Continuing to invest in hepatitis B vaccination, early detection and treatment, and public awareness campaigns can pave the way towards a world where every child is vaccinated, every person knows their hepatitis B status and every infected individual receives the optimal care and support that they need.
These observations were made in a cover story on “One life, one liver – Toward the elimination of viral hepatitis” authored by D. Mataraarachchi (attached to the Health Ministry's Epidemiology Unit) and published in the Journal of the College of Community Physicians of Sri Lanka's 29th volume’s second issue in August 2023. Mataraarachchi cited The Lancet's “Viral hepatitis elimination: A challenge, but within reach”, the World Health Organisation’s (WHO) “Hepatitis B fact sheet” and the “Guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection”, and Y-C. Hsu, D.Q. Huang and M.H. Nguyen's “Global burden of the hepatitis B virus: Current status, missed opportunities and a call for action” in this article.
Hepatitis B and C
Hepatitis B is an infection of the liver caused by the hepatitis B virus. The infection can be acute (short and severe) or chronic (long term). Hepatitis B puts people at high risk of death from cirrhosis (a chronic disease of the liver marked by the degeneration of cells, inflammation, and the fibrous thickening of tissue) and liver cancer. It can spread through contact with infected body fluids like blood, saliva, vaginal fluids and semen. It can also be passed from a mother to her baby. Hepatitis B can be prevented with a safe and effective vaccine. The vaccine is usually given soon after birth with boosters a few weeks later.
Hepatitis C is a viral infection that affects the liver. It can cause both acute (short term) and chronic (long term) illness. It can be life threatening. Hepatitis C is spread through contact with infected blood. This can happen through sharing needles or syringes, or from unsafe medical procedures such as blood transfusions with unscreened blood products. Symptoms can include fever, fatigue, the loss of appetite, nausea, vomiting, abdominal pain, dark urine and the yellowing of the skin or eyes (jaundice). There is no vaccine for hepatitis C, but it can be treated with antiviral medications. Early detection and treatment can prevent serious liver damage and improve long term health. Acute hepatitis C virus infections are usually asymptomatic and most do not lead to a life threatening disease. Around 30% (15–45%) of infected persons spontaneously clear the virus within six months of infection without any treatment. The remaining 70% (55–85%) of persons will develop chronic hepatitis C virus infection. Of those with chronic hepatitis C virus infection, the risk of cirrhosis ranges from 15% to 30% within 20 years.
Viral hepatitis has been a persistent public health problem across the world. An estimated 354 million people are currently living with the hepatitis B or C infection globally, with many unaware of their infection status due to the lack of symptoms in the early stages of the disease. The data indicates that at least one person across the world dies from viral hepatitis every 30 seconds, which amounts to over one million deaths per year. The number exceeds the annual death toll from human immunodeficiency virus and malaria combined. The burden is the highest in the WHO Western Pacific region and African region, where 116 million and 81 million people are chronically infected with hepatitis B, respectively. An estimated 18 million people are hepatitis B infected in the WHO South East Asia region.
The WHO has set a goal to eliminate hepatitis B as a public health threat by 2030. Under the elimination strategies, the number of new hepatitis B infections and deaths would be reduced by at least 90% and 65%, respectively, between 2016 and 2030. Hepatitis B elimination is currently defined as having less than 0.1% Hepatitis B surface antigen (HBs Ag) prevalence in those aged five years or less. The road map towards the elimination of viral hepatitis includes prevention, early diagnosis, treatment and community intervention strategies.
Setting realistic goal
The elimination of hepatitis B is a realistic goal. However, it will require concerted efforts from governments, healthcare providers and individuals. To achieve hepatitis B elimination, the WHO has outlined a comprehensive approach that includes four key strategies, namely, universal vaccination, diagnosis and treatment, blood and injection related safety, and public awareness and education.
Vaccination is one of the most effective ways in preventing hepatitis B infection. The WHO recommends that all infants receive three doses of the hepatitis B vaccine as part of routine childhood immunisation. In addition, catch up vaccination campaigns are essential in order to protect adolescents and adults who were not vaccinated during infancy. High risk groups such as healthcare workers, illicit drug users and people with multiple sexual partners should be vaccinated in order to prevent and control the spread of the disease.
The prompt and accurate diagnosis of hepatitis B is crucial for timely treatment and to prevent further transmission. It is essential in order to ensure access to affordable and realistic diagnostic services, particularly in resource limited settings. For those living with chronic hepatitis B, access to appropriate treatment and care is vital in order to prevent disease progression and to reduce the risk of complications. There are several medications approved to treat viral hepatitis B and C, and new drugs are in development. Monitoring and the regular follow up of patients on treatment are essential in order to ensure treatment adherence and to detect any potential drug resistance. In cases where complications arise, early intervention can be life saving. It is aimed to diagnose at least 90% of patients living with hepatitis B and to treat at least 80% of them by 2030.
It is recommended to screen 100% of all blood donations in a quality assured manner and to ensure that comprehensive harm reduction services are available for people who inject drugs.
Raising awareness about hepatitis B and C among the public is crucial in reducing stigma, promoting testing and encouraging preventive measures. Education campaigns targeting the public, including high risk groups as well as healthcare providers, play a significant role in increasing the knowledge and attitudes about hepatitis B and C and its modes of transmission.
The immunisation of infants against hepatitis B, the screening of blood for the hepatitis virus and the safe handling and disposal of needles and medical waste are some of the steps practiced in Sri Lanka in order to achieve the hepatitis B elimination status. Last year (2022), an island-wide survey was carried out by the Epidemiology Unit in order to determine the hepatitis B prevalence, which confirmed its control status in the country.
Despite significant progress toward elimination, several challenges persist globally in the quest for hepatitis B and C elimination. One of the primary obstacles is having limited availability and affordability of diagnostic tests, especially in low and middle income countries. It is estimated that only 10% of the people with chronic hepatitis B know their diagnostic status. Therefore, expanding access to these services is critical in order to ascertain that all at risk groups and those living with hepatitis are getting the appropriate care. In the meantime, the stigma and misconception surrounding hepatitis B and C continue to hamper testing and compliance with treatment, thus making it difficult to prevent and control the disease.