On World Hepatitis Day, July 28, 2021, AASLD joins colleagues and community voices around the world with an urgent call to action for Hepatitis Elimination by 2030 because “Hepatitis Can’t Wait.”
Hepatitis Elimination Can’t Wait
Over 350 million people in the world are living with viral hepatitis B and C, putting them at risk of cirrhosis, liver failure and liver cancer. One of these individuals dies every 30 seconds. Globally, liver cancer rates continue to climb, and a majority of cases continue to be caused by viral hepatitis.
However, the tools for viral hepatitis elimination exist. Prevention strategies for hepatitis are well known, and vaccines for hepatitis B are effective. Interventions and medications can also alter the course of the disease. For hepatitis B, there are treatments to suppress the virus, and for hepatitis C, there are remarkable cures. We know surveillance can detect liver cancer early so that interventions are effective. Yet there are considerable gaps in getting these tools to the people who need it the most. Virus transmission continues in our population, the opioid crisis continues to be a driver of new infections, and many with hepatitis are not receiving care and treatment. Most countries, including the US, are not on target to reach elimination by 2030, a goal set by WHO in 2016, and every year, 1.1 million lives are lost unnecessarily due to hepatitis.
Impact of COVID-19
The COVID-19 pandemic has highlighted similar tools needed for combating an epidemic: high quality and available testing, transmission prevention, vaccine development and effective treatments. We have also seen the importance of investing in a strong public health response, robust communication, and full community engagement. Sadly, COVID-19 has exposed many health inequities, especially amongst vulnerable populations, many of whom are the same communities affected by hepatitis. The pandemic has caused significant disruptions in hepatitis screening, care and treatment, and emerging data confirm that services halted in many areas and our progress to elimination has been jeopardized.[i], [ii], [iii].
Thus, on World Hepatitis Day 2021, the urgency of this global health crisis is even more dire, and we must accelerate our efforts to elimination.
Diagnosis Can’t Wait
One of the largest gaps for elimination is “finding the missing millions.” Globally, only 21% of people living with hepatitis C, and only 10% of those with hepatitis B have been diagnosed[iii]. In the US, universal one-time screening of all adults for hepatitis C was recommended by the CDC in 2020[iv], replacing previous birth cohort screening, due to the rise in cases in millennials. Those disproportionately affected by hepatitis B are often minorities who face language and access barriers to getting diagnosed. Further, hepatitis D, a more severe form of hepatitis B, is often not diagnosed and is estimated to affect 13% of people living with hepatitis B globally.
A recent study showed that universal screening of hepatitis B in the US could prevent 23,000 deaths from liver disease and liver cancer at an estimated cost saving of $596 million.[v] It is time to advocate for universal testing of hepatitis B for the general population- we have seen that our strategy of risk stratifying and testing only certain groups has not been effective.
To reach elimination, we must scale up hepatitis screening and innovate. As we learned from COVID-19, epidemics cannot be stopped without testing. Point of care tests exist for hepatitis B and C, and we must push for licensing and usage, especially in community settings. In addition, self-testing for hepatitis C has recently been endorsed by WHO.[vi] Screening in primary care and across various care settings is critical to reaching more people, and we must utilizing electronic medical records and other clinical decision support tools to better integrate and streamline testing.
Unfortunately, stigma and discrimination around hepatitis persist around the world and can be barriers to testing. We must invest in efforts to increase awareness and knowledge about hepatitis and empower and support people living with viral hepatitis to help combat stigma.
People living with hepatitis can’t wait for treatments and cures
Another critical gap in reaching WHO targets is the low treatment rates of people living with viral hepatitis. Worldwide, only 13% of people living with hepatitis C and 2% of people living with hepatitis B have received treatment. Global costs of antiviral medications have fallen, and generics are available for many therapies, yet many people still do not have access to treatment. In 2019, a call to action and commitment was issued by the liver associations in America, Europe, Asia-Pacific, and Latin America (AASLD, EASL, APASL and ALEH) to eliminate hepatitis C with a focus on treatment simplification, task shifting and decentralizing of care in order to expand access to hepatitis C cures to a wider population.[vii] Molecular diagnostics for viral load are often not available or are unaffordable in resource limited settings; thus, many people are unable to be assessed for treatment based on current guidelines. However, COVID-19 testing expansion has increased availability of those platforms for hepatitis B and C testing, which should be utilized more as we move forward.
