The purpose of this conference is to develop a research strategy that is a national strategy. We need to identify funding sources and prompt or stimulate these sources. This needs to be a cooperative group of researchers and it must include patients.

Programs must be developed to increase awareness, to increase the quality of care for the patient, and to increase networking among all facets involved. A report will come from this meeting and the hope is that we establish a network now and that this network continues into the future.

By Dr. Bob Remis,

Department of Public Health Sciences,

University of Toronto, McMurrich Building, 4th floor, 12 Queen's Park Crescent M five S West, Toronto, Ontario, M5S 1A8

telephone:416-946-3250, fax:416-978-8299

Very little is known about the distribution and impact of hepatitis C. We estimate the burden of hepatitis C infection to be about 240,000 in Canada. The estimated crude prevalence is 0.8% or 1 in 125. Compare this to the U.S. where there are 3,900,000 people infected with HCV-with the crude estimate of 1.5% or 1 in 66. These estimates only have a precision equal to 20%. The real number is probably closer to 340,000 in Canada and conceivably could be double the estimate in the US.

In British Columbia there are over 52,546 people infected with hepatitis C. BC, Alberta, Ontario, and Quebec account for two-thirds of all infections. Approximately two-thirds of those infected are males. The peak of those infected covers the adults that most likely experimented with IVDU in the 60's and 70's. At least that would explain the increase in this age group.

The NIH believes that the transfused rate of HCV infection is now stable. But the HCV burden that is not stable.

The natural History of HCV is very difficult to follow. Between 60 to 80% are asymptomatic. There is an extremely long latency period. Minimal disease occurs in the first two decades. More significant signs occur in the third and fourth decades.

The sequelae of long-term hepatitis C infection includes:

• Chronic active HCV
• Cirrhosis
• End staged liver disease
• Hepatocellular Carcinoma

Hepatitis C is an important cause of morbidity including dysfunction, disability and quality of life issues. It is also an important cause of mortality.

We are using the Laboratory for the Center of Disease Control (LCDC) model to predict the hepatitis C. burden in Canada. It is an indirect approach to estimate the duration of HCC infection. We see the following:

• Age specific prevalence from HCV working groups and reported cases
• The duration of infection for each age strata estimated from the epidemiology of HCV infection 15% transfusion, 70% IVDU
• The progression of parameters from infection to each sequence from the Spears model which assumes no successful treatment

mild HCV cirrhosis ESLD* Liver TX** HCC*** Death

1998 172,059 18,250 2090 137 217 533

2008 106,556 39,312 5,555 610 534 1522

* End Stage Liver Disease

**Liver Transplant

***Hepatocellular Carcinoma

When will it peak? In the US the decrease may not be as dramatic as presented. Has it occurred in Canada yet? We don't know. There may not be a downslope but rather a steady state. This is not good.

The Burden- The direct consequences for the health care system:

- diagnostic tests

-liver pathologies and biopsies

-physician and clinic visits

-hospitalization for active HCV, cirrhosis, hepatocellular carcinoma

-antiviral agents and drugs

-liver transplants

In Summary:

• HCV infection is more important then previously thought.
• an increase in HCV is presumed to be due to the IVDU epidemic in the 60 and 70's

Questions and concerns put forward by conference participants:

* there is a lot of cirrhosis in people that have no symptoms and go undiagnosed- they are not included in this lecture.

* there is no estimate for successful treatment and how do we do that? More cost.

* this prevalence is based on people that have tested positive for anti-HCV. We need to establish both RNA positive and anti-HCVpositive.

* we need to study the epidemiology of the subtypes of HCV.

* Blood taken from US airman in the 60's may also have contributed to the higher incidence.