Securing wider EU commitment to the elimination of hepatitis C virus

In 2016, the Hepatitis B and C Public Policy Association (HepBCPPA), gathered all the main stakeholders in the field of hepatitis C virus (HCV) to launch the now landmark HCV Elimination Manifesto, calling for the elimination of HCV in the EU by 2030. Since then, many European countries have made progress towards HCV elimination. Multiple programmes—from the municipality level to the EU level—were launched, resulting in an overall decrease in viremic HCV infections and liver-related mortality. However, as of 2021, most countries are not on track to reach the 2030 HCV elimination targets set by the WHO. Moreover, the COVID-19 pandemic has resulted in a decrease in HCV diagnoses and fewer direct-acting antiviral treatment initiations in 2020. Diagnostic and therapeutic tools to easily diagnose and treat chronic HCV infection are now well established. Treating all patients with chronic HCV infection is more cost-saving than treating and caring for patients with liver-related complications, decompensated cirrhosis or hepatocellular carcinoma. It is more important than ever to reinforce and scale-up action towards HCV elimination. Yet, efforts urgently need the dedicated commitment of policymakers at all governmental and policy levels. Therefore, the third EU Policy Summit, held in March 2021, featured EU parliamentarians and other key decision makers to promote dialogue and take strides towards securing wider EU commitment to advance and achieve HCV elimination by 2030. We have summarized the key action points and reported the ‘Call-to-Action’ statement supported by all the major relevant European associations in the field.     

Changing epidemiology of parenterally transmitted viral hepatitis: results from the hepatitis surveillance system in Italy

Background. In 1991, compulsory hepatitis B virus vaccination and screening for anti-hepatitis C virus of blood banks were introduced in Italy.

Aim. To evaluate the impact of preventive measures on the incidence and risk factors for parenterally transmitted viral hepatitis.

Methods. Data from the surveillance system for acute viral hepatitis for the period 1985–1999 were used. Temporal trends in distribution of reported risk factors were analysed by comparing three-year periods: 1987–1989 and 1997–1999.

Results. The incidence fno. cases per 100, 000 population) of hepatitis B was 12 in 1985 and 3 in 1999; the incidence of hepatitis nonA, non-B decreased from 5 to 1 in the same period. These decreases were more evident among young adults and before rather than after 1991. Multiple sexual partners, other parenteral exposures and dental treatment remain the most common risk factors for parenterally transmitted viral hepatitis. An increase in frequency over time was observed for other parenteral exposures, whereas a marked decrease was evident for blood transfusion and household contact with an HB-sAg carrier. Invasive medical procedures continue to represent an important source of infection. Intravenous drug use was reported particularly by young adults with non A, non-B hepatitis, with increased frequency over time.

Conclusions. Non-immunologic measures for preventing hepatitis B and non A, non B due to iatrogenic and other parenteral exposures, combined with hepatitis B virus vaccination, could further reduce parenteral transmission.     

Forgotten,not neglected: viral hepatitis in resource‐limited settings,recall for action

In 2010, the World Health Assembly adopted a resolution calling for interventions for the prevention and control of chronic viral hepatitis. These infectious diseases mostly affect resource‐limited countries accounting for 80% of the world's population and facing numerous obstacles to contain the epidemic. At a time when morbidity and mortality of chronic liver disease have been considerably improved in wealthy countries by new innovative strategies and new potent antiviral drugs, it is now urgent to recall for concrete actions from stakeholders of global health policy to reduce the burden in resource‐limited countries.     

Toward elimination and eradication of hepatitis B

Hepatitis B virus (HBV) causes important human health problems. It has infected one-third of the world's population and approximately 360 million people are chronic carriers. Worldwide, 0.5–1.2 million deaths are attributed to HBV infection annually. Therefore, global control of HBV infection is important. HBV infection can be intervened by interrupting routes of transmission, treating the chronically infected, and preventing the susceptibles with immunoprophylaxis. All these measures are effective. Nevertheless, although pegylated interferons or nucleos(t)ide analogs are effective for the treatment of chronic hepatitis B, chronic carriage of HBV is not easy to eliminate, as revealed by the frequent persistence of hepatitis B surface antigen, despite satisfactory responses to these treatments. On the other hand, hepatitis B vaccination has been shown to preclude HBV infection effectively. This is particularly true for pre-exposure prophylaxis. Worthy of note is the universal vaccination of newborn infants. This is the most effective means of preventing HBV infection, especially for those born to HBV carrier mothers. To eliminate and eradicate hepatitis B, first, HBV in the chronically infected should be eradicated or strongly and efficiently suppressed, so that the infection does not spread rampantly. Second, all the transmission routes should be interrupted. Lastly, but most effectively, is to immunize all susceptibles. The difficulties and possible solutions of each approach are discussed. In conclusion, the existing means to prevent and treat HBV infection render our goal toward eliminating and eradicating hepatitis B possible, although it will take much time and effort to achieve this objective.     

