Clinical Pearls & Morning Reports
Published May 22, 2019
By 2040, deaths from chronic hepatitis are projected to exceed the combined mortality associated with HIV infection, tuberculosis, and malaria. Recognizing both the advances that have been made and the continuing threat, the United Nations included the goal of combating viral hepatitis in its 2015 sustainable development goals, and in 2016, the World Health Assembly adopted the Global Health Sector Strategy on viral hepatitis that called for its elimination as a public health threat by 2030. Read the latest Review Article here.
Q: Does global elimination of chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection imply their complete eradication?
A: In global health parlance, elimination of a disease as a public health threat is a goal that falls between complete eradication and regional control. Elimination is the 2030 objective for HIV infection, tuberculosis, malaria, and viral hepatitis. For hepatitis, elimination is defined as a 90% reduction in incidence and a 65% reduction in the number of related deaths from a 2015 baseline.
Q: Are reliable epidemiologic data about viral hepatitis available?
A: Reliable epidemiologic data are a cornerstone of a public health response but are generally lacking for hepatitis. Even the core elimination outcomes for hepatitis are poorly measured. Incident HCV infection is almost never recognized, even when there is active surveillance. Likewise, hepatitis-related deaths are difficult to ascertain and are systematically underestimated.
A: In most high-income regions of the world, the major source of new HCV infections is injection drug use, which caused approximately 390,000 new cases in 2015. There are substantial challenges to reducing the incidence of HCV infection among people who inject drugs. For example, because of the opioid crisis in the United States, the national incidence of HCV infection doubled between 2010 and 2014 and continues to rise. Moreover, HCV infections are so widely distributed in rural areas that traditional means of providing conveniently located harm-reduction services are unlikely to work. Elsewhere (including some high-incidence regions), syringe-exchange services are illegal. Thus, other approaches to improving the availability or effectiveness of harm-reduction services or additional tools, such as HCV treatment or vaccination are needed. There are many challenges in diagnosing HCV infection and getting infected persons into treatment. HCV infections are generally asymptomatic. Although nearly all high-income countries recommend testing of people who inject drugs and other high-risk groups, the net effectiveness is diminished, since these groups are often not receiving care.
A: Chronic HBV infection occurs in approximately 5% of persons infected in adulthood, as compared with 90% of persons infected in infancy and approximately 50% of those infected in early childhood. Thus, the global incidence of chronic hepatitis B is largely driven by mother-to-infant and early-childhood infection, and that is the focus of the WHO elimination plan. The intervention that has had the greatest effect is expansion of so-called birth-dose HBV vaccination. HBV transmission from an infected mother is more effectively prevented when the first HBV vaccination is given to the infant within 12 to 24 hours after birth than when initially given at approximately 1 month in the pentavalent formulation. Thus, in 2009, the WHO recommended universal birth-dose HBV vaccination. However, by 2015, the practice had been implemented in only 39% of deliveries, and by July 2017, only 9 of the 47 WHO African region countries (19%) had adopted universal birth-dose vaccination. Further expansion requires reaching infants at birth, which is challenging in regions where home delivery is the custom.