Transcript Diapositive 1

Hépatite C
Prise en charge de l’adulte
Programme sur l’hépatite C au Sud
bilan et perspectives
du groupe de travail
Réunion de l’AC 12, ANRS, 28 février 2008
Réunion ANRS, hépatites virales en PED,
17 janvier 2007
Aspects prise en charge
• Outils virologiques pour le VHC (J. Izopet)
• Evaluation et traitement de la fibrose hépatique en Afrique (P. Cales)
• Evaluation de la fibrose hépatique au Burkina Faso (P. Bonnard & L.
Slama)
• Traitement des hépatites B chroniques au Sénégal (P.S. M’Baye & M.
Vray)
• Etudes sur le VHC au Cameroun
– Epidémiologie et études phylogénétiques du VHC au Cameroun (R. Njouom
& C. Pasquier)
– Histoire médicale du Cameroun et épidémiologie historique du VHC (ANRS
1299) (G. Lachenal)
– Traitement du VHC au Cameroun (O. Njoya)
• Etudes sur le VHC en Egypte
– ANRS viral hepatitis research site in Cairo (M. Mohamed & A. Fontanet)
– Immunological markers of HCV clearance (M. Albert & J. Decalf).
– Transmission intra-familiale de l'infection par le VHC (L. Abel & S.
Plancoulaine)
Cameroun
Richard Njouom, Centre Pasteur du Cameroun
Oudou Njoya Hépatologue, CHU de Yaoundé
HCV sero-prevalence in Cameroun
Nditam 1994
Pop: 368 (2,9%)
100
Yaounde 2003
N=1434 6.9%
Yokadouma 1994
Pop: 646 (3,3 %)
100
80
80
60
60
40
40
20
20
0
0
0
10
20
30
40
50 60
70
0
20
30
40
50 60
70
Mekas 1993
Ntem 1997
Pop: 408 (14,4%)
100
10
80
80
60
60
40
40
20
20
0
Pop: 644 (16,7%)
100
0
0
10
20
30
40
40
50 60
70
Nerrienet et al. J Med Virol 2005
0
10
20
30
40
50 60
70
Hétérogénéité et distribution des génotypes
HCV à Yaoundé
Richard Njouom, Centre Pasteur du Cameroun
Christophe Pasquier, Laboratoire de Virologie, CHU Toulouse
• n = 156
– Génotype : 1
70 45%
– Génotype : 2
37 24%
– Génotype : 4
49 31%
– nombreux sous-types (pour 1 et 4)
– Nombreux sous-types non classifiés
– Concordance parfaite des clusters NS5b et E2
(n=144)
Pasquier, J Med Virol 2005; 77:390-8
HCV
genotypes and subtypes n =156
Suivi virologique des patients VHC positifs sous
traitement antiviral
Résultats : de 2003 à nos jours (résultats au 17/01/2007)
Début TT
S12 (RVP)
M6-12 (RVFT)
M12-18 (RVS)
Génotype 1
34
22/34 (64,7%)
13/26 (50%)
10/23 (43,5%)
Génotype 2
14
14/14 (100%)
12/13 (92,3%)
12/13 (92,3%)
Génotype 4
22
13/22 (59,1%)
9/18 (50%)
7/16 (43,8%)
Total
70
49/70 (70%)
34/57 (59,6%)
29/52 (55,8%)
O. Njoya Hépatologue, CHU de Yaoundé
Richard Njouom, Centre Pasteur du Cameroun
17/01/2007
Egypt
Egypt
Network participants
•
In Egypt:
–
Most of activities are based at the National Hepatology and Tropical Medicine Research
Institute (NHTMRI) in Cairo and involve:
•
•
•
•
Ain Shams University: epidemiology (Prof Mostafa K Mohamed) and immunology (Prof Mona Rafik).
Cairo university: clinical expertise (Prof Gamal Esmat),
Minia University: virology (Prof Mohamed Abdel Hamid),
University of Mansoura: pathology (Prof Khaled Zalata).
Under the guidance of the Ministry of Health through the National Committee for the prevention
and control of viral hepatitis in Egypt.
