HBV nelle prigioni italiane: politiche e prassi

Giulio Starnini
Direttore U.O.C . Medicina Protetta – Malattie Infettive – Ospedale Belcolle ASL Viterbo

S. Dell’Isola, A. M. Ialungo, E. Rastrelli
Dirigente Medico U.O.C . Medicina Protetta – Malattie Infettive – Ospedale Belcolle ASL Viterbo


RIASSUNTO

L’infezione cronica da HBV  negli Istituti Penitenziari Italiani  rappresenta un problema di salute pubblica a causa dell’ellevata prevalenza della stessa e dell’insufficiente copertura vaccinale. Numerose sono inoltri i casi di forme croniche  evolute non diagnosticati e/o non adeguatamente inseriti in follow- diagnostici terpaeutici. Si sottolinea l’imprinscindibilità di politiche di gestione a livello centrale che consentano un adeguato monitoraggio dell’infezione e  l’adozione di campagne di vaccinazione. A livello regionale viene fortemente raccomandata l’adozione di PDTA, inserimento di  conoscenze specifiche su HBV nei percorsi di aggiornamento  obbligatorio  del personale,  iniziative permanenti di informazione alla popolazione detenuta.
Parole chiave: Prigione; Prevenzione; Vaccinazione


Articolo presente in – Cure and Chronicity N.2 

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Tubercolosi in prigione: il rischio della multifarmaco resistenza

Sergio Carbonara 
Clinica di Malattie Infettive – Università di Bari


RIASSUNTO

Le prigioni rappresentano un setting ad alto rischio per la tubercolosi (TB) tanto farmaco quanto non farmaco – resistente (o multifarmaco resistente – MDR), per svariati motivi: un alta concentrazione di gruppi ad alto rischio di TB in una popolazione ristretta, ambienti chiusi, sovrappopolazione, scarsa ventilazione, programmi di controllo inadeguati, alto turnover dei detenuti. Incrementare il controllo della TB in prigione crea un beneficio per l’intera comunità. Il controllo della TB – MDR risiede attualmente perlopiù su un insieme di interventi volti a prevenire la TB “di per se”, come diagnosi tempestiva, isolamento della TB respiratoria, trattamento con una terapia adeguata con una piena aderenza del paziente per tutto l’arco di cura. Un intervento tempestivo è necessario per connettere i servizi di cura della TB penitenziari a quelli della comunità per assicurare un proseguimento della cura ai detenuti scarcerati. Misure per ridurre il sovraffollamento e per migliorare le condizioni di vita di tutti i prigionieri dovrebbero essere applicate per ridurre la trasmissione della TB.
Parole chiave: Tubercolosi; Multifarmaco resistenza; Prigioni


Articolo presente in – Cure and Chronicity N.2

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Diffusione della infezione da HIV in prigione e gestione delle terapie antivirali all’interno e all’esterno

Emanuele Pontali
Dipartimento di Malattie Infettive – Ospedale galliera – genova


RIASSUNTO

La prevalenza del virus dell’immunodeficienza umana (HIV) nelle carceri è più alta rispetto alla popolazione generale.  Le prigioni ospitano individui con un incrementato rischio di acquisizione di HIV. Strategie di prevenzione e di intervento debbono essere implementate al fine di evitare la trasmissione dell’HIV all’interno delle prigioni.  La terapia antiretrovirale (ART) è possibile nelle carceri di molti paesi, ma in diversi scenari ancora si presentano ostacoli per una cura ottimale dell’HIV.  L’ART può portare a buoni risultati in detenuti HIV infetti. Le problematiche relative alla gestione dell’ART nelle prigioni sono presentate e discusse.
Tuttavia i benefici ottenuti sono spesso persi dopo il rilascio, a questo proposito numerose criticità sono state identificate e discusse; tra le più rilevanti la disponibilità di basilari e specifici programmi di cura dell’HIV, le prigioni come punto di inizio della cura dell’HIV per le popolazioni marginalizzate, policy e linee guida per la ART, cure specializzate, le modalità di somministrazione della ART, aderenza alla terapia e continuità di cura tra prigione e ambiente esterno.
Parole chiave: Rapporto dottore – paziente; Setting penitenziario; Assistenza sanitaria


Articolo presente in – Cure and Chronicity N.2 

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How physicians who cure HCV in Italy perceive current and future needs.

