Lancet commission sets agenda for the elimination of viral hepatitis

Viral hepatitis leads to around 1.3 million deaths a year, approximately 257 million people are living with hepatitis B virus (HBV) and 71 million with hepatitis C virus (HCV). Viral hepatitis is one of the leading causes of infectious disease and in 2016 the World Health Organization set targets for elimination of viral hepatitis by 2030, including a 65% reduction in mortality and a 90% reduction in new infections.

The Lancet Gastroenterology & Hepatology Commission on Accelerating the Elimination of Viral Hepatitis brought together experts from all continents to look at how progress towards the elimination targets could be supported and speeded up.

The Commission published its recommendations this week in the journal The Lancet Gastroenterology & Hepatology.

The Commission identified several major challenges in achieving elimination:

• The need to scale up testing and ensure access to affordable diagnostics.
• Access to affordable medicines.
• The need for a shift from an individualised to a public health approach to treatment and care; treatment needs to be simplified and decentralised in the same way that HIV treatment has been successfully simplified and scaled up.
• Sustaining and expanding adult and birth-dose vaccination against hepatitis B.
• The need to scale up and sustain harm reduction services and deliver testing and treatment for people who inject drugs.
• Identifying and mobilising sources of funding to support diagnosis and treatment in lower-income countries.
• National plans for elimination of viral hepatitis are needed, together with a stronger role for civil society in monitoring progress and developing policy.

The Commission recommends:

• A greater focus on promoting universal coverage of childhood vaccines (including HBV) at international and national levels, including international procurement and funding of birth-dose vaccination.
• Promotion of expanded harm reduction services and decriminalisation of drug use and engagement with drug services by people who inject drugs.
• Greater provision of health services in prisons that include testing and treatment for viral hepatitis.
• Improve infection control, reduce the use of medical injections, promote the use of single-use needles and syringes and improve the screening of blood donation.
• Improved access to diagnostics for viral hepatitis and reduced reliance on diagnostics by use of pangenotypic regimens for HCV treatment.
• Develop point-of-care tests, including dried blood spot sampling, for screening and treatment monitoring.
• Development of national screening and patient-centred treatment programmes based on sound epidemiological data.
• Develop local capacity, evidence, and guidance to inform scale up of services and simplified protocols suitable for task sharing.
• Engage healthcare workers, civil society, and governments by raising awareness and education and reduce discrimination.
• Consider compulsory licensing for hepatitis medicines for countries that cannot otherwise access generics to achieve affordable prices, and ensure access policies that meet the needs of low-income and middle-income countries.
• Develop the investment case for eliminating viral hepatitis and develop innovative financing mechanisms to help low-income, high-burden countries achieve their elimination goals.

Asia: Increase political engagement, develop investment cases, reduce transmission through unsafe medical procedures, maintain and expand HBV vaccine coverage and capitalise on cheap generic access to greatly expand treatment.

Middle East and North Africa: Improve surveillance to reveal burden of viral hepatitis, develop national elimination plans, improve HBV birth-dose vaccine coverage and adult vaccination, reduce transmission through unsafe medical procedures, increase treatment through access to cheap generics and improve targeted screening to identify people in urgent need of HCV treatment.

Americas: Improve resourcing of surveillance, focus on treatment and care for incarcerated populations, develop non-specialist services outside large urban facilities, improve the procurement of affordable medicines through mechanisms such as Pan American Health Organization.

European Union: Develop a regional strategy for drug procurement, develop costed elimination plans, strengthen HCV screening, harm reduction and treatment among the highest-risk groups, ensure access to health services for migrants, promote decentralised care.

Sub-Saharan Africa: Improve HBV birth-dose vaccine coverage and adult vaccination, promote universal maternal HBV screening, reduce transmission through unsafe medical procedures, increase HBV treatment through access to cheap generics, ensure access to high-quality nucleic acid testing, develop education programmes around HBV and HCV to decrease public stigma around viral hepatitis, mobilise community-based activist or support groups to support viral hepatitis programmes.

Eastern Europe and Central Asia: Develop surveillance, anti-discrimination policies, decriminalise drug possession, scale up harm reduction that includes opioid substitution therapy, improve awareness of viral hepatitis and cooperation between government and civil society, improve access to low-cost quality generics through use of TRIPS (Trade Related Aspects of Intellectual Property Rights) flexibilities.

Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission. Lancet Gastroenterology & Hepatology, published in advance online, 8 January 2019. (View here)

An interview with the lead author of the Commission's report, Professor Graham Cooke of Imperial College, London. (View here).