Hepatitis C: An Ongoing Public Health Challenge

Hepatitis C virus (HCV), a major cause of liver-related deaths, is an ongoing public health problem with 1.34 million deaths annually, similar to the mortality from HIV (1.1 million) and tuberculosis (1.4 million) [1,2]. It is estimated that 71 million people globally have chronic HCV infection [3]. 

Viral hepatitis results from inflammation of the liver due to a viral infection [3]. Almost all of these infections are caused by five viruses: hepatitis A (HAV), hepatitis B (HBV), hepatitis C (HCV), hepatitis D (HDV), and hepatitis E (HEV) [3]. HBV and HCV are responsible for 90% of fatalities due to hepatitis viruses [3]. There are different genotypes of HCV, but genotype 1 is the most prevalent, accounting for 46% of all HCV infections [3]. Genotype 3 is the second most common, causing 22% of HCV infections [3]. The highest reported prevalence of chronic HCV is in Central Asia and the Middle East [4]. Globally, Egypt has the highest prevalence of HCV, largely due to treatment programs for schistosomiasis with unsterilized needles [4]. 

An increase in hepatitis C infections is largely responsible for the global increase in liver cancer [4]. Liver cancer is now the fifth most common cancer among men and the ninth most common cancer among women [4]. Since the majority of people infected with hepatitis C are asymptomatic until the late stages of the disease, 40% to 80% of people with chronic hepatitis C infection are unaware that they are infected [4]. The largest burden of morbidity and mortality from chronic liver disease caused by hepatitis infection is in the nations of the developing world [4]. 

In 2016, the World Health Organization (WHO) adopted the Global Health Sector Strategy on viral hepatitis to eliminate hepatitis as a public health threat by 2030 [2]. The goal is to reduce hepatitis incidence from 6-10 million cases to 0.9 million cases, and to reduce yearly hepatitis deaths from roughly 1.4 million to 0.5 million by 2030 [2]. The WHO has assisted several countries in developing hepatitis control programs [2]. By November 2017, 84 nations had launched hepatitis control programs [2]. However, recent data shows that only 12 countries (Australia, Iceland, Switzerland, Italy, Mongolia, Spain, Egypt, France, Georgia, Japan, Netherlands, and United Kingdom) are on track to achieve the WHO hepatitis elimination goal [2]. 

In order to curb the hepatitis public health crisis, the WHO has identified five areas that require attention, three of which directly address HCV [2]. These areas include (1) injection and blood safety, (2) harm reduction, and (3) test and treatment of HCV [2]. Blood and injection safety is crucial to achieve the global hepatitis eradication target [2]. In 2015, 29 countries were not routinely screening all blood donations for transfusion transmitted infections such as HCV [2]. Moreover, despite harm reduction strategies such as needle and syringe programs, HCV transmission remains high among people who inject drugs [5]. There is an urgent need to improve blood transfusion and injection safety, especially in low- and middle-income countries, in order to reduce HCV transmission [2]. 

Only 11% of HCV cases are diagnosed, which creates challenges to providing proper treatment to those who are infected [2]. The WHO target is to diagnose 90% of HCV positive cases and treat 80% of cases by 2030 [2]. There are highly effective HCV drugs available in the market, but drug pricing remains an issue in many developed nations [2]. Other ongoing constraints to HCV treatment include limited health infrastructure for the treatment of marginalized populations (such as people who inject drugs or prisoners) and a low rate of HCV screening in many areas [5]. 

References 

1. Poortahmasebi, V., & Baghi, H. (2019). Living in the shadows of hepatitis. The Lancet Infectious Diseases, 19(11), 1171-1172. doi:10.1016/s1473-3099(19)30534-1 

2. Waheed, Y., Siddiq, M., Jamil, Z., & Najmi, M. (2018). Hepatitis elimination by 2030: Progress and challenges. World Journal of Gastroenterology, 24(44), 4959-4961. doi:10.3748/wjg.v24.i44.4959 

3. Jefferies, M., Rauff, B., Rashid, H. et al. (2018). Update on global epidemiology of viral hepatitis and preventive strategies. World Journal of Clinical Cases, 6(13), 589-599. doi:10.12998/wjcc.v6.i13.589 

4. Sharma, S., Carballo, M., Feld, J., & Janssen, H. (2015). Immigration and viral hepatitis. Journal of Hepatology, 63(2), 515-522. doi:10.1016/j.jhep.2015.04.026 

5. Hajarizadeh, B., Grebely, J., Martinello, M. et al. (2016). Hepatitis C treatment as prevention: evidence, feasibility, and challenges. The Lancet Gastroenterology & Hepatology, 1(4), 317-327. doi:10.1016/s2468-1253(16)30075-9