Joint society statement for the elimination of viral hepatitis
Authors: Javier Brahm, Laurent Castera, Jinlin Hou, Keith Lindor
Journal: Hepatology (2016)

Potential conflict of interest: Nothing to report. The Burden of Viral Hepatitis on Human Health Compared to better‐publicized infectious diseases such as HIV or malaria, viral hepatitis is often referred to as a silent killer. Of the five hepatitis viruses (A‐E), hepatitis B, C, and D viruses cause chronic liver disease leading to cirrhosis, liver failure, and liver cancer. Hepatitis B, C, and D viruses, which are transmitted through blood and body fluids, may also cause damage to organs other than the liver. Hepatitis A and E viruses are transmitted orally and cause acute hepatitis, which may result in acute liver failure and death. The World Health Organization (WHO) estimates that as many as 400 million people worldwide are living with chronic hepatitis viral infection. Liver cirrhosis is an important cause of mortality globally—more than 1 million people die of cirrhosis, with the majority due to viral hepatitis. Hepatocellular carcinoma, the most common form of liver cancer, is the third leading cause of cancer deaths, claiming more than 500,000 lives each year. The purpose of this statement is to highlight the need for public health interventions in order to prevent, diagnose, and treat viral hepatitis in a timely fashion to reduce the burden of viral hepatitis. Despite the enormous burden of viral hepatitis, patients with chronic viral hepatitis are often symptom‐free until they develop complications such as cirrhosis or liver cancer. Once symptoms occur, the interventions that are currently available are often ineffective and/or expensive. Health Care for Viral Hepatitis Highly accurate diagnostic tests are available for all hepatitis viruses. Simple inexpensive blood tests are available in many, but not all, countries to screen and identify patients with viral hepatitis infection. Confirmatory blood tests and routine biochemical tests allow early diagnosis of chronic liver disease due to hepatitis viruses before cirrhosis or hepatocellular carcinoma develops. For the majority of patients with chronic viral hepatitis, namely hepatitis B and C, effective medications are available for treatment. Treatment of chronic viral hepatitis B and C has been shown to reduce cirrhosis, hepatocellular carcinoma, and mortality. The most remarkable recent advance is that the vast majority of patients with chronic hepatitis C can be cured with 8‐12 weeks of oral medications with very few side effects. Chronic hepatitis B can also be effectively managed by long‐term suppression of the virus using safe oral medications, similar to HIV treatment. The most impactful public health intervention for viral hepatitis is prevention. Effective vaccines are available for hepatitis A, B, and E. Of these, immunization against hepatitis B virus is critically important—universal vaccination of infants starting at birth has been shown to reduce not only the prevalence of the infection of the birth cohort, but also its health consequences, including hepatocellular carcinoma, later in life. Other important public health measures include the elimination of health care–related transmission of hepatitis viruses by the screening of blood and blood products, proper sterilization of dental, medical, and surgical equipment, and implementation of safe injection practices. To reduce transmission of viral hepatitis from people who inject drugs, harm reduction programs, such as needle exchange programs, should be available. Public Health Mandate Given the large burden of viral hepatitis, governments around the world, although not universally, have made various efforts to mitigate its impact. Furthermore, the availability of effective means for prevention and treatment makes the elimination of viral hepatitis feasible. Recognition of viral hepatitis, as an important public health threat, motivates the implementation of subsequent actions. Accurate data can enable the understanding of locale‐specific information about viral hepatitis and inform proper allocation of resources. Screening for undiagnosed chronic viral hepatitis in definable population subgroups has been shown to be cost‐effective. Evidence‐based treatment guidelines facilitate the prioritization of antiviral therapy delivery. National programs for systematic immunization have resulted in demonstrable benefits at the population level. The significant progress recently made in the management of viral hepatitis is a result of a committed funding of research. WHO has set a goal to eliminate viral hepatitis as a major public health threat by 2030. Recommendation The leading professional organizations in liver disease, the American Association for the Study of Liver Diseases (AASLD), the European Association for the Study of the Liver (EASL), the Asian Pacific Association for the Study of the Liver (APASL), and the Asociación Latinoamericana para el Estudio del Hígado (ALEH), urge governments, health care organizations, and nongovernmental organizations to implement the following action plans: Recognize the public health burden posed by viral hepatitis as a priority and establish plans to curb its impact. Deploy data infrastructure to assess the public health impact of viral hepatitis. Establish practice guidelines, which make recommendations for immunization, screening, diagnosis, and treatment. Develop and implement comprehensive hepatitis prevention programs, including universal vaccination of all newborns against hepatitis B virus (HBV) infection. Define at‐risk populations to screen for hepatitis B and C virus infection. Make accurate screening and diagnostic tests available and affordable for public health programs. Implement and finance health care programs to diagnose and treat individuals with chronic HBV and hepatitis C virus (HCV) infection according to the accepted practice guidelines. The goal should be to minimize and, over time, eliminate the health burden of viral hepatitis. Support research in the laboratory, in patients and in the population.