Thursday, 25 July 2024


Eliminating Silent Killer Through Swift Actions

01 July 2024 | Analysis | By Ayesha Siddiqui

Hepatitis continues to wreak havoc globally, with the latest World Health Organization (WHO) report sounding alarms on viral hepatitis infections claiming 3,500 lives each day. The WHO estimates from 2022 reveal that 254 million people live with hepatitis B and 50 million with hepatitis C. The Asia Pacific (APAC) region is at the epicentre of this crisis, hosting the top 7 high-burden countries. Let's discuss the progress of the region towards achieving the 2030 targets for hepatitis elimination and identify what actions are needed to achieve these goals.

image credit- shutterstock

image credit- shutterstock

According to the WHO 2024 Global Hepatitis Report, viral hepatitis is on the rise and remains the second leading infectious cause of death globally, claiming 1.3 million lives annually, equivalent to tuberculosis. Ten countries account for nearly two thirds of the global burden of viral hepatitis B and C: China, India, Indonesia, Nigeria, Pakistan, Ethiopia,  Bangladesh, Vietnam, The Philippines and the Russian Federation. 

The APAC region is disproportionately affected, with 70 per cent of viral hepatitis deaths occurring here. Failure to act swiftly could lead to substantial economic losses, with projected costs of $558 billion for hepatitis B and $62 billion for hepatitis C due to illness and premature mortality, according to the Coalition for Global Hepatitis Elimination report. 

WHO has set a goal to eliminate viral hepatitis by 2030, aiming for a 90 per cent reduction in incidence and a 65 per cent reduction in mortality from hepatitis B and C. 

 

Progress so far

Most of the countries in the region have a national hepatitis elimination programme but progress remains somewhat unsatisfactory.

“Viral hepatitis has a devastating impact on South- East Asia and the Western Pacific regions, where an estimated 158 million people live with chronic hepatitis B and 16 million with chronic hepatitis C. Access to treatment for hepatitis B and C remains a challenge in many Asian countries due to cost and healthcare infrastructure limitations. Furthermore, vertical transmission (from mother to child) of hepatitis B is a major concern in the region. Such a heavy prevalence has a profound disruptive effect on society in the region. On top of causing a tragic loss of life, viral hepatitis poses a huge societal and financial burden and drives inequality,” said Benedetta Nirta, Deputy Director and Fundraising Manager at The Hepatitis Fund, Geneva.

However, several countries have shown active and systemic efforts to reach hepatitis elimination. Australia is spearheading regional efforts by focusing its national hepatitis strategy on raising awareness, enhancing access to testing and treatment, and integrating hepatitis B responses into harm reduction programmes.

“Hepatitis C cure implementation access is variable throughout the region, with the Australian government providing access DAAs (direct acting antivirals) to all people with hepatitis C, and which is being supported by the Eliminate hepatitis C Australia Partnership (EC Australia) is a four-year partnership project formed in 2018 to bring together researchers, implementation scientists, government, health services and community organisations to ensure the whole of Australia sustains high numbers of people accessing hepatitis C treatment to meet our elimination goals,” said Dr Jack Wallace, Senior Research Office, Viral Hepatitis Elimination Group, Adjunct Lecturer, Center for Social Research in Health, UNSW, Burnet Institute. His research focus for the past 15 years has been on investigating the lived experience of people with hepatitis B, and established Hepatitis Australia.

China has launched the Hepatitis C Elimination Action by 2030 as part of its ‘Healthy China 2030’ plan. The National Action Plan (2021–2030) targets health education, prevention, testing, treatment, and capacity building with 15 specific goals. Strategies include strengthening health education, enhancing prevention efforts, expanding treatment access, improving testing capabilities, and implementing supportive insurance policies. China has also updated HBV treatment guidelines and adopted a triple elimination strategy for mother-to-child transmission of HIV, syphilis, and HBV.

India launched the National Viral Hepatitis Control Program (NVHCP) in 2018 with the goal of eliminating Hepatitis C by 2030 and reducing morbidity and mortality from Hepatitis A, B, C, and E. The program provides free diagnostics and treatment for hepatitis B and C. It focuses on screening pregnant women for hepatitis B in areas with less than 80 per cent institutional delivery rates, ensuring access to birth dose hepatitis B vaccination and hepatitis B immunoglobulin as needed. Additionally, Indian Immunologicals Ltd, introduced India's first indigenous Hepatitis A vaccine, Havisure, in January this year crucial for preventing this highly contagious infection transmitted through contaminated food or water.

The government of Vietnam has shown commitment to forming a robust national response to bring down new infections and explore new ways to increase case detection, treatment, and cure to eliminate viral hepatitis by 2030. In Vietnam, an ongoing project co-funded by The Hepatitis Fund and the City of Geneva (Switzerland), has played a crucial role in advancing hepatitis elimination efforts. The project, implemented by PATH and Nghe An CDC, focuses on the triple elimination of vertical transmission—from mother to child—of HIV, hepatitis and syphilis in Nghe An province, Vietnam. The preliminary results in the second year of the project implementation are incredibly promising and have led to the approval of a provincial action plan for triple elimination. HepLINK, another project in Vietnam, fully funded by The Hepatitis Fund and implemented by PATH, engaged populations at risk of viral hepatitis in prevention, awareness raising, case detection and treatment, improved viral hepatitis outcomes and provided evidence for scaling and financing interventions that are integral to the elimination of hepatitis C and B.  The Vietnam Viral Hepatitis Alliance (V-VHA)  launched the HEAT program in Vietnam with the Coalition for Global Hepatitis Elimination and CDC's Division of Viral Hepatitis Laboratory. They're assessing hepatitis D epidemiology in Ho Chi Minh City and expanding hepatitis B and C testing and treatment nationwide. The initiative aims to scale up testing, implement effective care models, and foster a sustainable public-private partnership to eliminate viral hepatitis in Vietnam by 2030.

