Case Study: Hepatitis B and C › academics › colleges › PublicHealth › research...Case Study:...
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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
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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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3Ward J, CDC
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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%
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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
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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
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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
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Goals of HB Elimination
• End endemic transmission– Perinatal– Children– Adults
• Reduce morbidity and mortality in those already infected– Slow progression to cirrhosis– Reduce deaths
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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
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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…)
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Political Will
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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
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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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Ward J presentation to NAS 2015; CDC ACIP
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Ward J, CDC, 2015
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Ward J, CDC, 2015
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Ward J, CDC, 2015
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Ward J, CDC, 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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21Ward J, CDC, 2015
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Alaskan Hepatitis B Program: Geographic Challenge
McMahon, Alaska DOH
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McMahon, Alaska DOH
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McMahon, Alaska DOH
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McMahon, Alaska DOH
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McMahon, Alaska DOH
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McMahon, Alaska DOH
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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
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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
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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%
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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
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Thank you!
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Ward J, CDC, 2015
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34Ward J, CDC