WHO criteria for chronic hep B miss patients in Ethiopia needing treatment

Last Updated: 2019-04-01

By Marilynn Larkin

NEW YORK (Reuters Health) - World Health Organization treatment guidelines for chronic hepatitis B infection detect fewer than half of those in need of therapy in Ethiopia and may be unsuitable for sub-Saharan Africa, researchers say.

"Twenty percent of those living with chronic hepatitis B will die prematurely due to liver disease. The challenge is to identify and treat these 20%, and try to avoid treatment in the 80% who don't need it," Dr. Asgeir Johannessen of Oslo University Hospital in Norway told Reuters Health.

"In our study, when the World Health Organization's treatment criteria were used in real life in Ethiopia, only half of those in need of therapy were identified," he said by email. "After excluding those with obvious need for treatment - i.e., with clinical features of advanced liver disease - the WHO criteria failed to detect three quarters of those in need of treatment."

Dr. Johannessen and colleagues studied 1,190 treatment-na ve adults who attended a public chronic hepatitis B clinic in Addis Ababa. A transient elastography (Fibroscan) test result >7.9 kPa defined significant fibrosis and >9.9 kPa defined cirrhosis. Treatment eligibility was assessed using the latest guidelines from the European Association for the Study of the Liver (EASL) as the "gold standard."

As reported online March 28 in the Journal of Hepatology, 300 patients (25.2%) were eligible for treatment based on the EASL 2017 guidelines, whereas 182 (15.3%) were treatment-eligible according to WHO 2015 guidelines.

The sensitivity and specificity of the WHO criteria were 49% and 96.1%, respectively.

Most patients (51.6%) who fulfilled the WHO criteria had decompensated cirrhosis and might have a dismal prognosis even with therapy, the authors said.

Only 41 of 115 patients (35.7%) with compensated cirrhosis, who were likely to benefit most from therapy, were eligible for treatment based on the WHO criteria.

Dr. Johannessen noted, "The controversial point here is: should we have a high threshold for treatment, so that few 'healthy' people with hepatitis B will start treatment unnecessarily, but accepting that many in need of therapy never will get it? Or should we lower the threshold for treatment so that most of those in need of therapy will get it, but accepting that quite a number of 'healthy' hepatitis B patients will start treatment unnecessarily?"

"Our manuscript advocates for the latter, which definitely will save more lives, but also at a higher cost," he said. "Others will argue that we need to avoid over-treatment in settings with limited resources in order to save money and avoid over-burdening the healthcare system."

Dr. Geoffrey Dusheiko of University College London Medical School, coauthor of a related editorial, agrees there is "an urgent need to diagnose and treat patients at an earlier stage of the disease."

"Thus," he said, "new guidelines should be drawn up for African countries that recommend treatment to prevent the onset of advanced disease."

"The WHO should reconvene a panel to update the guidelines to target...earlier treatment," he stressed in an email to Reuters Health. "Also. the WHO and organizations such as FIND (Foundation for Innovative New Diagnostics) can validate and qualify point-of-care tests that are available or in beta testing - for example, dried blood spot testing or new cartridge-based tests for hepatitis B DNA - to expedite their rollout in urban and rural areas."

"Political organizations such as governments and the African Union should prioritize screening and case finding of chronic viral hepatitis B (and C) along with the diagnosis of HIV infection, removing the stigma that might dissuade individuals and pointing to effective safe and effective treatments," he added. "Governments and the media should devise large-scale campaigns to promote awareness of hepatitis B, which is the predominant form of chronic viral hepatitis in Sub Saharan Africa, as well as hepatitis C."

SOURCE: http://bit.ly/2HSbLHm and http://bit.ly/2HSH84e

J Hepatol 2019.