A National Strategy for the Elimination of Hepatitis B and C Phase Two Report (2017) / Chapter Skim
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2 Targets for Elimination
2 Targets for Elimination
Pages 29-56
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From page 29... ...
. Box 2-1, for example, describes the Republic of Georgia's viral hepatitis strategy in response to the country's high prevalence of hepatitis C
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infections, 80% decline in hepatitis C virus infections) Mortality: Viral 1.4 million deaths 10% reduction 65% reduction hepatitis B and C reduced to less than deaths 500,000 by 2030 (65% for both viral hepatitis B and C)
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. The modelers were chosen on the basis of their prior work in the field; only models that have been extensively validated and peer-reviewed were considered.1 Given the inherent differences in the biology, epidemiology, natural history, and treatment options for hepatitis B and C, the models presented in this chapter are not directly comparable.
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HEPATITIS B MODELS The author's full report Population Health Impact and Cost-Effectiveness of Chronic Hepatitis B Diagnosis, Care, and Treatment in the United States is shown in Appendix A Briefly, the author adapted a Markov model originally developed to study hepatitis B interventions in Shanghai, China
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added improvements in rates of care and treatment to the stated HHS target. For additional comparison, the modeler then included a scenario of 80 percent diagnosed, 80 percent of those in care, with 80 percent treatment among those eligible, and 80 and 95 percent patient adherence to monitoring and treatment.
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34 TABLE 2-2 Scenario Analysis Rates Received Treatment Rate HBV Among Treatment Adherence to Adherence to Scenario Diagnosed Care Eligible Patients Monitoring Treatment Natural History -- -- -- -- -- Current Practice 34.6%a 33.3%b 45%c 35.1%d 85%e HHS 2020 Target 66% 33.3% 45% 35.1% 85% HHS 2020 Target + Improved Rx 66% 80% 80% 35.1% 85% Hypothetical Scenario 80% 80% 80% 80% 95% WHO 2030 Target 90% 90% 80% 100% 100% Idealistic (Utopian) 100% 100% 100% 100% 100% NOTE: HBV = hepatitis B virus; HHS = Department of Health and Human Services; WHO = World Health Organization.
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If the United States were to meet the WHO target of 90 percent of chronic hepatitis B patients diagnosed, 90 percent of those in care, and 80 percent treatment among those eligible (hereafter the 90/90/80 scenario) , there would be about 50 percent fewer cumulative deaths related to hepatitis B in the United States over the next 15 years.
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in 15 Years Scenario HHS 2020 HHS + Hypothetical WHO 2030 Target Improved Rx Scenario Target Idealistic Cumulative Reduction D66/C33/T45 D66/C80/T80 D80/C80/T80 D90/C90/T80 D100/C100/T100 Hepatocellular carcinoma 2.66% 12.16% 25.66% 34.83% 47.66% cases Cirrhosis cases 1.55% 12.60% 33.65% 44.71% 63.23% HBV-related deaths 4.46% 19.14% 36.38% 50.42% 69.78% NOTE: HBV = hepatitis B virus; HHS = Department of Health and Human Services; WHO = World Health Organization.
