World Hepatitis Day 2015 - Focusing on Prevention

~Written by Theresa Majesty (Contact: theresa.majeski@gmail.com; Twitter: @theresamajeski)

The World Health Organization (WHO) states that approximately 1.5 million people die each year from the various types of hepatitis caused by hepatitis viruses A, B, C, D, and E. It is estimated that half a billion people worldwide are infected with hepatitis B or C virus, the strains responsible for the majority of cases of liver cirrhosis and liver cancer.

In order to bring attention to the large global burden of disease caused by viral hepatitis, 2015’s World Hepatitis Day is July 28th. This date was chosen to honor the birthday of Nobel Laureate Professor Baruch Samuel Blumberg who discovered the hepatitis B virus and developed the first hepatitis B vaccine. This year the emphasis is on prevention, with the slogan “Prevent hepatitis. Act now.”

We can prevent hepatitis by providing safe food and water (hepatitis A and E), vaccines (hepatitis A, B, and E), screening blood donations and providing proper equipment to maintain infection control (hepatitis B and C). While hepatitis B and C can be treated, many people in low- and middle- income countries lack access to treatment due to a lack of screening and the high cost of treatment. Until screening and treatment options become more accessible and affordable, prevention messages are incredibly important.

To help people learn how to prevent hepatitis, the WHO World Hepatitis Day 2015 campaign focuses on four key prevention messages:

1. Prevent hepatitis - know the risks
2. Prevent hepatitis – demand safe injections
3. Prevent hepatitis – vaccinate children
4. Prevent hepatitis – get tested, seek treatment

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Figure 1: A poster from World Hepatitis Alliance. 

If you’d like to get involved in raising awareness about hepatitis, please visit worldhepatitisday.org. There you’ll find some ideas on how to get involved, information on what social media campaigns have been formed, and materials to share to help spread the word that hepatitis is preventable.

The future of the fight against hepatitis looks promising. WHO has been increasing its efforts to fight hepatitis by establishing the Global Hepatitis Programme in 2011, and in 2014 moved that program to the cluster of HIV/AIDS, Tuberculosis, Malaria, and Neglected Tropical Diseases to help facilitate work between HIV/AIDS and hepatitis programs (due to the high number of people around the world living with both HIV and viral hepatitis). Furthermore, WHO, in conjunction with the Scottish Government and the World Hepatitis Alliance, is organizing the first ever World Hepatitis Summit in Glasgow, Scotland over 2-4 September 2015. This invite-only summit will bring together policy makers, patients, and other key stakeholders to determine how best to make lasting progress to reduce the global burden of hepatitis.

There is still progress to be made by the global community in order to win the fight against hepatitis. Key efforts, such as establishing events to publicize the global burden of viral hepatitis and holding summits to bring together the stakeholders that can make a difference, are contributing to saving lives in the fight against viral hepatitis.

Big Stories in Infectious Diseases for 2014

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com)

Not many people probably paid much attention to public health, much less global public health, before Ebola arrived in the US and Spain. Despite the focus on Ebola, there have been other global infectious disease developments in 2014.

Antibiotic Resistance

A major threat to humans worldwide is the emergence of antibiotic resistance. According to the Infectious Diseases Society of America, the CDC, WHO, the European Union, and President Obama, the problem of antibiotic resistance has reached crisis level. This is due to the overuse of antibiotics worldwide and major pharmaceutical suppliers who have basically abandoned antibiotic development because they don’t make enough money to justify the expense. This is a major problem because we could end up going back to death rates akin to the pre-antibiotic era, where something as simple as a minor cut could be deadly. Another fact to mention is the huge use of antibiotics in agricultural animals. Agricultural use accounts for 80% of antibiotic use in the US and that continued usage gives bacteria more exposure to the antibiotics and more opportunity to develop resistance.

Hepatitis C and HIV/AIDS

In case you didn’t hear, in only a 25 year span from the discovery of hepatitis C virus (HCV), we now have a treatment that cures 95% of the people who take the pill once a day for 8-12 weeks. I want you to let that soak in a minute…….because this is huge. HCV affects something like 250 million people around the world and now we can not just suppress the virus, but can actually clear it from someone’s body. Unfortunately, right now the cost of this treatment is $74,000 or more per person, basically putting this cure out of reach of anyone in middle or low income countries. Also in 2014, the world reached the tipping point for HIV/AIDS. That means that for the first time in the 30+ year epidemic, the number of people newly infected was less than the number of HIV positive people who got access to HIV medicines. While not every individual country has reached this milestone, and we still have a ways to go to get everyone access to life-saving medication, this tipping point shows that with continued effort the end of HIV/AIDS may be nearer than we thought.

Vaccine development

Vaccines have been around for a while and humanity has tried to create vaccines for all sorts of diseases. Work is being done to create vaccine platforms that don’t involve a needle such as embedding the “stuff” of the vaccine into a microneedle array (a small disk with several microscopic points that dissolve when embedded in the skin).  There is also an effort to create a universal influenza vaccine. A universal vaccine would target viral proteins that are conserved between the different strains of influenza and don’t mutate very often, so the vaccine could be effective no matter what strains are circulating each influenza season.

