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The Institute of Medicine report on viral hepatitis: A call to action
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Hepatology March 2010
Arun J. Sanyal *, On behalf of the Governing Board the Public Policy, Clinical Practice, Manpower committees of the AASLD
Division of Gastroenterology, Hepatology and Nutrition Virginia Commonwealth University School of Medicine Richmond, VA
email: Arun J. Sanyal (asanyal@mcvh-vcu.edu)
*Correspondence to Arun J. Sanyal, Professor of Medicine, Pharmacology and Molecular Pathology, Virginia Commonwealth University School of Medicine, MCV Box 980341, Richmond, VA 23298-0341
telephone: 804-828-6314
Chronic viral hepatitis remains a major cause of preventable morbidity and mortality in the world. The landmark study from the prestigious Institute of Medicine (IOM) summarized in this issue of HEPATOLOGY defines the issues that drive this problem and the need to tackle this aggressively,[1] an issue advocated by the American Association for the Study of Liver Diseases (AASLD) for many years.[2] The AASLD applauds this major effort that not only highlights the urgent need to address this public health problem but also provides direction for policy makers to begin to tackle the scourge of hepatitis B and C.
The public health impact of a disease depends on its prevalence and its consequences for the affected individual. The IOM report notes that one of every 50 Americans is affected by hepatitis B or C and that the majority of afflicted individuals are unaware of their disease. Many of these subjects thus go undetected and contribute to the burden of advanced liver disease and the rising tide of hepatocellular carcinoma. A principal cause for this is a lack of knowledge and awareness of chronic viral hepatitis on the part of health care and social-service providers. This is, in turn, driven by a lack of resources allocated to the eradication of these conditions at a national and state level. A major consequence of the failure to detect the disease early is that the treatment options available for those who have progressed to cirrhosis are more limited and require more resources. The decreased ability to tolerate t reatments and the impact of end-stage liver disease on the patient add a further social and economic burden on the affected individual and their family. These add to the cost of medical care nationally and negatively impact the ability of many small businesses to obtain affordable health care coverage. The implications of the IOM report for American, and indeed the world, are therefore highly significant.
The AASLD is committed to working toward the ultimate eradication of hepatitis B and C. This can be accomplished by prevention of acquisition of new infection and elimination of the virus in those already infected, thus getting rid of the reservoir of infection. These can only be accomplished by implementation of educational and preventive programs, active surveillance and identification of infected subjects, development of effective therapy, ensuring access to care, and mechanisms to make these treatments affordable. The availability of an adequately trained and educated workforce is essential to meet these goals. The IOM report is highly laudable because it makes specific recommendations to take on these issues. The AASLD is committed to working with the Centers for Disease Control and Prevention (CDC) and other federal agencies and stakeholders to get these recommendations implemented and further the goal o f eradication of chronic viral hepatitis.
Chronic viral hepatitis cuts across all socioeconomic sections of society. However, those who are most disadvantaged from a social and economic perspective often have the highest burden of disease and the most limited access to care. The AASLD strongly supports the recommendations for a comprehensive assessment of the hepatitis B and C evaluation program made by the IOM. However, the ability of the CDC to perform such an evaluation is likely to be limited by the modest US$19.3 million budget allocated for the Division of Viral Hepatitis in the current fiscal year, which constitutes only 1.8% of the budget for the Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention. The AASLD remains committed to advocating for greater funding for this division within the CDC and supports its effort in this area. The AASLD also supports the efforts of the CDC foundation to bring stake holders together to share research data and provide feedback on information and tools required to appropriately respond to the recommendations in the IOM report, and the AASLD and CDC will co-organize a workshop on this later this year. Finally, the AASLD has been and will remain a strong advocate for the bipartisan legislation The Viral Hepatitis and Liver Cancer Control and Prevention Act that was recently introduced by Representatives Mike Honda (D-Calif.) and Charles Dent (R-Pa.). This bill will authorize an initial US$90 million in funding in 2011 and additional funding later for the CDC to work with state health departments in their prevention, immunization, and surveillance programs.
A major recommendation of the IOM report is for the development of educational programs directed not only at the population but also to health care providers. Given the high prevalence of chronic viral hepatitis and its frequent clinically silent nature through the early phases of the disease, it is likely that many such individuals are normally only seen by family practitioners, primary care physicians, nurse practitioners, obstetricians, and gynecologists. As the leading professional society dedicated to the care of individuals with liver disease, the AASLD plans to develop educational materials and programming directed to these diverse groups to further actualize the recommendations of the IOM. It will also work in concert with the CDC and other agencies which are already active in the areas of education for health care providers. It will also be valuable to learn from the experience gained from other group s such as the Veterans Health Administration, and the AASLD will work toward developing partnerships to use the knowledge and information from such entities to promote the recommendations of the IOM for the general population. The Hepatitis B Special Interest Group of the AASLD is currently developing an initial educational module directed toward primary care providers.
The AASLD also strongly endorses the recommendations of the IOM for the development of programs designed to prevent the acquisition of new infection with hepatitis B or C. These programs are also likely to require substantial resource allocation, and the AASLD urges the federal government to act expeditiously on these recommendations. This will remain a cornerstone of the advocacy efforts of the AASLD.
Perhaps an area where the IOM report does not go far enough is to make specific recommendations about providing access and support for treatment of infected individuals via Medicare and other third-party payors. The report recommends referral for medical management without specific recommendations for provision of access to treatment. The AASLD believes that, given the availability of effective therapies, it is vitally important to treat appropriate populations of infected individuals. The achievement of a sustained virologic response to anti-hepatitis C virus therapy and viral suppression in those with active hepatitis B has already been shown to diminish the risks of disease progression. By treating the disease earlier in its course, it is likely that the social, medical, and economic burden of advanced liver disease and drain on the pool of organs available for liver transplantation will be alleviated. The AASLD supports and will advocate for the appropriate studies to be performed by federal agencies to validate this possibility and provide an evidence-based rationale for early detection and treatment of chronic viral hepatitis. The ability to provide access to effective treatment by the Ryan White Act made a great impact on the burden of human immunodeficiency virus. It is now time for similar legislation to help the millions with viral hepatitis.
A key factor that will determine the success of any initiative to control the burden of chronic viral hepatitis is the availability of an adequately trained workforce. Traditionally, the educational and training programs related to viral hepatitis have focused on gastroenterologists and hepatologists, who often practice in a tertiary care setting. Chronic viral hepatitis is largely present in the general population who do not normally see such physicians. It is therefore a national imperative to train additional classes of hepatologists and other health care providers who focus on community-based efforts to prevent, detect, and treat chronic liver disease including viral hepatitis. These will require restructuring of training in liver diseases across many specialties and nonphysician health care providers. The AASLD will use its committee structure to begin to develop an approach and work with sister societies and the American Board of Internal Medicine, family practices, etc., to actualize this recommendation of the IOM.
Finally, as noted by the IOM report, hepatitis B and C remain important causes of preventable death worldwide. The implications of the IOM report are therefore global and are likely to be helpful to the WHO as they respond to a proposed global resolution on viral hepatitis prevention and control at the 63rd World Health Assembly. We hope that by the synergistic activities of the federal agencies such as the CDC, NIH etc and other stakeholders such as the AASLD and WHO, we will map out the way towards global prevention and control of chronic viral hepatitis.
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