Advances in viral hepatitis: 50 years of Australian gastroenterology

Viral hepatitis classification, treatments and pathogenesis has been increasingly defined over the past 50 years. Australian researchers have made significant contributions in the areas of viral hepatitis A vaccine development, treatment outcomes for chronic hepatitis B and C, the role of liver transplantation and the pathogenesis of injury and disease progression. This review outlines some of these contributions.     

Liver transplantation for acute and chronic viral hepatitis

Summary. Hepatotrophic viruses are responsible for a substantial proportion of cases of both end-stage chronic liver disease and of acute liver failure which are treated by liver transplantation. We review here current practice in transplantation for viral-induced liver disease addressing, in particular, the selection of patients for transplantation and the increasingly recognized problem of recurrent disease in liver grafts.     

Innovative strategies for the elimination of viral hepatitis at a national level: A country case series

Viral hepatitis is a leading cause of morbidity and mortality worldwide, but has long been neglected by national and international policymakers. Recent modelling studies suggest that investing in the global elimination of viral hepatitis is feasible and cost‐effective. In 2016, all 194 member states of the World Health Organization endorsed the goal to eliminate viral hepatitis as a public health threat by 2030, but complex systemic and social realities hamper implementation efforts. This paper presents eight case studies from a diverse range of countries that have invested in responses to viral hepatitis and adopted innovative approaches to tackle their respective epidemics. Based on an investment framework developed to build a global investment case for the elimination of viral hepatitis by 2030, national activities and key enablers are highlighted that showcase the feasibility and impact of concerted hepatitis responses across a range of settings, with different levels of available resources and infrastructural development. These case studies demonstrate the utility of taking a multipronged, public health approach to: (a) evidence‐gathering and planning; (b) implementation; and (c) integration of viral hepatitis services into the Agenda for Sustainable Development. They provide models for planning, investment and implementation strategies for other countries facing similar challenges and resource constraints.     

Hepatitis C elimination among people who inject drugs: Challenges and recommendations for action within a health systems framework

The burden of hepatitis C infection is considerable among people who inject drugs (PWID), with an estimated prevalence of 39%, representing an estimated 6.1 million people who have recently injected drugs living with hepatitis C infection. As such, PWID are a priority population for enhancing prevention, testing, linkage to care, treatment and follow‐up care in order to meet World Health Organization (WHO) hepatitis C elimination goals by 2030. There are many barriers to enhancing hepatitis C prevention and care among PWID including poor global coverage of harm reduction services, restrictive drug policies and criminalization of drug use, poor access to health services, low hepatitis C testing, linkage to care and treatment, restrictions for accessing DAA therapy, and the lack of national strategies and government investment to support WHO elimination goals. On 5 September 2017, the International Network of Hepatitis in Substance Users (INHSU) held a roundtable panel of international experts to discuss remaining challenges and future priorities for action from a health systems perspective. The WHO health systems framework comprises six core components: service delivery, health workforce, health information systems, medical procurement, health systems financing, and leadership and governance. Communication has been proposed as a seventh key element which promotes the central role of affected community engagement. This review paper presents recommended strategies for eliminating hepatitis C as a major public health threat among PWID and outlines future priorities for action within a health systems framework.     

A global investment framework for the elimination of hepatitis B

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Prevention of viral hepatitis (B and C) reassessed

As hepatitis B and C viruses share modes of transmission, their combined occurrence is not uncommon, particularly in areas where both viruses are endemic and in individuals at high-risk of parenteral infection. Both viral hepatitis infections form an important global public health problem, responsible for over half a billion chronic infections worldwide.Their distinctive characteristics impact upon their epidemiology and transmission, and the success of the different prevention strategies.For several decades safe and effective vaccines have been available to prevent HBV infection. Universal vaccination is the cornerstone of global HBV control. Despite major success, vaccine uptake is hampered, and increasing efforts are required to eliminate acute and chronic hepatitis B. Unlike hepatitis C and HIV, HBV has not captured sufficient attention from policymakers, advocacy groups or the general public: a major challenge for the future.Although progress has been made in the development of an HCV vaccine, short-term successes are not expected. Even without a vaccine, successes can be reported in the field of hepatitis C due to e.g. implementation of universal precaution measures in health-care settings, screening of blood and blood products, and identification and counselling of infected people. Despite significant efforts, HCV transmission in injecting drug users is increasing.

