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Towards the Elimination of Hepatitis C in the United States
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"......all adults should be screened for hepatitis C, but special efforts must focus on high risk populations.....HCV elimination efforts continue to receive inadequate funding. Social stigma continues to impede meaningful policy changes. Eliminating hepatitis C from the U.S. is possible but it will require a sustained national commitment and strong political leadership."
Hepatology Nov 27 2017 - Sammy Saab, Long Le, Satvir Saggi, Vinay Sundaram, Myron Tong
Departments of Surgery1, Medicine,2 at the University of California at Los Angeles, Los Angeles, California; Olive View Medical Center at University of California at Los Angeles, Los Angeles, California3, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles California and Huntington Research Institute, Los Angeles, California
From Jules: I disagree, we do not need to start with including all these programmtic approaches to an HCV elimination program. To do so would prevent federal and state buy in to an elimination program and these are not necessary. We need routine screening, linkage to care, unfettered treatment, and support services for injection drug users and other difficult to treat populations. We will never get federal buy if we require all the services listed in this report. And they are not nesessary, in fact they are counter productive.
Abstract
The emergence of effective direct-acting antiviral (DAA) agents has reignited discussion over hepatitis C elimination potential in the United States. Eliminating hepatitis C will require a critical examination regarding technical feasibility, economic considerations, and social/political attention.
Tremendous advancement has been made in recent years with the availability of sensitive diagnostic tests and highly effective DAAs capable of achieving sustained viral response (SVR) in more than 95% of patients. Eliminating hepatitis C requires escalating existing surveillance networks to identify and respond to new epidemics. Basic prevention strategies such as community based outreach and education, testing and counseling, clean syringe and needle exchange programs, safe injection sites, opioid substitution therapies, and mental health services must be scaled up and adapted to target high risk groups.
Although costs of DAAs have raised budget concerns for hepatitis C elimination, studies have shown that eliminating hepatitis C will produce a savings of up to 6.5 billion USD annually along with other intangible benefits such as work productivity and quality of life. Simulation economic models and meta-analyses suggest that all adults should be screened for hepatitis C, but special efforts must focus on high risk populations.
There is growing recognition that social and political factors are at least as important as technical feasibility and economic considerations. Due to lack of promotion and public awareness, HCV elimination efforts continue to receive inadequate funding. Social stigma continues to impede meaningful policy changes. Eliminating hepatitis C from the U.S. is possible but it will require a sustained national commitment and strong political leadership. This article is protected by copyright. All rights reserved.
Introduction
Chronic hepatitis C virus (HCV) is a major medical and public health concern. Across the globe, approximately 170 million people are believed to be infected (1). In the United States, the prevalence is approximately 2% with between 5 and 7 million Americans infected with HCV (2). Chronic hepatitis C is a systemic infection and an important factor in morbidity and mortality. Hepatitis C is one of the most common causes of cirrhosis, a risk factor for hepatocellular carcinoma, and an indicator for liver transplantation.
Non-hepatic manifestations of HCV include insulin resistance, cryoglobulinemia, and renal disease (3). Infection of HCV is also associated with substantial health care utilization, with an estimated direct cost to be around 6 to 7 billion U.S. dollars annually in the U.S. alone (4,5). In addition, the cost of HCV extra-hepatic manifestations has been estimated to be 1.5 billion U.S. dollars in 2014 (6). Overall costs associated with HCV are believed to be even higher as current estimates do not include indirect costs of productivity (4).
The ultimate goal of public health is the eradication of diseases. Whereas eradication refers to the permanent infection incidence of zero throughout the world, elimination refers to an infection incidence of zero in a specific geographical area (7). Despite recent advances in medicine, smallpox remains the only human disease that has been confirmed to be eradicated globally by the World Health Organization (WHO) (8). Global efforts are currently underway for the eradication of other diseases such as polio, malaria, yaws and dracunculiasis (9). In the United States, in particular, several notifiable diseases such as polio and measles have been reported to be eliminated with vaccination playing an important role (10).
Criteria have been established to identify disease characteristics that are most likely to be candidates for eradication: technical feasibility, economic considerations, and social/political attention (Table 1) (7). Technical feasibility can be further defined by the accuracy of diagnostic tests and the role humans play in the life cycle of the infectious agent. The costs of treatment combined with the lack of infrastructure in developing countries pose as barriers for the global
eradication of HCV. However, HCV may be a potential candidate for elimination in the United States. Unlike other infections whose efforts to achieve eradication and elimination have revolved around immunization, the treatment of established HCV infection includes the use of direct-acting antiviral (DAA) agents. Our objective in this review is to ascertain the possibility of eliminating HCV using established public health qualifying criteria.
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