Awareness Identification and Treatment Chronic hepatitis B and C: BIBHEP

Since 1996 mortality from Hepatitis B and C has risen with 30% despite the availability of increasingly effective antiviral medication. Less than 50% of those in urgent need of antiviral medication actually receive it; in addition, at least half of the hepatitis antivirals prescribed are outdated 1-2nd generation drugs with a substantial risk of resistance. Lack of awareness is the main reason for the severe underutilization of hepatitis antivirals in western countries. The national program BIBHEP will raise and maintain awareness about the impressive health gain of antiviral therapy for chronic hepatitis B and C in two crucial areas: physicians and public health organizations. In addition, the program delivers tools for both primary and secondary care to facilitate identification and optimal treatment of chronic viral hepatitis by busy clinicians. A pilot project in 2011-12 showed excellent feasibility of this program, and may have contributed to documented small positive changes in the use of hepatitis B antivirals in 2011. To elucidate cause-effect relations the program also includes monitoring of processes and effects. Stringent analysis at the end of the program will bring forward relations between observed effects, BIBHEP interventions and other events potentially influencing the effects. The goals of the proposed 3-year national program is to start antiviral therapy according to national guidelines in 6,500 individuals with a 10-year risk of hepatitis-related mortality of > 10%, to increase the percentage of 3rd generation antivirals to 85%, and the compliance of antiviral drug therapy to 95%. Raising and maintaining awareness (work package 1) will be achieved by workshops in each of the 95 Dutch hospitals for their adherent general practitioners (GP), and in each of the 26 public health organizations for their adherent addiction care and STD physicians. For those unable to attend the workshops an operational 1-hour e-learning program will be promoted. A bimonthly newsletter for primary and secondary care with section on awareness, identification, treatment and hepatitis B & C shall maintain awareness and help in implementing identification or treatment in daily practice. Articles in medical journals and national or local newspapers shall strengthen the efforts to raise and maintain awareness. Facilitating identification of chronic virus carriers, efficient referral of candidates for antiviral therapy, decision making on antiviral therapy, monitoring treatment compliance and effects (work package 2) will be achieved by simple desk and online tools such as the BIBHEP card, a hepatitis alert domain in the GP’s electronic health record system and in the laboratory reporting systems, a 10-year Hepatitis Risk Score calculator yielding risk estimates without and with antiviral therapy, e-consultation and an e-compliance survey tool. Monitoring and analysis (work package 3) of the results will be based on monitoring awareness by online surveys; identification of chronic hepatitis B and C patients by collecting national and regional data on positive tests for HBsAg, antiHCV, HBVDNA and HCVRNA; treatment by monitoring the use of hepatitis antivirals, and mortality by yearly analysis of national mortality statistics. This database on effects will be expanded by collecting data on BIBHEP interventions and other events potentially influencing the effects. The proposed BIBHEP program consisting of 3 parts: Awareness, Identification & Treatment, and Monitoring & Analysis will abolish the large underuse of 3rd generation hepatitis antivirals in those at risk of hepatitis-related mortality within 10 years, and potentially will save more than 100 lives per year.