With few initial symptoms, hepatitis C is often not diagnosed until the appearance of chronic liver disease and liver cancer, making screening an option for insurers, says Jon Lambert
The World Health Organization (WHO) compares hepatitis C to a viral time bomb, estimating that about 3% of the world's population has been infected. This has created about 200 million chronic carriers, according to the WHO. Most of these people do not know they are ill and therefore are at risk of more serious complications.
Such is the extent of the disease that for every one person who is infected with HIV, there are more than four infected with hepatitis C.
The WHO indicates that as many as four million individuals may be chronically infected in the US, 10 million people in Europe, and 12 million in India.
Although the WHO classifies the UK as a low-prevalence country, there are an estimated 200,000 people in England who are chronically infected. Other estimates put the UK infection rate much higher - with up to 600,000 individuals at risk.
Whichever estimate is correct, it is clear that a significant number of individuals clearly are infected but not yet diagnosed, as only 46,000 cases have been confirmed by the Health Protection Agency (HPA). The Government's "Hepatitis C Action Plan" published by the Department of Health in July 2004 states that an estimated five out of every six people with chronic hepatitis C virus (HCV) are unaware of their infection.
The HPA has investigated the potential future increase in hepatitis C-related disease. Its figures show a potential dramatic and continued rise in the number of individuals with post-hepatitis C cirrhosis and end-stage liver disease or hepatocellular carcinoma in England and Wales from 1990 to 2010.
As a result of this trend, the Royal College of Physicians of Edinburgh has requested a substantial increase in resources to improve detection and treatment rates to avoid a public health crisis that could overwhelm liver treatment units. The college has called for high priority to be given to finding cases among former injecting drug users.
Approximately 80% of those who are newly infected with HCV progress to develop chronic infection, which puts them at risk of severe liver disease and liver cancer. This is an extremely high ratio, which is why the HCV epidemic is of such great concern to health professionals.
Hepatitis C differs substantially from hepatitis B, which is more prevalent but far less chronic. Indeed, only 5%-10% of adults with acute hepatitis B infection eventually develop a chronic illness (hepatitis C is described as chronic when the infection lasts longer than six months).
Nearly one in five sufferers will recover from the hepatitis C infection, but most will go on to become chronically infected by the virus. Current evidence suggests of 100 individuals infected with hepatitis C, 60 will develop some form of long-term symptoms of liver inflammation, 16 will develop cirrhosis of the liver over a 20-year period and at least two of the 16 will develop liver cancer.
There are many potential causes of hepatitis, including alcohol and drug use, autoimmune disease and certain viruses. According to the British Liver Trust, the most common cause of the disease is a virus that attacks and damages the liver. Five viruses have been identified as a source of hepatitis - A, B, C, D and E.
HCV was individually identified in 1989 and can be classified into at least six genotypes and more than 80 subtypes.
Most individuals at time of infection experience no initial symptoms, which is why hepatitis C is often undiagnosed. When present, symptoms may include tiredness, weight loss, jaundice and perhaps a short flu-like condition.
Prognosis is better in those with normal liver function and only minor biopsy changes. Those with an active form will have abnormal liver function and may have biopsy results indicating cirrhosis and possibly end-stage liver disease.
The goal of the treatment is for individuals with hepatitis C to become negative, or have undetectable levels of the virus, within 12 months. At the very least, it is important to reduce the severity of the disease in order to prevent long-term liver damage.
Treatment has evolved and improved over the last 10 years and will continue to do so. At present, treatment lasts 24 or 48 weeks, using a combination of pegylated interferon and ribavirin.
Side-effects
However, there are common and substantial side effects of the treatment, such as fatigue, muscle pain, headaches, nausea and vomiting, weight loss, depression, and mild bone marrow suppression potentially leading to anaemia, excessive bleeding and serious infection.
The development of effective treatment is clearly beneficial and encouraging, although not all sufferers are cured. Also, there appears to be a time period post-treatment where the virus can re-appear.
The success of the treatment can only be assessed between six and 12 months after treatment begins.
A further analysis is conducted between six and 12 months after treatment has stopped in order to assure a sustained response to the treatment.
