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AASLD 2013: Viral Hepatitis Epidemics in the U.S. and California

Deputy Assistant Secretary for Health Ronald Valdisseri described the hepatitis B and C epidemics in the U.S., the HCV cascade of care, and efforts to combat viral hepatitis at the AASLD Liver Meeting this month in Washington, DC. Public health officials in California also recently released a report on the hepatitis B and C epidemics in that state.

Valdiserri, director of the Office of HIV/AIDS and Infectious Disease Policy, opened the final plenary session with a talk focused on ending the "silent epidemic" of hepatitis C in the U.S. He also discussed the Viral Hepatitis Action Plan, which was initially released in May 2011 and will soon be renewed for 2014-2016.

Many outside field are unaware of impact of viral hepatitis, he noted. While estimates reach as high as 1.4 million cases of chronic hepatitis B and 3.9 million cases of chronic hepatitis C, only about half of people with HCV are aware they are infected.

While hepatitis B incidence has fallen by 90% since the introduction of universal HBV vaccination, hepatitis C incidence is on the rise. Alarmingly, Valdiserri said, rates have started to increase again for the first time in several years, which appears to be associated with new infections among young injecting drug users. Since the early 2000s clinicians have also reported outbreaks of apparently sexually transmitted HCV infection among HIV positive gay and bisexual men.

Valdiserri described a HCV "cascade of care" similar to the well-know HIV cascade:

• 50% (1.6 million people) have been diagnosed with hepatitis C;
• 32%-38% (1.0-1.2 million) are referred to care;
• 7%-11% (220,000-360,000) start treatment;
• 5%-6% (170,000-200,000) are successfully treated.

These proportions will be impacted in the coming years by expanded screening and the advent of direct-acting antiviral agents (DAAs) that more effectively treat hepatitis C. New screening recommendationsfromthe Centers for Disease Control and Prevention (CDC) and the U.S. Preventive Services Task Forcecalling for one-time HCV testing of all "Baby Boomers" born between 1945 and 1965 will likely result in substantially more people being diagnosed.

In the era of interferon-based therapy, it has been common practice to wait and see if people progress to moderate or worse fibrosis before subjecting them to 6 to 12 months of poorly tolerated treatment. Many people who know they have hepatitis C are waiting for new drugs and will likely take the plunge once they can be treated without interferon for as little as 8 to 12 weeks. And the new therapies are much more effective than the current standard of care: several interferon-free regimens have yielded sustained response rates of 90% or better in clinical trials, even for difficult-to-treat patients.

Expanded screening, more people taking advantage of treatment, and the higher cure rates of the new drugs should all contribute to improving what Valdiserri called the "sad bottom line" of only about 5% of people with hepatitis C now being successful treated.

But the cost of the new medications could be a limiting factor. At an opening-day press conference, AASLD president Gregory Fitz suggested that the next-generation DAAs "could easily be $100,000 or more" for a course of treatment.

Another limitation may be lack of providers to treat newly diagnosed individuals and people seeking the new treatments. Echoing a point made by Fitz, Valdiserri stressed that we cannot just rely on specialists. "We're not trying to turn primary care providers into hepatologists, but PCPs and mid-level providers can play a major role in the care and treatment of hepatitis C," backed up by expert consultation, he said.

"The news from this year's Liver Meeting couldn't have been more exciting as it confirmed that the promising hepatitis C treatment pipeline offers real hope to end this epidemic," said Ryan Clary, Director of Public Policy for the National Viral Hepatitis Roundtable. "However, the conference also highlighted the unacceptable percentage of people who don't know they are infected. We must strengthen our commitment to identify everyone who has hepatitis C and link them to care and a cure."

Hepatitis B and C in California

At the state level, the California Department of Public Health (CDPH) Sexually Transmitted Diseases Control Branch this month released its first surveillance report on Chronic Hepatitis B and Hepatitis C Infections in California. Although data have been collected since the 1980s, the information has never before been analyzed or compiled into a report.

According to the report, a total of 231,644 cases of chronic hepatitis B were newly reported to CDPH between 1989 and 2011. In 2011 alone, the department received 10,308 new reports, or 27.4 per 100,000 persons. Nearly two-thirds of these cases occurred among Asians and Pacific Islanders. HBV is endemic in much of Asia, and many people there have been infected via mother-to-child transmission.

A total of 501,664 chronic hepatitis C cases were newly reported in California between 1994 and 2011. There were 33,190 new reports in 2011 alone, or 88.3 cases per 100,000 persons. More than half (56%) of the recent cases occurred among Baby Boomers.

Among local health jurisdictions with populations of at least 100,000, San Francisco had the highest rate of newly reported cases of both hepatitis B and chronic hepatitis C in 2011.

11/27/13

Sources

R Valdiserri. Ending the Silent Epidemic of Viral Hepatitis in the U.S. 64th Annual Meeting of the American Association for the Study of Liver Diseases (AASLD 2013). Washington, DC, November 1-5, 2013.

R Valdiserri. Viral Hepatitis Action Plan 2012 Progress Report Released. Blog.AIDS.gov. November 6, 2013.

U.S. Department of Health and Human Services. Combating the Silent Epidemic of Viral Hepatitis: Action Plan for the Prevention, Care and Treatment of Viral Hepatitis. May 2011.

Office of HIV/AIDS and Infectious Disease Policyet al. Interagency Implementation Progress Report for the Action Plan for the Prevention, Care and Treatment of Viral Hepatitis. September 2013.

California Department of Public Health, STD Control Branch. Chronic Hepatitis B and Hepatitis C Infections in California: Cases Newly Reported through 2011. November 2013.