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Hepatitis is the seventh leading cause of death worldwide. The CDC estimates that between 700,000 and 1.4 million Americans suffer from chronic HBV and 2.7 to 3.9 million suffer from chronic HCV, contributing to 20,000 deaths annually.

The tools to prevent HBV and cure HCV are now available. Vaccination against HBV confers greater than 95% immunity, and recently developed antiviral treatments for HCV can cure infection in more than 95% of patients.

A new report from a committee formed by the National Academy of Sciences, Engineering and Medicine has concluded that both hepatitis B (HBV) and hepatitis C (HCV) could be eliminated as public health problems in the United States.

While the authors caution that elimination would require considerable will and resources, they believe that in the near term disease control is more feasible. Importantly, elimination is defined here as “cessation of transmission in the US, allowing that the disease itself may remain, but particularly undesirable clinical manifestations prevented entirely.” While disease control is defined as a “reduction in the incidence and prevalence of HBV and HCV and their sequelae with ongoing control measures.”

The Committee’s Charge

The World Health Organization believes global elimination of HBV and HCV is achievable by 2030 (90% reduction in new, chronic infections and 65% reduction in mortality). Elimination of HBV and HCV are also priorities for the Division of Viral Hepatitis at the Centers for Disease Control (CDC) and the Office of Minority Health in the Department of Health and Human Services (HHS). An interagency action plan already lays out goals for increasing individual awareness of HBV and HCV infection, reducing new infections and eliminating mother-to-child transmission of HBV by 2020.

Given the existing national initiative as well as growing global action towards hepatitis elimination, momentum is building to take more intensive action against viral hepatitis.  It was for this reason that the CDC and HHS asked the National Academy committee to carefully evaluate the feasibility of disease elimination in the United States.

Eliminating Hepatitis B

The first step to eliminating HBV is ending transmission of the virus. There is no animal reservoir for HBV. The virus is typically transmitted in one of three ways: from mother-to-child, direct contact with infected blood, or through unprotected sex with an infected partner. All three of the modes of transmission could be prevented through vaccination and, in the case of perinatal transmission, an added treatment with hepatitis B immune globulin within 12 hours of birth. Ending mother-to-child transmission and transmission to children is highly feasible due to existing immunization systems, however, receiving the same degree of vaccination amongst adults is more difficult. There is no system for vaccination of adults, and undiagnosed, asymptomatic chronic infections are a constant reservoir for infection. One approach might be to target high-risk populations through routine vaccinations at sexually transmitted disease clinics or prisons.

The second step to eliminating HBV is to reduce the burden of chronic infection. Individuals living with HBV require life-long disease monitoring. No action is needed when the disease is in the immune tolerant phase, however monitoring remains critical to detect progression to the immune active phase. In this phase, antiviral therapy is beneficial and prevents deaths from cirrhosis and liver cancer, however this treatment is not curative. The virus can typically be kept at bay, but the threat of reactivation means that antiviral treatment is rarely discontinued. Additionally, many patients undergoing antiviral treatment for HBV will at some point need immunosuppressive therapy for cancer, autoimmune disorders or organ transplant which can reactivate HBV and lead to liver failure.

Eliminating Hepatitis C

HCV is most commonly transmitted through contact with infected blood, however it can also spread through sexual contact and from mother-to-child. Like HBV, there is no animal reservoir for HCV. Unlike HBV, there is no vaccine for HCV. Individuals who inject drugs are at the greatest risk for contracting HCV. This is a difficult group to reach through intervention, but evidence suggests that needle exchange programs and programs that address substance abuse could lower transmission. These programs have achieved good coverage in urban areas, but injection drug use is increasingly common in rural areas meaning programs will need to be tailored to succeed in different environments. Treatment with curative antivirals would also reduce disease transmission and eliminate the disease burden of chronic infection for some, however, the high cost makes universal treatment unfeasible given the current policy environment. Additionally, the possibility of drug resistance is not well understood and could be compounded by poor adherence to treatment. Reinfection after cure is also possible, however research on this topic is limited since the treatments are so new.

Progression of HCV can lead to cirrhosis and is linked to the severity of fibrosis. In fact, 20-40% of people with chronic HCV will develop cirrhosis. Curing HCV prior to this progression will prevent deaths due to chronic infection. Sustained virological response can also restore liver function in patients with decompensated cirrhosis.

Plan of Action

The committee believes that, “The United States has the opportunity and a responsibility to be part of the global action against hepatitis B and C.” The report is the conclusion of phase one of a two-phase study. In their second report, due out in 2017, a national strategy for HBV and HCV elimination will be detailed with methods to address the critical factors and barriers to elimination described in this report.

Barriers to Elimination

Two tables from the report, reproduced here, summarize the barriers to elimination.

The entire report can be found at the following link:  https://tinyurl.com/hf6t6nt  ■

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