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Accelerating the Elimination of Viral Hepatitis: a Lancet Gastroenterology & Hepatology Commission

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Accelerating the Elimination of Viral Hepatitis: a Lancet Gastroenterology & Hepatology Commission The Lancet Gastroenterology & Hepatology Commission Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission Graham S Cooke, Isabelle Andrieux-Meyer, Tanya L Applegate, Rifat Atun, Jessica R Burry, Hugo Cheinquer, Geoff Dusheiko, Jordan J Feld, Charles Gore, Max G Griswold, Saeed Hamid, Margaret E Hellard, JinLin Hou, Jess Howell, Jidong Jia, Natalia Kravchenko, Jeffrey V Lazarus, Maud Lemoine, Olufunmilayo A Lesi, Liudmyla Maistat, Brian J McMahon, Homie Razavi, Teri R Roberts, Bryony Simmons, Mark W Sonderup, C Wendy Spearman, Bridie E Taylor, David L Thomas, Imam Waked, John W Ward, Stefan Z Wiktor, on behalf of The Lancet Gastroenterology & Hepatology Commissioners* Viral hepatitis is a major public health threat and a leading cause of death worldwide. Annual mortality from viral Lancet Gastroenterol Hepatol hepatitis is similar to that of other major infectious diseases such as HIV and tuberculosis. Highly effective prevention 2019; 4: 135–84 measures and treatments have made the global elimination of viral hepatitis a realistic goal, endorsed by all WHO *Commissioners listed in the member states. Ambitious targets call for a global reduction in hepatitis-related mortality of 65% and a 90% reduction appendix in new infections by 2030. This Commission draws together a wide range of expertise to appraise the current global See Comment pages 88, 90, 91, and 93 situation and to identify priorities globally, regionally, and nationally needed to accelerate progress. We identify 20 heavily Division of Infectious Diseases burdened countries that account for over 75% of the global burden of viral hepatitis. Key recommendations include a (Prof G S Cooke FRCP, greater focus on national progress towards elimination with support given, if necessary, through innovative financing B Simmons MSc) and Division measures to ensure elimination programmes are fully funded by 2020. In addition to further measures to improve of Surgery and Cancer access to vaccination and treatment, greater attention needs to be paid to access to affordable, high-quality diagnostics if (M Lemoine FRCP), Imperial College London, London, UK; testing is to reach the levels needed to achieve elimination goals. Simplified, decentralised models of care removing Drugs for Neglected Diseases requirements for specialised prescribing will be required to reach those in need, together with sustained efforts to tackle initiative (DNDi), Geneva, stigma and discrimination. We identify key examples of the progress that has already been made in many countries Switzerland throughout the world, demonstrating that sustained and coordinated efforts can be successful in achieving the WHO (I Andrieux-Meyer MD); The Kirby Institute, UNSW elimination goals. Sydney, NSW, Sydney, Australia (T L Applegate PhD); Harvard Executive summary The Asian region is home to 11 of the 20 most heavily T H Chan School of Public Viral hepatitis is a major public health threat and a leading burdened countries and accounts for ap proximately Health (Prof R Atun FRCP) and Harvard Medical School cause of death worldwide. Every year viral hepatitis kills an 70% of viral hepatitis­related deaths globally; this region (Prof R Atun), Harvard estimated 1·34 million people, com parable to mortality stands out in terms of disease burden and the need for an University, Boston, MA, USA; from other major infectious diseases including HIV/AIDS, invigorated response. MSF Access Campaign, Geneva, tuberculosis, or malaria. 96% of deaths are attributable to The nature of viral hepatitis epidemics differs signi­ Switzerland (J R Burry MSc); Universidade Federal do Rio hepatitis B virus (HBV) and hepatitis C virus (HCV), ficantly among countries, and responses at country level Grande do Sul (UFRGS), which are the focus of this Commission. The availability must be sensitive to and appropriate for the specific Porto Alegre, Brazil of highly effective prevention measures and treatments context. In this Commission we have sought expertise (Prof H Cheinquer MD); Liver has made the global elimination of viral hepatitis a realistic from all affected regions of the world, and we present Unit, Kings College Hospital, London, UK goal, endorsed by all WHO member states. Ambitious examples of success and guidance on how to overcome (Prof G Dusheiko FRCP); Toronto targets have been established, aiming for a global re­ barriers. Sharing these experiences will help all countries Center for Liver Disease, duction in hepatitis­related mortality of 65% and a make progress towards elimination. Toronto General Hospital, 90% reduction in new infections by 2030. Inclusion of Vaccination