Diagnosis of Viral Hepatitis Is Still a Major Challenge

Every year on July 28, the World Health Organization marks World Hepatitis Day to increase awareness and understanding of viral hepatitis. In Brazil, the whole month of July is dedicated to viral hepatitis awareness. This campaign, named Julho Amarelo, or Yellow July, was established in Brazil by Law No. 13.802 in 2019. It seeks to reinforce surveillance, prevention, and control of these infections.

According to the Brazilian Ministry of Health, between the years 2000 and 2021, more than 700,000 cases of viral hepatitis were diagnosed in Brazil. The Pan‑American Health Organization (PAHO) warns that global mortality from viral hepatitis is likely to exceed the number of deaths due to HIV, tuberculosis, and malaria combined by 2040. Paulo Abrão, MD, PhD, consultant for the Brazilian Society of Infectious Diseases and vice‑president of the State of São Paulo Society of Infectious Diseases, warns that clinicians, regardless of specialization, must ask all adolescent and adult patients for rapid hepatitis B and C tests at least once in their lives.

In 2022, the PAHO issued a warning for the Americas. According to the organization, the region records 10,000 new hepatitis B infections and 23,000 deaths each year. For hepatitis C, estimates show that it is responsible for 67,000 new infections each year, and 84,000 deaths.

Medscape's Portuguese edition spoke with Abrão about the topic. "I don't believe that the problem with viral hepatitis is getting worse. I think it has always been a big problem, and it has been around for a long time. We need to take action," he emphasized. For the doctor, the PAHO data likely reflect the increasing number of diagnoses in other South and Central American countries where the viral hepatitis scenario is worse than in Brazil.

"In Brazil, the number of new diagnoses is relatively stable. However, many people with these diseases are unaware that they have them. I think the greatest challenge is this: diagnosing the disease to be able to provide timely treatment," he said.

Hepatitis C Leads Diagnoses

Between 2000 and 2021, 280,000 hepatitis C cases were recorded in Brazil. The next most common were hepatitis B cases (264,640), followed by hepatitis A (168,175) and D (4259). According to the 2022 Epidemiological Viral Hepatitis Bulletin issued by the Brazilian Ministry of Health, the detection rate of confirmed hepatitis C cases across Brazil in 2021 was 5.2 per 100,000 people. The highest rate was found in Southern Brazil: 11.7 per 100,000 people. For hepatitis B, the detection rate across Brazil in 2021 was 3.4 per 100,000 people, the lowest observed in history. Southeastern Brazil had the highest incidence that year: 7.1 per 100,000 people.

The Brazilian Ministry of Health's press office informed Medscape that the 2022 viral hepatitis data will likely be released in the 2023 Epidemiological Hepatitis Bulletin, which is due to be issued in July. As of this writing, the bulletin was still in the final drafting phase.

Making Progress

The viral hepatitis scenario in Brazil is improving, said Abrão. In his view, this improvement is the result of the universal treatment program in effect for hepatitis C — all persons diagnosed with hepatitis C are treated, regardless of how much of the liver is compromised.

In the past, hepatitis C was treated using a subcutaneous medication administered for at least 1 year. This method of treatment caused various side effects, and, according to Abrão, only 20%-30% of patients were cured. "Today, treatment consists of a tablet taken by mouth for 3 months. There are no side effects, and 100% of patients are cured," he emphasized.

There have also been advances for hepatitis B. Abrão states that there are new medications, with fewer side effects, that are very effective. "There is a chance of cure, but it is lower than with hepatitis C. We have medications that fully control the disease and fully avoid complications arising, including cirrhosis and cancer. In most cases, patients must take the medication for the rest of their lives. It is a continuous‑use medication," he said.

According to Abrão, the Brazilian Public Health System (SUS) offers the best available medications in the world for hepatitis B and C, just as are offered for HIV. "These are areas with very competent assistance programs," he said, adding that the rapid diagnostic tests for hepatitis B and C are available throughout Brazil's public primary care services.

The SUS also offers a hepatitis B vaccine through the National Immunization Program. "It is indicated for all ages from birth to 100 years old. The vaccine is safe enough even for those living with HIV, for those with cancer, and for those who are immunocompromised because of other diseases," said Abrão.

There is also a hepatitis A vaccine available through the SUS. In this case, it is predominantly for children. "Outside of the pediatric age range, the SUS only recommends the hepatitis A vaccine for groups of people at higher risk for immunological [impairment] or previous liver injury; however, anyone can receive it if they have the means to pay for it [through private healthcare services]," he said.

Health Education Challenging

Despite the progress, Abrão pointed out that Brazil still has a few obstacles to overcome in the fight against viral hepatitis. "The first obstacle is better educating the population and healthcare teams. The second is increasing prevention using the hepatitis B vaccine and practicing behaviors that reduce the risk of infection. To overcome the third obstacle, we need to focus on diagnosis, because many people have the disease but don't know that they do," he said.

For Abrão, it is essential to take advantage of Viral Hepatitis Awareness Month in Brazil and World Hepatitis Day to remind people of the impact of viral hepatitis and to offer information that can help prevent, diagnose, and treat these diseases. "And this includes the healthcare team, which is often out of touch. I think these messages also apply to clinicians. They have to order tests for everyone, at least once, regardless of their area of specialization. If they don't order the test, they are missing out on the opportunity to diagnose that person," he said.

This article was translated from Medscape's Portuguese edition.

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