In terms of global killers, hepatitis now trumps HIV and equals tuberculosis. According to a new report, released on Friday by the World Health Organization (WHO), an estimated 1.34 million people died from hepatitis B and C in 2015, and about 325 million people are currently living with these infections. The numbers encompass a mix of trends in recent years—some increases, some decreases—but are particularly disconcerting because these viral illnesses are both preventable and treatable. Yet there is reason to be optimistic that the tide of these infectious and fatal diseases could now be forced to recede.
Hepatitis B (HBV) and C (HCV) are two distinct viruses, both of which colonize the liver. Babies born in countries with high rates of HBV are particularly at risk for the disease: Infected mothers can transmit the pathogen to infants during birth. Sex and needle-sharing are also common routes for the virus to travel. HBV can live outside the body for up to seven days, so touching dried blood containing the virus—an easily imagined hospital scenario—could result in infection.
HCV also finds dirty needles particularly conducive for moving from one host to another. After conquering the globe primarily along slave trade routes through the 18th century, the virus settled into hitching rides through unsterilized needles used for medical purposes and illegal drug injections.
Both HBV and HCV share the frustrating trait of silence: People who become infected may not know they are playing host to a contagious disease for decades. And when the virus does make itself known, whether through the liver damage disease known as cirrhosis or through liver cancer, the disease is too advanced for treatment to be of any use.
Last May, the WHO called for the elimination of viral hepatitis by 2030, as part of the Agenda for Sustainable Development. Reaching that goal requires a 90 percent reduction in new infections and a 65 percent reduction in deaths from these diseases at current levels. How to eliminate hepatitis is clear, but whether hepatitis will be eliminated is not.
A vaccine for HBV has been available since 1982, and the Centers for Disease Control and Prevention began recommending universal infant immunization in 1991. Some countries have included the HBV vaccine in routine immunizations since the early 1980s; others started doing so only in the 2000s. According to the new WHO report, 84 percent of children born in 2015 received the three recommended doses of the HBV vaccine. And since the vaccine was introduced (the timing varies by country), the proportion of children younger than five who have become infected fell from 4.7 percent to 1.3 percent. However, only about one-third of children worldwide are receiving the first dose of the vaccine at birth, leaving a window of risk that allows for new infections.
Addressing HBV requires not just the prevention of new infections, but also the treatment of current ones. Most of the 257 million people currently living with the disease are adults who became infected before the vaccine was available. Nearly half of the HBV population lives in a region of the world that the WHO calls “western Pacific,” which includes Australia and China. Sixty million people across Africa are infected with the virus.
Treatment rates for HBV are currently too low to eradicate the disease. Part of the problem is that most people with the disease don’t know they have it. Only 22 million people infected with the virus—9 percent of the HBV population—have received a medical diagnosis. Without a diagnosis, there’s no treatment. And without treatment, there’s no stopping the continued spread of the disease. Access to care is also problematic. Hepatitis B can be controlled with tenofovir, a drug also used to treat HIV. But in 2015, only 8 percent of people diagnosed with HBV were treating their disease.
No vaccine exists for hepatitis C. The disease is caused by a virus that mutates extremely fast. Immunizing bodies against a future infection has so far proven impossible, since the part of the viral genome that guides replication inside of a new host is a constantly moving target. But HCV is now curable. Decades of research finally led to drugs, available since 2013, that completely push the virus out of the body. About three months of daily treatment with one of these “direct-acting antivirals” leaves a person virus-free. These medications are notoriously expensive, but after a public outcry its manufacturers have agreed to reduce prices in low-income countries. In some countries, the WHO report notes, a full course of the medication now costs $200 (compared to about $80,000 in the United States). But the WHO found that in 2015, only 7 percent of people diagnosed with HCV had started treatment.
Risks of Needles
In other words, these diseases are preventable but not prevented; curable but not cured. Why?
One problem is the continued use of unsterilized needles by health-care workers—a cause that is surprising since it has been recognized for so long. Egypt became the country with the world’s highest rate of hepatitis C because of a public health effort to treat schistosomiasis, a parasite living in the Nile, using an injected medication that ended up spreading hepatitis C through villages along the riverbank. But despite the well-known dangers of reusing needles, the practice persists. In 2010, unsterilized needles led to 315,000 new HCV and 1.6 million new HBV infections. Katherine Gibney, an infectious disease physician at the Doherty Institute at Royal Melbourne Hospital, says health-care workers aren’t being trained properly. And, she says, “better funded health-care services are required to overcome this issue.” She points to the eastern Mediterranean region, which includes Egypt, as particularly needing such improvements.
Laith Abu-Raddad, professor of health policy and research and an infectious disease epidemiologist at Weill Cornell Medical College in Qatar, says that governments must improve efforts to halt these diseases in both Egypt and Pakistan, where HCV rates are also high. “We have the tools to largely eliminate this infection within a decade or so,” says Abu-Raddad, but “the public health response continues to lag.” Starting in 2014, the curative treatment for hepatitis C has been free for people between the ages of 18 and 70. But if the use of unsterilized needles persists, new infections will of course continue. He hopes that health-care workers in Egypt and Pakistan will begin using Smart Syringes, single-use needles that the WHO says should be used by health-care workers worldwide. Such attention is needed globally. Africa and the eastern Mediterranean carry the highest burden of HBV cases, but Europe is heavily infested with hepatitis C. And the raging opioid epidemic is also sickening people with HCV in the United States.
But even if every medical facility in the world was spick-and-span and used only sterilized needles, the viruses would still persist. That’s because injection-drug use is a major risk factor, and drug users typically do not have open access to clean needles. Providing sterile paraphernalia to drug users could help, says Gibney. “This kind of harm reduction is a scientifically proven health intervention that works and saves lives,” she says. “Authorities need to be encouraged to make good public health decisions based on evidence, not ideology.” In other words, withholding clean needles from drug users on the basis of opposing drug use is standing in the way of eradicating hepatitis.
So are cultural attitudes toward drug users, says Suzanne Wait, a managing director of The Health Policy Partnership, a consulting group. “Stigma and discrimination related to having hepatitis are a particular concern,” she says. Because these diseases are common among injection-drug users, getting tested for the disease is akin to acknowledging drug abuse. And many people with drug dependency could find adhering to medical care difficult. Patients not only need testing, says Wait, but also follow-up to ensure they are receiving proper care.
Despite these barriers, the WHO report strikes an optimistic note about reaching the 2030 eradication goal because vaccine and treatment services are, on average, improving. That improvement is partly due to the long-delayed acknowledgment of these diseases. “The world has only recently expressed its alarm about the burden of viral hepatitis,” writes WHO Director-General Margaret Chan in the new report. Others are less certain. “Deaths due to hepatitis B and C will continue to increase,” says Gibney, “until treatment is available to the millions of people who need it.”
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