Viral hepatitis in Asia-Pacific: a post-COVID-19 reset.

Viral hepatitis, a continuing and persistent pandemic, remains under-prioritised and under-resourced despite deaths from the infection in Asia-Pacific outnumbering those of HIV, tuberculosis, and malaria combined.1WHO Regional Office for South-East AsiaRegional strategy for the prevention and control of viral hepatitis. World Health Organization, New Delhi2013Google Scholar, 2Roth GA Abate D Abate KH et al.Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 1736-1788Summary Full Text Full Text PDF PubMed Scopus (3910) Google Scholar, 3Western Pacific WHO7 million deaths averted through hepatitis b vaccination.https://www.who.int/westernpacific/news/item/22-06-2016-7-million-deaths-averted-through-hepatitis-b-vaccinationDate: June 22, 2016Date accessed: May 17, 2023Google Scholar As a whole, Asia accounts for 73% of deaths from liver cancer globally;4International Agency for Research on CancerWHOLiver cancer fact sheet.https://gco.iarc.fr/today/data/factsheets/cancers/11-Liver-fact-sheet.pdfDate accessed: June 8, 2023Google Scholar these deaths are primarily attributable to hepatitis B and hepatitis C. Almost 80 million people in the WHO South-East Asia region and more than 120 million people in the Western Pacific region live with chronic hepatitis B or hepatitis C.5Center for Disease Analysis FoundationPolaris observatory.https://cdafound.org/polaris/Date: May 12, 2023Date accessed: June 8, 2023Google Scholar Funding specifically for viral hepatitis interventions are generally not included in domestic budgets, and programmes are unsupported within national strategic plans. Although the impact of COVID-19 on Asia-Pacific—a diverse, heterogeneous, and fragmented region—is yet to be fully understood, effects have been varied across and within countries, with vulnerable and marginalised populations being disproportionately affected. COVID-19 delayed or halted clinical trials, and disrupted health systems and supply chains, which diverted already fragile viral hepatitis resources and reduced the number of people tested, referred to clinical services, treated, or vaccinated. The likely consequences of COVID-19 on viral hepatitis are an increase in short-term incidence of chronic infections, further late detection of hepatocellular carcinoma due to disrupted surveillance, and continued transmission to future generations, threatening WHO's goal of eliminating hepatitis by 2030. Crucial lessons can be drawn from COVID-19 pandemic responses across Asia-Pacific, a region with the greatest global burden of viral hepatitis, in which most people who are infected remain undiagnosed. In accelerating testing and treatment uptake (table),6WHOGlobal progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. Accountability for the global health sector strategies 2016–2021: actions for impact. World Health Organization, Geneva2021Google Scholar and reducing transmission and liver-related mortality, lessons from responses to COVID-19 highlight that government attention, policy, programmes, and resources can be made available when a clearly recognised need exists and a compelling argument is made for them, particularly when supported by global calls for unified action. This context provides an enabling environment in which political will, supported with appropriate resourcing, aids multisectoral partnerships to drive innovative solutions that are delivered through responsive and resourced health services. Iterative cycles of new data integrated into clinical practice, powered by effective surveillance systems, enable a learning health system approach that progressively enhances patient care and health outcomes. Health literacy fosters an awareness and expectation within the community that a diagnosis should enable access to care through systematic linkages made to clinical services, with communities exposed to the language and concepts used within epidemiological science.TablePercentage of people infected with hepatitis B and hepatitis C who were diagnosed and treated in Asia-Pacific as at the end of 20196WHOGlobal progress report on HIV, viral hepatitis and sexually transmitted infections, 2021. Accountability for the global health sector strategies 2016–2021: actions for impact. World Health Organization, Geneva2021Google ScholarHepatitis BHepatitis CDiagnosedTreatedDiagnosedTreatedSouth-East Asia2%0·2%7%5%Western Pacific18%5%25%10% Open table in a new tab COVID-19 showed the fundamental necessity of a comprehensive and resourced strategic plan that uses a whole-of-government approach, in which ministries and agencies work across portfolios to achieve interdependent goals and deliver integrated policies and programmes. The challenge of meeting the needs of local communities can drive innovations such as those found in vaccine development, with diagnostics launched by public–private partnerships during the COVID-19 pandemic resulting in massive surges in testing, and in the widespread use of telemedicine for viral hepatitis. In a context where 2030 viral hepatitis elimination targets are not being met, the direct interventions to COVID-19 that were sustained over a compressed timeframe are now especially relevant and potentially feasible in viral hepatitis, as validated by Egypt's national hepatitis C programme, which successfully tested 50 million people and treated 4 million in a 6-year period.7Hassanin A Kamel S Waked I Fort M Egypt's ambitious strategy to eliminate hepatitis C virus: a case study.Glob Health Sci Pract. 2021; 9: 187-200Crossref PubMed Scopus (3) Google Scholar With enabling policies, appropriate resourcing, and—where necessary—leveraging public–private partnerships, viral hepatitis testing, treatment, and care can be effectively integrated into general community health services. Integration is an important step towards a fit-for-purpose public health infrastructure to deliver scaled-up testing to identify the missing millions of people who do not know their infection status, and provide linkages between diagnoses, prevention, and management of chronic viral hepatitis, cirrhosis, and primary liver cancer. Simplified models of care that allow for the decentralisation of viral hepatitis services to more accessible health facilities promote linkage to care and support increased access for all populations affected by viral hepatitis. The viral hepatitis pandemic must be understood as a public health challenge that affects families across generations and often across multiple countries. As an asymptomatic infection, viral hepatitis is easily overlooked or ignored by people with the virus, for whom the infection is a lesser priority than other health, social, cultural, family, economic, or settlement issues, particularly for migrants.8Lemoh C Xiao Y Tran L et al.An intersectional approach to hepatitis B.Int J Environ Res Public Health. 2023; 204879Crossref PubMed Scopus (0) Google Scholar Identifying and addressing the social determinants of health in the context of viral hepatitis and liver cancer will be essential in mitigating the overall burden of viral hepatitis in Asia-Pacific. Given the disruption from COVID-19, the global nature of hepatitis B infection, and the existence of cross-national communities, eliminating hepatitis B as a public health threat by 2030 will not occur without global access to curative interventions. However, even with curative treatments, elimination remains out of reach unless current systemic gaps in testing, treatment, and care are addressed. The clinical infrastructure for implementing a cure for hepatitis B is anticipated to be more complex than that for hepatitis C. Emerging evidence suggests that forward planning leveraging the prospect of a hepatitis B cure could shape public health policy, secure funding, and prepare health systems for proactive case finding and linkages to treatment. Community development and health education to drive demand will optimise system readiness and improve health service access. The clinical management of viral hepatitis is a dynamic space in which public policy needs to help health systems respond to new or evolving treatment paradigms and models of care. We are only as healthy as our neighbourhood. For many people with viral hepatitis living in Asia-Pacific, immigration is an important issue, with greater harmonisation between regional and global responses needed. Scope exists for the perspectives of people living in Asia-Pacific to be better addressed in—and integrated with—global policy for viral hepatitis elimination. We declare no competing interests. The Coalition to Eradicate Viral Hepatitis in Asia Pacific is a not-for-profit multidisciplinary body that advocates for public policy and funding reform to reduce the burden of, eliminate, and ultimately eradicate, viral hepatitis in Asia-Pacific. In the past decade, the Coalition to Eradicate Viral Hepatitis in Asia Pacific has received funds from AbbVie, BMS, Gilead, MSD, Roche, and the ZeShan Foundation.