World Hepatitis Day

July 28 is World Hepatitis Day. This year’s campaign theme was 'Find the Missing Millions'.

Diagnosing viral hepatitis is essential in order to reduce deaths from liver disease caused by hepatitis B or C. The European Centre for Disease Prevention and Control estimates that the majority of people in the European region with viral hepatitis are unaware of their infection.

The World Health Organization estimates that worldwide, 325 million people live with either hepatitis B or hepatitis C. Nine out of ten people – about 300 million – do not even know they are infected; out of these, less than 20% of people had access to testing and treatment services for hepatitis B and C infections at the end of 2016.

You can download this year’s campaign materials from the World Hepatitis Day website.

Treat all with hepatitis C, World Health Organization recommends

Everyone with hepatitis C should receive treatment with a pan-genotypic regimen, the World Health Organization recommends in new guidelines issued in July.

The World Health Organization says that the safety and effectiveness of newer direct-acting antivirals has shifted the balance of risks and benefits towards recommending treatment for all. Furthermore, growing access to lower-cost direct-acting antivirals is enabling treatment to be rolled out rapidly in some low- and middle-income countries.

The new guidelines update recommendations issued in 2016.

The new guidelines recommend:

  • Treatment for everyone 12 years and older diagnosed with hepatitis C. Treatment for children should be deferred until aged 12 or over.
  • Use of a pan-genotypic regimen to avoid the need for genotype testing.
  • Assessment of liver fibrosis by non-invasive tests (APRI or FIB-4).
  • Use of glecaprevir/pibrentasvir for people with chronic kidney disease.
  • Use of HCV RNA or HCV core antigen testing to monitor sustained virologic response 12 weeks after completion of treatment.
  • Re-treatment in cases of treatment failure with sofosbuvir/velpatasvir/voxilaprevir.
  • Use of simplified testing and treatment algorithms, integration of hepatitis C testing and treatment services into other services.

For people without cirrhosis the guidelines recommend the following regimens:

  • Sofosbuvir/velpatasvir 12 weeks
  • Sofosbuvir/daclatasvir 12 weeks
  • Glecaprevir/pibrentasvir 8 weeks.

For people with compensated cirrhosis:

  • Sofosbuvir/velpatasvir 12 weeks
  • Glecaprevir/pibrentasvir 12 weeks
  • Sofosbuvir/daclatasvir 12 weeks in countries with known genotype 3 prevalence < 5%
  • Sofosbuvir/daclatasvir 24 weeks in countries with known genotype 3 prevalence > 5 %.

Identifying people in need of hepatitis B treatment in Africa

Liver enzyme and hepatitis B 'e' antigen test results are sufficient to determine which people with hepatitis B need antiviral treatment for the infection in sub-Saharan Africa, a study carried out in West Africa has shown.

The findings, published in advance online by the Journal of Hepatology, show that expensive laboratory tests or Fibroscan equipment are not needed to determine which people are at higher risk of progressive liver disease and in need of treatment. Instead, blood tests costing less than $20 identified 85% of people in need of treatment.

Treatment of hepatitis B is now feasible using generic versions of antiviral drugs costing less than $50 a year. One of the major barriers to treatment is determining treatment eligibility. Not everyone with hepatitis B needs immediate treatment so, to test who is eligible, international guidelines recommend the use of hepatitis B virus (HBV) DNA tests to confirm viraemia and either liver biopsy or Fibroscan to test liver fibrosis.

But DNA testing and Fibroscan are not available in many settings. The West African study investigated whether basic laboratory tests that could be carried out in any health facility and interpreted by all grades of staff provided sufficient information to accurately select people in need of treatment.

The investigators evaluated a range of laboratory measurements and concluded that the combination of ALT levels and hepatitis B 'e' antigen predicted treatment eligibility.

The new diagnostic algorithm, called TREAT-B, was found to accurately identify HBV-positive people who require treatment in 85% of cases and could accurately identify those who do not need treatment in 77% of cases.

