World Hepatitis Day—July 28—offers a timely opportunity to turn the spotlight towards global efforts to address viral hepatitis. Worldwide, the hepatitis viruses are responsible for an estimated 1·34 million deaths a year, with a disproportionate disease burden in low-income and middle-income countries (LMICs). The ambitious WHO goal of eliminating viral hepatitis as a major public health threat by 2030 faces many obstacles, yet none are more significant than that posed by the COVID-19 pandemic.
Infection prevention is a foundational goal of efforts to eliminate viral hepatitis, particularly for hepatitis B virus (HBV), for which vaccinations are available but curative treatment does not exist. Progress in increasing birth-dose HBV vaccination rates has been hindered by the vaccine not being included in national vaccination schedules, births occurring at home, and lack of birth-dose vaccine awareness among health-care workers. Funding has also been an issue. COVID-19 is likely to place substantial further pressure on government budgets and change policy priorities; restrictions on movement and fear of infection might also increase home births and further limit immunisation access. Direct assessment of the impact of COVID-19 regulations on HBV vaccination coverage will therefore be important to ensure that they do not cause net harm.
For HCV, prevention efforts focus on harm reduction measures (eg, needle and syringe programmes [NSPs] and education packages) for populations at high risk, such as people who inject drugs, prisoners, and men who have sex with men. COVID-19 has led to widespread disruption or closure of harm reduction services. In England, the number of people accessing NSPs fell by 36% and needles distributed to those injecting psychoactive drugs halved as a result of lockdown restrictions. In LMICs, these pressures are likely to be even more keenly felt.
Underdiagnosis of viral hepatitis is a key bottleneck in elimination efforts. Globally, an estimated 91% of individuals with chronic HBV infection and 80% of those with chronic HCV infection were undiagnosed in 2017. Surveillance and diagnosis services have been disrupted by COVID-19, owing to redeployed staff, equipment, and closed facilities. In a World Hepatitis Alliance (WHA) survey of civil society organisations and frontline hepatitis service providers in 32 countries from March 30 to May 4, 2020, only 47 (36%) of 132 respondents reported that people were able to access testing services, with closure or avoidance of testing sites due to COVID-19 identified as key reasons. Global supply chain issues have also led to shortages of HBV and HCV test reagents, with LMICs disproportionately affected.
In individuals with a diagnosis, timely linkage to care and access to treatment is likely to be hampered by movement restrictions and suspension of centralised clinical services. The WHA survey data indicate that treatment access has been particularly affected by COVID-19 in LMICs, with 15 (52%) of 29 respondents from those countries reporting that patients are unable to access therapies. According to the HCV Action network, the impact of COVID-19 on HCV treatment in the UK has been less than feared, in part owing to expanded use of home medication delivery and telemedicine, but such an approach is likely to be less feasible in LMICs.
Despite the broad negative effects of COVID-19 on viral hepatitis elimination, there are glimmers of opportunity. From a practical perspective, developments arising from the need to rapidly decentralise elimination efforts, such as postal dried blood-spot testing and medication delivery, could enable improved care for difficult to reach populations. The ambitious possibility has also been raised of combining large-scale COVID-19 surveillance and contact tracing efforts, which have been initiated in many countries, with testing for viral hepatitis and other diseases. Politically, the pandemic has brought the use of mass testing, contact tracing, and vaccination to the fore, and there is optimism that success in these domains can be used to emphasise the tangibility of viral hepatitis elimination.
In the long-term, the negative economic effects of the pandemic will exert extra pressure on viral hepatitis-related public health initiatives, further endangering hopes of a hepatitis-free future. In the coming months and years, it will be crucial to ensure that policy makers do not lose sight of the clear benefits of viral hepatitis elimination, and that the opportunities presented by the current crisis are identified and seized upon when possible.
For more on the impact of COVID-19 on harm reduction services in England see Int J Drug Policy 2020; published online July 15. DOI:10.1016/j.drugpo.2020.102851
For more on combining COVID-19 surveillance with that for other diseases see Clin Infect Dis 2020; published online April 27. DOI:10.1093/cid/ciaa501
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