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government's Viral Hepatitis Action Plan, 2017-2020 (HHS, 2017b)
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. CDC data informed estimates of the distribution of HCV genotypes in the population and across newly diagnosed cases, while national reports and drug sale data were used to estimate the number of patients treated each year (Klevens et al., 2009, 2014; NCHS, 2015)
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The drop-off in the number of newly diagnosed cases is less pronounced in this model because HCV transmission will not decline much in a situation where only people with more advanced fibrosis are treated. Estimates of the percentage change in total viremic HCV infections (meaning cases with detectable HCV RNA)
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40 TABLE 2-5 Model Assumptions Regarding Numbers of People Treated, Diagnosed, and Newly Infected with HCV, as well as Their Ages and the Effectiveness of Treatment Over Time Scenario Assumption Wave 1 Wave 2 Wave 3 Wave 4 Wave 5 Base 2013 Years 2013-2015 2016-2017 2018-2019 2020-2024 2025-2030 Annual Treated 32,000 32,000 32,000 32,000 32,000 Annual Newly Diagnosed 110,000 110,000 77,780 55,000 55,000 Fibrosis Stage ≥F0 ≥F0 ≥F0 ≥F0 ≥F0 Annual New Infections 29,690 30,270 30,100 29,980 29,800 Treated Age 15-64 15-64 15-64 15-64 15-64 SVR 58% 58% 58% 58% 58% Base 2015 Years 2013-2014 2015-2016 2017-2019 2020-2024 2025-2030 Annual Treated 32,000 260,000 183,800 130,000 130,000 Annual Newly Diagnosed 110,000 110,000 77,780 55,000 55,000 Fibrosis Stage ≥F0 ≥F2 ≥F2 ≥F2 ≥F2 Annual New Infections 29,690 30,340 30,160 29,980 29,830 Treated Age 15-64 15-64 15-74 15-74 15-74 SVR 58% 90% 95% 95% 95%
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Aggressive ≥F0 Years 2013-2014 2015-2016 2017-2019 2020-2024 2025-2030 Annual Treated 32,000 260,000 260,000 260,000 260,000 Annual Newly Diagnosed 110,000 110,000 110,000 88,790 71,660 Fibrosis Stage ≥F0 ≥F1 ≥F0 ≥F0 ≥F0 Annual New Infections 29,690 30,340 22,620 11,150 2,730 Treated Age 15-64 15-64 15-74 15-74 15-74 SVR 58% 90% 95% 95% 95% Aggressive ≥F2 Years 2013-2014 2015-2016 2017-2019 2020-2024 2025-2030 Annual Treated 32,000 260,000 260,000 260,000 260,000 Annual Newly Diagnosed 110,000 110,000 110,000 95,940 83,670 Fibrosis Stage ≥F0 ≥F2 ≥F2 ≥F2 ≥F2 Annual New Infections 29,690 30,330 30,150 29,960 29,800 Treated Age 15-64 15-64 15-74 15-74 15-74 SVR 58% 90% 95% 95% 95% NOTE: HCV = hepatitis C virus; SVR = sustained virologic response.
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The model indicates considerable public health benefit to unrestricted treatment. Figure 2-1 shows that the total number of infected cases would drop 75 percent by 2030 (relative to the 2015 base scenario)
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FIGURE 2-1 Cumulative disease burden by scenario with percentage reduction relative to 2015 Base, United States, 2015-2030. NOTE: HCC = hepatocellular carcinoma.
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As Table 2-6 shows, more deaths would be averted by 2030 under the scenario where only patients with advanced fibrosis were treated, but unrestricted treatment reduces incident infections by 90 percent. Given that this committee was charged with identifying a strategy for the elimination of viral hepatitis, it favors the scenario that would elicit a sharp reduction in incidence.
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As Appendix B explains, the estimate of the number of patients treated every year comes from published data combined with expert consultation. This number is a bottleneck in the model, and it stands to reason that increasing the capacity of the health system to treat hepatitis C patients would allow a greater reduction in deaths, without compromising the reduction in total viremic cases or incident infections.
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The next four chapters of this report discuss the committee's proposed strategy for viral hepatitis elimination. Recommendations are directed to various federal and state government agencies, as well as to legislators and different private sector organizations.
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Such coordination is of particular concern for viral hepatitis response. The most recent nation action plan for viral hepatitis involved 23 different agencies and offices from 4 departments (HHS, 2017a)
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Ideally, the states would be fully supported by a national office, but motivated state health commissioners may be able to adjust their state's priorities to make viral hepatitis programming more prominent. The Problem of Stigma As this committee's earlier report made clear, there are aspects of the viral hepatitis epidemic that resist easy remedy (NASEM, 2016a)
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Outreach to such groups can be sensitive and could benefit from a unified plan for communication and service provision with an emphasis on bringing services to the target populations. Finally, this report discusses key gaps in the research on viral hepatitis and suggests research priorities for different federal agencies.
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2016a. Viral hepatitis–Statistics and sur veillance.
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2017b. National viral hepatitis action plan 2017-2020.
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2014. Estimating acute viral hepatitis infections from nationally reported cases.
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infection with today's treatment paradigm. Journal of Viral Hepatitis 21(S1)
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2016b. Global health sector strategy on viral hepatitis, 2016-2021: Towards ending viral hepatitis.
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2012. Hepatocellular carcinoma in Ol msted County, Minnesota, 1976-2008.
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