Editor's Note: July 28, 2024, marks the 14th World Hepatitis Day. Despite significant progress in combating viral hepatitis, it remains the most prevalent infectious disease in China. Hepatitis E (HEV) is particularly challenging, as China is a high-endemic region for the virus. To address the need for more standardized in-hospital screening procedures, accurate assessments, and a reduction in disease burden, the Chinese Consortium for the Study of Hepatitis E (CCSHE), in collaboration with the Chinese Physician Association for Infectious Disease and the National Clinical Research Center for Infectious Diseases, has developed the "Expert Consensus on the Process of In-Hospital Screening Management of Viral Hepatitis E in China (2023)" (referred to as the Consensus). During a recent academic exchange on hepatitis E prevention and control, Dr. Jian Wu, from the Affiliated Suzhou Hospital of Nanjing Medical University. Hepatology Digest invited Dr. Jian Wu to share his insights and experiences on hepatitis E prevention, diagnosis, and treatment, aiming to further raise public awareness and encourage proactive measures to curb the spread of the virus.Hepatology Digest: Could you briefly introduce the background of the Consensus? What are the current challenges China faces in in-hospital screening for hepatitis E?
Dr. Jian Wu: With the WHO’s goal of eliminating viral hepatitis as a public health threat by 2030, China has made remarkable strides in the prevention and treatment of hepatitis B (HBV) and hepatitis C (HCV). For example, HBV incidence has significantly decreased, from 269.9 per 100,000 people in 1990 to 138.4 per 100,000 in 2019, a reduction of 48.7%. Additionally, the prevalence of HBsAg among children under five has dropped dramatically, nearing the 2030 target. In the case of HCV, the use of pan-genotypic antiviral drugs has led to cure rates exceeding 95% after just 8 to 12 weeks of treatment.
However, when it comes to hepatitis E, China still faces significant challenges. The incidence rate has been rising in recent years, and the disease is often overlooked. Globally, there are approximately 20 million HEV infections each year, resulting in around 3.3 million cases of hepatitis E and 70,000 related deaths. Although our understanding of hepatitis E has improved significantly over the past decade, the situation remains concerning. Many HEV infections are missed or misdiagnosed due to insufficient screening, particularly among high-risk and special populations, which increases the risk of the disease progressing to chronic hepatitis or acute liver failure. In response to these challenges, the Consensus was developed, drawing on the expertise of specialists in infectious diseases, hepatology, laboratory medicine, and hospital infection control. Its goal is to raise awareness within healthcare institutions, providing a solid theoretical foundation and practical guidance for the precise diagnosis, effective treatment, scientific prevention, and comprehensive management of hepatitis E.
Currently, the challenges in in-hospital screening for hepatitis E in China include:
1. Limited Screening Scope: The current screening strategies are too narrow, failing to cover all potential high-risk populations. This results in a significant number of HEV infections being missed, hindering early detection and intervention.
2. Diagnostic Technology Limitations: The actual burden of hepatitis E is significantly underestimated. Existing laboratory diagnostic technologies have limitations, such as insufficient sensitivity in detection methods, the limited effectiveness of HEV IgM antibody detection due to its singularity, and significant discrepancies in the accuracy and consistency of various test reagents on the market. These issues collectively hinder the accuracy and efficiency of hepatitis E diagnosis.
3. Insufficient Clinical Awareness: Clinicians outside of infectious diseases and hepatology often lack awareness of the severity of hepatitis E and its potential as an underlying cause, especially when considering extrahepatic diseases. This further reduces the overall prevalence of hepatitis E testing.
4. Lack of Treatment Options: Currently, there is no specific antiviral treatment for HEV infection. Treating chronic or severe hepatitis E remains challenging, highlighting the urgent need for new therapeutic approaches to improve patient outcomes.
To address these challenges, it is essential to strengthen multidisciplinary collaboration, expand screening scope, optimize diagnostic technology, enhance clinical awareness, and actively explore effective treatment strategies to comprehensively advance hepatitis E prevention and control efforts.
Hepatology Digest: You mentioned the optimization of in-hospital screening management processes in your interpretation of the Consensus. How does this optimization contribute to more effectively identifying and managing hepatitis E patients in healthcare institutions?
Dr. Jian Wu: The strengths of the Consensus lie in its deep integration of systematic and practical approaches, which are reflected in the following key areas, forming the core framework for optimizing in-hospital hepatitis E screening management processes:
1. Screening Process: The Consensus outlines a standardized pathway for screening, specifying detailed steps and methods to ensure consistency and standardization in screening practices. This standardization significantly improves the accuracy and efficiency of screening results, laying a solid foundation for the early detection of hepatitis E.
2. Diagnostic Criteria: The Consensus provides clear definitions of diagnostic criteria, offering detailed diagnostic guidelines and procedures to assist healthcare professionals in accurately identifying hepatitis E patients, thereby reducing the occurrence of misdiagnosis and missed diagnosis.
3. Treatment and Isolation Measures: The Consensus emphasizes timely isolation and standardized treatment of confirmed hepatitis E patients, clearly outlining the specific implementation requirements for isolation measures and the principles for scientifically formulating treatment plans. This approach not only helps reduce the risk of virus transmission within healthcare institutions, protecting both patients and healthcare workers, but also promotes the standardization and individualization of treatment, improving treatment outcomes.
