Hepatitis C accounts for 48 percent of deaths by the liver disease worldwide. The consequences of chronic infection are liver cirrhosis and hepatocellular carcinoma, which develop in 20-30 percent of the patients. The disease can also lead to hepatic failure, need for liver transplantation, and death.
As hepatitis C is asymptomatic, it is difficult to know before a patient gets a blood test. This means that a patient can have the disease for 10 to 30 years, and suddenly realize they have the disease when suddenly diagnosed with cirrhosis or liver cancer.
However, the emergence of new drugs has made the illness one of the entirely curable diseases, and early diagnosis alone cures more than 95 percent of patients.
Encouraged by the recent development, the World Health Organization has set a goal to eradicate hepatitis C by 2030, and many countries have been coming up with plans to fight hepatitis C.
In 2016, Taiwan organized the National Hepatitis C Program Department to support the screening and treatment of hepatitis C patients. France started screening all adults for hepatitis C, despite the prevalence of disease remaining at a mere 0.42 percent in the country. In August last year, the United States also announced hepatitis C screening for all adults.
In Korea, however, a debate is still going on over including the hepatitis C antibody test in national health checkup service. Physicians have been continuously pushing the government to add the check to the health checkup service. In contrast, the government remains skeptical about it, citing low prevalence and cost-effectiveness.
To get a better grasp of why treating and eradicating hepatitis C is essential, Korea Biomedical Review contacted Professor Po-Lin Chan, a medical officer at the Division of Disease Control at WHO’s Western Pacific Regional Office.
Question: WHO has announced its plans to eliminate Hepatitis C by 2030. Could you explain a little bit more in detail why such an announcement was made?
Answer: Globally, viral hepatitis is a major public health threat. It is estimated that 257 million people worldwide are living with hepatitis B, and 71 million people are living with hepatitis C. Our reports show that an estimated 1.34 million people die from viral hepatitis every year.
Most of these deaths are due to cirrhosis and liver cancer. They are the consequence of chronic infection with hepatitis B or C.
To combat this global epidemic, the World Health Assembly adopted the resolution on viral hepatitis in 2010, recognizing viral hepatitis as a global health problem and the need for governments and populations to take action.
This was followed by the 2014 resolution calling for the member states to implement multisectoral national action plans and WHO to provide technical support to countries.
In 2016, the World Health Assembly endorsed the first-ever Global Health Sector Strategy on Viral Hepatitis (2016-2021), which calls for the elimination of viral hepatitis as a public health threat by 2030.
This call for action is aligned with the Sustainable Development Goal that calls for ending the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combating hepatitis, waterborne diseases and other communicable diseases by 2030.
Q: What is the situation in each country for the elimination of hepatitis C?
A: Each country establishes its national response to combat the hepatitis epidemic. There are major public health initiatives to eliminate hepatitis C in several high- and middle-income countries, including Australia, Egypt, Georgia, Japan, Malaysia and Mongolia.
These countries are providing universal coverage and affordable access to hepatitis C services, including testing and treatment using direct-acting antiviral drugs (DAAs), which cure more than 90 percent of those who complete the two or three months of therapy.
Q: Are there any countries that have not been doing so well in their efforts to eliminate hepatitis C?
A: There is much work yet to be done across the world to eliminate hepatitis C and countries are at different stages of implementing viral hepatitis elimination.
In 2017, only 19 percent (an estimated 13.1 million) of people living with hepatitis C knew their status globally, and only 5 million of those have been treated using DAAs.
Countries that are furthest along the path to hepatitis elimination are focusing on addressing key barriers to testing and treatment, including high prices of DAA medicines, affordability of hepatitis care and follow-up, and inclusion of hepatitis B and C care under health insurance and government financing.
They are also training of healthcare providers and ensuring excellent quality services are delivered at tertiary, secondary and primary care facilities.
Q: Are there recommendations or criteria that the WHO has published or announced in eliminating hepatitis C?
A: Elimination of hepatitis C virus (HCV) as a public health threat is defined by WHO as a 90 percent reduction of new infections and a 65 percent reduction of death due to hepatitis C by 2030 from the 2015 baseline.
To get to the elimination, a range of interventions is needed, including good infection control practices, safe injections in health and non-health settings, safe blood and transfusion services, and services that deliver good-quality testing and treatment services.
The WHO recommends countries to use DAA medicines, which can cure more than 90 percent of hepatitis C patients.
Notably, combination DAA drugs that act on all six subtypes of the HCV virus (also called ‘pan-genotypic’ regimens) are recommended so that delivery of hepatitis care can be simplified.
As part of the ‘test and treat’ approach, WHO recommends that all individuals who are confirmed to be HCV-infected are offered treatment.
Q: In Korea, hepatitis experts claim it should be included in the national screening program to combat hepatitis C. However, the government is opposing the introduction of state screenings because Korea falls short of the 5 percent prevalence rate for hepatitis C set by WHO. Do you have any opinions regarding the claim? (Reference: the prevalence of hepatitis C in Korea is less than 1 percent)
A: Countries can adapt the recommendations of WHO for testing and treatment according to their specific context and local risk factors and considerations.
In WHO’s Western Pacific region, less than 20 percent of those living with hepatitis C are diagnosed, and access treatment.
Testing is the first step to get those infected into heath treatment and care services and preventing or delaying the progression of liver disease.
WHO recommends general population testing in settings with intermediate prevalence (≥2 percent) or high prevalence (≥5 percent) of hepatitis C, and focused examination of the most affected populations in all environments.
Countries can implement a combination of approaches that will enable them to expand services toward hepatitis elimination.
Some countries are providing hepatitis C screening as part of health checkups for older people, offering to test based on the risk of infection and clinical symptoms or age. At the same time, others are offering universal testing for all adults.
Q: In South Korea, the public awareness of hepatitis C is low, and activities are being conducted to increase such awareness. Are there any activities or campaigns to improve hepatitis C awareness that the WHO recommends?
A: The World Hepatitis Day on July 28 is one of the global public health campaigns established by WHO to raise global awareness of viral hepatitis and promote prevention, diagnosis, and treatment.
In practice, countries organize national and subnational events to increase public awareness, working with a broad range of stakeholders and community actors in these activities.
Q: Finally, do you have anything to add to the Korean government, experts and the people about hepatitis C?
A: Cure of hepatitis C infection is possible with DAA drugs. More than nine out of 10 people who are infected will be cured with two to three months of treatment. This is an unprecedented opportunity to eliminate hepatitis C.
Taking action now will save lives and reduce the overall costs of healthcare due to advanced/late diseases such as cirrhosis and liver cancer, which are consequences of chronic infection with hepatitis B or C. WHO calls for public leadership in all member states to work to eliminate viral hepatitis as a public health threat by 2030.