Researchers Aim to Eliminate Hepatitis B and C as a Public Health Problem in the United States

On April 11, 2016, the the National Academies of Sciences, Engineering, and Medicine released the first of two reports, which outlines the goals of a 2-phase study that aims to eliminate HBV and HCV as a public health problem in the United States. A ‘public health problem’ is described in the report as, “a disease that commands attention as a major threat to the health of the community.” The elimination of HBV and HCV as a public health problem “would mean ending their transmission in the U.S., and for the infections that remain, preventing their undesirable signs and symptoms entirely.”

Since complete elimination of these diseases will take considerable time and resources, and will require overcoming many barriers, the researchers hope to first reduce the number of current and new HBV and HCV cases and prevent further deaths related to the two types of hepatitis.

Background on HBV and HCV

According to the Centers for Disease Control and Prevention (CDC), the most common types of hepatitis in the United States are Hepatitis A (HAV), Hepatitis B (HBV), and Hepatitis C (HCV). The National Academies report states that there are between 700,000 and 1.4 million Americans battling chronic HBV, and between 2.5 million and 4.7 million Americans with chronic HCV. Around 20,000 Americans die of chronic HBV and HCV every year in the United States.

HBV Treatment

HBV can be transmitted through unprotected sex with an infected partner, contact with contaminated blood, or from mother to child. Chronic HBV patients require lifelong medical monitoring.

In March 2015, the World Health Organization (WHO) released the first Guidelines for The Prevention, Care and Treatment of Persons with Chronic Hepatitis B Infection. The guidelines outline recommendations on who to treat, length of treatment, and when to stop treatment. WHO recommends that nucleos(t)ide analogues (NAs) tenofovir and entecavir be administered to adults, adolescents, and children 12 years of age and older, since they have a high barrier to drug resistance. Other NAs, such as lamivudine, adefovir or telbivudine are not recommended, since they can lead to drug resistance in patients.

According to the report, these therapies do not completely cure the disease, but rather they slow the progression of the disease and prevent death from cirrhosis and liver cancer.

HCV Treatment

In April 2014, WHO released treatment guidelines entitled, Guidelines for The Screening, Care and Treatment of Persons with Hepatitis C Infection. These guidelines state that the combination of pegylated interferon and ribavirin was seen as the best treatment option for HCV, with similar success rates in children as in adults. However, it was noted that in areas where access to medication might be limited, it is preferred to give priority to those with advanced fibrosis and cirrhosis.

These guidelines were updated in April 2016 to include the most recent HCV medications, as well as updated treatment regimens that account for HCV genotype and the patient’s clinical history.

According to the National Academies report, new direct-acting antiviral (DAAs) drugs have the potential of curing HCV in 8 to 12 weeks, and are successful in 94 to 99% of patients. This treatment can also lower the risk of developing liver cirrhosis and liver cancer in HCV patients, however, treatment is costly.

As with HBV, HCV can be transmitted through direct contact with the blood of an individual who harbors the disease. Although infection can be transferred from mother to child, and from an infected individual to another person through sexual contact, these methods of transmission are less likely to occur.

Charitha Gowda, MD, MPH, infectious diseases physician at Penn Presbyterian Medical Center discusses the preferred treatment method for hepatitis C.

Elimination of HBV

The National Academies researchers aim to eliminate HBV and HCV by terminating the transmission of the disease from infected to non-infected individuals and preventing signs and symptoms among infected individuals.

According to the study committee, HBV elimination can be accomplished through universal vaccination, where all populations at high risk of contracting HBV are vaccinated for the disease before infection occurs. As such, they suggest routine vaccines be administered to individuals in prisons or sexually transmitted disease clinics around the country. Furthermore, vertically transmitted HBV infections can be avoided through early detection and the administration of an HBV vaccine at birth. Present HBV vaccines are 95% effective.

Elimination of HCV

Unlike HBV, most HCV prevention is targeted at injection drug users since they have the highest probability of spreading the disease. The National Academies report notes that 3 methods of action are possible for targeting these individuals:

1. Curing injection drug users of HCV
2. Creating needle exchange programs so that users are not subjected to using contaminated needles
3. Treating injection drug users for substance abuse, which would lower the number of possible infections

The report notes that reducing the prevalence of HCV among this population can lower infections from 20% to 80%, however, this is not without complications as there is difficulty in reaching this population.

Eliminating HCV will require tackling the disease in its early stages as well as reversing advanced stages. Although there is a cure for HCV, medication costs are between $54,000 to $168,000, and therefore, private insurance companies and Medicaid have restricted drug access to only the sickest of patients.

Due to a recent funding increase from Congress, however, all US veterans will be treated for HCV, regardless of the stage of infection.

Barriers to Eliminating HBV and HCV

The National Academies report identifies many barriers hindering the elimination of HBV and HCV as public health problems in the United States:

1. Some infections go unnoticed since viral symptoms only present at later stages of infection.
2. Not all states have the proper funding needed for hepatitis surveillance, without which health officials cannot identify which populations are at highest risk of contracting the diseases.
3. Many infected individuals do not seek medical care out of fear or shame.
4. HBV and HCV prevalence is high in foreign-born nationals, who may not be able to access proper health care due to: Language barriers Social barriers Not qualifying for Medicaid
5. HBV and HCV prevalence is also high among underprivileged and less educated populations who may also be using contaminated needles in drug injection.
6. Prisoners are among the highest risk population for HCV, however treatment is expensive and resources to carry out treatment regimens are scarce.

Charitha Gowda, MD MPH, infectious diseases physician at Penn Presbyterian Medical Center, explains barriers to HCV treatment.

The National Academies study was sponsored by the CDC Office of Viral Hepatitis and the U.S. Department of Health and Human Services Office of Minority Health. The strategies needed to meet the study’s goals will be published in a second report in early 2017.