ㆍNo vaccines and symptoms, but complete cure with oral treatment
ㆍWHO’s declaration to eliminate, propelling each country to establish strategies
ㆍNecessary to reassess the policies amid COVID-19
In February, Health Kyunghyang launched an ambitious series of articles titled “Medical Discussion with the World's Great Scholars.” As well-received by both academia and readers, we expect to discuss with leading health, medical scholars at home and abroad the latest treatments for various diseases and directions of healthcare development based on future medicine. The second topic is “Hepatitis C Virus.” <Editor's Note>
Hepatitis C virus (HCV) is the main cause of liver cancer along with hepatitis B. In particular, HCV has a 70 to 80% chance of chronic progression, much higher than that of hepatitis B, and does not recover naturally. It is not easy to develop vaccines due to mutations, and asymptomatic infections mostly occur. However, eradicating HCV is possible as the infection is the only viral hepatitis that can be completely cured with oral administration. The World Health Organization (WHO) declared the elimination of hepatitis C by 2030 and is urging global efforts.
The panels of this discussion were ▲Jeong, Sook-hyang (Dept. of Gastroenterology, Seoul National University Bundang Hospital) ▲W. Ray Kim (Dept. of Gastroenterology, Stanford University Medical Center) ▲George Papatheodoridis (professor at the National and Kapodistrian University of Athens, Medical School) ▲Jia-Horng Kao (professor at National Taiwan University College of Medicine).
Individuals and countries should work together to fight hepatitis C. Countries should actively find patients with hepatitis C and improve their awareness of the disease through institutional assistance, and the public should be alert and active in participating in screening and treatment. Since hepatitis C leads to liver cancer, which brings serious socio-economic pressure, the effect of early detection and treatment is crucial. Hence, countries around the world are implementing various policies to fight hepatitis C, including state-sponsored hepatitis C screening and expanding the age of the targeted group for the screening.
- Has the public's awareness of hepatitis C increased since the release of the treatment for the complete cure?
Dr. Jeong from South Korea: In Korea, the Direct Acting Antivirus (DAA) for HCV began to be covered in 2015, and most of the new drugs have become able to be prescribed. Patient treatment performance is also excellent at over 95%.
The awareness level of HCV is also higher than in the past due to activities by the association and media reports. But more effort is still required. According to a survey conducted by the Korea Centers for Disease Control and Prevention (KCDC; previous name) in 2019, only 34% of the general population was aware of HCV. In the case of medical personnel, the recognition of HCV symptoms and infection pathways was high at 90%, but the treatment was relatively low at 75%. According to a telephone poll of 1,003 people conducted by researchers at Seoul National University Bundang Hospital, 56.4% have heard about hepatitis C, and only 9.1% had an antibody test.
Dr. Kim from the U.S.: Although public awareness is still low, the medical staff's awareness of hepatitis C is relatively high. In particular, the US Prevention Services Task Force (USPSTF) has been giving more attention to the virus and putting effort into fighting the infection lately.
Dr. Papatheodoridis from Greece: The degree of concern or awareness in Europe varies widely among different countries and different subgroups of the population including medical staff. The degree is high in medical staff with specialties close to hepatitis C, such as hepatologists, gastroenterologists, infectious disease specialists, and even those taking care of patients at high risk of HCV like nephrologists and hemophiliac/thalassemia specialists but remains low in other specialties. Regarding the governments, the awareness is good in those with implemented national plans for HCV elimination, but not in others.
Dr. Jia-Horng from Taiwan: When WHO adopted the Global Health Sector Strategy on viral hepatitis in 2016, it immediately caught the attention of the Taiwanese government, although Taiwan isn't a member state, and efforts towards the elimination of HCV were seriously considered. The Taiwan Hepatitis C Policy Guideline 2018-2025 was published in 2019. Its main strategies include active screening, continuum of care, preventive measures for high-risk populations, improving the awareness and liver health literacy of the people and medical staff on the prevention of new infections and reinfections, liver disease management, outcome evaluation of policy, interventions, and lowering barriers of access to care. The government leaders have culminated in a consensus of reaching the WHO goals in 2025—5 years earlier than the 2030 deadline set by WHO.
- What is the most appropriate screening strategy each country may implement for the early discovery of HCV?
Dr. Jeong from South Korea: Korea has a well-equipped national checkup system and a screening rate of more than 70%. Therefore, hepatitis C should be included in the national health screening program category, requiring those between 40 and 65 with a high prevalence rate to be checked up once in a lifetime.
Dr. Kim from the U.S.: Last year, the USPSTF published a new recommendation in a journal on the American Medical Association that those in their ages between 18 and 79 should take hepatitis C screening at least once in their lifetime. This may seem positive as the previous screening recommendation targeted only the risk group such as persons who inject drugs, homosexuals, or middle-aged people born between 1945 and 1965; however, the weak point is that not all citizens are being tested. In particular, measures are required for drug users, the group that has a high incidence rate of hepatitis C.
Dr. Papatheodoridis from Greece: In Greece, screening of all individuals born between 1945 and 1980 is recommended, endorsed, and reimbursed—while in other countries, screening of only high-risk groups or less frequently of the general population is recommended. The main challenge may not be the recommendation, but the actual implementation of screening in the target population.