Vito Di Marco – Biomedic department of specialistic and internal medicine – gastroenterology and epatology section – Palermo University, Italia


ABSTRACT

Aims: To optimize management of chronic HCV hepatitis, a Delphi method was used to facilitate
the consensus of experts in situations where the quality of evidence is variable and there is a lack
of clear recommendations to guide real-life clinical practice.
Methods: An Advisory Board agreed two questionnaires on epidemiological, diagnostic and therapeutic
choices. Questionnaires were administered in two rounds to an Expert Panel (EP).
Results: In total 443 physicians working in 235 Italian HCV referral centres replied to the
questionnaires. The EP did not agree on the prevalence of HCV infection in Italy and on
treating patients over 80 years with DAAs. They agreed on collaboration with GPs and
HCV testing in high-risk groups to increase access to DAAs. Over 90% agreed with quantifying
HCV-RNA, determining genotype, and testing for anti-HIV and HBsAg before DAAs.
Over 90% used transient elastography (FibroScan®) to evaluate the stage of liver fibrosis and
serum biomarkers were used by less than 20%. Ease of adherence to therapy, lack of drugdrug
interactions and the possibility of treating advanced liver disease were decisive factors
in therapy choice. Addition of ribavirin and time of therapy were less determining factors.
Monthly monitoring during therapy was considered appropriate and 80% were in favour of
HCV-RNA testing 24 weeks after the end of the therapy to confirm SVR. Over 80% agreed
with the need to continue follow-up of patients with advanced fibrosis/cirrhosis.
Conclusion: The expert panel did not completely agree on all procedures in managing patients
with HCV chronic hepatitis. Scientific organizations should review some recommendations
in their guidelines to facilitate access of patients to DAAs, increase centre capacity
and simplify follow-up post therapy.
Parole chiave: Delphi method; HCV; HCV management


Articolo presente in – Cure and Chronicity N.1 


HCV resistance to drugs: still a scourge?

Francesca Ceccherini-Silberstein – Department of Experimental Medicine and Surgery, University Tor Vergata, – Rome, Italia


ABSTRACT

The goal of therapy is to cure hepatitis C virus (HCV) infection and preventing hepatic cirrhosis,
hepatocarcinoma, severe extrahepatic manifestations and death.
The identification and characterization of HCV encoded proteins and their functional units
contributed to the development of highly effective direct acting antivirals (DAA) against
the NS3 protease, NS5A and the NS5B polymerase. In these last years, the introduction of
the DAAs in clinical practice has revolutionized the HCV treatment, allowing to achieve
>90-95% rates of sustained virological response (SVR) in many groups of patients.
Despite the excellent efficacy of DAA containing regimens, virological failures can occur,
often associated with development of resistance and with differences according to the type
of regimen and HCV genotype. The natural presence of resistance associated substitutions
(RASs), as well as their rapid emergence during incomplete drug pressure, are intrinsic
characteristics of HCV that greatly affect treatment outcome and the chances to achieve
a virolgical cure.
Nowadays, a high number of RASs in NS3, NS5A, and NS5B have been associated in vivo
and/or in vitro with reduced susceptibility to DAAs. Understanding more about RASs may
help us learn why the patients failed, and may allow the optimization of both first-line
treatment for other new patients that should start treatment and also retreatment choices
for patients that already have failed a DAA containing regimen.
keywords: HCV; Hepatitis C virus; Genotype; Resistance associated substitutions; Direct acting antiviral agents; Genotypic resistance testing; Antiviral therapy


Articolo presente in – Cure and Chronicity N.1 


Special groups special needs?

Massimo Puoti – Dept of Infectious Diseases – Niguarda Hospital – Milan, Italia


ABSTRACT

Hepatitis C Virus (HCV) causes extrahepatic disorders: cryoglobulinemia, lymphoproliferative
disorders, kidney and autoimmune inflammatory diseases. These conditions even
id subclinical should be identified in patients with HCV infection and screening for HCV
should be included in the clinical workup of these dsorders Early treatment of HCV infection
may halt the evolution of some of these disorders. The availability of Interferon
free all oral antiviral treatments has completely changed the clinical scenario of these
condition and the first reports confirm the efficacy of this approach even in patients with
extrahepatic disorders. Nevertheless a point of no return exists for all of them when HCV
eradication is not sufficient to reverse the clinical course of the disease. In this case other
approach should be combined or follow antiviral therapy in HCV infected subjects.
Parole chiave: HCV; Cryoglobulinema: lymphoma; Renal insufficiency


Articolo presente in – Cure and Chronicity N.1 


Is global (or regional) HCV elimination a realistic objective?

