Viral hepatitis “can and should be managed within primary care,” says Dr. Thomas Robertson.
Today, July 28, is World Hepatitis Day. Viral hepatitis is an inflammation of the liver, and its various types account for a significant disease burden worldwide.
To delve into the current disease state of hepatitis, and the steps that need taken to end hepatitis transmission by 2030, Contagion interviewed internal medicine specialist Thomas Robertson, MD, FACP.
Robertson is the associate program director and director of ultrasound education of the Allegheny Health Network (AHN) Internal Medicine Residency Program, as well as an assistant professor of medicine at Drexel University College of Medicine, and co-director of the Rethinking Incarceration and Empowering Recovery (RIvER) Clinic Center for Inclusion Health.
Contagion: Can you briefly outline the different kinds of viral hepatitis?
Dr. Thomas Robertson: There are a number of types of viral hepatitides, but the 3 main ones are: hepatitis A, Hepatitis B, and Hepatitis C. Hepatitis C makes up the dominant share of downstream sequalae of pathology caused by viral hepatitis in the USA, and that’s because so many of us are vaccinated as children against hepatitis B.Worldwide, both Hep B and C share a significant portion of causing chronic liver disease. Hepatitis A, for which we also have a vaccine, does not cause chronic liver disease, and causes a self-limited infection in over 99% of cases.
C: How are they transmitted?
TR: Hep A is transmitted through what we call the fecal-oral route: food, water, or some other substance contaminated with hepatitis A infected fecal material.
Hep B is transmitted from those who are infected to those who are not immune, predominantly through mother-to-child transmission in high prevalence areas, but also injection drug use and sexual intercourse are additional modes of transmission.
Hepatitis C is primarily spread through injection drug use these days. Rarely through sexual activity, almost never through blood transfusions anymore due to screening blood products.
C: What are the infection rates and mortalities for each type of viral hepatitis?
TR: Hep A has low infection rates due to vaccination in the USA, and usually occurs due to food outbreaks. In 2014, three were only about 2500 cases of Hep A in the USA for the entire year, giving it a case rate of about 0.4 per 100000 persons. There is almost no mortality from Hep A, with fulminant hepatic failure occurring in less than 1% of cases.
Hep B has a much bigger burden of disease worldwide, with well over 250million chronic HBV carriers and nearly 1,000,000 deaths from HBV-related liver disease per year worldwide. This is much less in the USA, where vaccines are nearly universal, with a rate of roughly 1 case per 100,000 persons. About 30% of those infected with HBV get noticeable hepatitis and jaundice. The risk of developing chronic HBV depends on the age when one acquired the virus, anywhere from 90% if perinatally acquired, to less than 5% if acquired as an adult. Overall, the risk of progression of chronic HBV to cirrhosis is about 20%, with a subsequent 15% risk of developing liver cancer.
Hep C has a larger disease burden in the USA, about 50,000 new cases annually which is almost 3x that of HBV. Symptomatic acute HCV infection is rare, so the real risk is chronic HCV infection, which about 75% of those who are exposed to the virus will go on to have chronic HCV. Over time, about 20-30% of chronic HCV infected patients will go on to develop cirrhosis, or scarring of the liver, which unleashes a subsequent complex cascade of health consequences, including a higher risk of liver cancer. In the USA, the age-adjusted mortality rate among patients with HCV is higher than those with HIV, and there are roughly 10-15,000 deaths per year in the USA due to chronic HCV infection, and more than 400,000 deaths yearly worldwide.
C: What kind of threat does hepatitis pose to the US, and to the world?
TR: Viral hepatitis was the seventh leading cause of death worldwide. They are big threats because they are increasing. Here in the USA, let’s start with HCV: among people aged 18-29, rates of HCV have increased by 400% in a 10-year span, predominantly driven by the opioid epidemic. This is important because we know the longer one has chronic HCV infection, the more likely the liver will become scarred, cirrhotic, and have a much higher risk of cancer.
Worldwide, I mentioned over 250 million people are carriers for chronic HBV with nearly 1000000 deaths annually, which has increased over 20% since 2000. And the shocking part is that HCV is basically universally curable with a short course of medication, and HBV is preventable with appropriate vaccination programs.
C: Are there any populations disproportionately affected by hepatitis?
TR: HCV in the USA is primarily driven by those who use drugs, primarily through injection but it is transmittable through other use practices as well. This has now shifted to younger individuals who would not have been eligible for routine screening under the previous guidelines. Fortunately, those changed in 2019 to recommend at least one time screening for all adults aged 18-79 in the USA—this is supported but the CDC, AASLD, IDSA and USPSTF. The reality is that 45% of those infected with HCV do not recall or report a classic risk factor, so universal screening is a huge positive step.
Regarding HBV, it primarily affects lower income countries in Asia and Africa, but does have higher prevalence in those who inject drugs here in the USA.
C: Can you talk about the stigma that persists around hepatitis?
TR: I don’t think many people really think too much about hepatitis, unfortunately, and most aren’t aware how rapidly and how drastically the demographics have shifted in terms of who is now most commonly affected.
