Global Update on Hepatitis Elimination

NIH Webinar Series

John W Ward, MD Task Force for Global Health

Rollins School of Public Health Emory University, Atlanta GA, USA

Source: WHO; Institute of Health Metrics and Evaluation Progress report on HIV, viral hepatitis and sexually transmitted infections, 2019

257 M

555,487

1.1 M

71 M

542,316

1.7 M

People living with HBV

Number of HBV-related deaths, 2019

Annual number of new HBV infectionsMajor risks- chronic HBV Perinatal Tm - 90% Horizontal Tm 30-50%

People living with HCV

Number of HCV-related deaths, 2019

Annual number of new HCV infectionsMajor risk: parenteral exposures Health care or community (e.g. persons who inject drugs)Other – ( e.g., perinatal)

Burden of HBV and HCV Globally

Without action by 2040, deaths from HCV will surpass TB, HIV, and malaria

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

2005 2010 2016 2040

TB HIV Malaria HBV and HCV HBV HCV

HBV and HCV

HCV 

Source: WHO Global Hepatitis Progress Report 2018

Top 20 countries represent 81% of global HBV-related deaths in 2019

0

50,000

100,000

150,000

200,000

250,000

Tota

l Dea

ths

AFRO EMRO EURO PAHO SEARO WPRO

Top 20 countries:30% SEARO25% WPRO15% AFRO10% EURO10% EMRO 10% PAHO

0

20,000

40,000

60,000

80,000

100,000

Tota

l D

eath

s

Top 20 countries represent 76% of global HCV-related deaths in 2019

AFRO EMRO EURO PAHO SEARO WPRO

Top 20 countries:25% SEARO25% WPRO25% EURO15% PAHO10% EMRO 10% AFRO

Hepatitis B Vaccination Averted 22 Million Deaths from 2000-2019 and Potential of 38 Million Deaths by 2030

 M 20 M 40 M 60 M 80 M

Measles

Hepatitis B

Yellow Fever

HPV

Hib

PCV

Rota

MenA

JE

Rubella

Deaths Averted by Vaccines 2000‐2019 and 2020‐2030 

2000‐2019 2020‐2030Li X, et al Lancet 2021;39:398-408.

Achievement of Interim 2020 Goal Global < 1.0 prevalence among children < 5 yrs.

Strategies to Eliminate Mother to Child Transmission of HBV ( < 0.1% Prevalence among Children < 5 years of age)

(43% coverage, 75% efficacy)

• Increase global HepB Birth dose coverage to 90%• Only 10% coverage in African region

• Implement HBsAg screening of pregnant women• If HBsAg+, HBV DNA or other virologic testing

• Improve prevention of perinatal transmission • Infant hepatitis B immune globulin < 12 hrs. of birth• Maternal antiviral prophylaxis as recommended

• Link with HIV and syphilis in “ Triple Elimination Strategies”

WHO 2020 https://www.who.int/publications/i/item/978-92-4-000270-8

Persons Who Inject Drugs

Global burden of HCV infection 11.8 million (50%) PWID 1.5M (15%) incarcerated persons

16Source: Larney S, Lancet Glob Health. 2017, Vikerman P, Addiction 2017, Cooke G, Lancet GastroenterolHepatol 2019; 4:135-184

Prevention Benefits 70% decreased risk with harm reduction (drug

treatment and syringe services) 90% prevention with addition of HCV treatment

Challenges Poor access to prevention Current global coverage: 33 vs. recommended >

200 needle/syringe exchanges per PWID/ yr.

Opportunities HCV vaccine would improve prevention

effectiveness

Hepatitis is a Health Disparity for Migrant Populations

Proportion of Migrants Comprising HBsAg+ Populations in EU countries

Ahmed AA, BMC Infect Dis. 2018; 18: 34.; Odimayo M, Clin Liver Dis 2020, Mohammed Ali, personal communication

Migrants- European Union Internally displaced persons- Nigeria Rohingya Refugees- Bangladesh

• 1–1.9 million migrants with chronic HepB

• 25% of all HBsAg+ persons in the EU

• Large differences by country

• 3000 IDPs, Edo State, mean age 18.5 yrs.