5. Patient Education and Communication: The Consensus also emphasizes the importance of patient education and communication, highlighting the need to enhance health education and communication regarding the disease. This helps patients fully understand their condition and preventive measures, improving their treatment adherence and self-management capabilities.
Hepatology Digest: What important progress has China made in the field of hepatitis E diagnosis and treatment?
Dr. Jian Wu: In recent years, under the leadership of academicians Zhuang Hui, Li Lanjuan, and Xia Ningshao, significant progress has been made in the field of hepatitis E diagnosis and treatment in China.
1. Screening and Diagnosis:
· Screening Scope: Specific and targeted screening recommendations have been developed for susceptible and high-risk populations, such as the elderly, individuals with underlying liver diseases, and women of childbearing age, ensuring comprehensive coverage and efficient implementation of screening efforts.
· Diagnostic Technology: New methods, such as antigen detection, have been introduced alongside serological testing and viral nucleic acid testing, significantly improving the accuracy and sensitivity of hepatitis E diagnosis.
· Diagnostic Criteria: As understanding of hepatitis E deepens, updated diagnostic standards have been established, clearly differentiating between acute infection, chronic infection, and past infection, providing clearer diagnostic guidelines for clinicians.
2. Treatment Procedures:
· Treatment Strategies: Comprehensive treatment plans have been developed for different stages of hepatitis E, ranging from ordinary infection cases to acute severe and chronic patients. These plans include antiviral therapy, artificial liver support therapy, and microecological regulation therapy, achieving personalized and precise treatment.
· Monitoring and Management: Clear guidelines have been established for monitoring indicators and time points during treatment, as well as comprehensive management and adjustment principles for untreated or treatment-failed patients, ensuring continuity and effectiveness in treatment.
· Follow-Up and Re-Examination: The follow-up and re-examination process has been strengthened, standardizing procedures to help doctors continuously track patients’ disease progression, adjust treatment plans promptly, and improve treatment outcomes.
3. Patient Education and Self-Management: There has been increased emphasis on in-hospital public health education, raising patient awareness of hepatitis E, enhancing their self-management capabilities, and improving treatment compliance, contributing to better patient recovery.
4. Attention to Extrahepatic Manifestations: There is growing attention to the extrahepatic manifestations of hepatitis E. HEV infection can affect multiple organs, including the nervous, hematological, and renal systems, indicating that hepatitis E is a systemic disease. Future research directions will be diverse, including in-depth investigations of HEV infection rates, genotype and subtype distribution, the pathogenesis and prevention strategies for severe hepatitis and HEV infection in pregnant women, and the development of new antiviral drugs for HEV.
Hepatology Digest: Under this year’s World Hepatitis Day theme of “Eliminate Hepatitis: Act Now,” what is the significance of the Consensus in advancing hepatitis E prevention and control efforts?
Dr. Jian Wu: Within the context of this year’s World Hepatitis Day theme, the Consensus provides significant impetus to hepatitis E prevention and control efforts, with its importance highlighted in the following areas:
1. Raising Awareness and Vigilance: The Consensus enhances awareness of the seriousness of hepatitis E across various sectors of society, increasing vigilance among healthcare professionals and the public, laying a solid foundation for subsequent prevention and control efforts.
2. Standardizing Screening Processes: The Consensus clearly defines standardized screening processes for hepatitis E, ensuring the regularity and accuracy of screening efforts. This helps in the timely detection and diagnosis of hepatitis E patients, particularly those with severe and chronic infections, effectively reducing cases of missed diagnosis and misdiagnosis.
3. Promoting Multidisciplinary Collaboration: The Consensus emphasizes the importance of collaboration across different medical disciplines and departments within healthcare institutions. It encourages cross-field and cross-disciplinary cooperation models in hepatitis E prevention and control, facilitating comprehensive and systematic management and control. This approach provides clear guidance for patient consultation, referral, treatment, and follow-up, optimizing the treatment experience, improving treatment outcomes, and enhancing the quality of life for patients.
4. Expanding Screening Scope and Depth: The Consensus also aims to improve the understanding and awareness of hepatitis E among non-infectious disease and non-hepatology clinicians, which helps to expand the scope and depth of screening efforts.
5. Providing Data Support and Policy Guidance: The Consensus includes specific requirements for quality control indicators and data collection, providing scientific evidence for monitoring and evaluating the effectiveness of prevention and control measures. This data can not only reflect the success of prevention efforts but also offer valuable support for policymakers, aiding in the effective allocation and rational use of public resources.
6. Advancing Global Prevention Efforts: In the context of achieving the WHO’s 2030 goals, the Consensus represents a significant milestone. It provides a concrete action plan for hepatitis E prevention and control in China and emphasizes the core role of systematic management and multidisciplinary collaboration in controlling hepatitis E. The implementation of these comprehensive measures will contribute to reducing the incidence and mortality of hepatitis E, protecting public health, and advancing global efforts in hepatitis E prevention and control.
Dr. Jian Wu’s Message for World Hepatitis Day
In the prevention and treatment of hepatitis B, C, and E, the key lies in “early screening, early prevention, and early treatment.” The advancement of diagnostic technologies has made early diagnosis possible, which is crucial for achieving the best treatment outcomes. Therefore, we urge all sectors of society to focus on screening high-risk and special populations, moving the prevention and treatment gateway forward, and initiating diagnosis and treatment as early as possible. This approach can not only effectively reduce the rates of severe cases and mortality among patients but also represents an important step towards the goal of eliminating viral hepatitis.
