Why countries can’t wait to act on viral hepatitis elimination

In 2016, the World Health Assembly adopted a global action plan for viral hepatitis elimination by 2030. On World Hepatitis Day 2021, amidst the COVID-19 pandemic, we look at the progress and opportunities to meet the target by 2030. With one person dying every 30 seconds from viral hepatitis related illnesses, ‘Hepatitis Can’t Wait’.

The COVID-19 pandemic has displayed with great gravity that unhinged transmission of infectious diseases have the capacity to drastically reduce the years of healthy life lived and devastate the global economy. Elimination of viral hepatitis continues to be possible with the commitment of political will and increases of investment towards the global target.

The current burden of viral hepatitis is difficult to quantify. The Global Burden of Disease study reported that viral hepatitis accounted for 1.45 million deaths in 2013, a 63% increase from 1990 (2). There are five main types of viral hepatitis — hepatitis A to E — all with different transmission routes and often delayed disease progression, making it difficult to accurately estimate the impact of viral hepatitis, and thus to foster investment in the global elimination strategy (3).

Combined, hepatitis B and C are among the top four infectious disease killers alongside tuberculosis, malaria, and HIV (4). The mortality attributable to viral hepatitis, unfortunately, is only half of the story. In more than half of cases, hepatitis B and C become chronic conditions without treatment, leading to the development of liver cancer and cirrhosis. WHO estimates that 325 million people are living with hepatitis B and C infections, adding staggeringly to impaired quality of life and the loss of work productivity globally.

In 2015, only 38% of children were administered a birth dose of the hepatitis B vaccine on time to prevent mother-to-child transmission (2). When looking at coverage of the 3rd dose of hepatitis B vaccine in the same year, 82% of children were covered globally — a good achievement but not yet meeting the 90% target of the elimination strategy (2). With the transmission of hepatitis B occurring primarily during birth from mother-to-child or early childhood infection, there is an urgent need to speed up vaccination.

Approximately only 8–18% of people infected with hepatitis B and C are diagnosed, with a lower proportion linked to treatment (3). WHO estimates that over 80% of people living with hepatitis are lacking prevention, testing, and treatment services (5). During the COVID-19 pandemic where screening and vaccination services for a range of diseases have been delayed or halted, this number is likely to increase (6). With the risk of mother-to-child transmission of hepatitis B and new treatments for hepatitis C being curative and more affordable, there is a moral imperative to increase viral hepatitis screening to avoid new cases developing and get existing patients the care they need.

The COVID-19 pandemic has diverted resources from scaling up viral hepatitis screening and vaccination in many countries and the economic losses due to the pandemic will make it difficult to raise new funding commitments towards viral hepatitis elimination in the immediate term (3).

Currently, countries are investing large sums to strengthen coronavirus disease surveillance and vaccination efforts, health care systems, and collaborations between all levels of healthcare workers. These advances, hopefully, be applied to other diseases — including viral hepatitis — when the end of the pandemic is in sight.

While achieving the 2030 viral hepatitis elimination goal seems unlikely in the wake of the COVID-19 pandemic, efforts should not be thwarted for eventual viral hepatitis elimination. The current health crisis should provide all stakeholders with an understanding of the importance of investment in healthcare systems and the fast-tracking of universal health coverage. Attainment of these advances will bring great progress in increasing the global prevention, testing, and treatment services for viral hepatitis (3).

Achieving the viral hepatitis elimination target will require several developments including 1) policies for the adoption and scale-up of hepatitis B birth doses including support from GAVI; 2) political will to implement national plans for viral hepatitis prevention, screening, and treatment in LMICs; and 3) support from global donors to implement these national plans in LMICs. In the time of shrinking health budgets and limited donor assistance for health, countries and global health groups looking to drive towards the viral elimination target should consider the formation of public-private partnerships to unlock capital and reach the goal. While the upfront political and financial investments for viral hepatitis elimination appear high, they have the capacity to cross‐cutting benefits to the global economy including saving lives, reducing years lived with disease and disability, and savings in healthcare spending for patients and national departments of health.

[1] World Health Organization. World Hepatitis day 2021. Available online at https://www.who.int/campaigns/world-hepatitis-day/2021

[2] GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 385: 117–71

[3] Wiktor SZ and Hutin YJF. The global burden of viral hepatitis: better estimates to guide hepatitis elimination efforts. Lancet 2016; 388: 1081.

[4] Cox, A.L., El-Sayed, M.H., Kao, JH. et al. Progress towards elimination goals for viral hepatitis. Nat Rev Gastroenterol Hepatol 17, 533–542 (2020).

[5] World Health Organization. Health topics — Hepatitis. Available online at https://www.who.int/health-topics/hepatitis#tab=tab_1

[6] Brammer CA, Kimmins LM, Swanson, et al. Decline in Child Vaccination Coverage During the COVID-19 Pandemic. MMWR Morbidity and Mortality Weekly Report 2020; 69. 630–631.