Hepatitis C, Public Health & Politics: P's of Public Health

Protection - Prevention - Promotion - Prognosis - Provision

PUBLIC HEALTH in combination with medical science is what we rely on to protect us from threats to our general well-being. Whenever a menace looms we expect our public health system to employ its tool box. However, the content of the tool box may vary from country to country, since many of the tools are reflections of solutions to specific situations faced in the past.

The political will to use the tools to address a particular health issue may also vary for many reasons.

Public Health tools for handling HCV could include:

- Surveillance: monitoring national prevalence (number of total cases) and incidence (number of new cases in a given period of time) of the virus, identifying asymptomatic chronic carriers of the virus, following these patients to determine when to provide treatment and making sure they adhere to the prescribed regimen

- Education: disseminating public and professional information about the disease, risk factors, how to avoid infection - on a regular basis and with a special effort on national and community level to mark World Hepatitis Day on July 28 initiating health education and training to reduce risk of transmission during exposures in nonmedical (e.g., commercial barbering, body piercing, tattoos, and traditional circumcision) and occupational (e.g., health care and sanitation worker) settings.

- Screening: testing all blood used for transfusions and blood products virus inactivation of plasma-derived products encouraging the use of as little transfusion blood as possible

- Infection-Control: enforcing infection control practices, encouraging use of therapeutic syringes with features to prevent reuse and injuries as well as safe handling and disposal of sharps and waste encouraging adequate sterilization of reusable material such as surgical or dental instruments

- Counselling: people with chronic, asymptomatic HCV including teaching them not to share toothbrushes and razors with others and to let their dentist and other medical workers know of their infection status, in order to give them a chance to protect themselves

-Harm Reduction: initiating harm reduction programmes, with counselling, needle-syringe exchange and opiate substitution therapy for injecting drug users,

However resources are limited and therefore political prioritization guides public health decisions. Public health may make recommendations, but whether or not these recommendations will be acted upon is something that will be determined at the political level. Therefore it is important to understand that there is public health and there are politics and these are not always aligned.

Even within public health there can be professional disagreements, communication and coordination problems as well as personal conflicts.

In the mid-1980's in the Danish Board of Health, the responsibility for AIDS policy was spread out over several divisions, often without coordination of the activities: The D-division oversaw epidemic diseases (among them AIDS), as well as diseases transmitted through transfusion. Medicines derived from blood belonged to the A-division, the Medicines Agency.

After screening for HIV had become possible the D-division initially stated that a general screening of donated blood would not mean a big difference in preventing the spread of AIDS. The Danish donor corps had a very high standard, coming from unpaid volunteers. Out of some 5,000 surveys already made by blood banks, no one had contained HIV. Statistically, the probability of transfusion transmitted AIDS in Denmark was assessed to be exceedingly small. Also, a general donor screening in Denmark was estimated to cost 20 million to 40 million Danish kroner per year, so from a cost-benefit point of view a donor screening was not found to be appropriate.

That is, as of mid-June, 1985. At a later date it could become necessary to introduce screening of donated blood. However, the D-division recommended that using only heat-treated factor concentrate in haemophilia treatment had to be considered seriously.

In contrast, the A-Division, the Medicines Agency, argued for not imposing an immediate requirement for heat treatment. Some of these reasons were professional, technical or economic, and it also had to be considered that none of the Danish producers in the Summer of 1985 mastered the technique of heat inactivation.

It has never been established - neither in the subsequent judicial investigation or the court proceedings, hemophiliacs filed against health authorities - what reasons weighted the most.

This is most fertile ground for journalism: to document and explore professional disagreements, communication and coordination problems as well as personal conflicts.

PREVENTING the spread of HCV does not require reinventing the wheel, as many of the items on the ought-to-do list are familiar from the HIV/AIDS list for preventing blood borne transmission: screening of donor blood and blood products (albeit for another antibody to detect HCV), enforcing infection control practices, education, harm reduction.

A number of these steps that has been used against HIV/AIDS probably have helped curb the spread of HCV. One big difference has to be noted: HCV can stay active outside the human body much longer than HIV. Consequently, infection control practises (e.g., washing hands, sterilisation of reusable, medical equipment and cleaning of surfaces) have to be even stricter for HCV.

It has to be said, though, that all the HIV/AIDS prevention effort never managed to tackle one underlaying cause of spread of blood borne infections in low and middle income countries: unnecessary injections. In Egypt, where there is a generalised HCV epidemic, the prevalence is highest in people with ongoing or a past history of medical injections. It will require massive education to change the belief that you have to have an injection for everything.

Based on past health crisis situations, we have learned that handling a threat requires a well-functioning and well-staffed healthcare system, political will, a willingness to pay the cost and/or find solutions. All of this applies to HCV

Jean-Michel Pawlotsky, Professor, University of Paris-Est.

As most chronic patients are asymptomatic (as we know it until now), it might seem easy to ignore the disease, but there can be serious impacts on a community or a country’s health care resources. However, if a large group of individuals all begin to exhibit liver disease in a relatively similar time frame, as expected in this case, then governments will indeed be faced with an acute problem. What course of action politicians decide to take determines the outcome of this public health issues.

The reluctance to act is a common hurdle. When a blood test for HCV became available in the 1990's some countries were slow to incorporate it as part of the regular screening of blood in hospitals as they had already spent a considerable amount in the 1980's to set up screening for HIV/AIDS.

Even before HCV was identified in 1989 it was known that a non-A, non-B Hepatitis was circulating in the blood supply. It has been estimated that in the US the risk of contracting hepatitis from blood-transfusion was 30 per cent in 1970. Thanks to screening of donor blood, the risk in the US has been almost zero since 2000.

The semantics of screening blood is worth understanding: countries must screen for HCV antibodies, should screen for HCV antibody and antigen, when combination antibody-antigen assays are available, and can screen for HCV RNA depending on available finances, laboratory infrastructure, and HCV incidence in donors.

But even within each tier there are tests and then there are tests, some better than others. This raises the question what public health as an authority can and will do to control that the standards set are complied with?

Charles Gore, president of WHA - World Hepatitis Alliance

Questions worth asking:

- Overuse of (unnecessary) injections with unsterile equipment seems to be a driver in spreading the virus, seen not only in Egypt, but in many low and middle income countries. Can information counter the popular belief that injections works against most everything?

- How to make shure that the needle being used in a medical procedure was sterile?

- How to make shure that the needle being used for an injection in a market stall was sterile?

- A key question that was asked in country after country with regard to tainted blood and HIV/AIDS could also be applied to HCV: did public health do enough and in time to curb the spread of nonA, nonB Hepatitis? Or did they opt to do nothing against better knowledge?

Next: Screening Strategies