Mothers and children can’t wait
Viral hepatitis can be transmitted from mother to child, and prevention strategies are paramount for giving the next generation a “Hepatitis Free Future. "Testing before birth needs to be expanded, and CDC recommends hepatitis B and C screening during all pregnancies. For hepatitis B, the cornerstone of preventing mother to child transmission (PMTCT) strategies is the administration of the birth dose vaccine to the infant within 24 hours of birth. Despite the availability of a vaccine for decades and costing a mere $0.20 USD, only 43% of infants receive it worldwide[viii]. Women with high HBV viral loads (over 200,000 IU/ml) are at higher risk of transmitting the infection to their infants, but administration of antiviral therapy in the last trimester has been shown to reduce this risk[ix]. Access to screening, vaccination and antiviral treatment is imperative for ensuring that their infants do not get infected. Testing for hepatitis C is also now recommended in every pregnancy. Though treatment to prevent HCV transmission during pregnancy is not yet available diagnosis ensures infants receive appropriate follow-up and mothers get linked to care and treatment after delivery to ensure they are cured before future pregnancies.
We cannot forget children living with hepatitis. In children under 5 years of age around the world, 6.4 million are living with hepatitis Biii and face a future of lifelong disease until curative therapy is developed. It is estimated that there are 3.26 million children under 18 living with hepatitis C[x]. Direct acting antivirals can now be used for hepatitis C in children 3 and over, and there must be an emphasis on treating and curing children to give them a hepatitis free future.
AASLD’s members work tirelessly caring for patients, conducting research, developing recommendations, educating the public and providers, and serving as advocates for viral hepatitis and those affected by viral hepatitis. From our Governing Board and leadership to our Viral Hepatitis Elimination Taskforce, our Special Interest Groups (Hepatitis B, Hepatitis C, and Public Policy), and our Patient Advisory Group, AASLD has done and continues to do much work in the area of viral hepatitis. On this World Hepatitis Day, we join the collective global movement to accelerate progress to Hepatitis Elimination, because Hepatitis Can’t Wait.
[i] Pley CM, McNaughton AL, Matthews PC, Lourenço J. The global impact of the COVID-19 pandemic on the prevention, diagnosis and treatment of hepatitis B virus (HBV) infection. BMJ Glob Health. 2021 Jan;6(1):e004275. doi: 10.1136/bmjgh-2020-004275. PMID: 33402334; PMCID: PMC7786543.
[ii] Blach S, Kondili LA, Aghemo A, Cai Z, Dugan E, Estes C, Gamkrelidze I, Ma S, Pawlotsky JM, Razavi-Shearer D, Razavi H, Waked I, Zeuzem S, Craxi A. Impact of COVID-19 on global HCV elimination efforts. J Hepatol. 2021 Jan;74(1):31-36. doi: 10.1016/j.jhep.2020.07.042. Epub 2020 Aug 7. PMID: 32777322; PMCID: PMC7411379.
[iii] Progress report on HIV, viral hepatitis and sexually transmitted infections 2019. Accountability for the global health sector strategies, 2016–2021. Geneva: World Health Organization; 2019 (WHO/CDS/HIV/19.7)
[iv]Schillie S, Wester C, Osborne M, Wesolowski L, Ryerson AB. CDC Recommendations for Hepatitis C Screening Among Adults — United States, 2020. MMWR Recomm Rep 2020;69(No. RR-2):1–17. DOI: http://dx.doi.org/10.15585/mmwr.rr6902a1
[v] Mehlika Toy, David Hutton, Aaron M Harris, Noele Nelson, Joshua A Salomon, Samuel So, Cost-Effectiveness of One-Time Universal Screening for Chronic Hepatitis B Infection in Adults in the United States, Clinical Infectious Diseases, 2021;, ciab405, https://doi.org/10.1093/cid/ciab405
[vi] Recommendations and guidance on hepatitis C virus self-testing. Geneva: World Health Organization; 2021
[vii]Call-to-Action to Advance Progress Towards Viral Hepatitis Elimination: A Focus on Simplified Approaches to HCV Testing and Cure, Viral Hepatitis Elimination: Call to Action | AASLD, accessed July 7, 2021
[viii] Progress report on HIV, viral hepatitis and sexually transmitted infections 2019. Accountability for the global health sector strategies, 2016–2021. Geneva: World Health Organization; 2019 (WHO/CDS/HIV/19.7
[ix] Terrault NA, Lok ASF, McMahon BJ, Chang KM, Hwang JP, Jonas MM, Brown RS Jr, Bzowej NH, Wong JB. Update on Prevention, Diagnosis, and Treatment of Chronic Hepatitis B: AASLD 2018 Hepatitis B Guidance. Clin Liver Dis (Hoboken). 2018 Aug 22;12(1):33-34. doi: 10.1002/cld.728. PMID: 30988907; PMCID: PMC6385899.
[x] Schmelzer J, Dugan E, Blach S, Coleman S, Cai Z, DePaola M, Estes C, Gamkrelidze I, Jerabek K, Ma S, Montoya S, Razavi-Shearer D, Razavi-Shearer K, Robbins-Scott S, Razavi H, El Sayed MH. Global prevalence of hepatitis C virus in children in 2018: a modelling study. Lancet Gastroenterol Hepatol. 2020 Apr;5(4):374-392. doi: 10.1016/S2468-1253(19)30385-1. Epub 2020 Jan 16. PMID: 31954439.