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

Acknowledgement

This chapter was written with the input of several experts within the Viral Hepatitis Prevention Board (www.vhpb.org).