• despite the availability and widespread use of effective hepatitis B vaccines, efforts are required to optimise uptake of the vaccine in universal and risk group immunisation programs

• because the development of a hepatitis C vaccine has not yet been successful, prevention and control measures are the major challenge to all those involved in public health

• screening for HBV and/or HCV should be followed by adequate management of positive patients, including counselling, referral, and possible treatment if available

• nosocomial transmission of viral hepatitis can and should be prevented by reinforcing and maintaining blood donor selection and screening procedures, strict adherence to universal safety measures in health-care settings, and thorough evaluation and communication of nosocomial infections

• immigrants should be socially fully integrated, including access to health services, to control the epidemic spread of imported infections

• the HBV and HCV epidemic among IDUs needs to be controlled by continuous educational programs for the general public and health professionals, accessible substance abuse treatment and rehabilitation programs (including outreach to homeless and socially excluded users), implementation/reinforcement of harm-reduction programs, HBV testing and vaccination of non-immune IDUs, and HCV testing and treatment in correctional facilities

• the possibility and benefits of HCV treatment should be established; adequate treatment can reduce the reservoir of chronic carriers, thereby diminishing transmission

• to make sure that HBV vaccination does not lose its place on the agenda of governments, agencies, and international organizations, as a consequence of its success so far and the interest in other vaccine-preventable diseases

• to further investigate the long-term protection after HBV vaccination and the role of cell-mediated immunity

• to assess the impact of HBIG in perinatal transmission and its possible effect on the immune response later in life

• to measure the impact of globalisation and international migration on the incidence of new hepatitis B cases

• to better understand the role of HBV genotypes in transmission, natural history and treatment

• to continue research on the treatment of (acute) HBV cases

• to improve/optimise HBV surveillance and to quantify the impact of HBV mutants.

• good surveillance data for HCV are absent in many regions of the world, and consequently there are gaps in our understanding of incidence, risk factors, transmission, and disease progression

• improvements in assays and/or testing algorithms for hepatitis C are required to optimise surveillance data

• development of hepatitis C vaccines is needed

• more insight into HCV immunology and cross-protection is required

• there is a need to measure the impact of globalisation and international migration on the incidence of new hepatitis B and C cases

Report from the International Symposium on viral hepatitis, 24–25 October 1997, Warsaw, Poland

The authors present the results of an International Symposium on 'Viral Hepatitis', held in Warsaw on 24–25 October 1997 and dedicated to the scientific activity of Professor Adam Nowoslawski, the founder of the Polish school of Immunopathology, with many contributions to the viral hepatitis research. The symposium was divided into main sessions and poster reports which covered most of the topics in this field. This successful meeting has gathered many distinguished speakers from different countries and was attended by ca. 350 participants, mainly from Poland, but also from the neighbouring countries.     

Testing to sustain hepatitis C elimination targets in people who inject drugs: A network-based model

Little is known about the level of testing required to sustain elimination of hepatitis C (HCV), once achieved. In this study, we model the testing coverage required to maintain HCV elimination in an injecting network of people who inject drugs (PWID). We test the hypothesis that network-based strategies are a superior approach to deliver testing. We created a dynamic injecting network structure connecting 689 PWID based on empirical data. The primary outcome was the testing coverage required per month to maintain prevalence at the elimination threshold over 5 years. We compared four testing strategies. Without any testing or treatment provision, the prevalence of HCV increased from the elimination threshold (11.68%) to a mean of 25.4% (SD 2.96%) over the 5-year period. To maintain elimination with random testing, on average, 4.96% (SD 0.83%) of the injecting network needs to be tested per month. However, with a ‘bring your friends’ strategy, this was reduced to 3.79% (SD 0.64%) of the network (p < .001). The addition of contact tracing improved the efficiency of both strategies. In conclusion, we report that network-based approaches to testing such as ‘bring a friend’ initiatives and contact tracing lower the level of testing coverage required to maintain elimination.     

