The Lancet Gastroenterology & Hepatology Commission
Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission

https://doi.org/10.1016/S2468-1253(18)30270-XGet rights and content

Viral hepatitis is a major public health threat and a leading cause of death worldwide. Annual mortality from viral hepatitis is similar to that of other major infectious diseases such as HIV and tuberculosis. Highly effective prevention measures and treatments have made the global elimination of viral hepatitis a realistic goal, endorsed by all WHO member states. Ambitious targets call for a global reduction in hepatitis-related mortality of 65% and a 90% reduction in new infections by 2030. This Commission draws together a wide range of expertise to appraise the current global situation and to identify priorities globally, regionally, and nationally needed to accelerate progress. We identify 20 heavily burdened countries that account for over 75% of the global burden of viral hepatitis. Key recommendations include a greater focus on national progress towards elimination with support given, if necessary, through innovative financing measures to ensure elimination programmes are fully funded by 2020. In addition to further measures to improve access to vaccination and treatment, greater attention needs to be paid to access to affordable, high-quality diagnostics if testing is to reach the levels needed to achieve elimination goals. Simplified, decentralised models of care removing requirements for specialised prescribing will be required to reach those in need, together with sustained efforts to tackle stigma and discrimination. We identify key examples of the progress that has already been made in many countries throughout the world, demonstrating that sustained and coordinated efforts can be successful in achieving the WHO elimination goals.

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Executive summary

Viral hepatitis is a major public health threat and a leading cause of death worldwide. Every year viral hepatitis kills an estimated 1·34 million people, comparable to mortality from other major infectious diseases including HIV/AIDS, tuberculosis, or malaria. 96% of deaths are attributable to hepatitis B virus (HBV) and hepatitis C virus (HCV), which are the focus of this Commission. The availability of highly effective prevention measures and treatments has made the global elimination of

The global burden of viral hepatitis and need for high quality data

In 2016, more than 75% of the global burden of hepatitis and its related diseases was shouldered by only 20 countries (figure 1). Meaningful progress towards the WHO targets for elimination will require a focus on progress within these countries, half of which are in Asia, the region with by far the greatest burden of disease.3 Strikingly, only two of the most heavily burdened countries—USA and Japan—have made progress in reducing the burden of viral hepatitis in the past 20 years (appendix p 3

Prevention of viral hepatitis

The shared routes of transmission for HBV, HCV, and HIV—through percutaneous or mucosal exposure to infected blood and bodily fluids—confers advantages in streamlining viral hepatitis prevention efforts, with a focus on integrated responses rather than vertical programmes. Key priorities for prevention are summarised in panel 1.

The HBV and HCV epidemics vary substantially in different geographical settings, with different risk groups and risk factors for infection. As such, it is important that

Screening and diagnosis

Timely diagnostic testing is crucial for disease prevention through early detection and treatment, particularly for chronic infections such as HBV or HCV that can have a long asymptomatic phase. For viral hepatitis, insufficient testing and linkage to care, rather than access to drugs, is an increasing barrier to elimination efforts. In 2017, only 9% of the estimated 257 million people with chronic HBV infection and 20% of the 71 million with chronic HCV infection were estimated to have been

Access to medicines for viral hepatitis

There are different challenges to ensuring widespread access to HBV and HCV treatment. Access to HCV treatment has been a major focus of attention since the marketing of sofosbuvir, but it is also a crucial time to explore ways to improve access to HBV treatment. Two key long-term HBV treatments are recommended in international guidelines, TDF and entecavir, which are sufficient for the management of most patients with chronic hepatitis B. As of 2018, both drugs are off-patent in most major

Innovative financing for viral hepatitis

Achievement of elimination will depend less on technical capabilities and more on leadership, political will, and financial considerations. Even when there is strong leadership and political will, availability of finances, the application of funds, and health system capabilities will determine the magnitude and the speed of response.