Dr. Jia-Horng from Taiwan: In Taiwan, we put much effort to increase public awareness for HCV infections by doing mass screening programs with simple and rapid methods as well as linking the patients to point-of-care. Since 2021, the government has started a nationwide screening program for HBV and HCV infection once in a lifetime between the age of 45 and 79.
- What should each country or international society most urgently do to increase the rate of diagnosis and treatment of HCV?
Dr. Jeong from South Korea: Active screening through a national screening system will help discover patients with HCV. Then, a strategy is needed to increase the rate of treatment by directly connecting the patients to treatment.
Dr. Kim from the U.S.: The government and international societies should continue to take effective measures to ensure that the people actively participate in the diagnosis and treatment of hepatitis C. It is also important to eliminate misconceptions or fears about the treatment of the infection.
Dr. Papatheodoridis from Greece: The government should develop detailed national plans for HCV elimination, start its implementation immediately, monitor the results of the activities, and make improvements if needed.
Dr. Jia-Horng from Taiwan: For the global elimination of HCV by 2030, there should be ▲blood donor screening for HCV ▲safe injection practices ▲stringent infection-control programs to reduce the burden of HCV infections ▲antiviral treatments for HCV patients. However, a huge amount of work needs to be done in the coming decade. Even if the Member States has already established various strategies, they still need to ensure that those affected have access to hepatitis services. A recent study on high-income countries showed that even with the introduction of curative HCV regimens, 80% of them were not on track to meet the HCV elimination target by 2030, and 67% were off track by at least 20 years. Therefore, the most urgent issue for the government and the international community is to improve HCV screening and treatment to make HCV elimination achievable.
- What are the social benefits and cost-effectiveness of early discovery and treatment of HCV?
Dr. Jeong from South Korea: According to a study published in Liver International in 2019, an incremental cost‐effectiveness ratio (ICER) of $7435 compared with no screening was spent when integrated the anti-HCV test into the National Health Examination Program for those between the ages of 40 and 65—the group with the highest incidence rate of HCV in the country. This is much lower than the $27,205, the maximum limit of willing-to-pay (which indicates cost-effectiveness). The screening also reduced 32 hepatitis C-related deaths per 100,000 people and prevented liver cancer of 19 people. Also, the 40 to 65-year-old population recently used a national health examination and were screened twice (a model that selects and examines those who missed the first screening) and treated with the latest treatment drug that costs about KRW 5.33 million (about US $4,200) compared to high-risk group screening strategies.
Dr. Kim from the U.S.: The reason why the U.S. is recommending universal screening is that analysis has shown that screening and treatment are cost-effective. In that study, if the prevalence of HCV is greater than 0.1%, it meets the societal standard for cost-effectiveness. However, this doesn’t mean that universal screening will eventually save money. Society still needs to invest funds to help improve the health outcomes of its citizens. Also, since HCV is a stigmatizing disease as well, early diagnosis and treatment will help eliminate the stigma.
Dr. Papatheodoridis from Greece: HCV not only causes liver injury, progress to cirrhosis and hepatocellular carcinoma, but it also affects the patients’ quality of life and productivity. Also, given that there is no vaccine for HCV, treating HCV patients is the key method for preventing secondary HCV infections, particularly in patients with high-risk factors.
Dr. Jia-Horng from Taiwan: Previous studies showed that successful treatment of HCV at an early stage significantly reduces the disease burden of liver cirrhosis, cirrhotic complications, HCC, and extrahepatic illness over time—which will exert remarkable socio-economic effects in the future.
- How does COVID-19 affect WHO’s goal to eliminate global HCV?
Dr. Jeong from South Korea: To actively implement the screening strategy for hepatitis C, which has already proven its cost-effectiveness, government assistance along with securing the federal budget is essential. Also, to immediately advance the patients diagnosed via the screening to treatment, the medical team should be thoroughly informed of the simplified treatment strategy. Besides, the treatment guidelines need to be updated as well. Korea will become a world leader in eliminating the disease if it actively operates the hepatitis C eradication project for about five years as the prevalence of the infection is relatively low in the country.
Dr. Kim from the U.S.: Due to the global economic devastation caused by COVID-19, there is a lack of cooperation and funding from various institutions to fight hepatitis C. Although HCV seems less significant compared to COVID-19 from a global perspective, we should expand the perception that hepatitis C is an infectious disease that requires public awareness. For now, WHO's goal appears unachievable, but what needs to be done is to first collect resources and reassess the policies to accomplish the goal.
Dr. Papatheodoridis from Greece: Definitely, the COVID-19 pandemic has affected the efforts for HCV elimination in most parts of the world. However, the efforts should restart as soon as possible in each country, and the need for the continuation of implementing national plans or strategies is now greater than ever.
Dr. Jia-Horng from Taiwan: The associated economic downturn due to COVID-19 affects every sector of the community and undermines the funding allocated for HCV elimination, making WHO’s global elimination goal by 2030 difficult. To accomplish this goal, we need to reassemble the resources once the pandemic is restrained and assess the status of each country to revise the national goal as well as action plans.