In Second Place and Gaining: Viral Hepatitis

“Only 1 in 20 people with viral hepatitis know they have it.”

The World Health Organization

“Hepatitis C was a devastating disease but because fundamental research was done in hepatitis C, it is now curable. It is now absolutely curable with new medications. So this is transformative.”

Laurie Glimcher, MD, American physician scientist, CEO Dana-Farber Cancer Institute

The day before my April 10, 2024 Germ Gems post “‘Leading Infectious Disease Killer in the World’: TB Regains the Title,” the World Health Organization (WHO) sounded the alarm on viral hepatitis—the second leading infectious cause of death globally. According to Heather Bradley, an epidemiologist at the Emory Rollins School of Public Health, “Before the COVID-19 pandemic, viral hepatitis in the U.S. killed more people than all 60 other reportable infectious diseases combined including HIV, pneumonia, and tuberculosis.” The WHO reported that now viral hepatitis causes 1.3 million deaths globally per year—the same as TB.

It is especially disturbing that the number of lives lost to viral hepatis continues to climb despite the availability of an effective vaccine and curative therapies. In today’s Germ Gems post, I provide an overview of viral hepatitis, including what everybody should know about this silent killer.

The culprits and the epidemiology of infections. Hepatitis is inflammation of the liver. There are non-infectious causes of hepatitis including, but not limited to, heavy alcohol use, medications, and autoimmune diseases. There are also viruses other than the “hepatitis viruses” that cause liver inflammation, e.g. cytomegalovirus and Epstein-Barr virus.  But, it is the following five types of viruses that are designated as the etiologies of viral hepatitis—Hepatitis A virus (HAV), Hepatitis B virus (HBV), Hepatitis C virus (HCV), Hepatitis D virus (HDV), and Hepatitis E virus (HEV). And HBV and HCV are the pathogens responsible for most of the suffering and death worldwide. Globally, 3,500 people die every day due to HBV and HCV infections.

HBV and HCV belong to different viral families and have different genomes—DNA in the case of HBV and RNA in the case of HCV. Nonetheless, the two viruses have much in common. Both are blood borne viruses that can be transmitted through contact with body fluids during sex, unsafe injections (injection drug use), and unscreened blood transfusions. In addition, HBV can be transmitted from mother to child during birth. Unfortunately, in about half the cases of HBV infection and in 10% of the cases of HCV infection, the source of infection cannot be determined.

New WHO data from 187 countries show that the estimated number of deaths from viral hepatitis increased from 1.1 million in 2019 to 1.3 million in 2022. Of these deaths, 83% were caused by HBV and 17% by HCV.  It’s estimated that in 2019 about 60 million people were living with chronic HCV infection and that this virus caused 290,000 deaths per year, whereas 296 million people were living with HBV infection that caused about 820,000 deaths per year.

The diseases. Both HBV and HCV can cause acute and chronic forms of liver disease. People suffering from acute hepatitis may get better quickly, but may develop a long-term or chronic condition. And, in some cases, chronic hepatitis may lead to liver damage, cirrhosis, liver cancer, or death.

The symptoms of acute viral hepatitis include:

·      pain or bloating in the belly;

·      dark urine and pale (or clay-colored) stools;

·      fatigue;

·      low-grade fever;

·      pruritus (itching);

·      jaundice (yellow skin or eyes);

·      anorexia (loss of appetite);

·      nausea and vomiting; and

·      weight loss.

But many patients with HBV or HCV infection have no symptoms when first infected. Nonetheless, they may develop liver failure 10-20 years later. Because of this, the Centers for Disease Control and Prevention recommends that at least once in their lifetime, all adults aged 18 years or older be screened for HBV and HCV infection to determine whether vaccination or treatment is needed.

Prevention and treatment. In 1965, Baruch Blumberg discovered HBV. In 1989, Michael Houghton, Harvey Alter, and Charles Rice discovered HCV. These discoveries set the stage for ensuring breakthroughs in the prevention and treatment of viral hepatitis. (The Nobel Prize in Physiology or Medicine was awarded to Blumberg in 1976 and to Houghton, Alter, and Rice in 2020.)

In 1981, the U.S. Food and Drug Administration approved a plasma-derived hepatitis B vaccine for human use. In 1982, vaccines to protect against HBV infection were implemented. By 1986, research resulted in a second generation (DNA recombinant) hepatitis B vaccine. The vaccine protects against HBV for at least 20 years and, in all likelihood, lasts for life.

 In 1991 the U.S. embarked on a strategy to eliminate HBV transmission that included the universal HBV vaccination of infants (beginning at birth) and also of high risk groups. Consequently, the prevalence of chronic HBV infection fell substantially among populations whose infection rates were previously high.

Even though safe and highly effective vaccines against HBV have existed since the 1980s, many infants in low and middle-income countries do not receive HBV vaccination.  Moreover, a vaccine for HCV has yet to materialize. Therefore, the only way to prevent HCV infection is through behavioral changes such as practicing safe sex and not sharing needles.

Antiviral therapies, however, have changed the landscape of the management of chronic HBV and HCV. (See “Management of hepatitis B and C in special populations,” World Journal of Gastroenterology, 2021.) Now there are antiviral drugs that not only can successfully treat chronic HBV but also cure chronic HCV infections.

Can viral hepatitis be eliminated? In 2016, the WHO set the ambitious goal of eliminating viral hepatitis as a public health problem by 2030. And in 2023, the Biden Administration announced an unprecedented effort to end HCV nationwide—defined as a 90% reduction in new infections and a 65% reduction in viral hepatitis-related deaths—by 2030. (The president’s initiative has been in the budget for the last two years, but Congress has not introduced legislation to fund it.) Given the rising number of cases and deaths due to HBV and HCV, the goal to eliminate viral hepatitis doesn’t seem feasible without adequate funding.

 As Dr. Bradly pointed out her April 17, 2024 article in STAT, “Viral hepatitis is a silent killer. It can’t be eliminated if it isn’t tracked.” And a key weakness to achieving the elimination of viral hepatitis by 2030 is the absence of dedicated staffing to conduct routine surveillance activities for viral hepatitis. Presently, only 3% of the public health jurisdictions in the U.S. say they could make progress toward eliminating viral hepatitis with current federal resources.

It’s time that the government provide funding for necessary public health infrastructure nationwide and for the president’s initiative. According to a recent paper published by the National Bureau of Economic Research, funding President Biden’s initiative “would prevent 24,000 deaths in the next decade and save $18.1 billion in medical costs for people with untreated hepatitis C.” Viewed from this perspective, this is a deficit reduction program in the long run.