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VIENNA – A global scientific strategy for treating hepatitis B – developed by the International Coalition for the Elimination of HBV after consultation with more than 50 scientists – was published here at the International Liver Congress 2019.
Despite effective treatment for hepatitis B and a preventative vaccine, 887,000 people worldwide have died of the virus in 2017, according to a report by the World Health Organization. And for the 257 million people chronically infected with the virus, there is no cure.
In Africa, the prevalence is 3% and "deaths among infected adults born before the age of vaccination will continue to increase if they are not diagnosed and treated," according to the WHO report.
"This is unacceptable," said Peter Revill, MD, of the Peter Doherty Institute for Infection and Immunity in Melbourne, Australia, a member of the coalition.
Still, research on hepatitis B is largely underfunded, "to the point of being compared to a neglected tropical disease," he said. Medscape Medical News.
And a "one size fits all" solution does not apply. The life cycle of the virus depends on the genotype and the transmission varies from one region to another, so "different countries may need different approaches," he explained. "In China, it is mother-to-baby, in other areas, transmission to the adult is a problem."
In addition, the immune system of some people can solve the virus. others, who have an exhausted immune system or who simply do not have a chance, can not.
We were surprised to learn that the diagnosis error was so much above average in radiology.
Now the coalition has reached a scientific consensus on how to develop a cure, said Revill. "The strategy must be comprehensive," he added. "Hepatitis B has no borders."
Su Wang, MD, discovered that she had contracted hepatitis B after donating blood to the university. Since she was in China, she was allowed to continue her medical studies, but this is not true everywhere.
In many parts of the world, the disease is still heavily stigmatized, said Wang of Saint Barnabas Medical Center in Livingston, New Jersey.
For many patients, the virus has serious consequences. Ms. Wang said she heard about people who lost their family, their job, and even the right to study to become a health worker. Stigma itself can change lives, she recounted, telling the story of a five-month-old pregnant woman who was asked to leave the home of her boyfriend's family after the diagnosis.
In poor countries, even when patients take medication, they often find it difficult to get their blood tested for viral load. They do not know if the treatment has an effect.
"It's a complex disease," Wang explained. "My patients are learning that research is in progress" and are confused by the slow progress and frustrated by the lack of curative treatment.
Consensus for a two-level approach
"Hepatitis B is a complicated animal," explained Revill. The coalition members "admitted that we needed a two-tiered approach: we need to both target the virus and stimulate the host response."
The viral life cycle of hepatitis B is even more complicated than that of hepatitis C. "Current drugs do not target the covalently closed circular [ccc]DNA, the reservoir of viral persistence that hides in the nucleus ".
According to this strategy, scientists must first and foremost tackle how to confront c-cDNA in the hepatocyte nucleus, which forms the stable minichromosome of the genome of the hepatitis B virus.
"We suggest that research directed toward the elimination of cccDNA" or the permanent deletion of the transcription of the cDNA is a priority, said the coalition in its report published online in the Lancet Gastroenterology and Hepatology.
An understanding of the mechanisms of cDNA and the development of serum markers of cDNA DNA and methods to degrade it would contribute to healing, as well as methods to prevent the transcription and development of functional in vitro dcc DNA systems.
"A true cure for HBV requires the removal of intranuclear cDNA from infected hepatocytes, so it is essential to understand the mechanisms involved in the biogenesis, regulation, and stability of the cDNA to achieve HBV eradication, "said Fabien Zoulim, MD, PhD, of Hospices Civils de Lyon in France, who is also a member of the coalition.
A second research priority is the immune system.
We must strengthen the exhausted immune response if we want to eliminate the infection.
"We need to strengthen the exhausted immune response if we want to eliminate the infection," Zulim said Medscape Medical News.
Many components of the immune system must be examined to obtain viral clearance. Innate immunity and adaptive immunity against the virus are therefore essential.
This would involve determining whether the mechanism of T cell depletion is reversible, durable and necessary, and identifying biomarkers in the blood that best reflect the intrahepatic immune response. The degree of immune-mediated destruction required and the category of patients must also be established.
"The combination strategies will be an important first step in finding a cure," said Zoulim.
Improve prospects
This strategy of treating hepatitis B is really good because it describes the complexities and offers hope, said Wang Medscape Medical News.
There is a lack of understanding of the virus she has witnessed in her infected patients. "I tell them that you can lead a normal life, that I am infected," she said.
"I started to understand that the patient's voice was important, so I try to make patients more vocal, more demanding and share their experiences," she added. .
"This strategy is much more than a guideline," she said. "For patients, it's a realistic view – even for me."
Revill, Zoulim and Wang did not reveal any relevant financial relationship.
International Liver Congress (ILC) 2019. Presented on April 10, 2019.
Follow Medscape Gastroenterology on Twitter @ MedscapeGastro and Ingrid Hein @ingridhein
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