As WHO drafts its global health strategies, a need to reconsider viral hepatitis response

The World Health Organization recently announced that it was seeking input on the three global health sector strategies — HIV and AIDS, viral hepatitis and sexually transmitted infection — it was drafting until April 30. The strategies, which will cover 2016-2021, will be finalized at the 69th World Health Assembly in 2016.

Among the three health issues, viral hepatitis has arguably received the least attention. According to Jennifer Johnston, executive director of the Coalition to Eradicate Viral Hepatitis in Asia Pacific, viral hepatitis is the eighth highest cause of mortality around the world, causing around 1.4 million deaths from acute infection and hepatitis-related liver cancer and cirrhosis every year. It is a toll comparable to that of HIV and tuberculosis, and yet funding to combat viral hepatitis has significantly paled.

In the most recent report on donor funding for global health released by the University of Washington’s Institute for Health Metrics and Evaluation, viral hepatitis is not included among the diseases that donors have addressed.

More recently, at the Global Fund to Fight AIDS, Tuberculosis and Malaria’s 32nd board meeting held last November, the Global Fund stated that while it has received a number of requests from countries for hepatitis C treatment financing and it has given some support for hepatitis C treatment under its Technical Review Panel, it has “not specifically considered the question of funding for hepatitis C nor the broader question of financing for other co-infections and co-morbidities of the three diseases.”

Hepatitis B incidence is even higher than that of hepatitis C — despite the introduction of a hepatitis B vaccine in 1982. There is currently no vaccine for hepatitis C.

“Hepatitis B is very contagious — it is 100 times more virulent than HIV, while hepatitis C is 10 times more virulent than HIV,” Johnston told Devex.

‘Incidence has fallen dramatically’ but more needs to be done

In Asia, where the global hepatitis burden is the highest, national immunization programs have lowered hepatitis B incidence, but low public awareness of viral hepatitis and minimal investments in monitoring, screening, diagnosing and providing care for those with viral hepatitis have blunted the impact of these efforts.

“Though the vaccine was available in the 1980s, many countries have been slow to incorporate it in their vaccine schedules and, in particular, to incorporate the birth dose, which is what helps prevent maternal transmission,” Charles Gore, president of the World Hepatitis Alliance, told Devex.

Johnston pointed out that it was not until the 1990s when many Asian countries introduced national immunization programs.

“This means that a large proportion of the population are currently unvaccinated, and could pass the virus on if they do not know of their infection,” she said.

Johnston noted that, in the latest WHO hepatitis policy survey, only eight out of 26 Asia-Pacific countries that responded said that they have a government unit dedicated to hepatitis prevention and control.

In China alone, 93 million people are living with chronic hepatitis B. This translates to a prevalence of less than 8 percent, “which is not unusual for Asia,” according to Gore.

“Incidence has fallen dramatically, but China is still left with the huge problem of preventing a significant proportion of the already infected from dying from cirrhosis and liver cancer, which can only be done by greatly increasing access to anti-viral drugs,” he said.

While remarkable reductions of cases have occurred among people under 20 years old, for those older than 20, “up to 10 percent have a chronic hepatitis B infection and remain at risk of liver disease, including cancer,” Johnston said.

A combination of factors has contributed to hepatitis B’s persistence in China.

“Poor awareness of the infection among people living with the virus means that they are not receiving the treatment they need, a situation that is compounded by poor, inaccurate knowledge among the wider community that manifests in stigma and discrimination,” Johnston said.

Still, knowledge of one’s infection does not always guarantee that a person will seek treatment. Given the high costs and poor reimbursement of medical services in China, those with hepatitis B are often deterred from properly managing their infection. Compounding these problems is the lack of capacity of primary health care professionals to screen for hepatitis B, Johnston added.

“These factors need to be addressed through a broader hepatitis policy that does not simply focus on infant immunization, but also attends to monitoring, diagnosis, treatment, care and public education, turning what is currently a specialist health care service into a strategic public health response,” she said.

Guidelines, regional action plans first steps to meet targets

Even with China excluded, hepatitis B prevalence in Asia-Pacific is still the highest. Johnston pointed out that in the western Pacific, most countries have hepatitis B infection rates that exceed 6 percent of the adult population. Gore did say that the region, which hit its 2012 target of lowering hepatitis B incidence in children to below 2 percent and is now even eyeing a less than 1 percent target in 2017, actually leads the world in curbing hepatitis B incidence.

But even he conceded that the success of the western Pacific in suppressing hepatitis B cases “unfortunately does little for those already infected.”

Dr. Nick Walsh, medical officer for viral hepatitis at the WHO Regional Office for the Western Pacific, noted that regional action plans can complement the WHO global strategy for viral hepatitis.

“Currently we have drafted a Regional Hepatitis Action Plan for the Western Pacific and will be engaging in consultations with countries and stakeholders in the coming months,” he told Devex.

Last month, WHO published its first guidelines for the prevention, care and treatment for those living with chronic hepatitis B infection. The guidelines are an initial step toward reaching the ambitious and yet achievable targets that need to be included in the WHO’s viral hepatitis strategy.

The Lancet Infectious Diseases Inaugural Summit, which will be held April 10-12 in Shanghai, China, will be the first time that viral hepatitis will take center stage in cancer discussions.

“Liver cancer is the second most common cause of cancer death in the world, and approximately 60 percent to 80 percent of hepatocellular carcinoma [the most common type of liver cancer], is caused by chronic hepatitis B virus infection that is contracted in early childhood,” Johnston said.

What are your thoughts on the seemingly low attention the global health community has given toward addressing viral hepatitis? Let us know by leaving a comment below.

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