Hepatitis C virus (HCV) is endemic worldwide and according to the World Health Organization (WHO), there are about 150 million chronic carriers worldwide. The infection is a leading cause of liver diseases like cirrhosis and hepatocellular carcinoma (HCC); thus, HCV infection constitutes a critical public health problem. There are increasing efforts worldwide in order to reduce the global impact of hepatitis C through the implementation of programmatic actions that may increase the awareness of viral hepatitis and also improve surveillance, prevention, and treatment. In Brazil, about 1,5 million people have been chronically infected with HCV. The country has a vast territory with uneven population density, and hepatitis C incidence rates are variable with the majority of cases concentrated in the most populated areas. Currently, the main priorities of Brazilian Ministry of Health's strategies for viral hepatitis management include the prevention and early diagnosis of viral hepatitis infections; strengthening of the healthcare network and lines of treatment for sexually transmitted diseases, viral hepatitis, and AIDS; improvement and development of surveillance, information, and research; and promotion of universal access to medication. This review aims to summarize the available data on hepatitis C epidemiology and current status of efforts in prevention and infection control around the world and in Brazil.
Hepatitis C, a liver disease caused by the hepatitis C virus (HCV), can array in severity from a mild illness, lasting a few weeks, to a serious condition that can lead to chronic liver disease, end-stage cirrhosis, and liver cancer. Worldwide, it is estimated that 350,000 people die every year from complications of hepatitis C disease [
The hepatitis C virus is transmitted through contact with infectious blood. There are defined risk factors for hepatitis C virus infection, such as transfusions of HCV-infected blood, contaminated injections during medical procedures, and injection drug use. However, the risk for HCV transmission by sexual or interfamilial contact is not well established [
According to the World Health Organization (WHO), viral hepatitis is not being addressed seriously, since the early stages of the disease are silent and because of the insidious way in which chronic liver disease is caused. Many HCV-infected patients are unaware of their disease, and the number of people who have been infected with this virus might be underestimated. Therefore, morbidity and mortality related to hepatitis C are likely to increase over the next years [
HCV is endemic worldwide and there is a large degree of geographic variability in its distribution [
Table
Worldwide prevalence of hepatitis C virus.
Region | Prevalence of HCV |
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Africa [ |
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Sub-Saharan Africa | 2.2% (0.1%–13.8%) |
Central Africa | 6% |
West Africa | 2.4% |
Southern and East Africa | 1.6% |
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Americas [ |
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North America | |
Canada | 0.7% |
United States | 1.3% |
Latin America | |
Argentina, Brazil, Mexico, Puerto Rico, Peru, and Venezuela | 1.4–2.5% |
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Asia and Oceania [ |
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South Asia | |
India | 3.4% |
Southeast Asia | |
Vietnam | 2–2.9% |
East Asia | |
Taiwan | 4.4% |
China | 1–1.9% |
Australasia (Australia and New Zealand) | 2.7% |
Melanesia,Micronesia,and Polynesia regions | 2.6% |
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Eastern Mediterranean [ |
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Egypt | 15% |
Pakistan | 4.9% |
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Europe [ |
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Central Europe | |
Czech Republic, Poland, Romania, and Hungary | ≤0.5% |
Romania | ≥3% |
Western Europe | |
France, Germany, Greece, Italy, Norway, Portugal, Spain, Sweden, Switzerland, and UK | ≤0.5% |
Rural areas in Greece and in Italy | ≥3% |
Eastern Europe | |
Russia | ≤0.5% |
Parts of Russia | ≥3% |
In the region of the Americas, North America countries such as Canada and the United States present low HCV prevalence rates [
An estimated 17 million people in the Eastern Mediterranean region suffer from chronic HCV infection and approximately 800.000 people are infected with HCV annually [
In the European region, approximately nine million people are chronically infected with HCV [
Chronic HCV infection occurs in approximately 30 million people in the Southeast Asia region [
