5 Questions: Samuel So on stamping out viral hepatitis in the U.S.

The United States could be free of viral hepatitis as a public health problem by 2030, but support from the highest levels of government would be needed, according to a recently published report from the National Academies of Sciences, Engineering and Medicine.

Though not widely seen as a major problem, viral hepatitis causes more than 20,000 deaths in the United States annually and more than 1.4 million worldwide, mostly due to infection with either the hepatitis B virus or the hepatitis C virus. Often symptomless at first, these infections can lead to liver damage and cancer.

Samuel So, MD, a professor of surgery and the Lui Hac Minh Professor in the School of Medicine, served on the committee that wrote the report, “A National Strategy for the Elimination of Hepatitis B and C,” which was published March 28. An expert on chronic hepatitis B and primary liver cancer prevention, research, treatment and health policy, So established the Asian Liver Center at Stanford in 1996 to address the especially high rates of chronic hepatitis B infection and liver cancer in Asians and Asian-Americans. He also leads several health-promotion campaigns to fight the disease.

Recently, writer Rosanne Spector asked him some questions about fighting the diseases.

Q: Why does it make sense to try to eliminate hepatitis B and C by 2030?

So: Because millions of deaths could be averted. As many people die of liver cancer and liver cirrhosis caused by chronic hepatitis B and C as HIV/AIDS in the world each year. In the United States, annual deaths from hepatitis B and C are greater than deaths from all the infectious diseases combined and is three times higher than deaths from HIV/AIDS.

Although eradication is rarely possible, in 2016 the World Health Assembly passed a resolution to set a goal to eliminate viral hepatitis as a major public health problem by 2030, and asked each nation to develop national strategies for elimination.

Our committee believes it is feasible to eliminate hepatitis B and C as a public health problem in the United States by ending transmission and preventing the morbidity and mortality among people with chronic infection. Similar global elimination efforts have been mounted against neonatal tetanus and trachoma, an infection that causes blindness.

There is no better time to act. With the new hepatitis C medications, over 95 percent of people with chronic hepatitis C are cured after only two to three months of treatment. Hepatitis B is preventable with vaccination, and hepatitis B antiviral treatment — although not curative — can prevent disease progression and most of the related deaths. Our report found that if diagnosis, care and treatment of chronic hepatitis B and C are increased, 90,000 deaths in the United States would be averted by 2030, and new hepatitis C infections would drop by 90 percent. 

Q: Why hasn’t eliminating hepatitis B and C in the United States been a priority?

So: It’s unfortunate that most people, including policymakers, philanthropic foundations and many leaders in academic medicine and global health, are not knowledgeable or aware of the prevalence and seriousness of chronic hepatitis B and C infections, their link to rising rates of liver cancer and the opportunities for elimination. Despite being a major national and international public health problem, viral hepatitis receives less than 1 percent of the National Institutes of Health research budget.

Through research, outreach and advocating for changes in national policies and guidelines, our center has worked diligently in collaboration with leaders in national governments, the Centers for Disease Control and Prevention, the World Health Organization and donors to build the case for elimination. So, I am really excited that we are finally talking about national and global elimination of hepatitis B and C.

Q: What are a few of the biggest challenges you see?

So: Chronic viral hepatitis is a silent disease and most of the infected have no symptoms. In the United States, an estimated two-thirds of people infected with hepatitis B and half of those with hepatitis C are not aware they are infected. 

Among the biggest challenges are diagnosing people who are living with chronic hepatitis B and C and providing them with access to care and antiviral treatment. Although screening is covered by the Affordable Care Act and by Medicare, health care providers rarely suggest it. And most primary care providers have not been trained to screen and provide care and treatment for patients with chronic viral hepatitis.

A major challenge in hepatitis C elimination is access to treatment, due to the cost of the most effective medication. As a result, only few of the estimated 700,000 hepatitis C patients on Medicaid, in correctional facilities or covered by Indian Health Services have received treatment. The report discussed possible ways to procure drugs at a lower cost to treat these neglected populations, including purchase of a drug’s patent or license by the government.

Q: What would it take to eliminate these diseases?

So: It would require our government to recognize elimination of hepatitis B and C as a national priority and to oversee a coordinated, funded effort that includes eliminating mother-to-child hepatitis B transmission; increasing access to adult hepatitis B immunization; increasing chronic hepatitis B and C screening, vaccination, care and treatment in primary care and correctional facilities; eliminating restrictions for hepatitis C treatments; expanding needle exchange and opioid-agonist therapy; and finding a source of sustainable financing to overcome the costs of hepatitis C medications.

Q: What can individuals do to help?

So: Protect you and your family, and contact your national and local elected representatives to support the development and funding of hepatitis B and C prevention, vaccination, screening, treatment and research programs. If you were born abroad, except from western Europe, or your parents were born in Asia or Africa, you should ask your doctor for a one-time blood test for hepatitis B. If you were born between 1945 and 1965 or had a transfusion of blood or blood products before 1992, or have injected drugs even once, ask your doctor for a one-time test for hepatitis C. If you are running a clinic or are a health care professional, make sure your patients are offered hepatitis B and C screening and hepatitis B vaccination according to the ACA and Medicare guidelines, and build hepatitis screening, care and treatment into the electronic medical system you use so it’s a no-brainer.