Eliminating HBV, HCV 'No longer pipe dreams'

John Ward, MD

Scientists at the Task Force for Global Health recently presented an assessment of what must be done to achieve the World Health Organization (WHO) goal of eliminating hepatitis B and C virus infections as public health threats by 2030 and to prevent more than 7 million related deaths.

The report was authored by John Ward, MD, a Senior Scientist at the US Centers for Disease Control and Prevention (CDC) assigned to the task force, and Alan Hinman, MD, a Consulting Advisor for the Center for Vaccine Equity (CVE) program at the task force. The Task Force for Global Health is a nongovernmental organization based in Decatur, Georgia, with field offices in Addis Ababa, Ethiopia, and Islamabad, Pakistan.

The WHO goal targets a 90% reduction of 2015 levels in new chronic infections, to fewer than 1 million new infections per year and a 65% reduction in deaths to fewer than 500,000 deaths per year.

Alan Hinman, MD

"Despite the imprecision inherent in WHO's goals to eliminate HBV and HCV as public health threats, elimination targets are useful and have several purposes," Ward and Hinman explained.

"The goals convey a sense of urgency and increase awareness of the opportunities for improving health through HVB and HCV prevention and cure. The acceptance of numerical targets focuses program planning and promotes accountability of program operations," they wrote.

The scientists pointed out that effective interventions are available to prevent HBV and HCV transmission and premature mortality, but that the challenge is to increase their use.

The 3-dose series of the HBV vaccine has been over 95% effective in preventing infection and protecting against chronic infection for more than 30 years, for example, but vaccinating newborns, a necessary step to eliminating chronic HBV infection globally, remains elusive. In 2015, only 39% of newborns received the HBV vaccine globally.

"The integration of hepatitis B vaccination with other services provided by maternal and child programs is necessary to achieve high vaccination coverage," Ward and Hinman indicated.

Ward and Hinman anticipated that in June 2019, Gavi, the Vaccine Alliance, which supports HB vaccine purchase and administration to increase infant immunization in low-income countries, will announce whether it will extend subsidies for the vaccine to newborns. They projected that by 2020, the successful introduction of the vaccine in all 73 Gavi-eligible countries will prevent 4.8 million HBV-related deaths.

Although progress is being made toward a vaccine for HCV, in the current absence of a preventative agent, Ward and Hinman emphasized the importance of preventing blood-borne exposure, and programs that focus on high-risk populations.

"With sustained improvements in blood safety and infection control, the successful elimination of HCV transmission is contingent on the effectiveness of HCV prevention among PWIDs (persons who inject drugs)," they indicated.

Ward and Hinman related data indicating that PWIDs with adequate access to opioid substitution therapy (OST) and syringe services programs (SSPs) reduce their risk of HCV transmission by 74%. Currently, however, they found that 89% of PWID cannot obtain treatment for their addiction despite wanting to stop using drugs. They also noted that increases in HCV incidence in the US are greatest in states without SSPs.

These preventative services are also in short supply globally. In 2017, of 179 countries, only 93 and 86 reported having SSP and OST programs, respectively. Although the WHO sets a target for 2020 of 200 needle/syringe sets per PWID annually, Ward and Hinman find that current distribution is approximately 33 sets per PWID annually.

Screening and treatment programs are also lagging, they indicated, with both HBV and HCV infections under-diagnosed and under-treated. They related data indicating that, in 2015, only 22 million (9%) of HBV-infected persons had been diagnosed and only 1.7 million (8%) of those who were diagnosed received treatment. They also cited an estimate that of the 71 million persons infected with HCV globally, only 14 million (20%) have been diagnosed, and only 7% of those diagnosed received treatment.

Ward and Hinman are optimistic, however, concluding, "with sufficient capacity, national HBV and HCV elimination programs will successfully meet and ultimately exceed goals for global elimination of HBV and HCV as public health threats."

In an accompanying commentary, Harvey Alter, MD, Distinguished NIH Scientist, Emeritus, National Institutes of Health (NIH), Bethesda, MD, and Francis Chisari, MD, Professor Emeritus, The Scripps Research Institute, La Jolla, CA, observed that it is remarkable that there can now be a conversation about eliminating HBV and HCV and thereby reducing incidence of hepatocellular carcinoma.

"These are no longer pipe dreams, but complex objectives that require expansion of the global public health infrastructure and cooperation among government, industry, and philanthropies in developed and developing nations," Alter and Chisari wrote.

The paper, “What is Needed to Eliminate Hepatitis B Virus and Hepatitis C Virus as Global Health Threats,” was published in Gastroenterology.