A relatively modest amount of the new funding for the global response to viral hepatitis will be channelled to global development and health agencies to be used for

Viral hepatitis in Asia

Asia experiences a greater challenge from HBV and HCV infections than any other region of the world,9 with half of the 20 most heavily burdened countries being from this region. The region accounts for 74% of deaths from liver cancer globally, mainly attributable to HBV and HCV.167 The region is home to approximately 180 million HBsAg positive individuals and 31 million viraemic with hepatitis C.7, 8 Countries in Asia with a high burden of viral hepatitis span the economic spectrum from high

Viral hepatitis in the Middle East and North Africa

An estimated 15·5 million people in the Middle East and North Africa (MENA) are chronically infected with HBV, and 8·5 million with HCV.7, 8 Prevalence of HBV and HCV varies across the 22 countries in the region; HBV prevalence ranges from 16% to 19% in Mauritania and Somalia to 0·5% in Bahrain (appendix pp 11, 12). HCV prevalence in Egypt exceeds 6% (4·4% in those aged less than 60 years), which is higher than in any other country in the world.196, 197, 198 Egypt also dominates the region with

Viral hepatitis in the Americas

The Americas account for just under 10% of both deaths and DALYs attributed to viral hepatitis globally. By contrast with Asia, HCV is the greatest challenge to public health in the region, accounting for 70–80% of hepatitis-related deaths (figure 9). The USA, Brazil, and Mexico account for approximately half of the regional disease burden (figure 9), and are home to approximately 4·2 million HBsAg positive individuals and 7 million individuals with HCV viraemia.7, 8 An estimated 2·7–3·5

Viral hepatitis in the European Union

The burden of viral hepatitis in the 28 member states of the EU varies significantly from country to country, but is greatest in Italy and Germany (figure 10). A relatively high prevalence of viral hepatitis in new member states have added to the overall regional disease burden (figure 10).

In 2016, the prevalence of chronic hepatitis B in the EU was estimated at 0·89% (4·5 million individuals), with country level HBsAg prevalence ranging from 0·1% to 5·5%.8 HBV vaccination in the EU countries

Viral hepatitis in sub-Saharan Africa

HBV is endemic in sub-Saharan Africa. WHO estimates prevalence of HBsAg at 6·1–8·8%30 with approximately 80 million chronically infected and 1·96 million co-infected with HIV.8 The burden of HCV is also significant, with approximately 10 million infected.7 In west and central Africa, 5·7% are co-infected with HCV and HIV.271, 272 HBV and HCV infection in the ten most heavily burdened countries in sub-Saharan Africa (figure 11) account for approximately 200 000 deaths annually, equating to just

Viral hepatitis in eastern Europe and central Asia

The Eastern Europe and Central Asia (EECA) region is one of the most heavily affected by viral hepatitis and HIV. The HCV epidemic is growing, with an estimated 9·9 million individuals with HCV viraemia7 in the region and a particularly high prevalence of viral hepatitis–HIV co-infection among PWID.255 In addition, approximately 8 million individuals in the region have chronic HBV infection.8

As in sub-Saharan Africa, there is a lack of reliable epidemiological data on viral hepatitis in most

Viral hepatitis in Oceania

Australia, New Zealand, and Pacific Island countries and territories form part of the WHO Western Pacific region, which has high viral hepatitis prevalence, particularly HBV, which causes a similar burden of mortality as for tuberculosis, HIV, and malaria combined.299 In 2016, the combined DALYs due to hepatitis B and C in Australia, New Zealand, Papua New Guinea, Solomon Islands, Fiji, Vanuatu, Guam, Tonga, Kiribati, and Samoa was approximately 1·5 million (figure 13). The region is home to an

Sustaining progress towards hepatitis elimination

There is no doubt that the once-in-a-generation transformation of HCV treatment has energised the movement towards elimination of not just HCV, but also HBV—with scalable treatment options now available for both these major infections. The past 3 years have seen substantial progress towards elimination, including the universal adoption by countries of the WHO GHSS in 2016 and adoption of more detailed regional action plans; the specific inclusion of viral hepatitis in the SDGs; the emergence of

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    Commissioners listed in the appendix

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