Chronic hepatitis C infection: how much are physicians aware of?

Introduction

Hepatitis C virus (HCV) infection is a global health problem. One hundred and seventy million people are still chronically infected worldwide and are at risk of cirrhosis and cancer. Four million people are added to this figure every year and 350.000 people die due to HCV-related conditions annually [1, 2]. The primary route of transmission is parenteral, but HCV is also known to be transmitted through needle-stick injury, sexual intercourse and maternal transmission [3, 4]. Chronic HCV infection usually has an asymptomatic course unless it leads to complications, which constitutes the major problem in diagnosis [5, 6]. A study in Turkey where 36.554 people were screened according to the epidemiological screening method has found an anti-HCV seroprevalence of 0.9% [7]. Based on this ratio, it is estimated that approximately 722 thousand patients are anti-HCV positive in Turkey, and based on the rate of progression to chronic disease of 85%, approximately 614 thousand people are estimated to have chronic hepatitis C. Considering that nearly 4000 people are treated for chronic hepatitis C every year based on the IMS (International Medical Statistic) reports, one can conclude that a great number of individuals remain undiagnosed and continue their lives untreated among the society. Undiagnosed cases represent risks for not only transmitting the disease but also developing chronic hepatic complications such as cirrhosis and hepatocellular carcinoma. Similarly, a study from the USA has reported that 45–85% of patients with chronic HCV infection were unaware of their disease [8].

A cure rate of up to 95–100% has been achieved with the current therapies in chronic HCV infection [9]. However, the facts that the patients are not aware of their conditions added to the inadequate knowledge and awareness of healthcare providers on hepatitis C constitute obstacles in preventing the spreading of the disease as well as in identifying and treating the existing cases. Moreover, due to poor awareness of medical practitioners, some HCV-positive people have not been advised to seek further medical care. Some studies show that the majority of health professionals lack the knowledge and skills for caring HCV-positive people effectively. These studies also show that social prejudice toward self-reported behavior and fear of contracting hepatitis C, negatively affect health professionals [10]. Few studies are done regarding HCV awareness [10–12]. Although, in Turkey there is one study investigating the awareness of medical school students, nurses and dentists about HCV, there is no study showing the awareness of physicians about HCV [13].

Studies have shown that age of physicians and their specialties are important markers for HCV awareness [10, 11].

Aim

The purpose of our study is to measure the awareness of hepatitis C among physicians employed in Istanbul, and investigate the relationship between awareness and the specialization field, age and presence of chronic hepatitis/ positive family history.

Material and methods

Results

The study included 125 (62.1%) family physicians and 76 (37.9%) internal medicine physicians, employed in Istanbul Province. Most of the physicians were women (58%) and their mean age was 30.9 ±7.1 years (range: 23–45 years). 75 (37.3%) physicians were between ages of 23–28, 67 (33.3%) physicians were between ages of 29–32, and 59 (29.4%) physicians ages was greater than 32. Of the physicians, 77% worked in hospitals, 22% in maternal and infant health center and 1% in community health centers.

Four (2%) of the physicians had chronic hepatitis (B or C) while 12 (6%) had never been tested. Seventeen (8.4%) of the physicians had a relative with chronic hepatitis. HCV positivity, either in the physician or a relative, was identified in a total of 21 (10.4%) physicians.

According to the questionnaire results, 70 (35%) of the physicians answered that HCV prevalence in Turkey was below 1%, and 131 (65%) answered that it was above 2%. For the questions on routes of transmission, the most common responses were transfusion, tooth extraction and post-IV drug injection (68%, 15% and 11%, respectively). For the question, “Can patients with chronic HCV be asymptomatic and present with hepatic cirrhosis?”, 86% of the physicians answered yes and 14% answered no. The correct response rate of this question was significantly higher in internal medicine physicians (80% vs. 93%, p = 0.017) (Table I). Relationship between physcians’ specializations and the correct answer is shown in Figure 1.

Figure 1

Rate of accurate responses to between the speciality of physicans in Table I

Almost all of the physicians correctly responded that HCV may be transmitted with blood transfusion but 11% of them responded than the disease may not be transmitted with sexual contact, 14% answered that illegal drug and IV injection will not transmit the disease, 26% responded that there could be no maternal transmission and 31% answered that sharing scissors, razors and toothbrush with others would not result in transmission. In addition, 17%, 1%, 3% and 4% of the physicians inaccurately responded that transmission may occur by kissing, sharing clothes, using the same restroom or handshaking, and working in the same environment, respectively. When examined based on transmission routes, there were no significant differences between physicians’ specializations and positive familial history, but physicians aged 23–28 had significantly poorer awareness at some points. Compared by age groups, it was detected that physicians in the 23–28 age group answered the 4^th (93% vs. 100% and 98%), 5^th (93% vs. 98% and 100%), and 6^th (96% vs. 100% and 100%) questions correctly in less proportion. Also in question 8, it was observed that physicians in the 29–32 age range answered the question correctly in a significantly higher proportion (respectively 82%, 91%, 74%) than physicians in other ages (Table II). Significant relationship between the ratio of correct answers for HCV transmission and the physcians’ age is shown in Figure 2.

