ESCMID Global 2025: The challenges of eliminating viral hepatitis
In 2024, the World Health Organization (WHO) reported that aside from tuberculosis, viral hepatitis was the most common cause of mortality due to infectious diseases worldwide. Furthermore, despite a slow decrease in the global incidence of viral hepatitis B (HBV) and C (HCV) in recent years, mortality due to these viruses has been increasing. In 2016, WHO launched the Global Health Sector Strategy, which aimed to end viral hepatitis by 2030, defining elimination as a 90% reduction in incidence and 65% reduction in mortality for HBV and HCV from 2015 to 2030. One challenge to achieving this goal is the proportion of undiagnosed individuals living with viral hepatitis. According to WHO, 254 million people globally were estimated to have HBV in 2022, but only approximately 10% had been diagnosed. Likewise, 50 million people globally were estimated to have HCV in 2022, but only approximately 30% had been diagnosed.
One current strategy to closing this gap and providing patients with diagnoses and treatments is reflex testing, which is the automatic addition of testing based upon initial test results. With one patient-provided sample, reflex testing can provide complete data for diagnosis, staging, coinfection, and management strategies. For example, if a patient tests positive for the hepatitis B surface antigen, this sample could be reflexed and tested for hepatitis D virus (HDV) antibodies (anti-HDV). Furthermore, if the patient tests positive for anti-HDV, this sample could be reflexed and tested for HDV-RNA. Some advantages of reflex testing include the automatic addition of testing, the fact that active infections can be confirmed using one sample, the streamlining of the diagnostic process without needing additional patient visits, reduced diagnostic delays, increased linkage to care, improved patient outcomes, and enhanced efficiency in laboratory and clinical workflows.
The advantages of reflex testing have also been evidenced in primary literature. In a retrospective 2023 study by Rohit Nathani and colleagues that was published in the Journal of Viral Hepatitis, over 11,000 HBV patients were studied for five years, and 12.9% of patients were subsequently screened for HDV infection. Researchers confirmed that 18% of the patients who were found to be positive for HDV would have been missed if the researchers had followed risk-based screening guidelines. Furthermore, the European Association for the Study of the Liver published Clinical Practice Guidelines on HDV in 2023 in which it recommended that all HBV patients should be screened for anti-HDV antibodies at least once, due to evidence that reflex testing of anti-HDV in HBV-positive patients resulted in a five-fold increase in HDV diagnoses. Overall, reflex testing can be useful for generating prevalence estimates and finding undiagnosed individuals.
Another strategy to close the gap of undiagnosed individuals living with viral hepatitis is opt-out testing, which is a proactive screening system. This strategy was tested in London hospitals, in which any patient who entered the emergency department and had a blood draw was automatically tested for bloodborne viruses. In a two-year period (April 2022-March 2024), nearly 2,000 HBV infections, over 760 HCV infections, and almost 400 human immunodeficiency virus infections were newly diagnosed. Closing the gap of undiagnosed individuals is clinically important to link patients to the appropriate care, and also offers epidemiological importance to reduce the transmission of these infections.
One particular challenge in eliminating viral hepatitis is reaching populations that may experience obstructions in accessing proper healthcare services. These 'hard-to-reach' populations include people who inject drugs, prisoners, immigrant communities, homeless individuals, individuals with mental health disorders, and racial and ethnic minorities. Particular strategies for reaching these populations can include integrating hepatitis care into existing healthcare, expanding access to screening and treatment, expanding harm reduction services, and addressing stigma and lack of awareness. Altogether, effective hepatitis management and elimination strategies require a collaborative and multidisciplinary approach involving the community and healthcare professionals.
"ESCMID Global 2025: The challenges of eliminating viral hepatitis" was originally created and published by Clinical Trials Arena, a GlobalData owned brand.
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