need for finding and treating those infected with HCV is on the increase. This thesis aims to improve case finding by evaluating the effectiveness and the economic consequences of a variety of case finding strategies for hepatitis C. Chapter 1 provides an overview of why improvements in case finding of hepatitis C are important. Chapter 2 demonstrates that increased efforts in case finding strategies to reach the target population and medical professionals are worth the effort. Section 2.1 shows that a public campaign aimed at increasing awareness and case finding of HCV in the general population can be effective, but only with a supplementary support programme for primary care. In Section 2.2 we conclude that in a campaign aimed at HCV case finding among injecting and non-injecting hard drug users, pro-actively offering HCV consultation and testing by professionals in addiction care organisations is essential to attain effect. Chapter 3 illuminates the economic side of HCV case finding. Section 3.1 demonstrates that if a case finding strategy is found to be clearly effective it is also likely to be cost-effective. For high-risk populations such as hard drug users the gain in effect is relatively high and costs of case finding can be kept low. In Section 3.2 the current costs of HCV treatment in daily practice in the Netherlands, in relation to treatment outcome and side effects, are discussed. Although success rates have improved substantially in the past decades, the current costs of unsuccessful treatment and side effects are high. Section 3.3 shows the effectiveness and cost-effectiveness of a nationwide hepatitis C campaign and its interventions in the Netherlands. The intervention aimed at hard drug users in addiction care was clearly effective and cost-effective. The intervention aimed at risk groups in the general population showed only a moderate effect, leading to considerable uncertainty about cost-effectiveness. This could in part be contributed to the unfavourable circumstances of its implementation. However, the overall number of HCV carriers identified by this large scale campaign remains moderate. Chapter 4 describes the effect of a new HCV case finding strategy in primary care practice. We demonstrate that routine testing for HCV in patients with an ALT elevation of 50 to 100IU/L could theoretically lead to the identification of an estimated 1,200 to 1,300 chronic HCV carriers in the Netherlands alone. The final chapter describes the lessons learned from the thesis and the role of different health care professionals in the identification of hepatitis C.