World Hepatitis Day 2013: This is hepatitis. Know it. Confront it.

Journal of Infectious Diseases

By John Ward, MD

On the 28th of July, countries around the globe will commemorate the third annual World Hepatitis Day. One of only eight health campaigns recognized by the World Health Organization, this health observance raises awareness of the silent yet growing epidemic of viral hepatitis worldwide. Globally, each year, 1.4 million persons lose their life to viral hepatitis (as reported in the Global Burden of Disease Study 2010), approaching the number of deaths from HIV/AIDS (1.5 million) and surpassing mortality from tuberculosis and malaria (1.2 million each).

Deaths from viral hepatitis are caused by one of five hepatitis viruses. Hepatitis A and hepatitis E, which spread through person-to-person contact and contaminated food or water, are major causes of acute hepatitis, particularly in areas of the developing world suffering from poor hygiene. Hepatitis B virus (HBV) and hepatitis C virus (HCV) cause chronic infection that can result in liver disease and death. Hepatitis D requires hepatitis B for replication, and co-infection with both viruses increases the risk of severe liver disease. Worldwide, 240 million people have chronic hepatitis B infection, and 180 million are living with hepatitis C.

Hepatitis B vaccination has been a profound and enduring achievement in prevention of viral hepatitis. Since 1982, more than one billion doses of hepatitis B vaccine have been administered worldwide, preventing an estimated 3.7 million deaths. Because HBV can be transmitted from mother to child at birth, vaccinating newborns, preferably within 24 hours of delivery, can prevent 85% of HBV infections transmitted from infected mothers to their children. Unfortunately, several barriers prevent universal provision of a birth dose of hepatitis B vaccine globally, including education of healthcare workers, timely access to newborns delivered at home, and lack of coordination between immunization and maternal and child health care providers. As a result of these obstacles, as few as one in four infants worldwide receive hepatitis B vaccine within 24 hours of birth. However, in China, which shoulders 50% of the global burden of hepatitis B mortality, these challenges have been overcome through increasing the number of infants born in birthing facilities and through obstetrical staff acceptance of the responsibility to vaccinate newborns against hepatitis B. As a result, birth dose coverage increased from 40% in 1992-1997 to 74% in 2002-2005 (Vaccine. 2010 Aug 23;28(37):5973-8).

The benefits of vaccination will soon be joined by the benefits of viral hepatitis care and treatment particularly for hepatitis C. Effective, oral antiviral medications are now available to treat chronic HBV infection; 90% of HBV patients treated with one of these antivirals achieve viral suppression. Although a vaccine for hepatitis C remains elusive, antiviral therapies for HCV play a critical role in preventing disease progression and can lead to virologic cure. New all-oral therapeutic options anticipated for the near future are expected to require shorter durations of treatment (e.g. 12-24 weeks rather than the current 24-48 week regimens), improve rates of viral clearance, and cause fewer serious adverse events. The benefits associated with medical management and therapy can only be realized when persons with chronic viral hepatitis infections are identified through testing and linked to needed care. Unfortunately, barriers to viral hepatitis testing and referral persist worldwide. They include a low level of HBV- and HCV-related knowledge among the public and providers, inadequate screening policies, the affordability of treatment, inequitable access to care for marginalized populations, and limitations in health infrastructure that compromise testing and disease surveillance. As a result, many if not most persons infected with HBV or HCV are unaware of their infection, and a smaller proportion of infected persons receive proper care and treatment.

Timely changes in national policies can elicit significant changes in the way countries approach viral hepatitis prevention and control. For instance, to reflect current hepatitis C epidemiology, HCV testing recommendations were recently expanded in the United States. In 2013, CDC and the US Preventive Services Task Force called for both risk-based screening and one-time screening of persons born from 1945 through 1965, among whom the burden of HCV infection is highest. The new recommendations are expected to improve identification of people living with chronic HCV infection and enhance linkage to care and treatment for those found to be infected.

These recommendations must be accompanied by improvements in care and treatment. For example, professional training regarding viral hepatitis can be improved and best practices for delivering these services identified. Further, countries can expand laboratory capacity to include appropriate diagnostics (e.g. laboratory-based or point-of-care tests) and virologic supplemental testing to confirm current infection and quantify viral load. Policy directives also can highlight opportunities for cost-effective integration of services, including incorporating HCV and HBV prevention and care services into other services and encouraging the use of telemedicine to expand access to testing, care, and treatment.

The global burden of viral hepatitis is tremendous. With new opportunities for improved viral hepatitis prevention and control coming to light worldwide, increased communication and collaboration between policymakers, community organizations, providers, and the public will become even more critical to overcoming significant barriers to prevention and control. Annual commemoration of World Hepatitis Day creates an impetus for such collaboration by raising viral hepatitis awareness and eliciting the actions needed to prevent new infections and improve health outcomes for those already infected.

John Ward, MD, is Director of the CDC’s Division of Viral Hepatitis and Clinical Assistant Professor at Emory University School of Medicine.

To raise awareness of World Hepatitis Day, the editors of Clinical Infectious Diseases and the Journal of Infectious Diseases have highlighted recent, topical articles, which have been made freely available throughout the month of August in a World Hepatitis Day Virtual Issue. Oxford University Press publishes the Journal of Infectious Diseases and Clinical Infectious Diseases on behalf of the HIV Medicine Association and the Infectious Diseases Society of America (IDSA).