Hepatitis C treatment for people without liver damage

Successful hepatitis C virus (HCV) treatment with direct-acting antivirals (DAAs) significantly reduces the risk of death for people who do not have advanced liver disease, investigators report in Hepatology. A sustained virologic response (SVR) reduced mortality risk by up to two-thirds. The observational study involved over 40,000 US military veterans.

It was possible to study the effect of early treatment, in people without substantial liver damage, because the US Department of Veterans Affairs provides treatment for all veterans with hepatitis C through its own healthcare facilities.

The study looked at the risk of death in people with hepatitis C without cirrhosis who had a FIB-4 score of less than 3.25, indicating less serious liver damage. The study compared approximately 40,000 people who had received DAA therapy to a control group of approximately 60,000 people who did not receive DAA treatment.

Mortality rates during follow-up were 1.6% for SVR patients, 3.6% for non-SVR patients and 5% for the untreated controls.

Analysis showed that SVR reduced the risk of death from any cause by 66% compared to non-SVR and by 68% compared to no treatment.

“Successfully treating HCV before the development of clinically apparent advanced liver disease translates into a significant mortality benefit,” conclude the authors. “Increasing access to DAAs for all HCV-infected individuals should result in fewer deaths.”

Improved survival after liver transplant

Survival among people with hepatitis C virus (HCV) undergoing liver transplant has improved significantly since the introduction of direct-acting antivirals (DAAs), investigators from Catalonia report in the Journal of Hepatology. Thanks to DAAs, there was also a decrease in the number of people with HCV needing a liver transplant.

The proportion of people for whom HCV-related disease was given as the reason for transplant fell significantly from 47% in 2008 to 35% in 2016. The sharpest falls in HCV-related transplant indications occurred in 2015 and 2016.

Over the period of the study, 1114 people underwent transplant. Overall three-year survival in the entire cohort increased from 82% to 91%. This improvement was due to improved survival among people with HCV, which increased from 76% to 91%. In contrast, survival remained stable among non-HCV patients.

Access to HCV treatment for people with substance use or mental health issues

The proportion of people with chronic hepatitis C virus (HCV) infection who receive antiviral treatment has increased substantially since the introduction of direct-acting antivirals (DAAs), investigators from the United States report in Hepatology. However, people with mental health and/or substance abuse disorders continue to be less likely to receive treatment than other groups. The cumulative probability of treatment was just below 14% for people with these disorders compared to almost 22% for people without them.

The study looked at treatment rates at four large treatment centres in the United States between 2011 and 2017 in 29,544 people with chronic hepatitis C infection. Almost two-thirds of people (59%) had a mental health and/or substance use diagnosis. In the pre-DAA era, 39% of these people were treated, increasing to 46% in the DAA era. People with a mental health or substance use diagnosis were around 55% less likely to receive treatment in the pre-DAA era and around 35% less likely to receive treatment in the DAA era.

Ramucirumab for liver cancer

Ramucirumab (Cyramza) led to improved overall survival and delayed disease progression in people with hepatocellular carcinoma (HCC), according to study results presented at the American Society of Clinical Oncology (ASCO) annual meeting last month in Chicago.

The REACH-2 study showed that second-line treatment with ramucirumab extended median survival by only about a month compared with placebo. However, the proportion of people who were still alive at 18 months after starting treatment more than doubled, from 11.3% to 24.5%.

Sorafenib (Nexavar) is the standard first-line systemic therapy for advanced HCC, according to recently updated HCC guidelines from the European Association for the Study of the Liver (EASL). The guidelines also recommend lenvatinib (Lenvima). Regorafenib (Stivarga) is recommended for second-line treatment, and cabozantinib (Cabometyx) has shown good results in clinical trials. Although EASL does not yet recommend immunotherapy for liver cancer, the US Food and Drug Administration has approved the checkpoint inhibitor nivolumab (Opdivo) for HCC.

Ramucirumab (Cyramza) is a monoclonal antibody that interferes with angiogenesis, or blood vessel formation. By blocking activation of vascular endothelial growth factor receptor 2 (VEGFR2), the drug prevents the development of new blood vessels needed to supply growing tumours.

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