It is World Hepatitis Day today (28 July 2021). [1] While we are in the midst of the covid-19 pandemic crisis, let us not overlook the impact of covid on endemic viral infections that cause disease and deaths each and every year. Clinical and public health interventions and resources remain necessarily focused on the covid response, but careful, unified responses are also urgently required to mitigate the long term global health impact of the pandemic on other diseases. 

Despite advances in safe, affordable, and effective vaccination and treatment, Hepatitis B virus (HBV) causes close to a million deaths each and every year, stretching back in pre-covid history, and continuing for the foreseeable future. [2] 300 million adults and children in the world are currently HBV-infected, but because of gaps in awareness and diagnosis, it is estimated that only 1 in 10 of these are aware of their status, among whom only a minority have access to appropriate and consistent clinical care. [3] 

Most of those with chronic HBV infection come into contact with the virus at birth or early in life, yet the infection continues to carry stigma and shame. [4] Some languages don’t have a name for HBV infection, and in those that do, it frequently goes unspoken. [3,5] HBV has historically lacked the profile it deserves in contrast to other infections that cause a similar threat to human health, such as malaria, tuberculosis, and HIV. Will the covid pandemic push HBV even further into the shadows, or can we capitalise on the opportunity to challenge discrimination and promote open dialogue?

Publishing new scientific data for HBV has always been difficult. The infection is not seen as a priority by Western Europe and North America, where authors, reviewers, and publishers are disproportionately located, and gaps and caveats in new data often inhibit publication. [6] In contrast, the pandemic has led to an extraordinary outpouring of scientific literature, with over 96,000 papers listed on PubMed in 2020-21 for covid/SARS-CoV-2, which is more than double the number of papers ever published about HBV (since it was first reported in 1967). [7] The long term impact of the pandemic on scientific publishing remains uncertain, but we need to ensure that valuable work on covid does not eclipse other output, and that rapid advances in interdisciplinary working, open data and use of pre-prints are sustained. [8]

HBV infection is typically silent until lasting liver damage or cancer has developed. The incidence of most cancers worldwide is declining, but hepatocellular carcinoma (HCC) is on the rise, mainly because of the unchecked influence of HBV. [9] This cancer typically presents late, by which time the window of opportunity for curative intervention has already closed, leading to poor outcomes. Expert recommendations aim to reduce the disruptive influence of the pandemic on prompt therapy for HCC, but inevitable delays already have a quantifiable impact on life expectancy for patients with cancer. [10,11,12]

Much of the burden of long term HBV complications is avoidable if we provide education, screen widely to identify infection, intervene to prevent transmission, and treat to avoid liver disease. [13] Such strategies can be incorporated within existing infrastructure, depending on the setting, for instance, linking to HIV and sexual health services, antenatal care, migrant healthcare, or clinical provision for other chronic diseases. While the pandemic has disrupted many such services, it has also enhanced awareness and dialogue about infectious diseases, and created new opportunities for engaging with communities and providing clinical care. [14]

As a result of the pandemic, vaccines have gained a consistent place at the centre-stage in public awareness (see a Vaccinologist in Vogue). [15] The overwhelming global response has been positive when immunisation is made available and accessible. However, there are concerns about the anti-vaxx movement and the impact of vaccine hesitancy, potentially eroding trust in the most vulnerable communities. HBV immunisation is already enshrined in infant vaccine programmes, but 17 million babies missed routine vaccinations in 2020, and sustaining progress on birth doses and three dose coverage for the HBV vaccine regimen are increasing challenges in the pandemic era. [16,14]

While curative therapy is not yet available for HBV, work is underway to develop new HBV drugs, or immunotherapeutic vaccines. High profile multi-centre covid trials, such as the RECOVERY trial, have demonstrated the huge gains that are possible through new frameworks, permitting agile clinical studies that can move at pace. [17] The HBV field could gain much from aligning with this strategy.  

International sustainable development goals have set elimination targets for viral hepatitis by 2030 that were ambitious even pre-covid. [18] Now, healthcare resources, personnel, and laboratory capacity have been diverted to the emergency. Lock-down has disrupted clinical services. The UK government has slashed research funding, including Official Development Assistance (ODA) budgets. [19] Populations that have long been neglected by healthcare, education, resource-allocation and policy are hardest hit by both covid and HBV. [14] World Hepatitis Day is a reminder that we need to dig deep to redress inequity, capitalise on new insights and opportunities, and focus on positive interventions that can drive progress towards HBV elimination. 