For epidemiological surveillance in Brazil, the Ministry of Health defines the confirmed cases of hepatitis C as those in which the individual meets the conditions of suspected case and presents positive anti-HCV and detectable HCV-RNA. Therefore, the total number of confirmed cases of hepatitis C in Brazil is 82,041 (Table
Hepatitis C confirmed cases in Brazil according to the Ministry of Health [
Region | Number of cases among the years | |||||||||||||
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1999 | 2000 | 2001 | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | 2011 | 1999– | |
Brazil | 188 | 309 | 632 | 2,031 | 4,021 | 7,135 | 8,572 | 9,280 | 9,517 | 9,936 | 10,534 | 10,321 | 9,565 | 82,041 |
North | 2 | 30 | 19 | 34 | 70 | 68 | 128 | 100 | 226 | 268 | 274 | 230 | 195 | 1,644 |
Northeast | 1 | 0 | 6 | 34 | 106 | 208 | 383 | 426 | 382 | 549 | 671 | 637 | 728 | 4,131 |
Southeast | 110 | 166 | 363 | 1,423 | 2,791 | 5,126 | 6,073 | 6,600 | 6,430 | 6,571 | 7,095 | 6,528 | 5,946 | 55,222 |
South | 72 | 111 | 223 | 400 | 910 | 1,530 | 1,743 | 1,924 | 2,105 | 2,248 | 2,143 | 2,561 | 2,337 | 18,307 |
Central-west | 3 | 2 | 21 | 140 | 144 | 203 | 245 | 230 | 374 | 300 | 351 | 365 | 359 | 2,737 |
Brazil is divided into five geographic regions according to specific characteristics with regard to physical, human, economic, and cultural aspects (Figure
Division of the Brazilian territory into five regional geographic areas [
Brazilian regions: (a) distribution of hepatitis C confirmed cases according to the Ministry of Health [
Between blood donors, a variant regional distribution of hepatitis C infection was observed in 2002 [
The Brazilian Ministry of Health launched a nationwide cross-sectional survey to estimate hepatitis infection prevalence in the urban population of all Brazilian state capitals and the Federal District [
The latest epidemiological report on viral hepatitis produced by the Ministry of Health revealed that, in 2011, the overall hepatitis C detection rate in Brazil was 5 per 100,000 population [
Hepatitis C detection rates in Brazil according to the Ministry of Health [
According to WHO, tailored prevention and control strategies for viral hepatitis are necessary because of the differences in the geographic distribution, transmission, diagnosis, and treatment of hepatitis infections among the world [
Global efforts to reduce hepatitis C burden could benefit from a focus on primary prevention [
Surveillance for hepatitis C is important in order to identify HCV-infected people and, therefore, reduce the risks for HCV transmission and development of chronic liver disease [
According to Averhoff and colleagues [
Overall, eradication of HCV around the world is an extremely challenging task that may be possible through a combination of strategies including the education on infection prevention, clinical and targeted community screening, linkage to disease management, and treatment with new therapeutic regimens [
In Brazil, the department called STD, AIDS, and Viral Hepatitis Department is part of the structure of the Ministry of Health’s Surveillance Secretariat and intends to reduce HIV/AIDS and viral hepatitis transmission and to promote patients’ quality of life [
As recommended by WHO [
In order to promote education to the general population about the risks of hepatitis, modes of transmission, and prevention of those diseases, the Brazilian Ministry of Health promotes several public campaigns aiming to increase the awareness of viral hepatitis and to encourage individuals that could have been exposed to hepatitis C to get free diagnostic tests in Counselling and Testing Centres (CTC) [
As a strategy to improve the access to diagnosis of hepatitis C, the Brazilian Ministry of Health started, in 2011, the distribution of HCV rapid tests for HCV screening to the CTC; the expansion of the network of laboratories that performed molecular biology based tests for diagnosis hepatitis C; and the purchase and distribution of viral load and genotyping tests for hepatitis C [
Despite these initiatives, it is worth noting that, in Brazil, about 1,5 million people have been chronically infected with HCV in Brazil and only about 12 thousand people are currently under treatment for hepatitis C, which reflects the large number of individuals without access to diagnosis [
Among the programmatic actions for the control of hepatitis C in Brazil is the publication by the Ministry of Health of national protocols and clinical practice guidelines on management and treatment of chronic viral hepatitis C [
Recommendations for the treatment of hepatitis C in Brazil according to the Ministry of Health [
Hepatitis C Treatment | |
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Acute | |
