Halfway through HBV elimination - are we not waiting?
Journal
International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases
Journal Volume
134
Pages
299
Date Issued
2023-09
Author(s)
Abstract
Seven years have passed since World Health Organization (WHO) published her very first global health sector strategy on viral hepatitis in June 2016 for advocating global hepatitis elimination [[1]World Health Organization. Global health sector strategy on viral hepatitis 2016-2021. Towards ending viral hepatitis. Website: https://www.who.int/publications/i/item/WHO-HIV-2016.06, accessed on 15 July 2023.Google Scholar]. This strategy contributes to the development of targets for the reduction of the incidence and mortality of chronic viral hepatitis by 90% and 65%, respectively, to be achieved by 2030 [[1]World Health Organization. Global health sector strategy on viral hepatitis 2016-2021. Towards ending viral hepatitis. Website: https://www.who.int/publications/i/item/WHO-HIV-2016.06, accessed on 15 July 2023.Google Scholar]. Hence, we still have another seven years before this “deadline” comes. July 27 is World Hepatitis Day. Right at the exact halfway of the proposed timeline for hepatitis elimination, it is the perfect time on World Hepatitis Day 2023 to review what have been achieved so far in the Asia-Pacific, where many countries belong to the high/intermediate endemicity areas for hepatitis B virus (HBV). One of the most remarkable achievements in the Asia-Pacific region has been the launching of universal neonatal HBV vaccination in the 1980s-1990s, which formed the cornerstone of programmes for preventing mother-to-child transmission (MTCT) of HBV [[2]Center for Health ProtectionSurveillance of viral hepatitis in Hong Kong –2016 update report.15 July 2023https://www.chp.gov.hk/files/pdf/viral_hepatitis_report_2016_final.pdfGoogle Scholar,[3]Liu CJ Chen PJ. Elimination of hepatitis B in highly endemic settings: lessons learned in Taiwan and challenges ahead.Viruses. 2020; 12: 815https://doi.org/10.3390/v12080815Crossref PubMed Scopus (17) Google Scholar]. Timely administration of hepatitis B Immunoglobulin (HBIG), preferably within 12-24 hours to newborns of mothers who are positive for hepatitis B surface antigen (HBsAg), is pivotal to circumvent MTCT of HBV infection. Together with continuous reduction in HBsAg seroprevalence in children and young adults, the risk of hepatocellular carcinoma (HCC) in young adults has decreased dramatically, as illustrated in studies in Taiwan and Hong Kong [3Liu CJ Chen PJ. Elimination of hepatitis B in highly endemic settings: lessons learned in Taiwan and challenges ahead.Viruses. 2020; 12: 815https://doi.org/10.3390/v12080815Crossref PubMed Scopus (17) Google Scholar, 4Wong GL Hui VW Yip TC Liang LY Zhang X Tse YK Lai JC Chan HL Wong VW. Universal HBV vaccination dramatically reduces the prevalence of HBV infection and incidence of hepatocellular carcinoma.Aliment Pharmacol Ther. 2022; 56: 869-877https://doi.org/10.1111/apt.17120Crossref PubMed Scopus (10) Google Scholar, 5Liao SH Chen CL Hsu CY Chien KL Kao JH Chen PJ Chen TH Chen CH. Long-term effectiveness of population-wide multifaceted interventions for hepatocellular carcinoma in Taiwan.J Hepatol. 2021; 75: 132-141https://doi.org/10.1016/j.jhep.2021.02.029Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar]. The remaining issue is to protect babies who are born to highly-viraemic mothers. Antiviral therapy with tenofovir disoproxil fumarate (TDF) to hepatitis B e antigen (HBeAg)-positive mothers or those with high serum HBV DNA (≥200,000 IU/mL) during weeks 28-32 of pregnancy, continuing for at least four weeks postpartum, is now recommended and adopted in our region [[6]Kao JH Hu TH Jia J Kurosaki M Lim YS Lin HC Sinn DH Tanaka Y Wai-Sun Wong V Yuen MF East Asia expert opinion on treatment initiation for chronic hepatitis B.Aliment Pharmacol Ther. 2020; 52: 1540-1550https://doi.org/10.1111/apt.16097Crossref PubMed Scopus (27) Google Scholar]. Common challenges are the suboptimal awareness and inadequate resources to measure mothers’ serum HBV DNA levels before 3rd trimester of pregnancy, and unwillingness in some highly-viraemic mothers to start TDF. Public education to women of child-bearing age as well as professional