Hepatitis — Meeting the Challenge of an Epidemic

Dieterich, Douglas, MD
Professor of Medicine, Division of Liver Diseases
Mount Sinai School of Medicine
New York, NY
Also by this Author 

An estimated 5 million people in the United States - approximately 2 percent of the population - are infected with chronic hepatitis B (HBV) or hepatitis C (HCV). Yet, most are unaware of their infection until symptoms of liver cancer or liver disease develop many years after they have been infected. Each year about 15,000 people die from liver cancer or liver disease related to HBV and HCV1. This number is projected to rise dramatically in the coming years as baby boomers, who represent the majority of those affected by this epidemic, reach end-stage liver disease2.

Dr. Douglas Dieterich, Professor of Medicine at the Mount Sinai School of Medicine, New York, discusses the seriousness of the hepatitis epidemic and reviews how increased screening, combined with therapeutic advances, can help mitigate its impact. 

The Case for Increased Screening

Dr Dieterich believes we are at a critical point in dealing with hepatitis due to the aging of the baby boomer generation, those born from 1946 to 1965. “These people represent the vast majority of the epidemic”, explains Dr. Dieterich “and they're the ones who are going to be suffering the most from end-stage liver disease in the next 10 years. In fact the mortality rate from hepatitis C is expected to quadruple over this period.”

The CDC currently recommends risk-based screening for HBV and HCV but there is a rationale to expand this to screening based on date of birth, i.e. birth-cohort screening. A recently published study demonstrates that such an approach to screening for HCV in primary care settings is cost-effective3. “Based on this study a move from risk-based screening for HCV to one-time screening of all baby boomers with an antibody test should be considered”, says Dr. Dieterich. “Local outreach initiatives to screen high-risk communities can also be very effective.”

New Approaches to Patient Management

Given the asymptomatic nature of the disease a broader approach to HBV and HCV screening will enable more timely intervention and potential eradication of infection before progression leads to significant morbidity or mortality. Such a change, however, is likely to increase the number of patients being treated, raising the question of whether there are enough specialists available to meet the demand. Dr. Dieterich believes this problem can partly be addressed by internists becoming expert in treating HCV, and by infectious disease doctors playing an active role in managing patients. 

More patients are already being seen by HCV specialists following the approval last year of two protease inhibitors, telaprevir and boceprevir. Broad promotion of these drugs has led to greater awareness about hepatitis among the general public and an increase in referrals for treatment. Once a patient tests positive for antibodies and infection is confirmed, typically by a qualitative RNA test, genotyping then determines whether a patient should be considered for one of these new therapies4,5. For those with Genotype 1 these drugs can shorten the standard regimen of treatment from 48 weeks to 24 weeks and may result in cure. Response to therapy is monitored at regular intervals by a quantitative RNA test6,7.

New classes of drugs on the horizon for treating HCV include nucleotide and nucleoside analogs, as well as non-nucleoside analogs, host-targeted agents and NF5A inhibitors. “Introduction of one of these classes could change therapy dramatically”, observes Dr. Dieterich, “as they may allow us to do away with interferon, which causes the majority of the side effects.” With any new therapy genotype testing and testing for drug resistance are likely to remain standard practice.

References:

  1. A National Strategy for Prevention and Control of Hepatitis B and C. Institute of Medicine of the National Academies. (Accessed January 30 2012). Available from:
    www.iom.edu/viralhepatitis
  2. Rein DB, Wittenborn JS, Weinbaum CM, Sabin M, Smith BD, Lesesne SB. Forecasting the morbidity and mortality associated with prevalent cases of pre-cirrhotic chronic hepatitis C in the United States. Dig Liver Dis. 2011;43:66-72.
  3. Rein DB, Smith BD, Wittenborn JS, et al. The Cost-Effectiveness of Birth-Cohort Screening for Hepatitis C Antibody in U.S. Primary Care Settings. Ann Intern Med. Published online Nov 4 2011. Accessed January 30, 2012. 
    www.annals.org/content/early/2011/11/03/0003-4819-156-4-201202210-00378.full
  4. The ABCs of Hepatitis. Department Of Health & Human Services. Centers for Disease Control and Prevention. Division of Viral Hepatitis. Publication No. 21-1076. June 2010
  5. Hepatitis C. Lab Tests Online. American College of Clinical Chemistry. Updated on April 29, 2011. (Accessed January 30 2012). Available from:
    labtestsonline.org/understanding/analytes/hepatitis-c/tab/test
  6. Prescribing information for INCIVEK™ (telaprevir). Vertex Pharmaceuticals Incorporated.
  7. Prescribing information VICTRELIS™ (boceprevir). Schering Corporation, a subsidiary of Merck & Co., Inc.