The World Health Organization has recently initiated a global health strategy, which will run between 2016 and 2021, to eliminate hepatitis C as a global public health threat by 2030. Specific targets will include reducing the number of new infections each year by 70% to around 1 million and cutting the fatality rate by 60%.
In a study published recently by the journal Clinical Microbiology and Infection, Lanini et al.[if !supportFootnotes][ii][endif] explore the global challenges ahead and the interventional strategies available to meet them successfully.
“One of the core elements of a global control programme against hepatitis C will be the new direct acting antiviral (DAA) drugs. These are extremely effective, with short- duration oral treatment courses achieving cure rates in excess of 90%,” explains senior author Giuseppe Ippolito (National Institute for Infectious Diseases Lazzaro Spallanzani-IRCCS, Rome, Italy).
Clinical trials have now shown that a combination therapy of the nucleotide analogue inhibitors NS5B and NS5A leads to complete viral clearance in 85-100% of people who are living with HCV. Encouragingly, this occurs across all HCV genotypes and, the access to therapy is not precluded to patients with advanced stage of liver disease or whether other treatments have failed due to viral resistance and other factors.
Prevention, however, is always better than cure and so another major strategy will be to limit the rate of infection in healthcare settings through increased screening of donated blood for viral contamination and a substantial reduction in unsafe injections. Data shows that these challenges arise mainly in countries such as Nigeria, Gabon, Egypt and India but outbreaks of hepatitis C infection in Europe due to unsafe medical practices are not unheard of. An example of iatrogenic transmission of HVC was reported as recently as 2008 in Spain.[if !supportFootnotes][iii][endif]
Beyond that, it will be vital to increase implementation of primary prevention measures. As well as improving safety in healthcare in low to middle income countries, this will also involve reducing transmission within high-risk populations in high-income countries such as intravenous drug users and prisoners.
One of the main challenges will be to ensure that the people with the greatest need are targeted effectively. “We have effective treatments in the form of DAAs but, currently, these are neither affordable or accessible in many low and middle income countries,” cautions Ippolito. “Global pressure will be required to encourage generic competition to reduce the cost of medicines and diagnostics. This could include direct price negotiations with the pharmaceutical companies responsible for DAA manufacture, differential pricing and voluntary licences,” he adds.
Other action points for the WHO global health strategy against HCV will include:
- Collecting more accurate surveillance data to enable prioritisation of resources.
- Vastly increased coverage of prevention programmes to limit blood-borne transmission.
- Increasing access to simple and reliable diagnostic tests and services. In Egypt, for example, although a high-profile treatment programme is in place, fewer than 4% of the population at risk of chronic HCV infection can access testing.
- Expansion of public health programmes across the board in high, middle and low income countries.
- Increased national awareness of the health threat posed by hepatitis C, new national strategies for control and designated budgets to achieve goals.
Without concerted effort worldwide, the 2030 goals seem huge but successful public health programmes have already achieved similarly massive objectives – HIV being a prime example. “The global response to HCV and other infectious diseases control can learn from the innovative HIV service delivery approaches that have already been used successfully in marginalized and vulnerable populations across the world,” concludes Ippolito.
Hepatitis C virus (HCV) is a single strained RNA virus that is the main cause of non-A and non-B hepatitis.
Although acute infection with HCV is generally mild and seldom asymptomatic up to 80% infected individuals cannot clear the virus and develop a lifelong chronic infection. This leads to progressive liver damage that, if untreated, can lead to cirrhosis, liver cancer and death.
Having been infected with HCV once does not provide any long-term immunity, so reinfection after virus clearance and super infection with multiple HCV strain can occur.
The lack of immunity to HCV, and the fact that the virus has 7 genotypes and 67 subtypes (at least) has made developing a vaccine difficult.
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[i] Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015: 386; 743-800. doi: 10.1016/S0140-6736(15)60692-4
[ii] Lanini S, Easterbook PJ, Zumla, A, Ippolito, G. Hepatitis C: Global epidemiology and strategies for control. Clinical Microbiology and Infection. 2016: doi: 10.1016/ j.cmi.2016.07.035
[iii] Martínez-Bauer, E. et al. Hospital admission is a relevant source of hepatitis C virus acquisition in Spain. J. Hepatol. 48, 20–27 (2008).