martes, 14 de junio de 2016

A Neglected Epidemic


13 June 2016 
Dear Colleagues,

It is uncommon to encounter a worldwide epidemic that is in most of the world, essentially a neglected disease.

With more than 150 million people infected globally and over 500,000 deaths annually, but with little surveillance and very low levels of diagnosis and treatment until the disease has reached end stages, infection with Hepatitis C is the rare major public health issue that attracts little attention from international philanthropies or health care activists.

The nature of HCV's transmission varies depending on geography and economics. In the developing world, a past history of inadequate sterilization and reuse of medical equipment, especially syringes and needles, has left a legacy of infection. In the developed world, what should have been a dwindling reservoir of disease as those who had received transfusions of unscreened blood and blood products aged and died, has been reinvigorated by a pandemic of intravenous drug users, most of them young adults. Nosocomial transmission of HCV is a recurring problem worldwide. Whatever the means of introduction, HCV left untreated, in most people, leads to a chronic infection that eventually causes fatal liver inflammation, cirrhosis, or cancer in the vast majority of cases. Hepatocellular carcinoma is one of the most common cancers in developing countries and the third most common cause of cancer-related mortality worldwide.

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Because Hepatitis C causes few symptoms during its acute phase, yet has a much higher risk of chronic infection leading to liver disease than other hepatitis viruses, early identification and timely treatment prior to the development of complications is essential. But there is little demand for testing in wealthy nations, due in part to stigma and in part to ignorance of the risks. These dynamics apply in poor nations, too, but are compounded by lack of human and financial resources to address the problem.

For those of us primarily concerned with emerging infectious diseases, Hepatitis C stands out: it is simultaneously a chronic disease and an epidemic. It creates a huge burden of disease, usually progressing to end-stage liver disease or liver cancer, yet we know both how to prevent it and how to cure it.  In the past, Hepatitis C treatment was difficult, with severe side-effects and not all patients responding. But new medicines are so successful that we've entered an era where 90% of patients can be cured, where eradication is perhaps possible. However, these drugs are so expensive - as much as $90,000 per course - and in such short supply that even in wealthy countries their general application is unlikely. The Lancet notes that, even if manufacturers offer low-income countries steep discounts, 75% of people with hepatitis C live in middle-income countries regarded as emerging markets by pharmaceutical companies and will not benefit from these concessions. Their widespread use in the resource-constrained countries of Africa and Asia is improbable any time soon.

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Best regards,

Larry Madoff, MD

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