training for healthcare practitioners taking care of pregnant women would be valuable to further reduce the risk of MTCT of HBV and hence the new HBV infections of the new-borns. Overall, a handful of hurdles, namely inadequate awareness, insufficient manpower and inefficient linkage to care leading to obstacles to HBV elimination, are yet to be overcome before 2030. The very high caseload of HBV diseases in Asia hampers the effective implementation of universal screening in high endemicity regions and causes challenges in ensuring high antiviral treatment uptake [[7]Lai JC Wong VW Yip TC Hui VW Tse YK Lee HW Liang LY Lui GC Chan HL Wong GL. Secular trend of treatment uptake in patients with chronic hepatitis B: a territory-wide study of 135 395 patients from 2000 to 2017.J Gastroenterol Hepatol. 2021; 36: 3487-3499https://doi.org/10.1111/jgh.15664Crossref PubMed Scopus (2) Google Scholar]. Most of the governments are developing their own strategies tailor-made for their local situation. For example, Taiwan initiated the viral hepatitis screening policy in 2011, starting with patients attending healthcare services and who were older than 45; the screening has been broadened to all adults aged 45-79 years since September 2020 [[8]Chen DS. Fighting against viral hepatitis: lessons from Taiwan.Hepatology. 2011; 54: 381-392https://doi.org/10.1002/hep.24500Crossref PubMed Scopus (54) Google Scholar]. In order to learn from best practices, international collaborations led by either the government, academia or patient groups would be beneficial. For example, patient-led organisations focusing on hepatitis, such as the Yellow Warriors Society of the Philippines, help fill the gaps in the national response when it comes to awareness, education, and stigma prevention. Simplified logistics for clinical service may lessen the workload in specialist hepatology clinics while allowing management of more patients. Care pathways need to be simplified and antiviral treatment for HBV should be decentralised to general practitioners and primary care setting to increase treatment uptake and ensure compliance [[9]Duchesne L Lacombe K. Innovative technologies for point-of-care testing of viral hepatitis in low-resource and decentralized settings.J Viral Hepat. 2018; 25: 108-117https://doi.org/10.1111/jvh.12827Crossref PubMed Scopus (30) Google Scholar]. The theme of World Hepatitis Day 2023 is “We're not waiting”. Over the years, the WHO hepatitis elimination advocacy has led to many new strategies, which are leading to better HBV control. The world can't wait to accelerate the elimination efforts so that the pre-set targets can be met by 2030, if not earlier. In high endemicity Asia Pacific, the progress may appear slow as changes in practices and behaviour take time. The lessons we learn are the dedications of different parties, continuous modifications of the strategies according to the evolving situations locally or globally (e.g. during COVID-19 pandemics). Both high-level Government-led policies and community participation are important for engaging stakeholders in the development and implementation of HBV elimination plans. The successful execution of these strategies to eventually eliminate HBV depends fundamentally on the robust involvement of healthcare services. Implementation of targeted measures is predicted to have a substantial impact on the drive towards the elimination of HBV. Grace Wong was partly supported by the Health and Medical Research Fund (HMRF) of the Food and Health Bureau Commissioned Research on Hepatitis (CID-CUHK-D) in Hong Kong. Grace Wong has served as an advisory committee member for AstraZeneca, Gilead Sciences and Janssen, as a speaker for Abbott, AbbVie, Bristol-Myers Squibb, Echosens, Furui, Gilead Sciences, Janssen and Roche, and received research grant from Gilead Sciences. JO has served as local advisory board member and speaker for Roche, Hi-Eisai, and received research grant from Gilead Sciences. AK has no conflicts of interest to declare. T-HS has served as a consultant for Gilead Sciences, and was on speaker's bureaus for Abbvie, Bayer, Bristol-Myers Squibb, Gilead Sciences, Lilly, Merck Sharp and Dohme, Roche, Sysmex and Takeda, and received research grant from Gilead Sciences
SDGs
Type
editorial