New Frontiers for Disease EradicationCase Study: Hepatitis B and C

University of Colorado

Jon Kim Andrus, MDAdjoint Professor and Director Vaccines and ImmunizationCenter for Global HealthUniversity of Colorado

Denver, Colorado, October 2017

Learning Objectives

• Understand the approach to the elimination of Hepatitis B and Hepatitis C in the United States compared to approaches used in traditional disease elimination

• Appreciate the scientific prinicples of the strategies to be used for Hepatitis B and Hepatitis C elimination in the United States

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Key Considerations

• Viral hepatitis is the 7th leading cause of death globally; HB and HC cause 1 million deaths/year (20,000 in USA)

• Both disproportionally affect racial and ethnic minorities, and marginalized persons, e.g. IVDUers

• HBV3 95% effective, HC Rx cure 95%

Task at hand• Develop measurable, overarching goals

for Hep B and C that are feasible to achieve given advances in control

• Recognize and incorporate lessons learned from previous work

• Apply those lessons to complex issues:– Two different diseases– Variance in disease progression: acute, self-

limiting infection; asymptomatic infection; and chronicity

• Define and plan for challenges reaching the target

Eradication - StrungmannForum 2010

Global eradication – the worldwide absence of a specific disease agent in nature as a result of deliberate control efforts that may be discontinued where the agent is judged no longer to present a significant risk from extrinsic sources (e.g., smallpox).

Regional or national eradication – the absence of a specific disease agent in a defined geographic area as a result of deliberate control efforts that must be continued to prevent reestablished endemic transmission (e.g., polio, measles, rubella, guinea worm).

Cochi & Dowdle

Zero cases as a target consideration• What makes it possible?

– Effective strategies– No animal reservoirs– Environmental ½ life relatively short– Disease burden priority

• What makes it difficult?– Asymptomatic transmission– Potential for chronicity– Surveillance– Sustaining the gains– Costs– Community engagement

Goals of HB Elimination

• End endemic transmission– Perinatal– Children– Adults

• Reduce morbidity and mortality in those already infected– Slow progression to cirrhosis– Reduce deaths

Goals of HC Elimination

• End endemic transmission• Eliminate (prevent) chronic infection• Reduce morbidity and mortality in those

already infected– Slow progression to cirrhosis– Reduce deaths

Strategies• Prevent and contain acute infection

– HB vaccination– Highly effective drug treatments for HC

infection– Other public health measures (e.g. IVDU,

surveillance, education…)• Contain chronic infection

– Drugs for HB infection, although less effective, and drugs for HC

– Other public health measures (e.g. IVDU, surveillance, education…)

Political Will

Hepatitis B Virus

• Hepadnaviridae family (DNA)• Numerous antigenic components• Humans are the only known host• May retain infectivity for >7 days at room

temperature

Source: CDC Epidemiology and Prevention of VPDs 2015

Hepatitis B Virus Infection

• > 350 million chronically infected worldwide

• Cause of chronic hepatitis and cirrhosis• Cause of 50% of hepatocellular

carcinomas• >600,000 deaths worldwide in 2002• In the US, vast majority of new cases

occur among foreign born

Source: CDC Epidemiology and Prevention of VPDs 2015

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Cascade of care – 3 million persons living with HC infection

• 50% tested• 38% receive basic care• 23% HCV RNA tested• 11% treated

Holmberg et al, NEJM, 2013

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Alaskan Hepatitis B Program: Geographic Challenge

McMahon, Alaska DOH

McMahon, Alaska DOH

McMahon, Alaska DOH

McMahon, Alaska DOH

McMahon, Alaska DOH

McMahon, Alaska DOH

Key Findings and Conclusions• Viral hepatitis is the 7th leading cause of death

globally; HB and HC cause 1 million deaths/year (20,000 in USA)

• HB and HC are generally asymptomatic until late stages

• Both disproportionally affect racial and ethnic minorities, and marginalized persons

• HBV3 95% effective, HC Rx cure 95%• Elimination poses challenges but certainly is

feasible

Global implications

• Need for clear targets; feasible and measurable

• HB combination vaccines– Whole versus acellular pertussis vaccine

• Combination vaccines IPV• Opportunities

– Save lives faster– Equity

Examples of Elimination Goals

• Maternal neonatal elimination: <0.5 cases/1000 LB by 2015

• Congenital syphilis: <0.5 cases/1000 LB by 2015

• Malaria: by 2015 reduce global deaths by 75% and global cases by 75%

Summary• Clearly, an elimination target would help galvanize the

high-level political commitment and focus so vitally needed for HB and C

• The elimination of Hep B and C as a “public health concern” should address challenges for diseases that have both acute and chronic forms

• Elimination will mean the diseases will remain, but transmission will stop and the most undesirable forms of the diseases will be prevented

NAS: Phase One Report. Eliminating the Public Health Problem of HB and HC in the US, 2016

Thank you!

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