On July 28th, the United States joins countries around the globe to observe the third annual World Hepatitis Day. One of only eight health campaigns recognized by the World Health Organization (WHO), this health observance raises awareness of the silent yet growing epidemic of viral hepatitis worldwide. Each year, 1.4 million persons lose their life to viral hepatitis, similar to the number of deaths from HIV/AIDS (1.5 million), tuberculosis and malaria (1.2 million each).
Deaths from viral hepatitis are caused by one of five hepatitis viruses. Hepatitis A and hepatitis E, which are spread fecal-orally either by person-to-person contact or contaminated food or water, are major causes of acute hepatitis, particularly in areas of the developing world suffering from lack of access to clean water and poor sanitation and hygiene. A report in this week’s Morbidity and Mortality Weekly Report describing an outbreak of hepatitis E in a refugee camp in South Sudan reminds us of this often neglected disease that disproportionately kills expecting mothers in many of the poorest countries of the world (see this week’s MMWR).
Hepatitis B virus (HBV) and hepatitis C virus (HCV) cause chronic infection that can result in liver disease and death. Worldwide, 240 million people are living with hepatitis B and 180 million are living with hepatitis C. More than 1 million people die each year from chronic hepatitis B or C.
Although available data reveal viral hepatitis as a global health threat, there are important gaps in epidemiologic data measuring the disease’s burden. Information about new infections is also spotty in many parts of the world, particularly Eastern Europe, central and south Asia, and most of Africa. In Africa, the burden of HIV coinfection with HBV and HCV is underappreciated and doubtless causes significant morbidity and mortality. Fortunately, the United States President’s Emergency Program For AIDS Relief (PEPFAR), which provides bilateral funding to 49 countries and regional programs in Africa, the Middle-East, Asia, Europe, the Americas, and the Caribbean, has a strong presence in Africa and other countries with high hepatitis burden. Country PEPFAR programs are increasingly recognizing the importance of preventing HIV and viral hepatitis coinfection, and the potential to extend the expertise and infrastructure from PEPFAR to combat viral hepatitis. With careful planning and coordination PEPFAR can greatly promote viral hepatitis control in much of the world at little additional cost.
Through partnerships at the international, regional, and country level, CDC’s Division of Viral Hepatitis (DVH) works to control viral hepatitis globally. WHO is CDC’s major global partner in this effort. CDC provides a medical officer to the WHO headquarters to spearhead hepatitis control activities. The initial focus of global hepatitis control was exclusively to promote hepatitis B vaccination of children and newborns. Since 1982, more than 1 billion doses of hepatitis B vaccine have been administered to children worldwide. The GAVI Alliance alone has been instrumental in preventing more than 3.7 million deaths from hepatitis B through its support for national immunization programs. Because HBV can be transmitted from mother to child at birth, vaccinating newborns – ideally within 24 hours of delivery – can prevent 85 percent of HBV infections transmitted from infected mothers to their children. There are significant challenges, however, in reaching all newborns with a timely dose of hepatitis B vaccine. Currently, as few as one in four infants worldwide receive hepatitis B vaccine within 24 hours of birth and fewer than 50 percent of countries (92 of 193) report offering the birth dose as part of their routine hepatitis B immunization program. CDC will continue to provide assistance to WHO and its partners to improve access to hepatitis B vaccine for newborns living in the world’s poorest countries. For example, CDC recently assisted in a review of the infant immunization program in Laos to identify strategies for overcoming barriers to newborn hepatitis B vaccination. That effort is also reported this week in the MMWR.
In response to a resolution by the World Health Assembly, in 2011, the WHO established a Global Hepatitis Program (GHP). The GHP developed a global strategy with four priorities: a) awareness, education, and advocacy; b) data for decision making; c) prevention including vaccination; and d) care and treatment. CDC supports WHO/GHP in implementing this strategy by providing both technical and financial support. CDC is currently assisting WHO in drafting guidelines to improve viral hepatitis surveillance, implementation of hepatitis B vaccine birth dose and treatment guidelines for HCV and HBV in low-resource settings. CDC also works closely with WHO regional offices. For example, CDC has assigned staff to assist the WHO’s Western Pacific Region reach the ambitious goal of reducing the prevalence of hepatitis B to less than 1 percent among children less than 5 years of age. CDC also works directly with countries requesting technical assistance/support. For example in Pakistan, CDC is working with USAID to improve hepatitis surveillance and develop a national strategy to control HCV. In Egypt, the country with the world’s highest prevalence of HCV, CDC is working with WHO and the Pasteur Institute to develop a comprehensive plan to confront the epidemic for the Egyptian Ministry of Health. In Vietnam, CDC is working closely with PEPFAR and WHO to support the Vietnamese government in developing surveillance for HBV and HCV. And, as described in this week’s MMWR, CDC assists with evaluation and improvement of hepatitis B vaccination programs in Laos and other countries.
CDC actively seeks to participate in public-private partnerships to accomplish viral hepatitis prevention and control activities globally. Without those partnerships the large gaps that already exist between the richest and poorest countries could grow larger. There’s also agreement that partners need to work together to prevent viral hepatitis transmission and reduce mortality by providing care and treatment to the 400 million people living with HBV or HCV. In this era of effective treatments for HBV and emerging safe all-oral treatments for curing HCV, the next step is ensuring access to these effective therapies for all people suffering with chronic hepatitis. The Viral Hepatitis Action Coalition (VHAC) of the CDC Foundation has been a great partner in expanding the capacity of CDC to provide technical assistance to countries with large burdens of hepatitis. However, much remains to be done. The work ahead includes describing the burden and epidemiology of viral hepatitis in Sub-Saharan Africa where the disease is poorly understood, controlling transmission in countries with low vaccination coverage and poor quality healthcare, and providing care and treatment to the millions already infected in countries such as China, Egypt and Pakistan.
With increased awareness of hepatitis’ global burden, the silent epidemic is beginning to emerge from the shadows. This emergence has led to a great demand for technical assistance and support for countries that want to confront the epidemic. This is a monumental task at a time of great opportunity. CDC welcomes partnerships in this effort. For more information on World Hepatitis Day, please see the CDC Hepatitis homepage.