We also sadly see stigma transmitted within the healthcare system—people denied treatment for their HCV due to things such as alcohol use, homeless, even active injection drug use—which goes against guidelines practices and all of the data that exist.
C: How do you get messaging and treatment to most impacted groups without adding to stigma?
TR: We focus on screening, particularly high-risk individuals, and use a multidisciplinary team to address social determinants of health and other barriers to treatment. We don’t deny treatment to anyone who has chronic HCV unless either they choose not to undergo treatment, or have less than one year of life expectancy. We’ve tracked data and have had an extraordinary success in treating and curing high-risk individuals (including those with active injection drug use) of their HCV, more quickly and with reduced liver scarring than if they had been referred to a subspecialist for treatment.
The other piece to this is not sitting back behind 4 walls waiting for patients to come to you. Outreach is key. We have rapid HCV testing now that results in 20min so moving beyond the traditional confines of an office and doing outreach testing in the community is an important way to capture other individuals, show dedication to marginalized populations, and build connections to care.
C: What are the prevention and treatment options for hepatitis infection?
TR: For HCV, since we don’t have a vaccine, prevention focuses on reducing transmission. This includes a harm reduction approach, focusing on safe injection/drug use practices, using barrier protection for sexual encounters, education on how the virus can be transmitted, and increasing access to multidisciplinary substance use treatment centers to reduce risky behaviors, particularly injection drug use.
There is also the concept of treatment as prevention, similar to the HIV campaign—where treating and curing someone’s HCV eliminates the possibility of that person spreading the virus. Models show a reduction in overall prevalence and transmission, suggesting the possibility of a 90% reduction in incidence by 2030 as more people who use injection drugs are treated.
The modern HCV treatment options, called Direct Acting Antivirals (DAAs), are truly a miracle of science—one of the most revolutionary advances in modern medicine. Treatment involves a short course of medication—typically 8-12 weeks—with some follow up blood work. This leads to a >95% cure rate.
For HBV, prevention is key through vaccination which is traditionally a 3-part series done as a child. Treatment for HBV is much more complicated, difficult to undergo, and less effective than for HCV.
C: What can you tell us about hepatitis vaccination?
TR: It works remarkably well for HAV and HBV and is the key to reducing the prevalence of these diseases worldwide. Occasionally we see immune titers that are not quite high enough, which prompts us to revaccinate. But all in all, these vaccines are incredibly safe and effective.
C: What policies and programs currently exist to end viral hepatitis in the US?
TR: Within the USA, the American Association of the Study of Liver Diseases (AASLD—the leading scientific and medical organization in the US regarding liver diseases) supports the World Health Organization’s (WHO) HCV elimination target of 2030 which has a goal of reducing new infections by 80% and HCV related mortality by 65% compared to 2015 levels. A lot of local health depts have their own programs, including here in Allegheny County (HepC Free Allegheny).
C: What are some recent developments in hepatitis prevention and treatment?
TR: I mentioned the DAAs being a miracle of modern medicine, and I don’t think that’s an exaggeration. HCV wasn’t discovered until the mid-1990s, and the initial treatments were horribly tolerated and marginally effective.
Since the advent of DAAs, cure rates and tolerability have skyrocketed. The most recent advances are that all of the DAAs used now are pangenomic, meaning they will cure any and all HCV genotypes, which makes it much easier for a clinician to understand which medication to use and how to treat.
C: What steps need taken in the fight against hepatitis?
TR: For HCV: it starts with education primary care clinicians. This is disease is now to a point where it can be easily screened for and treated right within a primary care office, and there is much data out there showing this.
This fight also involves expanding screening beyond brick-and-mortar clinics, taking that leap to outreach to marginalize populations, as well as not denying treatment to those persons with ongoing risk. The other piece is focusing on risk-factor modification, so education on safe drug use practices, supporting substance use treatment, etc.
For HBV the fight is to continue to vaccinate: to promote the truth of the vaccine’s efficacy and safety.
C: What developments do you hope to see this World Hepatitis Day?
TR: I want to see more primary care clinicians empowered to treat HCV. This is not a subspecialist disease anymore—it can and should be managed within primary care and that can be done actually more quickly and with less issues than by subspecialists, and the data support that.
The other thing I want to see is increased screening in the community particularly for marginalized populations, more outreach, and more support for substance use treatments. It’s imperative to highlight again and again is that active drug use or other risky behaviors is not a reason to not treat—that goes against all available data and guideline recommendations.
For HBV, it focuses on continuing vaccination awareness and getting as many people vaccinated as possible
C: What do you wish clinicians, and the general public, knew about hepatitis?
TR: How important of a problem it is and how easy it is to treat these days. There are also collateral benefits from treatment that are difficult to quantify in a study, but I see all the time: people are more engaged in their healthcare and empowered when they see their HCV cured.
The other thing is that treatment is covered by insurance, despite a high cost it’s actually cost effective for healthcare systems to treat, and that data exists as well.