Epidemics

I just want to touch on a few of the epidemics you may not have heard much about this year. There was an epidemic of enterovirus D68 this year that caused more severe disease than we had expected as enterovirus infections generally only cause mild respiratory symptoms in kids. A mosquito-borne disease, Chikungunya, has been sweeping the Caribbean and causing fever and severe joint pain. Guinea worm, affecting people living in Africa and Asia, grows inside the body and then erupts from anywhere in the body causing severe and debilitating pain. Guinea worm is on target to be the second disease eradicated in human history (after smallpox) and is being eradicated not with the use of expensive medicines but through inexpensive but challenging to implement behavioral change. 

A Comprehensive Approach to HIV and Hepatitis C Interventions

~Written by Kathleen Lee, MPH Epidemiology, Vanderbilt University Medical Center (Contact: kathleen.g.lee@vanderbilt.edu)

One of the primary goals of public health, epidemiology, in particular, is estimating and examining the burden of disease. The burden in a population, however, is usually not just attributable to one illness or one causative agent. Many disease states carry with them the high likelihood of co-infections or opportunistic infections. Human immunodeficiency virus (HIV) and Hepatitis C (HCV) share at least one common route of transmission and often co-infect individuals. There are an estimated 40 million people worldwide who are infected with HIV and about 60-180 million globally are infected with HCV.1 Understanding the disease process as a whole means taking into consideration not only biological aspects of co-infection, but how this co-infection is propagated, or even mitigated, by patients’ behavior as well as their access to care. An all-inclusive and early detection approach to HIV-HCV treatment can help reduce the burden of disease in the affected population, and can help decrease transmission.

Effective interventions should focus on prevention, or at least early detection and treatment. This is not only good for the patient, but also for the health system. Between 2010 and 2019 it was estimated that HCV expenditures would be $10.7 billion.2 As disease progresses, costs increase (more medications, hospitalizations, etc.). Treatment should not only concentrate on drug therapy, but also address risk behaviors. Interventions, such as needle and syringe exchange programs (NSP) and opiate replacement therapy (ORT) are just some options that public health officials can use (and have used effectively) to curb HCV and HIV transmission in the community. Counseling is not a tool that should be overlooked as many of the co-infected population are affected with mental illness, a known risk factor for HIV acquisition. 

Both diseases separately represent a serious health concern, especially among injection drug using populations, but HIV-HCV co-infection introduces additional complications in treatment and disease progression of both conditions. Early interventions, especially during the acute phases of both diseases, can lead to better patient outcomes. Early treatment in co-infected individuals who have not yet been on antiretroviral therapy (ART) do better than those on existing ART regimens. The latter should be considered for treatment regimen changes to ensure minimal side effects and maximum adherence. Alcohol use in both HIV and HCV populations is a contributing factor to liver-related morbidity.3 Inclusion of alcohol and drug rehabilitation programs with drug therapy could decrease liver-related morbidity among co-infected patients. This is incredibly important because liver disease is the leading cause of mortality among co-infected individuals. 

Comprehensive interventions are useless if they cannot reach the population. Much has to be done to ensure that the delivery of these interventions captures as wide of an audience as possible. This includes having a well-trained staff of health workers and specialists who are able to support and motivate patients, convenient locations and times that are easily accessible for patients, and pricing should be affordable, if free is not an option.3 Many of the individuals taking advantage of such programs are often low-income, marginalized, and stigmatized by society. Giving these individuals the ability to take control of their condition and be aware of the risk behaviors and prevention strategies available for them could allow for better adherence to treatment, and consequently, better medical outcomes. Much like any other infectious disease that disproportionately affects low-income and vulnerable populations, the distribution and availability of resources are of utmost importance.

All of the above would be futile if there are no set standards to test and screen individuals who are most in need of these treatments. The lack of consensus among public health officials and the government regarding standardized screening among high-risk populations may contribute to the ongoing transmission of HIV and HCV, as well as co-infection. Ensuring sustainability of screening and treatment programs requires engagement and cooperation at all levels, from the patient to the care provider, to the community, to researchers, and even outward to national and international governing bodies.

1. Alter MJ. Epidemiology of viral hepatitis and HIV co-infection. J Hepatol. 2006;44, Supplement 1(0): S6-S9.

2. Wong JB, McQuillan GM, McHutchison JG, Poynard T. Estimating future hepatitis C morbidity, mortality, and costs in the United States. Am J Public Health. 2000;90(10): 1562-

3. Viral Hepatitis: Hepatitis C Treatment. US Department of Veterans Affairs.  http://www.hepatitis.va.gov/provider/reviews/HCV-treatments.asp. Page updated December 9, 2013. Accessed October 21, 2014.