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(i) Conventional interferon (IFN) monotherapy in a daily dose of induction (alpha-2a at a dose of 6 MUI or |
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Chronic hepatitis genotype 1 | |
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Association of pegylated interferon (PEG-IFN) and RBV for 48 to 72 weeks: |
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Chronic hepatitis monoinfected with genotype 1 and with advanced fibrosisa or compensated liver |
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(i) Triple therapy with PEG-IFN alpha, RBV, and telaprevir: |
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Chronic hepatitis genotypes 2 and 3 in the absence of predictors of low sustained virologic response (SVR)d,e | |
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Combination of conventional IFN and RBV for 24 weeks: |
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Chronic hepatitis genotypes 2 and 3 in the existence of predictors of low SVRe | |
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Combination of PEG-IFN and RBV for 24 to 48 weeks: |
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Chronic hepatitis genotypes 4 and 5 | |
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Association of PEG-IFN alpha and RBV for 48 to 72 weeks: |
bPatients with compensated liver disease (Child-Pugh score ≤ 6; class A), with no history of previous decompensation.
cMay be considered for patients with advanced fibrosis (Metavir F3 and F4/cirrhosis) according to criteria for individualization of treatment that contraindicates the use of telaprevir for 12 weeks.
dPatients who have predictors of low response to the treatment with conventional INF should receive treatment with PEG-IFN.
ePredictors of low response to the treatment with conventional INF: METAVIR score ≥ F3; and/or clinical manifestations of liver cirrhosis; and/or viral load higher than 600,000 UI/mL.
A national survey about acute hepatitis C was coordinated by the Brazilian Society of Hepatology between the years 2000 and 2008 [
Regarding the treatment of chronic hepatitis C, Azevedo and colleagues [
Most of the studies evaluating the efficacy of the treatment for chronic hepatitis C in Brazil were performed before the recent introduction of boceprevir and telaprevir for the treatment of patients chronically infected with HCV genotype 1 with advanced fibrosis. Therefore, there is expectation for the possibility of better treatment responses with the use of protease inhibitors in those patients. Further studies will be necessary in order to evaluate the impact of those drugs in the treatment of chronic hepatitis C in Brazil, especially because HCV genotype 1 is common in the country [
In a study on the cost of hepatitis C treatment for the Brazilian Health System, Blatt and colleagues [
Since there is no vaccine available in order to prevent HCV infection, the need for improvement of prevention strategies is particularly important regarding hepatitis C control. The estimated absolute numbers of infected individuals shown by the national seroepidemiological survey of hepatitis A, B, and C infection indicated the burden of hepatitis C in the near future [
Prevalence studies may be useful tools not only to verify the impact of the existing hepatitis prevention strategies on the disease epidemiology, but also to create novel disease control strategies. However, Brazilian hepatitis prevalence studies usually present characteristics that may limit their results as of representative value for the whole country: most studies are conducted in restricted areas and not nationwide [
The need for improvement of prevention activities is particularly important regarding hepatitis C, since there is no vaccine available in order to prevent HCV infection. In this regard, comprehensive testing strategies must ensure the identification of infected individuals who are at increased risk for spreading hepatitis C virus.
In addition, public-health measures worldwide should focus on approaches that may increase the awareness of hepatitis C and also expand the capacity of health systems with respect to surveillance, prevention, treatment, and implementation of effective programmatic actions to control the disease. In this context, implementation of standard precautions in health-care facilities to avoid nosocomial infection and effective public education seem to be the key tools in order to reduce the global impact of HCV infection.
In Brazil, the number of hepatitis C confirmed cases slightly decreased since 2010 (Table
The authors declare that there is no conflict of interests regarding the publication of this paper.