The United States can end hepatitis B and C transmission and prevent related morbidity and mortality given enough time, resources, and will to surmount a variety of barriers, according to a new report from the National Academies of Sciences, Engineering, and Medicine.
A more feasible short-term goal is to control viral hepatitis by reducing the incidence and prevalence of hepatitis B (HBV) and C virus (HCV) infections, states the report, which is the first of a two-phase study. The second part, to be published in early 2017, will outline a strategy to achieve the goals.
“Disease elimination” once meant stopping all new infections in a population, but eliminating a public health problem “can be a less absolute goal,” Dr. Brian Strom, chancellor of Rutgers Biomedical and Health Sciences, wrote along with his associates. “The WHO has accepted a non-zero target in its work against viral hepatitis,” they added. “The organization’s provisional target is a 90% reduction in incidence, and a 65% reduction in mortality by 2030.”
Furthermore, those are global targets – countries should base their own strategies on their specific viral hepatitis disease burdens and epidemiologic features, Dr. Strom and his associates emphasized. For example, universal vaccination could eradicate HBV in the United States in two generations, but there is no cure for the 700,000-1.4 million Americans who are already infected. Mother-to-child HBV transmission is rare here, but better screening and surveillance could help prevent the 800-1,000 cases of vertical transmission that still occur annually.
More than a third of newborns in the United States do not receive the HBV vaccination on the day they are born, and 28% remain unvaccinated when they are 3 days old, “but childhood catch-up is possible,” the experts also wrote. Vaccinating adults is more complicated, but targeting high-risk groups such as prison inmates or patients at sexually transmitted disease clinics might work, they added. Vaccination is especially important, because chronically infected HBV patients need lifelong medical follow-up to prevent progression and death from cirrhosis and liver cancer, they emphasized.
The hepatitis C virus presents a different picture – there is no HCV vaccine, while the novel direct-acting antivirals can theoretically cure nearly all chronic infections. But in reality, high drug costs and the massive burden of undiagnosed HCV mean that only a small fraction of patients can be cured, the authors acknowledged. On an individual basis, the benefits of direct-acting antivirals outweigh the costs of treating genotype 1 HCV and associated morbidity, they add. But on a population level, “eliminating HCV infection would require near universal access to treatment, something that appears infeasible given the current pricing and policy environment.”
Several other barriers also impede progress against HBV and HCV. For example, only five states and two large cities receive enough funding for comprehensive viral hepatitis surveillance, Dr. Strom and his associates noted. If local and state public health departments cannot track infections, they cannot characterize their epidemics. In addition, viral hepatitis remains a source of stigma, adding to fear and avoidance of testing and undermining elimination efforts. Stigma, avoidance, and the fact that HBV and HCV are asymptomatic in the early stages all contribute to a large population of chronically infected patients who do not know their status.
Moreover, many state Medicaid programs will not cover foreigners until they have lived in the United States for 5 years, and the Affordable Care Act does not cover care for short-term residents and undocumented immigrants, the report stated. Newly infected HCV patients tend to have fewer resources, lower educational levels, and more often use injection drugs, making them harder to reach and screen through the health system. “Prisons are a promising venue in which to treat HCV, but treating HCV is expensive for the prison system. The cost of the direct-acting antivirals is high, and the staff time required to manage an inmate in treatment often far exceed the available resources,” the report stated.
The study was sponsored by the Centers for Disease Control and Prevention Office of Viral Hepatitis and the U.S. Department of Health and Human Services Office of Minority Health. The authors disclosed no conflicts of interest.