The global burden of viral hepatitis

By Dr Graham Cooke, Clinical Senior Lecturer in Infectious Diseases, Imperial College London

A couple of weeks ago we published our paper on the burden of viral hepatitis. We’d hoped that the Lancet would publish it in time for World Health Assembly in May and it might get a bit of attention. That couldn’t be done, so it came out on the 6th July. The same day as Chilcot. Not a brilliant piece of planning, it has to be said, and a reminder of how much I have to learn about PR.

With colleagues at Imperial, we have been studying and writing about hepatitis for some years. But there’s always been a feeling that hepatitis has been relatively low profile in the global health community, and not just because of major enquiries into wars. So how did we end up writing a paper on the burden of hepatitis?

Most of the health impact of viral hepatitis is from two viruses, hepatitis B (HBV) and hepatitis C (HCV) – both cause liver scarring (cirrhosis) and liver cancer (hepatocellular carcinoma). The world has had a good HBV vaccine for a long time, and in the last few years we have seen great progress in new treatments for both viruses. Hepatitis B can be controlled, like HIV, with daily medication. But a revolution in treatment really kicked off in late 2011 when data was presented on the first a new class of curative treatments for hepatitis C, sofosbuvir (then known catchily as PSI-7977).  As soon as we saw that data it was clear that the step forward in treatment could transform treatment, not just in developed health systems, but potentially in all health systems.

Some months later, I found myself in the elegant surroundings of Carlton Terrace with a couple of students from our BSc in Global Health (sign up, places going fast…) for the launch of the Global Burden of Disease (GBD) Project. The GBD is an impressive attempt to systematically quantify both mortality and morbidity from disease and allow comparison of one disease relative to another. It’s not perfect, but has been restlessly trying to improve since it started in 1990. What could have been a very long day was more lively than could have been reasonably expected. The chair of proceedings, a widely respected senior epidemiologist, clearly didn’t feel like being overly generous to the project’s leader, Chris Murray, on his big day. It felt at times like a best man’s speech where he tells the groom he could have done better for himself. During quieter moments, I read the paper on a memorably uncomfortable chair. Hepatitis didn’t appear to feature, but I realised that the data was there, but hidden away amongst the figures on cirrhosis and liver cancer. In such an influential work, this is a problem for those of us trying to raise the profile of a disease when there are other important causes of those conditions (alcohol for one).  A bit cross (possibly made worse by the chair), I reached for a calculator to work out what the disease rankings would look like if viral hepatitis was presented as a single entity. To suggest it was the back an envelope would be overestimating the degree of rigour involved, but we later published a piece suggesting that by bringing the hepatitis figures together they could be recognised as a leading cause of mortality and that this approach could have a much better impact in  global policy circles.

Delegates at the Hepatitis Modelling meeting in 2013
Delegates at the Hepatitis Modelling meeting in 2013

In 2013, I found myself at a hepatitis modeling meeting where I met Abie Flaxman, one the key member of the GBD team (and once memorably described as the Nate Silver of Public Health, hopefully a reference of greater relevance in an election year). Softening my now well-rehearsed chuntering about the GBD and hepatitis, I found someone who was not only smart, but who got the issue and wanted to help. And our collaboration grew from there, propelled by Jeff Stanaway, one of Abie’s colleagues. The work developed in a number of directions from that initial discussion and the process of how we finally got it done and published, not an entirely smooth or painless process, can wait another time. But we got there.

So what does it show? Well, amongst other things, viral hepatitis is the 7th leading cause of death in the world, having now overtaken HIV, TB and malaria. There’s much more in the paper, but this headline is probably what you’ll (hopefully) see quoted at least once this World Hepatitis Day.

graham cooke diagram
Leading causes of death and the change between 1990 and 2013.

Further reading

Read the full report here

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