Committee outlines path to eliminate viral hepatitis in the US by 2030

Issue: April 2017

The National Academies of Science, Engineering and Medicine recently released phase two of its report outlining a strategy for eliminating viral hepatitis in the United States by 2030, potentially saving 90,000 lives.

“Viral hepatitis is simply not a sufficient priority in the United States,” Brian L. Strom, MD, MPH, chair of the committee and chancellor and university professor at Rutgers Biomedical and Health Sciences, Rutgers University, said in a press release. “Despite being the seventh leading cause of death in the world — and killing more people every year than HIV, road traffic accidents or diabetes — viral hepatitis accounts for less than 1% of the National Institutes of Health research budget.”

The CDC and HHS, American Association for the Study of Liver Diseases (AASLD), the Infectious Diseases Society of America (IDSA) and the National Viral Hepatitis Roundtable sponsored the report, which offers five strategic directions for the potential elimination of viral hepatitis in the country. Phase one of the report identified the feasibility of viral hepatitis elimination. WHO has a similar goal to eliminate HBV and HCV worldwide by 2030.

“Due to recent technological advances, we now have a unique opportunity to eliminate these terrible and underappreciated diseases as public health problems,” Strom told Infectious Disease News. “This report gives a roadmap of how to accomplish that.”

Collecting data

Eliminating viral hepatitis in the U.S. will require accurate measurement of the national disease burden. Standardized screening, follow-up, monitoring and linkage to care of all viral hepatitis cases reported through public health surveillance as well as understanding the epidemiology of viral hepatitis in high-risk populations are necessary.

The committee recommends a “central coordinating office” at the highest level of federal government to oversee the national effort to eliminate viral hepatitis. They also suggest that the CDC work with the National Cancer Institute to attach viral etiology to reports of liver cancer in its periodic national reports, and support cross-sectional and cohort studies in high-risk populations.

Interventions

Necessary interventions to eliminate viral hepatitis that were mentioned in the report include expanding access to adult HBV vaccination, providing early testing for HBV viremia to help determine the best course of treatment for pregnant women who are HBsAg–positive, expanded access to syringe exchange and opioid agonist therapy for high-risk patients, and eliminating restrictions that are not medically indicated for the use of direct-acting antivirals for all chronic HCV patients.

Although increased screening could place a burden on the health care system, any measure that sheds light on the subclinical burden of HBV and HCV infection would benefit society and aid in the elimination of these diseases, according to the committee.

Providing service

Patients most affected by HBV and HCV are often the most difficult to reach. The authors of the report suggest that HHS work with states to offer care and support services for special populations with viral hepatitis “on the scale of the Ryan White system.”

A significant barrier to care for some patients is that they are required to be treated by a specialist. Consequently, the report recommends that AASLD and IDSA partner with primary care providers and their professional organizations to develop a referral system for medically complex patients.

In addition, incarcerated people are heavily affected by viral hepatitis. The committee points out that the criminal justice system has an opportunity to screen, vaccinate and treat patients to reduce the burden of HBV and HCV.

Eliminating financial barriers

Direct-acting antivirals (DAAs) are responsible for a significant decrease in HCV cases, but they are expensive. As none of the approved DAAs will come off patent before 2029, inability to access this treatment may result in tens of thousands of deaths and billions of dollars wasted in medical costs, according to the report. The committee recommends that the federal government purchase the rights to DAAs for use in neglected market segments, such as Medicaid, the Indian Health Service and prisons. This could be done through the licensing or assigning of a patent in a voluntary transaction with an innovator pharmaceutical company, according to the report.

Research

Further research into immune response and curative therapies for chronic HBV and HCV would aid the goal of eliminating viral hepatitis in the U.S. by 2030. Research should also focus on stigma alleviation, understanding of drug users’ networks, and incarcerated patients, the committee said.

“Elimination of hepatitis B and C as U.S. public health problems is possible if the strategy outlined in the committee’s report were implemented. Improvements in testing, diagnosis and care, as well as increased preventive measures and focused research, are possible, but they will require the cooperation of various federal and state government agencies, professional societies, legislators and private sector organizations,” the authors wrote. “The committee provides a path toward mitigating these problems, avoiding about 90,000 deaths by 2030.” – by Talitha Bennett

References:
National Academies of Sciences, Engineering, and Medicine. A national strategy for the elimination of hepatitis B and C: Phase two report. http://www.nationalacademies.org/hmd/reports/2017/national-strategy-for-the-elimination-of-hepatitis-b-and-c.aspx. Accessed March 30, 2017.
WHO. Combating hepatitis B and C to reach elimination by 2030. Advocacy brief. http://www.who.int/hepatitis/publications/hep-elimination-by-2030-brief/en/. Accessed March 30, 2017.

Disclosure: Infectious Disease News was unable to confirm relevant financial disclosures at the time of publication.