Putting an end to viral hepatitis

IN May 2016, the World Health Assembly adopted the Global Health Sector Strategy on Viral Hepatitis (2016–2020) with the objective of eliminating viral hepatitis as a major public health threat by 2030.

The target is to reduce new viral hepatitis infections by 90% and reduce deaths due to viral hepatitis by 65%, focusing mainly on hepatitis B and hepatitis C, both of which can cause chronic liver disease including cirrhosis and liver cancer.

Although viral hepatitis caused an estimated 1.4 million deaths in 2015, more than either HIV or malaria, it has received suboptimal attention from policymakers and donors.

We have three main types of viral hepatitis in Malaysia – hepatitis A, B and C. Eliminating hepatitis A should not be too difficult in a high-middle-income country like ours.

One of the world’s most common infectious diseases, hepatitis A is highly contagious and sometimes fatal. Although it does not cause chronic infection, recovery can be slow. Generally, the prevalence of hepatitis A is declining because of improvement in standards of environmental and personal hygiene, and availability of safe and adequate water supply and the hepatitis A vaccine.

Over two billion people are infected with hepatitis B worldwide, with one to 1.5 million dying each year from their infection. There are about 400 million chronic carriers worldwide, 75% of whom live in Asia. Hepatitis B is 100 times more infectious than HIV. The good news is there is a vaccine to prevent the disease and it is recommended for intravenous drug users, dialysis patients, HIVinfected individuals, pregnant women, sexual and household contacts of HBV carriers and healthcare workers.

Currently, there are approximately 500,000 patients in Malaysia who are infected with Hepatitis C and it is estimated that 2,000 new cases are reported every year.

In September 2017, the Health Minister issued a press statement recognising that hepatitis C is a major public health concern in Malaysia. He stated that it is crucial to increase access to its treatment for the benefit of the nation. He also announced efforts to make available cheap drugs to treat hepatitis C as “the cost of treatment for hepatitis C is exorbitantly expensive, making it less accessible to the patients. The Cabinet had approved the use of Rights of Government under Patent Act 1983 (Act 291) by exploiting the patented invention of Sofosbuvir tablet 400mg. The implementation of the Rights of Government for the 400mg Sofosbuvir tablet is for use in government facilities only (Health Ministry and Armed Forces hospitals), whereby at the initial phase it would only be offered at 12 government hospitals. The selection criteria of patients that will receive the treatment will follow the clinical guideline set by the clinical specialist.”

While I laud the minister for making Sofosbuvir 400mg available to Malaysians, it makes little sense to me to limit the use of the drug to only 12 government hospitals. Furthermore, the current treatment for hepatitis C involves the use of at least two drugs, not one. So how can we hope to eliminate hepatitis C if treatment is only restricted to some government hospitals, and that too with only one drug?

I had a conversation with the good minister sometime ago regarding these concerns of mine and he assured me that a new drug combination would soon be made available to all public and private hospitals at affordable prices. But time is of the essence. The Health Ministry must realise that in order to eliminate hepatitis C, other strategies must be implemented. These include educating the laypublic on the disease and encouraging doctors on the need to screen patients for hepatitis C in addition to all the usual tests they normally do.

If the test is positive, they should refer the patients to trained specialists for further tests to be conducted and for a decision to be made on treating the patients with direct acting antiviral agents (DAAs) which can cure about 95% of cases. This is imperative as hepatitis C is asymptomatic and there is, at present, lack of awareness, education and medical coverage for this disease.

Not many have been diagnosed and out of those who have, not many have received treatment either because of ignorance or inaccessibility, and unaffordability to procure the new antiviral agents.

One study evolved that only 20% of people with HCV have been diagnosed, ranging from around 44% in high-income countries to 9% in low-income countries.

If cheap treatment is available, then all patients should be treated. Otherwise, those in the high-risk category should receive immediate treatment. These include those with advanced fibrosis or compensated cirrhosis, those undergoing organ transplants, patients with genotype 3 (the majority type found in Malaysia), those with hepatitis B or HIV co-infection, those with co-existent liver disease such as fatty liver, obese patients and those with co-morbid conditions such as diabetes. Otherwise, eliminating hepatitis C with the new effective drugs will remain a pipe dream.

We have the tools needed to move towards elimination targets, such as an effective vaccine for hepatitis B and a curative treatment for hepatitis C. What we need now is the political will to scale up prevention, diagnosis, and treatment programmes and the involvement of all stakeholders including the Malaysian Liver Foundation (MLF), which is ready to work with the Health Ministry in its fight to eliminate hepatitis.

You cannot fight alone. Let us share the burden together.