Barriers faced by migrants in accessing healthcare for viral hepatitis infection

Background: The morbidity and mortality of hepatitis B virus‐ and hepatitis C virus‐related complications are disproportionately higher in the culturally and linguistically diverse population (CALD) when compared with Australian‐born individuals. Aim: This project aims to elucidate the barriers faced by the CALD population in accessing viral hepatitis management. Method: CALD outpatients attending a viral hepatitis clinic in a tertiary teaching hospital were invited to participate in interviews. Questions pertained to: reason for screening for viral hepatitis, barriers to healthcare, perceived community view of viral hepatitis, main source of information of viral hepatitis and suggestions to engage members of CALD to seek healthcare. Results: The total number of participants was 60. The two major countries of birth included China (40%) and Egypt (17%). In 40% of the cohort, viral hepatitis was identified through screening programmes. Importantly, 37% were diagnosed as a result of complications of hepatitis infection, presenting late in the stage of disease. Forty‐five per cent of participants perceived language to be a chief barrier. twenty‐two per cent reported cultural barriers to accessing healthcare. Of these, 53% reported fear of discrimination/stigma. The lack of knowledge of available treatments/options was stated as a major obstacle in 40%. The two prevailing recommendations were greater education and awareness (85%) and changes in the health system itself (11%). Conclusion: Substantial hurdles identified by participants include cultural differences, language difficulties, cultural beliefs, stigma and misinformation. These data demonstrate the need for the greater dissemination of information in culturally and linguistically appropriate mediums to raise awareness about viral hepatitis, pathogenesis and available treatments.     

血清HGVRNA阳性病毒性肝炎94例研究

目的分析血清HGVRNA阳性病毒性肝炎的临床特点。方法全部病例入院后即检测血清AB，C，D，E型肝炎病毒标志及肝功能试验，抗-HGV采用ELISA法，HGVRNA采用RT-PCR法，均由302医院免疫室统一检测．结果在94例血清HGVRNA阳性患者中，单纯HGV感染（单纯感染组）18例，HGV合并其他肝炎病毒感染（合并感染组）76例，单纯感染组中以急性肝炎为主（61．1％），合并感染组以HBV＋HGV感染最多，占引例（5．3％）．51例中，以慢性肝炎（41．2％）及肝硬变（37．2％）为主，单纯HGV感染临床可表现为急、慢性肝炎及重型肝炎，其中，急性肝炎临床特点为：消化道症状较轻：半数以上有轻-中度黄疸，也可有重度黄疸者；ALT轻度增高；全部病例恢复顺利，合并感染组病情恢复也较顺利．11例重型肝炎，生存率45．4％．HGV与HBV合并感染者中，住院期间，HBsAg阴转率24．0％，HBeAg阴转率62．5％，HBVDNA阴转率55．6％结论单纯HGV感染以急性肝炎为主，亦可见于慢性肝炎及重型肝炎，合并感染级以慢性肝炎及肝硬变为主，并分析各自临床特点HGV与HBV合并感染时，对HBV可能有抑制作用.     

Australian Liver Association (ALA) expert consensus recommendations for the use of transient elastography in chronic viral hepatitis

Since the introduction of Transient Elastography (TE) into Australia in 2008, non‐invasive liver fibrosis assessments have integrated themselves into clinical hepatology. The Australian Liver Association (ALA) recognizes these technologies perform an important role in the assessment of chronic viral hepatitis B and C. However, in the setting of viral hepatitis and many other chronic liver diseases, there remains no consensus or guidelines regarding the performance, utility or reporting of TE. Accordingly, the ALA sought to produce an expert consensus statement for the use of TE in chronic viral hepatitis. The recommendations incorporated in this document are based upon a thorough literature review and draw on extensive clinical experience using TE. The initial draft was presented at Australian Gastroenterology Week (AGW) 2013. Through a collaborative process and expert external review a finalized document was presented at AGW 2014.     

Treatment as Prevention for Hepatitis C (TraP Hep C) – a nationwide elimination programme in Iceland using direct‐acting antiviral agents

A nationwide programme for the treatment of all patients infected with hepatitis C virus (HCV) was launched in Iceland in January 2016. By providing universal access to direct‐acting antiviral agents to the entire patient population, the two key aims of the project were to (i) offer a cure to patients and thus reduce the long‐term sequelae of chronic hepatitis C, and (ii) to reduce domestic incidence of HCV in the population by 80% prior to the WHO goal of HCV elimination by the year 2030. An important part of the programme is that vast majority of cases will be treated within 36 months from the launch of the project, during 2016–2018. Emphasis is placed on early case finding and treatment of patients at high risk for transmitting HCV, that is people who inject drugs (PWID), as well as patients with advanced liver disease. In addition to treatment scale‐up, the project also entails intensification of harm reduction efforts, improved access to diagnostic tests, as well as educational campaigns to curtail spread, facilitate early detection and improve linkage to care. With these efforts, Iceland is anticipated to achieve the WHO hepatitis C elimination goals well before 2030. This article describes the background and organization of this project. Clinical trial number: NCT02647879.