Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
Please can you outline the major findings of the recent report published by The Economist Intelligence Unit (EIU): ‘Tackling hepatitis C: Moving towards an integrated policy approach’?
As with ‘The silent pandemic: Tackling hepatitis C with policy innovation,’ which was published in January 2013, this report highlights that the hepatitis C virus (HCV) is a serious public health issue. We at Janssen are committed to being a positive catalyst in the fight towards tackling this disease.
The report also revealed that many countries around the world have been somewhat slow to respond with national policies on hepatitis C, despite the recent government pledges to fight the disease. I think some countries are doing something, but, in an ideal world, it would be nice if they could do more.
Thirdly, in terms of the main takeaways from the report, with a peak in the hepatitis C related complications expected in the 2020-2025 time frame, it is imperative to take action now in order to prevent a steep increase in HCV related liver cancer and mortality.
As you may have heard from the past report, this is called the silent pandemic because in most cases hepatitis C doesn’t give any signals of disease until the patient starts having the serious consequences of long-term infection such as cirrhosis or liver cancer. Because of the nature of the disease unfortunately we expect, as early as 2020 in the United States and a bit later in Europe and the rest of the world, there will be a peak incidence of HCV related complications.
If nothing gets done now to identify the patients and to try to treat them, especially those that are more advanced, in a few years we are going to be seeing the worst of the consequences of the HCV epidemic.
What progress has been made over recent years to raise awareness of hepatitis C?
I think a lot of things have been done and we are certainly better off than we were before. Has enough been done? Probably not.
The report describes some of the things that have been done and I want to commend the patient and advocacy groups, which I think are sitting in the front seat of all the policy and awareness activities that have been conducted so far.
For example, the European Liver Patient Association (ELPA) has recently launched a project in conjunction with the World Hepatitis Alliance to work with European countries analysing the current policies for addressing HCV and helping stakeholders to develop national strategies.
Is this going to cover all of the needs? Probably not, but at least it is an initiative.
At a more regional level there is involvement of external stakeholders. This has taken a variety of forms as the report describes.
In Western Europe and North America, charities and other organizations such as The Hepatitis C Trust and ELPA offer information and support to patients. In the case of ELPA, they analyze existing national and Europe-wide action plans to develop an advocacy strategy.
If you look at the report you will see concrete examples of things that have been done. The Centers for Disease Control and Prevention (CDC) in the United States have launched an initiative to protect people born between 1945 and 1965 – the so-called “baby boomers” – because they know that most of the prevalence for hepatitis C resides within that age bracket and therefore the recommendation for testing is going to allow to identify these patients and hopefully those who need urgent treatment will be treated.
Across the globe there are a number of initiatives taking place to create more awareness. There are even TV campaigns in the US creating awareness of hepatitis C.
Interestingly enough a lot of these started happening as a result of the advances that we’ve made in terms of treatments.
The virus was identified in 1989, so this is going to be the 25th anniversary of the discovery of the virus. I have been working with hepatitis C since 1992 and the treatment options back then were very limited and very poor in terms of efficacy and safety.
Throughout the years we knew hepatitis C was a huge problem and there were many people infected around the world but nothing really got done. All of the campaigns were very limited in scope and breadth.
It was not until the last two or three years where there was an explosion in terms of the advances in treatments that became available that people began reacting positively and starting to ramp up all of the awareness campaigns.
Now there is a treatment that comes in different forms and different companies have different treatments. Ultimately all of them result in very high cure rates – 90% of patients, or even a higher proportion, can be cured in a safe, short and convenient manner with a number of treatments that will become available very soon.
There are no more excuses other than creating awareness so people can think about it, then develop a base to identify and diagnose these patients to hopefully offer them a treatment and a cure.
Why have some countries been slow to respond with national policies on hepatitis C?
I can only speculate as to why they may be slow. They may have good reasons to be slow: they may have other healthcare priorities that have led them to be slow.
In the report there is a table called ‘Euro Hepatitis Index’ on page 8 of the report, which is an objective assessment of how countries are addressing the hepatitis pandemic.
Why Lithuania, who is at the bottom of the list, has not achieved the same as France, who is at the top, I can only speculate.
All I can say is that I hope that everyone gets to the level that France has reached and that France exceeds its current level so it’s a virtuous cycle to do more and better for those affected by this disease.
Why does epidemiological data still remain scarce and why is it important that countries invest in data?
Clearly some people do not recognize hepatitis C as an important health issue and, therefore, they are not investing sufficiently to conduct the proper epidemiological studies to derive that data.
Again it is a question of recognition of the problem and investing accordingly. Some of the countries have invested more, others have invested very little.
What is clear is that the data is needed because unless you understand the magnitude of the problem, which is derived through the epidemiological data, you will not be able to properly address the problem and you will not know what level of investment is needed to address the problem.
Again this goes in hand in hand, it is first about recognizing that there might be a problem and then investing accordingly in the right objective data that may allow you to put in place the right programs and awareness campaigns.
How do Janssen hope to elevate the disease as a serious public health issue?
We have a number of approaches.
We are helping first and foremost by bringing new innovative medical solutions to hepatitis C through our development programs.
We also try to support the creation of reports that elevate the disease and create awareness at the government level and at the public level.
Speaking specifically about this report we provided financial support to the Economist Intelligence Unit to independently talk to experts in the field and derive the conclusions that we see in the report.
We think that initiatives like this one and the first version of The Economist’s report, which I think was very well received, are helping to create awareness.
For many people the first report was an eye opener. They were not even aware of hepatitis C. It all depends where you live. For example, if you live in Egypt everyone knows about hepatitis C as everyone has been touched by it, everyone has a family member who has died or is suffering from hepatitis C.