Philippa Matthews, consultant in clinical infection in Oxford and an Associate Professor at Oxford University.

Competing interests: PM is funded by a Wellcome fellowship. She leads research to study the diverse outcomes of HBV infection, through collaborations in the UK, South Africa and Uganda. She also receives research funding from the NIHR, which supports work to enhance the molecular diagnostics of viral infection. During 2020-21 she has been heavily involved in the clinical and academic response to the COVID pandemic, working as part of a large inter-disciplinary team in Oxford.

References:

1 World Hepatitis Day 2021 – Hepatitis can’t wait https://www.who.int/news-room/events/detail/2021/07/28/default-calendar/world-hepatitis-day-2021 (accessed 18 Jul 2021).

2 WHO Hepatitis B Factsheet. 27 July 2020. https://www.who.int/news-room/fact-sheets/detail/hepatitis-b (accessed 18 Jul 2021).

3 O’Hara GA, McNaughton AL, Maponga T, et al. Hepatitis B virus infection as a neglected tropical disease. PLoS Negl Trop Dis 2017;11:e0005842.

4 Mokaya J, McNaughton AL, Burbridge L, et al. A blind spot? Confronting the stigma of hepatitis B virus (HBV) infection – A systematic review. Wellcome Open Res 2018;3:29.

5 Mugisha J, Mokaya J, Bukenya D, et al. A Study of Knowledge, Experience, and Beliefs About Hepatitis B Virus (HBV) Infection in South Western Uganda. Front Public Health 2019;7:304.

6 Matthews PC. FAIR data needed to liberate hepatitis B virus (HBV) from the catch-22 of neglect. J Glob Health 2019;9:010310.

7 Alter H. Baruch Blumberg (1925-2011). Nature 2011;473:155.

8 Sohrabi C, Mathew G, Franchi T, et al. Impact of the coronavirus (COVID-19) pandemic on scientific research and implications for clinical academic training – A review. Int J Surg 2021;86:57–63.

9 Liver Cancer – Statistics. 2012.https://www.cancer.net/cancer-types/liver-cancer/statistics (accessed 18 Jul 2021).

10 Shiina S, Gani RA, Yokosuka O, et al. APASL practical recommendations for the management of hepatocellular carcinoma in the era of COVID-19. Hepatol Int 2020;14:920–9.

11 Sud A, Jones ME, Broggio J, et al. Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic. Ann Oncol 2020;31:1065–74.

12 Lai AG, Pasea L, Banerjee A, et al. Estimated impact of the COVID-19 pandemic on cancer services and excess 1-year mortality in people with cancer and multimorbidity: near real-time data on cancer care, cancer deaths and a population-based cohort study. BMJ Open 2020;10:e043828. 

13 The fight against viral hepatitis: Call for stories. https://www.nohep.org/news-resources/the-fight-against-viral-hepatitis-call-for-stories/ (accessed 18 Jul 2021).

14 Pley CM, McNaughton AL, Matthews PC, et al. The global impact of the COVID-19 pandemic on the prevention, diagnosis and treatment of hepatitis B virus (HBV) infection. BMJ Glob Health 2021;6. 

15 Vogue. The vogue 25: Meet the women shaping 2020. British Vogue. 2020.https://www.vogue.co.uk/news/article/the-vogue-25-the-women-shaping-2020 (accessed 18 Jul 2021).

16 Kuchler H. Covid pandemic triggers drop in routine childhood vaccinations. Financial Times. 2021. https://www.ft.com/content/988cb29e-e8a2-414a-a1f2-9a65824b9d2d (accessed 18 Jul 2021).

17 RECOVERY trial, https://www.recoverytrial.net (accessed 18 Jul 2021).

17 WHO releases first-ever global guidance for country validation of viral hepatitis B and C elimination. https://www.who.int/news/item/25-06-2021-who-releases-first-ever-global-guidance-for-country-validation-of-viral-hepatitis-b-and-c-elimination (accessed 18 Jul 2021).

18 Lemoine M, Cooke GS, Thursz M, et al. Cuts to UK official development assistance budget jeopardise global viral hepatitis elimination goals. Lancet Gastroenterol Hepatol 2021;6:527–8.