The fight to eliminate viral hepatitis: Have we done enough?

IN May, 2016, the World Health Assembly adopted the Global Health Sector Strategy on Viral Hepatitis (2016–20) 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 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 policy makers and donors.

We have three main types of viral hepatitis in Malaysia that is Hepatitis A, B and C. Eliminating Hepatitis A should not be too difficult in a high middle income country like ours. It is one of the world's most common infectious diseases, 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, the availability of safe and adequate water supply and a Hepatitis A vaccine.

Over two billion people are infected with Hepatitis B worldwide. Around 1-1.5 million die each year from Hepatitis B virus (HBV) infection and 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 that there is a vaccine to prevent the disease and is recommended for IV drug users, dialysis patients, HIV-infected individuals, pregnant women, sexual and household contacts of HBV carriers and health care workers.

There are about 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 is crucial to increase access to its treatment for the benefit of the nation. He also announced efforts to make affordable drugs available 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 (Ministry of Health [MoH] and Armed Forces hospitals), whereby in the initial phase it will only be offered at 12 MoH 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 MoH hospitals. Furthermore, the 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 MoH hospitals and that too, with only one drug?

I had a conversation with the good minister some time ago regarding these concerns of mine and he assured me that a new drug combination will soon be made available to the public and private hospitals at affordable prices. But time is of the essence.

MoH must realise that to eliminate Hepatitis C, other strategies must be implemented. These include educating the layman 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, which are can cure about 95% of cases. This is imperative as the disease 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 been diagnosed, 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 Hepatitis C virus have been diagnosed, ranging from around 44% in high-income countries to 9% in low-income countries. If affordable 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, which is ready to work with the MoH in its fight to eliminate hepatitis. You cannot fight this alone. Let us share the burden together.

Tan Sri Dr Mohd Ismail Merican
Malaysian Liver Foundation