•
In France:
–
–
–
–
–
–
–
–
•
Institut Pasteur, Paris: epidemiology (Dr Arnaud Fontanet); immunology (Dr Matthew Albert),
INSERM U370, Paris: virology (Prof Christian Bréchot, Dr Valérie Thiers),
Necker Hospital, Paris: clinical expertise (Prof Stanislas Pol),
INSERM U707, Paris: mathematical modeling and cost-effectiveness studies (Prof AlainJacques Valleron, Dr Bernard Larouzé, Dr Fabrice Carrat, and Dr Michaël Schwarzinger),
INSERM U550, Paris: genetic epidemiology (Dr Laurent Abel),
Beaujon Hospital, Paris: pathology (Prof Pierre Bedossa),
Saint Louis Hospital: virology HBV (François Simon),
Nantes Hospital: virology (Cyrille Féray)
International collaborators:
–
–
U.S.A: Prof Stewart Cooper (clinical immunology), Dr Eric Delwart (virology), Dr Chris
Loffredo (epidemiology)
U.K.: Prof Nishi Charturvedi (epidemiology)
Research programme
Asymptomatic
Chronic infection
50-85%
HCV infection
Cirrhosis
20%
Hepatocellular
carcinoma
1 to 4 %/year
Jaundice
25%
1 to 2 months
INCUBATION
HCV
risk factors
10 to 30 years
6 months
ACUTE PHASE
Fever
Hospitals
CHRONIC PHASE
Treatment
efficacy
Village
cohort
Treatment
efficacy
Factors associated with HCV
clearance:
Facteurs associated with transmission
& chronicity /morbidity
-epidemiology
-lipids
-virology
-immunology
-co-infection (HBV)
-genetic epidemiology
-CV risk factors
-virology
Mathematical modeling:
Prediction, cost-effectiveness
HCV antibody prevalence (%) by age and sex
Zwyat Razin, 2002 (n = 4020) (ANRS 1211).
HCV antibody prevalence (%)
60
50
40
males
females
30
20
10
60+
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
0
Age group (in years)
(Arafa et al, J Hepatol, 2005)
HCV-related morbidity among adults
(n= 2425, 18-65 yrs), Zwyat Razin, 2002.
*
HCV-related
advanced liver
disease
1,5%
Chronic HCV
infection and
elevated ALT
26 PBH
107/266
4,5%
Chronic HCV
infection
11,7%
284
18,5%
HCV antibodies
0
13 trt
indications
20
* Cirrhose décompensée ou F3/F4 PBH
448
40
60
80
100
(Mohamed MK, J Med Virol, 2006)
Egyptian National Control Strategy
for Viral Hepatitis
2008-2012
• MOHP, National Committee on viral hepatitis
– Patient management
• 9 liver centers where 10,050 patients where currently receiving
treatment as of Jan 2008, usually a wing in a MOHP hospital
• Another 6 more centers in 2008
• National headquarter is NHTMRI
– Collection of information on patient recruitment and
follow-up in the centers
• Need to be standardized and computerized
• Development of a web-based data entry system planned
To contribute to the evaluation of the network of treatment
centers before proceeding further
Liver centers open in Egypt as of Jan 2008
Alexandria ▲
▲ Damietta
Tanta ▲ ▲ Al Mansurah
▲ Az Zaqaziq
Cairo ▲▲
†
Asyut ▲
Suhag ▲
SUDAN
Currently,
• 48 wks PEG IFN + Ribavirin at a total cost of
3000 euros.
• 4 categories of patients
– Health insurance (HIO) (40%) : PEG-IFN
– Contract patients (8%):
• not covered by HIO.
• Private-sector employers have agreed to pay for trt in MOHP
facilities. PEG-IFN + Riba
– Private patients (7%):
• pay for their own trt in MOHP or private clinics
– Patients treated at government expense (45%): no
insurance;
• preliminary evaluation (paid for by MOHP)
• voucher for trt that covers 12 wks injections but not the cost of
ribavirin
Liver fibrosis evaluation among HCV
genotype 4 infected patients in Egypt
P Bonnard, G Esmat
• To evaluate and compare
– diagnostic accuracies of the non-invasive methods for fibrosis
assessment for the diagnosis of significant fibrosis
• Non invasive methods have been validated in western
countries
• In Egypt,
– Steatosis is more common,
– Elevated BMI may compromise elastometry
– Co-infection with S mansoni, HBV
• 400 patients referred to NHTMRI
– Liver biopsy (routinely performed). “Gold standard”
– Elastometry
– Blood tests to calculate: APRI, Fib-4, Fibrometre, Fibrotest
• Expected start of the inclusions : October 2008
Key points to be discussed
• Need of non-invasive markers of fibrosis
– Cost-effectiveness
• Efforts on the cost of treatment including
– Antiviral therapy :
• Generic?
– And monitoring : PCR
• In the context of a National program
– Including screening strategies
• Advanced liver diseases,
– Co-factors,
– management
– Epidemiological tools to follow-up trends?