Causing more than 1.4 million deaths each year, the burden of viral hepatitis is becoming impossible to ignore. The World Health Assembly has acknowledged that most people with hepatitis B or C are unaware that they are infected. What can be done to improve diagnosis of this disease? Abi Millar talks to Mark Thursz, professor of hepatology at Imperial College London.
Fifteen years ago, 189 governments across the world signed up to the United Nations’ Millennium Development Goals. Alongside poverty, hunger and child mortality, the nations turned their attentions to infectious diseases. Specifically, they pledged to halt the spread of HIV / AIDS, malaria and tuberculosis by 2015.
While these diseases still present a major global health burden, it is fair to say significant progress has been made. TB rates are falling slowly, we have seen a wide scale reduction in malaria incidence and mortality, and deaths from HIV / AIDS plummeted from 1.7 million in 2005 to 1.3 million in 2013. All three have benefitted from dedicated financing, strong public health programmes and collaboration from governments across the world.
Unfortunately, the situation is not so encouraging for viral hepatitis, which was ignored altogether by the Millennium Development Goals. Despite similar mortality rates, this chronic liver condition has historically tended to slip under the radar. Until 2008, not a single person at the World Health Organization was tasked with dealing with hepatitis specifically.
“We’ve had viral hepatitis for millennia and people have just lived with its consequences,” says Mark Thursz, professor of hepatology at Imperial College London. “There are fewer people infected with HIV worldwide, but because that came along and was so devastating so quickly, it became a global health priority. Viral hepatitis has never reached that level of prominence.”
This low profile belies its virulence. A 2014 study in The Lancet showed that while other communicable conditions have declined, deaths from viral hepatitis increased by 50% between 1990 and 2010. Today, the condition kills over 1.4 million people per year, making it the world’s leading cause of death from infectious diseases.
The situation may sound inexplicable at first glance – how, in an era of concerted disease prevention, has a deadly infection been able to rise so sharply while garnering so little public awareness? – but it is clear that times are changing. As the disease burden becomes impossible to ignore, the global health community is starting to take note.
In 2010, following lobbying from the World Hepatitis Alliance and patient groups, the World Health Assembly signed its first resolution on viral hepatitis B and C. Emphasising the need for global coordinated action, the resolution officially recognised the scale of the pandemic.
Four years later, the World Health Assembly agreed on a second, stronger resolution, which compels the United Nations member states to act with urgency. The report expressed concern ‘that preventative measures are not universally implemented and that equitable access to… diagnostics and treatment regimens for both hepatitis B and C are lacking in many parts of the world, particularly in developing countries’.
Certainly, we should not underestimate the magnitude of the task ahead. While the viruses can lead to liver cirrhosis and cancer, hepatitis B and C are asymptomatic in the majority of patients. This means most sufferers have no idea they are infected, and the long-term consequences are apt to arise by stealth.
In addition to his work in a London clinic, Thursz conducts research both in the UK and in sub-Saharan Africa. This gives him a window into the problems faced by hepatitis sufferers in the developing world.
“In sub-Saharan Africa, virtually nobody is diagnosed with chronic hepatitis B or C infection – it’s not high up on people’s awareness and there are no governmental treatment programmes,” he explains. “But at a reasonable estimate, 1 in 12 of the global population have had hepatitis B or C, so there are 500 million people chronically infected.’
“If viral hepatitis is responsible for death, it’s usually through decompensated cirrhosis, or liver cancer, which in sub-Saharan Africa is the number one male cancer in adults. Most people there will know somebody who has died of liver cancer, without necessarily being aware of why they got it.”
While hepatitis B and C are often grouped together, the two are distinct viruses with their own routes of transmission. Broadly speaking, hepatitis C is spread through direct contact with the blood of an infected person, whereas hepatitis B may also be spread through other bodily fluids.
“In Western countries, transmission of hepatitis C is usually through intravenous drug use, then occasionally things like tattoos and occasional lapses in infection control measures,” says Thursz. “At my clinic, we also see a lot of people who come from countries with a high prevalence of infection, which will almost invariably be transmission through medical procedures. With hepatitis B, depending on what region of the world you’re from, a proportion will be mother to child transmission, and the rest is horizontal transmission.”
The viruses also need to be tackled in different ways. While both are eminently treatable and preventable if the right procedures are followed, hepatitis C has a cure but no vaccine, and hepatitis B has a vaccine but no cure.
The hepatitis B vaccine, which first became available in 1981, has slashed rates of infection in the developed world. In the US, for instance, acute hepatitis infection (often a precursor to chronic infection) has declined by 82% since the introduction of routine vaccinations for children. Currently, the World Health Organization estimates that around 79% of children are inoculated worldwide.
Thursz believes that while it would theoretically be possible to eliminate hepatitis B within a sensible time period, current efforts will need to be scaled up significantly.
“While the vaccine is already beginning to have some impact on the prevalence of infection in young people, what’s missing is delivering vaccines to the children of mothers who are infected, to prevent neonatal infection,” says Thursz. “And then if you really want to have a quick impact on the morbidity and mortality associated with hepatitis B, you need to do screening and treatment.”
With hepatitis C, the potential is even clearer – new drugs have been introduced that can eliminate the virus altogether. Approved by the FDA in 2014, the direct-acting antivirals sofosbuvir and ledipasvir have been show to cure over 90% of patients within 12 weeks. Hepatitis B treatments, by contrast, only suppress the viral load and therefore need to be taken for life.
So given these pharmaceutical solutions, why is hepatitis proving such a headache to eradicate? The first and most obvious reason is poor awareness among healthcare professionals, and therefore low rates of diagnosis. Over the next few years, we are likely to see attempts to tighten up infection control practices, alongside some major pilot projects to demonstrate the effectiveness of screening.
A second, and perhaps more intractable, reason is funding. Because hepatitis has never received the funds allocated to HIV, TB and malaria, many developing countries lack the resources they need to allocate treatments.
“In sub-Saharan Africa, HIV patients may well be treated with three drugs including tenofovir, which is active against both HIV and hepatitis B,” says Thursz. “If you have HIV, you’ll get those drugs free – they’ll be paid for by the Global Fund or Medecins Sans Frontiers or some other global donor – and you can basically live a normal lifespan on antiviral therapy. But if you’ve got hepatitis B, they can’t give you that tenofovir, even if you go along to a clinic with end-stage liver disease. We’ve seen a patient who was denied tenofovir until he was able to contract HIV.”
This situation, patently ridiculous, highlights what needs to happen next: the creation of an equivalent global fund that will provide antiviral therapy for hepatitis B and C. Once hepatitis achieves the same level of prominence as other major communicable diseases, it is likely that we will see screening, prevention and treatment efforts to match.
With the original Millennium Development Goals set to conclude at the end of this year, the post-2015 development agenda is currently under discussion. If viral hepatitis is once again omitted, this is likely to prove a major setback for professionals working in the field. If it is included, however, that will expedite the changes in attitude that are taking place throughout the global healthcare community.
After all, despite their present morbidity, hepatitis B and C are highly manageable infections in theory. And while realistic about the challenges that lie in store, Thursz does not believe we should give up hope.
“We either need to change the politics of the global fund donors, or we need to set up a new hepatitis fund in order for those treatments to become available,” he says. “Will it be happening soon? No. Will it happen in the future? Yes.”
This article appears in the Spring 2015 edition of Practical Patient Care