If current trends in obesity and diabetes continue, at least 520 million people will be living with non-alcoholic fatty liver disease (NAFLD) in western Europe, China, Japan and the United States by 2030, according to modelling by the Center for Disease Analysis published in the Journal of Hepatology. The number of people with decompensated cirrhosis as a result of the most advanced form of NAFLD will more than double in each country.

NAFLD occurs when fat accumulates in the liver due to metabolic disorders including type 2 diabetes. NAFLD occurs most frequently in people who are obese.

Liver fat accumulation causes no symptoms in most people but in some it may eventually become severe enough to cause inflammation and liver damage (non-alcoholic steatohepatitis, or NASH). In a minority of people with NASH, liver damage will progress to end-stage liver disease (decompensated cirrhosis) or liver cancer (hepatocellular carcinoma). The risk of progressive liver disease is higher in older people, obese people or people with type 2 diabetes.

The study, carried out by the Center for Disease Analysis and researchers in eight countries, looked at the estimated total burden of NAFLD and the proportion of people with NASH or decompensated cirrhosis due to NASH, based on national epidemiological data. The study also estimated the future demand for liver transplants as a result of decompensated cirrhosis caused by NASH.

The researchers constructed a model of the total burden of these conditions in 2030 based on current trends.

By 2030, the model estimates that the prevalence of NAFLD will have risen in all countries, with the biggest numerical growth in China owing to population growth (61 million new cases). The prevalence of NASH will also rise, by almost half in all countries and cases of advanced NASH will make up a rising proportion of all NAFLD and NASH cases, as the population ages and the prevalence of type 2 diabetes rises.

In the United States the number of people with NASH and decompensated cirrhosis will increase by 161% to 376,140 cases. In 2030 alone, modelling suggests that 105,430 cases of decompensated cirrhosis will occur because of NASH. This enormous increase in cases of advanced liver disease will have serious implications for healthcare costs and the demand for liver transplants, the authors warn.

Deaths due to NASH (including deaths from cardiovascular disease) will increase most sharply in Italy, France and China, the modelling finds. Approximately 163,000 people will die as a result of NASH in China in 2030, and 83,000 in the United States.

These projections of disease and deaths could change if the global burden of obesity is altered by changes in diet, taxes on sugar, effective treatment, or if medication to reduce liver fat and arrest the progression of liver damage due to NASH become widely available.

A study presented at last month’s AASLD Liver Meeting showed that even among people who are not obese, a surprising number already have metabolic abnormalities and non-alcoholic fatty liver disease (NAFLD). The study took a sample from the National Health and Nutrition Examination Survey (NHANES) and found that 7.7% of people with a body mass index below 25 had NAFLD. The prevalence of NAFLD was higher in lean people with metabolic abnormalities such as high cholesterol levels and hypertension, and highest in people with diabetes.

But, the researchers stressed that no-one with NAFLD, but no metabolic abnormalities, died of cardiovascular disease during the 19-year follow-up period, and that the presence of diabetes was the most important driver of NAFLD in this population.

New figures from the US Centers for Disease Control and Prevention (CDC) show that approximately 4.1 million adults are hepatitis C virus (HCV) antibody positive and approximately 2.4 million – about 1% of the US adult population – are HCV RNA positive, indicating active infection. These figures are based on 2013-2016 NHANES findings along with additional data on incarcerated and homeless people, nursing home residents and those in the military.

This figure represents a decrease of around 1 million since the advent of direct-acting antivirals, suggesting that the number of people achieving a cure may now exceed the number of new HCV infections.

Nevertheless, CDC estimates that 41,000 people were newly infected with hepatitis C in 2016.

Study results show that HCV prevalence is highest in states heavily impacted by the ongoing opioid epidemic. West Virginia, Tennessee and Kentucky are the states with the highest prevalence.

Looking at the MappingHCV dataset, researchers found some improvements in hepatitis C screening and linkage to care in the United States. Five million people were screened for hepatitis C in 2016 compared with four million in 2013. The proportion who received confirmatory HCV RNA testing to check for chronic infection increased from 45% in 2013 to 76% in 2016. Of these, 63.9% had chronic infection.

The study found that young adults diagnosed with hepatitis C were less likely to receive treatment, regardless of whether they saw a specialist or primary care physician. The researchers said that as well as stepping up efforts to screen older people, US healthcare providers also need to develop screening programmes that can reach younger people who may be less engaged with health care and less likely to be covered by health insurance.

Public Health England has issued guidance for clinicians in the use of resistance testing in the management of hepatitis C. The document provides detailed guidance on research findings to date regarding the implications of resistance-associated substitutions (RAS) for each class of direct-acting antivirals. The document also recommends adjustments to treatment and duration of therapy in the presence of RAS for specific regimens.

Rwanda has launched a 5-year national plan to eliminate hepatitis C, the first country in sub-Saharan Africa to commit to the goal.

Rwanda’s government aims to screen four million people for hepatitis C over three years. The estimated prevalence of hepatitis C is 8%. The plan is supported by the Clinton Health Access Initiative.

Egypt is midway through a national campaign to screen the entire adult population for hepatitis C. At least 19.5 million people have already been screened and approximately 5% have tested positive. Treatment for hepatitis C is being funded by the World Bank as part of a larger national prevention and elimination programme.

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