global update on hepatitis elimination
TRANSCRIPT
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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/
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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
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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%)
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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
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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
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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
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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
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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