If you live in areas of low prevalence you are not aware of the disease, but that does not mean you are not at risk.
Hepatitis C has been somewhat neglected for many years but now it has taken a new turn, primarily I would say as a result of the significant advances in treatment.
Why is a peak in hepatitis C-related complications expected in 2020-2025 and how can we take action to prevent mortalities associated with this disease?
Basically, as was stated in the first report, hepatitis C is called a silent pandemic, so millions of people were probably affected many years ago (around 30-45 years ago) through many routes of infection.
In the old days people were infected through blood transfusions and through unsafe medical practices. By this I mean having received an injection for a vaccine with poorly sterilized needles or syringes: that in itself could have been sufficient to transmit hepatitis C.
Things have evolved over the years and hopefully I would like to be able to say that these types of transmission don’t occur anymore. Certainly, infection by blood transfusion should not happen anymore as the blood is screened throughout the world these days.
The unsafe medical practice route of infection is debatable. For example, in countries like Egypt who have a prevalence of close to 5% or higher in certain areas, with such a high prevalence, if they are not very careful about how they conduct their medical procedures they may be transmitting hepatitis C.
We’ve heard there are about half a million new infections a year in Egypt still today, so that’s what we call a very dynamic epidemic. Whereas in other places of the world it is more of a prevalent epidemic where you have people who were infected 30 years ago and now they are chronically infected and then the disease is evolving.
Chronic hepatitis C is a disease that takes many years to manifest. Unfortunately, in about 20% of patients the disease progresses more severely and they develop what is called cirrhosis and around 5% may develop liver cancer. These are very serious diseases, which can result in death if untreated.
Based on the time that most have people got infected in the past, we estimate that there will be a peak in the incidence in the complications associated with hepatitis C around the 2020-25 period.
That does not mean that we’re not seeing liver cancer today. As a matter of fact the number one cause of liver transplant today is hepatitis C. What we’re saying is that the peak incidence of liver cirrhosis and liver cancer is likely to be around 2020-2025.
The good news is that if we create awareness that results in identification of patients and treatment, we could avoid this peak or at least make this peak a lot flatter compared to if nothing was done. Because if you identify a patient today and treat them successfully, his or her chances of developing cirrhosis and/or liver cancer are going to diminish significantly.
Do you think it will be possible to eradicate hepatitis C altogether in the future?
That is an interesting concept. I think eradication is a big word that needs to be used cautiously. For me talking about eradication of a viral disease that’s chronic, that doesn’t cause too many symptoms until it manifests at the very end of the disease, is quite challenging.
Usually you can talk about the eradication of more acute viral diseases where you can see symptoms and you can identify very rapidly who’s infected and who’s not. But as we’ve been saying, most of the patients who are chronically infected with hepatitis C do not know that they are infected.
Before talking about eradication you would need to identify every patient that’s chronically infected and in the absence of symptoms that would be quite challenging.
So I think talking about eradication outright is perhaps too ambitious but I think we can talk about preventing people from experiencing severe liver disease and/or death as a result of hepatitis C.
I would be more than satisfied by saying that in the future we’re going to avoid people dying from the long-term consequences of hepatitis C. Essentially, eradicating the disease as a serious public health concern.
What are Janssen’s plans for the future?
We’re going to continue to bring innovative medical solutions to treat the disease.
We’re going to continue our awareness campaigns supporting the key stakeholders that are better prepared to do that. We want to work in partnership with governments and stakeholders to try to address needs at the local level.
For example, the solutions that a country such as Romania may need are different from what the United States or France may need. We want to work with all of them to really tailor the programs that are needed to address the HCV problem at a local level and a regional level.
Finally, one of the things that is very important to us and that we have done in the past is to make sure we have in place the right access programs to make our medicines available to everyone. We have a legacy of doing that in HIV and we are working to do that in hepatitis C.
Where can readers find more information?
Readers can find a copy of the EIU report available on the following sites:
About Gaston Picchio
Dr. Gaston R. Picchio is Hepatitis Disease Area Leader at Janssen Research and Development, one of the Janssen Pharmaceutical Companies of Johnson & Johnson, where he leads a world-class team focused on the development of interferon-free combination therapies for the treatment of hepatitis C virus (HCV) infection.
He joined Johnson & Johnson in 2002 as Scientific Director Hepatitis at Ortho Clinical Diagnostics and in 2003 joined Tibotec/Virco. Since joining the company, Dr. Picchio has contributed to the development, filling and launch of several HIV medicines and two medicines for the treatment of chronic HCV infection, a first-in-class protease inhibitor (PI) as well as a next-generation PI.
Prior to Johnson & Johnson he worked during different periods at the Scripps Research Institute in La Jolla, California, United States and the National Academy of Medicine of Buenos Aires, Argentina where he worked on HCV and HIV, including early in his career, the development of a humanized mouse model to study HIV and EBV pathogenesis. He started his career by undertaking a fellowship in Virology and Immunology at the National Academy of Medicine of Buenos Aires.
Dr. Picchio has published more than 90 peer-reviewed articles and presented over 50 invited lectures focused on diagnostic, clinical, and basic research aspects of HIV, HCV and other human viruses. He holds a Masters degree in Molecular Biology and a Doctorate from the University Centro de Altos Estudios en Ciencias Exactas of Buenos Aires.
1. The silent pandemic: Tackling hepatitis C with policy innovation
* Non-governmental organisation
† People who inject drugs
Infographic developed by Janssen based on the findings of The Economist Intelligence Unit report: 'Tackling hepatitis C: Moving towards an integrated policy approach'.
The report was made possible as a result of financial support from Janssen Pharmaceutical NV (Janssen).