against HBV, which has been a major public Toronto, Canada (Prof J J Feld MD); Medicines viral hepatitis in the Sustainable Development Goals health success, is projected to have prevented 310 million Patent Pool, Geneva, (SDGs) reflects a recognition of the importance of viral cases of hepatitis B between 1990 and 2020. Maintaining Switzerland (C Gore); Institute hepatitis to development. high childhood vaccination coverage rates remains crucial of Health Metrics and This Commission was formed to take stock of the global to all elimination plans. Because of the success of HBV Evaluation, University of Washington, Seattle, WA, USA situation as we embark on the journey to elimination and vaccination in preventing infection in later life, the pro­ (M G Griswold MA); Aga Khan identifies key interventions needed to accelerate progress. portion of new chronic HBV infections that arise through University, Karachi, Pakistan Elimination will require comprehensive hepatitis strategies mother­to­child transmission is projected to rise from 16% (Prof S Hamid FRCP); Burnet Institute, Melbourne, VIC, within affected countries and focused action at the national in 1990 to 50% in 2030. The increasing proportion of new Australia and subnational levels, including the intensification of infections through mother­to­child transmission makes (Prof M E Hellard FRACP); both prevention and treatment efforts. Some countries are access to birth dose vaccine a key priority. Hepatology Unit and advancing faster than others, typically those that have a Elimination of viral hepatitis will require a shifting Department of Infectious Diseases, Nanfang Hospital, national hepatitis strategy in place and strong political emphasis from a focus on individual patients to an Guangzhou, China leadership. emphasis on a co ordinated public health approach to (Prof JL Hou MD); Department Analysis for this Commission finds that 20 countries interruption of trans mission and infection through pre­ of Epidemiology and account for more than three­quarters of the global burden vention and treatment. In the short term, this will require Preventative Medicine, Monash University, Melbourne, of viral hepatitis. An effective response in these countries simplified, standardised packages of interventions that VIC, Australia (J Howell PhD); is crucial if global elimination targets are to be achieved. can be delivered at scale. HBV and HCV share common Liver Research Center, Beijing www.thelancet.com/gastrohep Vol 4 February 2019 135 The Lancet Gastroenterology & Hepatology Commission Friendship Hospital, Beijing, routes of transmission, and tackling both together can countries. In the absence of voluntary licensing some China (Prof J Jia MD); Alliance produce improved public health outcomes while yield­ countries might still need to consider compulsory licens­ for Public Health, Kyiv, Ukraine ing economic efficiencies. Not only will treating HBV ing as an alternative option. (N Kravchenko MS); Health Systems Research Group, and HCV interrupt transmission, it will also help pre­ Despite progress in access to drugs and diagnostics, Barcelona Institute for Global vent as many as one in 20 of all cancer­related deaths viral hepatitis lacks the major global support provided to Health (ISGlobal), Hospital worldwide. HIV, tuberculosis, or malaria, and insufficient financing Clinic, University of Barcelona, Barcelona, Spain The development of public health programmes adapted remains a huge challenge for elimination efforts. With (Prof J V Lazarus PhD); College of to national settings is a priority for both HBV and HCV the current emphasis on universal health­care coverage, Medicine, University of Lagos, and will require education and training programmes, as countries need to be supported in creating fiscal space Lagos, Nigeria well as a change in regulations, as part of a shift to more to invest in programmes to eliminate hepatitis. Invest­ (Prof O A Lesi FMCP); Medicines Patent Pool, Geneva, decentralised services. Requirements for specialist care ment plans are needed to support national policies and Switzerland (L Maistat MS); will need to be minimised, with greater emphasis placed to ensure that evidence­informed decisions are made Liver Disease and Hepatitis on task­sharing approaches in which less specialised regarding which interventions will provide the greatest Program, Alaska Native Tribal staff deliver treatment and care. A policy shift towards public health returns. In China, for example, investing in Health Consortium, Anchorage, AL, USA treating all individuals with HCV, irrespective of disease comprehensive HBV programming is projected to result (Prof B J McMahon PhD); Center stage, and using pangenotypic regimens would greatly in savings of more than US$1·5 for each $1 spent by 2030. for Disease Analysis simplify care delivery and has the potential to decrease
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