Benedetta highlights efforts made by other Asian countries, “Taiwan has made significant strides in tackling hepatitis C and is on track to achieve elimination by 2025. Other countries, like Indonesia and the Philippines, have seen stronger engagement and interest from policymakers in the last couple of years. Indonesia is providing free testing and treatment, while the Philippines is enhancing public education, improving screening protocols, and offering free clinical treatment. Thailand is also making similar efforts.”

 

Ending the silent killer

We have the tools such as efficacious treatments and diagnostics tests to the medical to combat viral hepatitis.  Despite this, elimination of the disease remains an elusive goal.  To achieve the WHO public health goals of eliminating viral hepatitis by 2030, we need robust public health policies, increased awareness and access to care. 

“The critical next step to addressing hepatitis elimination is to establish and strengthen care networks so health systems can reach and support patients in need. To do so requires eliminating barriers to education, testing, and treatment – we need a coordinated effort to elevate disease awareness, make testing easily accessible, and immediately link those diagnosed to care while at the same time simplifying treatment,” said Dustin Haines, Vice President and General Manager Asia, Middle East, and Turkey, Gilead, Hong Kong

In 2021, Gilead Sciences launched the biennial ALL4LIVER Grant to empower local communities in the fight against viral hepatitis. In 2023, 71 organisations received the Grant, including two non-profit organisations based in India: Chennai Liver Foundation and FIND. 

Vertical transmission (from mother to child) of hepatitis B is a major concern in the region. It is crucial to increase coverage of hepatitis B vaccination, particularly at birth, to prevent mother-to-child transmission.

“For prevention, all babies born are recommended to receive the birth dose of hepatitis B vaccine and complete the vaccine series – and 80 per cent of babies complete this recommendation in Western Pacific. To eliminate hepatitis B, this needs to be improved. Additionally, it is recommended that all pregnant women are screened and provided treatment if needed during pregnancy to prevent mother to child transmission,” said Chari A. Cohen, President, Hepatitis B Foundation, United States

One of the major roadblocks is that the majority of people with hepatitis are unaware of their condition. Only one in eight persons with hepatitis B is diagnosed, and only one in 30 receive treatment to suppress their infections. Similarly, only one in five persons with hepatitis C is diagnosed, with one in ten receiving treatment to cure their infections, says the Coalition for Global Hepatitis Elimination. 

“In terms of diagnosis, only one quarter of people in Western Pacific are diagnosed. We need large-scale efforts and funding to screen people so that everyone with hepatitis B has the opportunity for care and treatment to prevent liver cancer. However, there is a lack of funding for screening in many areas. Additionally, hepatitis B is highly stigmatised, and in many countries, people with hepatitis B face discrimination. So, in order to scale-up screening in a way that respects human rights and can be effective, we need governments to protect people who have hepatitis B from discrimination – and we need to improve awareness and normalise discussion around hepatitis B to remove stigma,” said Chari. 

Dr Wallace adds, “ Many people within the region are tested for hepatitis B through non-health services such as workplaces, educational settings and when seeking work visas. The implications of this testing means that the social impact of a hepatitis B diagnosis essentially affects people's social and familial lives and their willingness to access health services for their hepatitis B infection. Within many countries in this region, a hepatitis B diagnosis has significant social implications with stigma, discrimination affecting employment and education.”

Efforts are underway to enhance education and awareness regarding hepatitis B, combat stigma and discrimination, and increase funding and prioritisation through grassroots advocacy. These initiatives are mainly spearheaded by small nonprofit organisations, community-based groups, academic researchers, and other partners. Comprehensive public education campaigns are essential to raise awareness about hepatitis prevention, transmission, and available treatment options.

“Community engagement and multisectoral partnerships are critical components of hepatitis eradication efforts. The APAC Liver Disease Alliance, of which The Hepatitis Fund is a member, plays a crucial role by providing a neutral platform for policy discussions and advocacy campaigns. This platform allows various stakeholders, including governments, non-governmental organisations (NGOs), academia, and healthcare organisations, to collaborate and maximise the impact of their work, ultimately implementing effective strategies to eliminate hepatitis and other liver diseases,” said Benedetta.

Despite the availability of affordable generic viral hepatitis medicines, many countries struggle to procure them at reduced prices. There is a critical need to expand access to affordable and effective diagnostic and treatment options, especially in rural and underserved areas.

“In terms of treatment, hepatitis B is treated with very effective antiviral therapy that suppresses the virus and can prevent liver damage and liver cancer in most people. There are many treatment access barriers, including cost. Many people cannot afford or access treatment, which is recommended for years – if not lifelong at this point. Treatment access needs to be improved. Finally, there is no cure yet for hepatitis B. While we have effective vaccines to prevent infection, and effective treatment to help people stay healthy if they have hepatitis B, we are still seeing new infections, and much illness and death. People with hepatitis B need better treatment options, and ideally, a cure or functional cure for hepatitis B – this would look like a finite course of treatment that would significantly reduce risk of liver cancer even after treatment ends and would eliminate risk of viral transmission,” said Chari.

We possess powerful tools for preventing, diagnosing, and treating hepatitis; the challenge lies in implementing them at scale. Many barriers can be overcome with improved policies, targeted interventions, and concerted efforts from all stakeholders. Achieving the elimination goal by 2030 remains feasible if swift actions are taken now.

 

Ayesha Siddiqui

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