Why is there a WHO alert on viral hepatitis?

What are the findings in the Global Hepatitis Report 2024? Why does India have such a high disease load of hepatitis B and C? Is the increasing prevalence of nonviral forms of the disease, like alcoholic liver disease and nonalcoholic fatty liver diseas

The story so far:

ndia accounted for 11.6% of the total viral hepatitis disease burden globally in 2022, making it the country with the second highest disease load after China, according to the World Health Organization’s (WHO) Global Hepatitis Report 2024 released recently. Bangladesh, China, Ethiopia, India, Indonesia, Nigeria, Pakistan, the Philippines, the Russian Federation and Vietnam, collectively shoulder nearly twothirds of the global burden of hepatitis B and C.

IWhat does the report highlight?

As per the report, the disease is the second leading infectious cause of death globally — with 1.3 million deaths per year, the same as tuberculosis, a top infectious killer. New data from 187 countries show that the estimated number of deaths from viral hepatitis increased from 1.1 million in 2019 to 1.3 million in 2022. Of these, 83% were caused by hepatitis B, and 17% by hepatitis C. Every day, there are 3,500 people dying globally due to hepatitis B and C infections. Half the burden of chronic hepatitis B and C infections is among people aged 3054 years old, with 12% among children under 18 years of age. Men account for 58% of all cases.

What is hepatitis?

“Hepatitis is an inflammation of the liver that is caused by a variety of infectious viruses and noninfectious agents leading to a range of health problems, some of which can be fatal,” says Sharad Malhotra, HOD, Gastroenterology Hepatology and Therapeutic Endoscopy, Aakash Healthcare, Delhi. There are five main strains of the hepatitis virus, referred to as types A, B, C, D and E. While they all cause liver disease, they differ in important ways including modes of transmission, severity of the illness and geographical distribution. In particular, types B and C lead to chronic disease and together are the most common cause of liver cirrhosis, liver cancer and viral hepatitisrelated deaths. An estimated 354 million people worldwide live with hepatitis B or C, and for most, treatment remains beyond reach, according to the WHO.

Why is India vulnerable?

Doctors attribute the large number of cases to several reasons including high population density, lack of awareness to symptoms, screening and treatment and not adhering to or having access to good hygiene practices.

Dr. Sudeep Khanna, senior consultant, gastroenterologist, Indraprastha Apollo Hospitals, explained that one of the major reasons for the increasing burden of hepatitis in India is the high prevalence of chronic viral hepatitis B and C infections. “These chronic infections often remain asymptomatic for decades; furthermore, the lack of widespread screening programmes and limited awareness about the importance of hepatitis testing contribute to a significant proportion of cases going undiagnosed. Undiagnosed cases continue to transmit the infection, perpetuating the cycle of transmission and leading to a rise in the overall burden of the disease,” he said. The physician added that another important factor contributing to the rising number of hepatitis cases is the increasing prevalence of nonviral forms of the disease, such as alcoholic liver disease (ALD) and nonalcoholic fatty liver disease (NAFLD). Doctors note that the high consumption of alcohol, particularly in urban areas, has led to a significant increase in ALD cases. Additionally, the rapid rise in obesity and metabolic disorders, coupled with sedentary lifestyles and dietary changes, has fuelled an epidemic of NAFLD in both urban and rural populations. These conditions can progress to more severe forms of liver disease further compounding the burden of hepatitis in India.

Men report larger number of cases. Manoj Gupta, HOD, Liver Transplant and GI Surgery, PSRI Hospital, Delhi, states that this is due to highrisk behaviour like use of IV drugs, sharing injections while using IV drugs and sexual behaviour. “Multiple sex partners, or male to male sex is a very highrisk factor for these hepatitis B and C infections,” he said.

How can it be prevented?

Hepatitis B can be prevented through vaccination and the report highlights the need to ensure coverage, while hepatitis C is curable with medicines. In India, the numbers of deaths due to viral hepatitis aren’t comparable to tuberculosis, say experts, adding that cost of treatment is also among the lowest as India makes the generic version of the drugs. Also, the government’s viral hepatitis control programme offers the vaccine to highrisk adults such as healthcare workers. Treatment for both hepatitis B and C is available under the programme. With an initial rollout of the hepatitis B vaccine in certain cities and districts of India in 20022003, the Indian Government included Chronic Hepatitis B infection (HBV) vaccine in the childhood immunisation programme in 201112.

Hepatitis B can be prevented through vaccination, and the report highlights the need to ensure coverage; hepatitis C is curable with medicines

Why is the report significant?

This is the first consolidated WHO report on the viral hepatitis epidemiology, service coverage and product access, with data for action. This report presents the latest estimates on the disease burden and the coverage of essential viral hepatitis services from 187 countries across the world. It also found that across all regions, only 13% of people living with chronic hepatitis B infection had been diagnosed, and approximately 3% (7 million) had received antiviral therapy at the end of 2022. Regarding hepatitis C, 36% of people had been diagnosed and 20% (12.5 million) had received curative treatment. These results fall well below the global targets to treat 80% of people living with chronic hepatitis B and hepatitis C by 2030. However, it does indicate slight but consistent improvement in diagnosis and treatment coverage since the reported estimates in 2019.

What is the way forward?

Mother to child transmission is responsible for most new infections, and in India, elimination of hepatitis B requires extensive treatment coverage, immunising and protecting every newborn and ending any discrimination against patients, said Dr. S.K. Sarin, ViceChancellor, Institute of Liver and Biliary Sciences, Delhi. The report cautions that despite the availability of affordable generic viral hepatitis medicines, many countries fail to procure them at lower prices. Pricing disparities persist both across and within WHO regions, with many countries paying above global benchmarks.

The report adds that service delivery remains centralised and vertical, and many affected populations still face outofpocket expenses for viral hepatitis services. It has outlined a series of actions to advance a public health approach to viral hepatitis, designed to accelerate progress towards ending the epidemic by 2030. This must look at expanding access to testing and diagnostics, shifting to policies for equitable treatment, strengthening prevention efforts and improved funding both at a global level or within countrys’ health budgets, said WHO.