The silent nature of viral hepatitis infection has an enormous impact on the capacity and willingness of governments across the world to develop and implement effective policy and health responses to these diseases.
The burden of viral hepatitis is stark, particularly in Asia Pacific where the prevalence is greatest, with approximately 340 million people living with chronic hepatitis B and hepatitis C. This is almost eight times the number of people in the region infected with HIV, tuberculosis (TB) or malaria (42 million). In 2011, the World Health Organisation’s (WHO) south-east Asia office reported there are 120,000 deaths annually related to hepatitis C and 300,000 related to hepatitis B.
Viral hepatitis is a significant health problem, but its silent nature – there are no symptoms in the early phases, so people are often unaware that they are infected with hepatitis B and C until it is too late – has meant that the diseases have not had the same global and regional response as HIV, TB and malaria, and this lack of co-ordination continues to undermine global health efforts.
In 2010, there were signs that things were changing, with the agreement of a resolution on viral hepatitis by the World Health Assembly, but its implementation to date has been slow and unco-ordinated. Ahead of World Hepatitis Day on Saturday, this week’s publication of a global framework by WHO is another important milestone, but it runs the risk of failing to deliver if the denial that exists around chronic hepatitis, among individuals and in health systems, is not addressed.
Hepatitis B, which is transmitted from mother to child or through bodily fluids, is prevented with a safe and effective vaccine. There has been some recent good news from China, which successfully reduced the number of children under five with hepatitis B from 5.5% in 1992 to less than 1% in 2005, according to WHO.
But there remain huge barriers for implementing vaccination programmes among babies and young people in the region. Although there is access to vaccines, the implementation can be problematic where there are fundamental weaknesses in health systems. In countries such as Papua New Guinea or Laos there are simply not the health services nor workers available to carry out vaccinations.
For most people with viral hepatitis, the infection has no obvious symptoms, meaning that their disease is likely to progress to a point where treatment has limited impact. Most people with viral hepatitis do not know they are infected. Even in countries such as Taiwan and Australia where hepatitis is recognised as a priority health issue, a sizeable proportion of people are yet to be diagnosed.
There are systemic barriers to testing in many countries in the region such as Vietnam, Singapore, Philippines, or Thailand where people are required to pay for testing. This essentially limits the number of people who know they are infected and the ability to reduce the impact of infection.
Hepatitis B infection is complex, and liver damage as a result of the infection occurs over many years. Most people with chronic hepatitis B will not require treatment, but will need to be monitored to identify when liver damage is taking place. Only about 15-25% of people need to receive treatment for the infection.
However, for people who do know that they have the infection, access to health services can be an issue. Of the 300,000 to 400,000 people living with chronic hepatitis B in Hong Kong, 80,000-90,000 people (25%) need treatment, and only half are being treated
Like many 21st-century health issues, viral hepatitis knows no borders. Migration and other movements of people mean that comprehensive and co-ordinated responses to the infection within and across countries are imperative if the burden of infection is to be reduced or eliminated.
In collaboration with the Australian Research Centre in Sex, Health and Society at La Trobe University, the Coalition for the Eradication of Viral Hepatitis in Asia Pacific (Cevhap) has developed a research plan to assist countries and the World Health Assembly to identify the essential elements of a strategic response to chronic viral hepatitis. This work is under way, with assessment of the policy in Taiwan, a needs assessment of people with chronic viral hepatitis across five locations in China, and support for the facilitation of partnership development initiatives in Malaysia and India.
Lessons from other international health issues such as HIV can support the development of effective policy and health responses to viral hepatitis. One lesson is the importance of broad-based partnerships in policymaking, something that has been woefully lacking in Asia. More important, however, is the need for WHO to establish a sustainable mechanism for international funding and implementation of the new global framework and the newly formed Global Hepatitis Programme, similar to those that exist for HIV, TB and malaria.
An effective policy framework can prevent new infections, ensure people can access clinical care, and reduce the burden of infection at an individual, country and regional level. That will only be possible if funding is increased considerably. The global response provided by UNAids, the Stop TB Partnership and the Rollback Malaria Partnership show what can be achieved if governments, the medical community, donor organisations and civil society work together.
Viral hepatitis can be eliminated with resources, co-ordination and willingness, but, as the world recognises the second WHO-endorsed World Hepatitis Day, a lack of funding remains the single greatest barrier to tackling these diseases.
Professor Ding-Shinn Chen is a distinguished chair professor at the department of internal medicine, College of Medicine, National Taiwan University and is chair of Cevhap. Jack Wallace is a research fellow at the Australian Research Centre in Sex, Health and Society at La Trobe University, Melbourne, and a founding member of Cevhap