• HBsAg+ • 15.9% IDPs

• 9.9.-11.2%, general population

• HBsAg+ IDPs were not vaccinated

• > ~1 million refugees from Myanmar

• Anti-HCV

• 10.65% Refugees

• 0.53-1.3%, host country

Sources – WHO (Center for Disease Analysis )

HBV 257 millionGlobal: Diagnosed 10%; On treatment 2% HCV 71 million

Global: Diagnosed: 19%; Treated 5 million

HBV and HCV are Under-Diagnosed and Under-Treated Infections

Progress report on HIV, viral hepatitis and sexually transmitted infections 2019 http://www.who.int/hepatitis/publications/

Liang TJ, Hepatology 2015; Lok A, Hepatology 2015; http://apps.who.int/hiv/amds/price/hdd/Default0.aspx

Current therapy- Long term viral suppressive therapy

Benefits • Reduced risk of liver cancer- 50% • Reduced risk of all cause mortality- 40%• Relatively safe, inexpensive (<$450/yr. generic global)• ~ 20% of patients exceed HBV DNA threshold for treatment

Limitations • Access to affordable HBV DNA monitoring • Access to long term care in resource constrained settings

Research for a functional cure• Loss of HBsAg • Simplify care with finite duration of therapy • Halt liver fibrosis and progression to HCC

Treatment of Chronic HBV infection

62% of Persons with HCV Live in Countries with Access to HCV Medication < $150

Ward J Gastroenterology 2019; Chhatwal J, unpublished data, Who Global Hepatitis Report 2017

One-several pills/day for 8-12 weeks > 90% cure

Reduced risk of liver cancer (80%) and all –cause mortality (75%)

Challenges of Scaling-up HBV and HCV Testing

Source: Ward J. Gastroenterology (2019); FIND and CHAI. HCV Diagnostics Market Intelligence Report (2017).

HCV testing bottlenecks

Algorithm

Utilization

Cost

Technology

│ 21

• HCV anti-HCV (exposure) + PCR or cAg (HCV detection) • HBsAg (active infection) + HBV DNA or HB e antigen • Capacity- laboratory and/or point of clinical care options • Lack of testing policies •• Lost- to-follow during testing and care

• Often unaffordable costs (up to $200 per test) particularly for PCR testing

• Research priorities • Simplification- e.g. single test to diagnose HCV infection• Affordability: e.g., Point-of-care test or lab-based test <$2

More than Two of Three Deaths from Primary Liver Cancer Deaths are Attributable to HBV and HCV infection

https://www.globalhep.org/;

HBV 40% of liver cancer Median survival of 10.3 months

• HCC screening improves early detection increasing survival • < 20% of eligible patients receive screening • New serologic options are needed

Singal. J Gen Intern Med. 2012 Jul; 27(7):861-7. Singal A. Aliment Pharmacol Ther. 2009 Jul; 30(1):37-47; Singal A. Clin Gastroenterol Hepatol . 2015 Nov;13(12):2140-51

HCV 29% of liver cancer Median survival of 8.3 months

Countries Are Starting to Eliminate HCV

Egypt

• In 2008, HCV prevalence 6% (8M); highest globally

• In 2018, national campaign to test persons 18-59 yrs. • Key features: affordable tests/medicines, health

promotion• Tested 42 M persons; 2.2. M HCV+ 92% treated; 98%

cured

India

• National hepatitis elimination plan• Model HCV program in Punjab (2.6% HCV prevalence)• Testing all adults in 25 medical centers, prisons • 163,000 tested; 85,000 treated; 93% cured of HCV

Rwanda

• Estimate HCV prevalence 4%-5%• Set out a 5-year national elimination plan• Integrate HCV with HIV test and treat centers • Test > 6 million persons; diagnose/ treat 300,000 HCV+

Australia• Government committed to unlimited HCV therapy • Simplified models of care developed• Within 3 years; 33% treated; 20% decline in HCV deaths

│ 23

The 2020 Nobel Prize for Discovery of Hepatitis C Virus

24

“For the first time in history, the disease can now be cured, raising hopes of eradicating Hepatitis C virus from the world population” -Nobel Committee

HCV discovery made possible accurate tests and curative therapies

Science is not an end but a means to achieve a greater purpose.Harvey Alter Michael Houghton Charlie Rice

Dr. Ward with Dr. Alter and CDC virologist Dr. Dan Bradley

25th anniversary of HCV discovery, 2014

Summary• HBV and HCV are major causes of liver cancer and mortality

• HBV and HCV elimination goals are feasible and cost-effective

• Hepatitis prevention has averted millions of premature deaths

• Model programs demonstrate how to scale up effective elimination programs

• Research can improve technologies and implementation strategies that advance progress toward hepatitis elimination