Alfredo Alberti – Department of Molecular Medicine University of Padova, Italia


ABSTRACT

A number of direct antiviral agents against the hepatitis C virus have recently become
available and proven highly effective in terminating chronic infection in the vast majority
of treated patients. Considering that HCV carriers represent the exclusive reservoir of
hepatitis C in nature, there is the possibility to use antiviral therapy to achieve elimination
of Hepatitis C . In an outcome model developed by the World Health Organization, global
HCV elimination can be obtained by identifying 90% of infected individuals, and by treating
at least 80% , and this is expected to generate drastic reduction in hepatitis C incidence
and prevalence, with >65% reduction in HCV related morbidities and mortality. To achieve
such ambitious goal, WHO has called into action individual State Members to organize
National HCV elimination programs. These programs should be further decentralized into
microelimination programs adjusted to the local epidemiology and resources. HCV elimination
actions need to combine increased awareness on the infection and disease in the
Community, clinical case finding and targeted screening intervention, effective linkage to
care and educational programs on prevention of transmission and reinfection for high
risk groups. Unrestricted access to antiviral therapy and adequate financial support and
infrastructures for large scale treatment programs are obviously essential prerequisites
to start any HCV elimination programs. However they are necessary but not sufficient, as
the main barriers to achieve the final goal currently consist in the asymptomatic nature of
chronic HCV infection, with large numbers of yet undiagnosed cases requiring extensive
and expensive screening programs, and in the substantial risk of reinfection in patients
with risk behaviors, in the absence of a prophylactic vaccine and of strict adherence to
harm reduction strategies. With these caveats in mind, HCV elimination programs are
currently planned in many Countries, including Italy.
Parole chiave: Hepatitis C; Global Elimination; Direct Antiviral Agents


Articolo presente in – Cure and Chronicity N.1 


Third-wave drugs: pharmacokinetics, pharmacodynamics and DDI

Giovanni Di Perri – Infectious Diseases Unit, School of Medicine, University of Torino, Italia


ABSTRACT

In few years, thanks to new development dynamics, chronic HCV infection treatments have
seen a huge improvements. Duration of treatment have been reduced, with a higher efficacy
rate and a better profile of safety and tolerability. In this scenario, directly acting antivirals
(DAAs) are the new form of anti-HCV treatment, suitable for the vast majority of patients.
Parole chiave: HCV infection; Third-wave drugs, DAAs


Articolo presente in – Cure and Chronicity N.1 


HCV cure and the course of liver disease

Massimo Colombo, Vincenzo Boccaccio – Department of Medicine, Clinical and Research Center Humanitas Research Hospital, Rozzano, Italia


ABSTRACT

Clearance of the hepatitis C virus (HCV) through antiviral therapy is associated with halting
the progression of liver disease and decreasing the frequency of hepatitis C complications
including cirrhosis, clinical decompensation, liver cancer and liver-related mortality.
These are messages generated by observational studies of patients who have been tretaed
with interferon and followed for decades. Conversely, it is still unclear whether the same
is true for patients achieving a cure of HCV with interferon-free regimens based on direct
antiviral agents (DAA), mainly owing to the limited follow up of the concerned real life
studies. This not withstanding, both roll over and observational studies have provided preliminary
evidence that in the short term the rates of complications of hepatitis C are reduced
following a cure of infection with DAAs. Importantly, scrutiny of the Veterans Affairs
cohorts in the USA suggests a reduction of both the incidence of hepatocellular carcinoma
(HCC) and liver related mortality even in patients with more advanced liver disease. In
this latter patient population, however, one major unsolved issue remains how to identify
patients with decompensated liver who will gain survival benefits following a sustained
virological response (SVR) to DAA, a benefit that in the past could not be achieved by interferon,
compared to those who apparently remain at risk of further decompensation and
death even after clearing the infection. While this dilemma in some centres has fuelled a
controversy on strategies of listing decompensated patients to liver transplantation, questions
arose also regarding an increased risk of accelerated recurrence of aggressive HCC
that was reported in an unexpected high number of patients after a cure of HCV with
DAAs. This finding,infact, was not appreciated in the interferon era while it poses some
limitations to the universal utilisation of DAAs as adjuvant therapy in HCC patients.
Parole chiave: hepatitis C; Interferon; Direct antiviral agents; Hepatocellular carcinoma.


Articolo presente in – Cure and Chronicity N.1 


Hepatitis C – The ever-changing scenario

Antonio Craxì – Università di Palermo, Italia


ABSTRACT

Chronic infection with HCV has an enormous diffusion, with an estimated worldwide prevalence
of above 70 million persons with viraemic infection in 2013 [1]. Chronic liver disease (cirrhosis
and hepatocellular carcinoma) linked to HCV is at a global level, the 7th leading cause of death.
The number of persons with viraemic HCV infections in the European Union (EU) has been
estimated by modeling to be 3.238.000 of a total population of 509.868, in 2015 equating to a
prevalence of 0,64% [2]. In 2015 modeling indicated that, out of an estimated 1.180.000 people
known to have HCV viraemia (36,4% of the total infected population), 150 000 were treated
(12,7% of the diagnosed population), 133.000 were cured (4,1%), and 57.900 were newly infected
(1,8%). Additionally, 30.400 HCV-positive immigrants entered the EU. It was hence calculated
that to achieve WHO targets, unrestricted treatment needed to increase from 150.000 patients
in 2015 to 187.000 patients in 2025 and diagnosis needs to increase from 88.800 new cases
annually in 2015 to 180 000 in 2025 [2].


Articolo presente in – Cure and Chronicity N.1


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