Sustained virological response rates (where the viral load is cleared or reduced) are now achievable in more than half of those individuals with chronic hepatitis C who are considered candidates for treatment. Viral clearance is associated with a reduction of liver inflammation and fibrosis on liver biopsy, and it is reasonable to assume that viral clearance will translate into a reduction in mortality and morbidity.
In its 2002 study "Hepatitis C - Strategy for England", the Department of Health indicated that successful antiviral treatment clears the virus in at least 50% of people, with some signs and symptoms of liver disease. While treatment does appear to prevent progression, there have been no long-term studies to measure success rates.
The number of individuals undergoing liver transplantation due to hepatitis C tripled between 1995 and 2004; despite this radical treatment, the virus always reappears in the new liver.
The lack of real data relating to the success rates for treatment must alert insurers assessing these risks to be cautious over future predictions and long-term risk assessment.
Risk factors
A number of important risk factors are understood to influence the clinical course of hepatitis C infection. These include being more than 40 years old at the time of infection, being male, having a co-infection with hepatitis B or HIV, steatohepatitis (an inflamed and fatty liver) and a suppressed immune system.
The numbers of individuals infected annually with hepatitis C has started to increase again in 2002 after reaching a plateau in 1999. Males account for 67% of those infected.
Importantly for insurers, over half of the individuals were aged between 25 and 39, which are key insurance and healthcare purchasing ages. These ages probably reflect the higher proportion of men who are injecting drug users.
A recent study, which solely considered those individuals who had acquired hepatitis C via a blood transfusion, indicated that in the first decade after infection, mortality levels were approximately 50% higher than expected for chronic hepatitis C patients. These figures suggest that mortality may increase in the future.
In addition, the risk of dying directly from liver disease was found to be nearly six times greater than normal in those individuals infected with hepatitis C. Alcohol excess was demonstrated to be a poor combination with hepatitis C as it was implicated in 40% of the deaths from liver disease among hepatitis C patients.
Those relatively few individuals who have had an acute episode only or those who have cleared the hepatitis C virus by treatment - as evidenced by a satisfactory post-treatment time period - could be considered a standard risk for insurance.
However, those many individuals suffering from a chronic form of the disease may experience a substantial premium loading to any life cover applied for and are unlikely to be considered for any form of disability insurance, subject to the degree of progression of the condition.
There is clearly a need for an early diagnosis, but this is an actual need that is difficult to meet, given the hidden nature of the disease with few individuals suffering initial symptoms.
In view of the increasing prevalence, particularly in those of an insurance purchasing age, insurers might consider including full hepatitis screening as part of their routine medical requirements, at an appropriate level of cover.
Jon Lambert is a European life and health underwriting executive at GE Insurance Solutions
How hepatitis C is contracted
The HCV infection can be caught in a variety of ways including:
• Intravenous drug use. Among those diagnosed with hepatitis C infections, intravenous drug use is the single biggest risk factor, accounting for approximately 87% of infections in the UK.
• Contact with blood. Routine screening for antibodies to HCV in blood donations was introduced in the United Kingdom in September 1991. At that time, evidence showed that one in 2000 donors was positive for antibodies to hepatitis C. The Health Protection Agency estimates that 2% of UK sufferers have contracted the virus through transfusion, with a further 2% infected as a result of being a blood product recipient.
• Sexual contact. Transmission of hepatitis C through sex is thought to occasionally occur. It appears to be less easily transmitted in this way than hepatitis B.
• Body piercing, including acupuncture and tattoos. It is understood that a number of individuals have become infected with hepatitis C by the use of unsterile needles.
• Mother to baby. The risk of a mother with hepatitis C infecting her baby during pregnancy, or during the birth, is considered to be about 6%, according to the British Liver Trust.
• Medical or dental procedures. Transmission can occur where infection control is inadequate.
• Healthcare workers. These individuals may be at risk of hepatitis C infection from their occupation, although incidences are extremely rare.
• Unknown route of infection. In many cases due to the duration of time since potential infection, the actual transmission route remains unknown.
