JAMA Forum: Mounting a Global Response to Chronic Viral Hepatitis  

Howard K. Koh, MD, MPH (Image: Harvard T.H. Chan School of Public Health)

Until recently, formulating national strategies to address the epidemic of chronic viral hepatitis was not a priority for most countries. Although Australia and Taiwan led the way years ago, few others initially followed.

Now, however, recent calls for action, including 2 major reports from the National Academies of Sciences, Engineering, and Medicine (NASEM), highlight the urgency for a global response.

A Profound Disease Burden

Together, the hepatitis B (HBV) and hepatitis C (HCV) viruses chronically infect more than 400 million people worldwide. Chronic viral hepatitis ranks as the seventh leading cause of mortality globally, causing nearly 1.5 million annual deaths (greater than from HIV, tuberculosis, or malaria). Viral hepatitis also accounts for 80% of the global liver cancer burden. In the United States, viral hepatitis chronically infects an estimated 4.4 million (HBV 850 000, HCV 3.5 million) and ranks as the leading cause of infectious disease mortality; its more than 22 000 deaths a year exceed that of HIV and all other notifiable infections combined. In addition, viral hepatitis has fueled a tripling in US liver cancer incidence since the 1970s, and is responsible for a third of current liver transplantations.

Yet despite this profound disease burden, awareness in the United States remains low. Even people who are infected (about two-thirds of those with HBV and about half with HCV) are unaware of their infection status.

Coordinating National Responses

More nations have begun to step up. For example, in 2011, the US Department of Health and Human Services (HHS) first unveiled a US national Action Plan for the Prevention, Care & Treatment of Viral Hepatitis (which I oversaw as HHS Assistant Secretary for Health). Reaching high-risk populations with strategies for education, prevention, testing, and treatment involved engaging diverse groups. They included health care workers, “baby boomers” (born between 1945-1965), communities of color (including Asian Americans, Native Hawaiians, and Pacific Islanders, who make up 6% of the US population but more than half of those with HBV), injectable drug users, incarcerated populations, and people living with HIV/AIDS.

The 2011 action plan fostered national alignment and coordination of stakeholders. New education and early detection efforts included Centers for Disease Control and Prevention (CDC) educational campaigns, including outreach in multiple Asian languages; innovative online tools for personal risk assessment, testing, and vaccination; and an annual National Hepatitis Testing Day.

In a related development, US Preventive Services Task Force recommendations in 2013 and 2014 that expanded to include HCV screening for baby boomers (as well as other target populations) and HBV screening for those born in endemic areas in Asia and Africa increased the potential for early detection, especially because the Affordable Care Act requires new health plans to cover high-value preventive services without cost sharing. Other critical efforts strengthened limited surveillance and data-monitoring systems, while joint communication from HHS, the Department of Justice, and the Department of Education emphasized that federal laws protect HBV-infected health care students from discrimination.

Despite these developments, a dynamic and complicated set of factors has led to mixed outcomes. For example, early adoption of updated screening recommendations is suggested by an initial national analysis showing a significant 91% rise (2011 to 2014) in HCV antibody testing in baby boomers, but overall testing rates remains very low (3.3%). Although a preliminary analysis suggests rising awareness of infection status for HCV patients, intravenous drug use associated with the opioid crisis has ignited the doubling of HCV estimated annual incidence (from 16 500 [2011] to 33 900 [2015]). Moreover, the decline of HBV annual incidence of about 85% (after the introduction of a vaccine in 1981) stalled and even reversed in several states. Meanwhile, the annual CDC hepatitis budget, though increasing from $20 million in 2010 to $39 million in 2017, remains severely underfunded.

Hepatitis C virus treatment represents a special set of opportunities and challenges. On the one hand, the US Food and Drug Administration approval of multiple oral direct-acting agents since 2011 has made cure possible for more than 90% of those infected. On the other hand, the exorbitant costs of these medications have put treatment out of reach for many and strained state Medicaid budgets. For example, most states placed restrictions on HCV treatment with sofosbuvir, possibly violating federal Medicaid law, countering recommendations from professional groups, including the Infectious Diseases Society of America and the American Association for the Study of Liver Diseases. Over the past few years, HCV curative treatment costs have declined but remain a barrier to care for many.

Recognizing these challenges, the recently released HHS National Viral Hepatitis Action Plan 2017-2020 now resets and reaffirms shared national goals. It also joins a wide range of organizations—including the Department of Justice, the Federal Bureau of Prisons, and the Department of Veterans Affairs—with HHS to implement strategies and monitor indicators of progress. For example, increasing the HBV vaccine “birth dose” to 85% (from 72.4% in 2014) and increasing HBV vaccination among health care personnel to 90% (from 67.7% in 2014) should lower perinatal transmission and better protect clinicians, respectively.  The 2015 Congressional partial lifting of a ban on use of federal funds for syringe service programs could help expand the number of these programs nationwide and reduce viral hepatitis (and HIV) incidence.

Desperately needed are improved systems of care to increase the percentage of HCV-infected persons—currently at 9%—who can successfully navigate all the steps of the “treatment cascade,” from early diagnosis to access to indicated treatment and, ultimately, to cure (i.e., sustained virology response). Doing so can begin to narrow some major health disparities in hepatitis outcomes for high-risk populations. The NASEM reports have set goals of the elimination of hepatitis B and C as public health threats, with special attention to innovative DAA financing strategies for direct-acting agents; such proposals would certainly inform current and future action plans.

Increasing Global Commitment

Meanwhile, many more countries outside the United States have lately fashioned national roadmaps. The World Health Organization recently released its first Global Health Sector Strategy on Viral Hepatitis (2016-2021) as part of the Agenda for Sustainable Development Goals. At least 39 countries have now created action plans and several dozen more are in the process of doing so. But making those plans come alive will require each country to summon substantial resources, programs, and political will.

The global health community increasingly recognizes that chronic viral hepatitis is preventable, treatable, and often curable. Sustained worldwide action must now follow these explicit strategies to bring a future in which new infections are eliminated, those infected know their status, and where everyone has access to the care and treatment they need and deserve.

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About the author: Howard K. Koh, MD, MPH, is the Harvey V. Fineberg professor of the practice of public health leadership at the Harvard T. H. Chan School of Public Health and the Harvard Kennedy School. He is also the former Massachusetts commissioner of public health and the 14th assistant secretary for health for the US Department of Health and Human Services. A quadruple-boarded physician, Dr Koh has published more than 250 articles in the medical and public health literature, earned more than 70 awards for interdisciplinary achievements in public health, and has received 5 honorary doctorate degrees.

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Categories: Health Policy, Liver/Biliary Tract/Pancreatic Diseases, Public Health, The JAMA Forum

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