Figure 2

Questions on the routes of chronic HCV transmission and their answers. Rate of accurate responses to between the age of physicans in Table II

The question that who should be screened for anti-HCV was examined; There were significant relationship between specialty but there were no significant differences betweenpositive familial history and physicians’ age. Internal medicine specialists had better awareness on screening tests compared to family physicians. In total (64% vs. 72%) and in questions 1 (80% vs. 93%), 2 (84% vs. 96%), 3 (78% vs. 91%), 4 (58% vs. 79%), 6 (69% vs. 88%), 10 (52% vs. 71%), and 16 (30% vs. 46%), we found that internal medicine physicians had a significantly high correct percentage (Table III). Significant relationship between the ratio of correct answers for the conditions that anti-HCV test should be used and physcians’ specialization is shown in Figure 3.

Figure 3

Responses to the question, “For which of the following groups you request HCV tests?” Rate of accurate responses to between the speciality of physicans in Table III

Discussion

About 20–30% of the patients with untreated chronic HCV develop cirrhosis and advanced liver disease leading to HCC after 20 years. The annual ratio of developing HCC was found as 1–7% [16]. Because the condition is asymptomatic in 70–80% of the patients, a very low proportion of them present to healthcare facilities and most of these patients have advanced stage liver disease and complications at the time of presentation. Another important factor associated with the low number of treated cases is the poor awareness [17]. There has been a dramatic increase in success rates among treated individuals. In 90’s, sustained virologic response (SVR) with standard interferon therapy was 5–20%, which was increased to 54–63% with the pegylated interferon and ribavirin combination and then to 70–75% with the advent of protease inhibitors in 2011 [18–20]. Currently, SVR can be achieved in 95–100% of the cases with combined use of the latest generation NS5A and NS5B inhibitors [9]. On the other hand, because a HCV vaccine has not been developed and given the absence of post-exposure prophylaxis, spreading of HCV can only be prevented by improving the awareness and identifying and treating infected individuals.

To fight against HCV, it is so important to know how virus transmits. HCV is usually transmitted with IV drug injection in developed countries, while the transmission is often through blood transfusion and medical materials in developing countries [21, 22]. Significant HCV transmission is reported during schistosomiasis treatment in Egypt, the country with highest seroprevalence and during kala azar treatment in India [21]. Perinatal and sexual transmission risks are known to be low in HCV. The rate of transmission during delivery in HCV-infected mothers has been reported as 2.7–8.4% and 15–20% of the acute hepatitis cases have been associated with sexual contact [14, 21]. In our study, we observed a significant awareness deficiency about HCV transmission. Awareness about HCV transmission among physicians has been studied by some researchers in some countries. In a similar study to our study, Feng et al. have reported that 89% of the respondents thought that hepatitis C was not transmitted by kissing, hugging, or sharing eating utensils. Eleven percent mistakenly believed that the disease was not transmitted from mother to infant, by sharing a needle or syringe, by sharing a razor or toothbrush, or by having sex with a partner with HCV infection [10]. Rana et al. in a study investigating the awareness of orthopedic surgeons about HCV, have reported that; The majority of surgeons (56%) were unaware that HCV infection was a sexually transmitted disease and 82% did not know about the possibility of its transmission perinataly. Of all the subjects 93% knew that HCV could be transmitted through blood transfusions and 88% knew about its transmission through a needle-stick injury [23]. In comparison to other studies, we found that data of our study was similar to Far East countries and we saw that HCV awareness was much worse in Pakistan. In our study we also found that young physicians were significantly less aware. Therefore experience is thought to be one of the most important factors in preventing HCV transmission.

Centers for Disease Control and Prevention (CDC) published a guideline on HCV screening in 1998 [24]. The guideline updated by NIH in 2002 was finalized by United States Preventive Services Task Force (USPSTF) in 2013 [15, 25]. The guideline states that individuals with elevated hepatic functions tests, those at risk of parenteral, sexual, vertical and percutaneous transmission and those with positive familial history should particularly be screened. In addition, the latest USPSTF guideline states that individuals born between 1945 and 1965 should be screened because this age group represented 75% of the chronic HVC population in the United States. In their studies with physicians, Ferrante et al. have reported that awareness on which patient profile should be screened was low [11]. In our study, we observed a significant awareness deficiency on this subject too. In our study we also observed that internal medicine physicians have a better awareness about the HCV transmission routes. We believe that the family physicians’ inadequate training and seeing fewer patients with hepatitis C are factors which play role in this case.

This study has several limitations. It was conducted with family physicians and internal medicine physicians in Istanbul Province, so the results can’t be generalized to other physicians. Also our study can not be used to generate population estimates because of the small number of respondents. Majority of the participants in our study were aged between 20–40. So it caused to be non-homogeneous distribution in terms of all physicians’ age. In addition, the small sample size limited our power to detect statistically significant differences between subgroups. However, since Istanbul is the country’s largest and most cosmopolitan city, we believe that it reflects the overall average. This study was designed through family physicians and internal medicine physicians, because we believed that these physicians are screening more patients with risk of HCV and are encountered more often in these patients than other physicians. Being the first study investigating objectively the HCV awareness of physicians in Turkey is one of the main strengths of our study.

Conclusions

Considering that 0.9% of our population is infected, it is evident that complications and mortality associated with chronic HCV will be an important healthcare issue in the upcoming years. The priority is identifying and treating existing patients. In our study; physicians were found to be insufficient in answering the questions on HCV transmission routes and who should be screened. When examined based on transmission routes, there were no significant differences between physicians’ specializations and positive familial history, but physicians aged 23–28 had significantly poorer awareness at some points. Internal medicine specialists had better awareness on screening tests compared to family physicians but there were no significant differences between positive familial history and physicians’ age. Physicians’ awareness should be improved to prevent hepatitis C virus transmission and to identify existing conditions. We therefore believe that raising HCV awareness of physicians in primary and secondary care is the most important step in fight against chronic HCV.