At the 35th European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Global conference in Vienna, Austria, held from 11 April to 15 April 2025, the challenges of eliminating viral hepatitis were discussed.
In 2024, the World Health Organization (WHO) reported that aside from tuberculosis, viral hepatitis was the most common cause of mortality due to infectious diseases worldwide. Furthermore, despite a slow decrease in the global incidence of viral hepatitis B (HBV) and C (HCV) in recent years, mortality due to these viruses has been increasing. In 2016, the WHO launched the Global Health Sector Strategy (GHSS), which aimed to end viral hepatitis by 2030, defining elimination as a 90% reduction in incidence and a 65% reduction in mortality for HBV and HCV from 2015 to 2030. One challenge to achieving this goal is the proportion of undiagnosed individuals. According to the WHO, 254 million people globally were estimated to have HBV in 2022, but only around 10% had been diagnosed. Likewise, 50 million people globally were estimated to have HCV in 2022, but only around 30% had been diagnosed.
One current strategy to close this gap and provide patients with diagnoses and treatments is reflex testing – the automatic addition of testing based upon initial test results. With one patient-provided sample, reflex testing can provide complete data for diagnosis, staging, co-infection and management strategies. For example, if a patient tests positive for the hepatitis B surface antigen (HBsAg), this sample could be reflexed and tested for hepatitis D virus (HDV) antibodies (anti-HDV). Furthermore, if the patient tests positive for anti-HDV, this sample could be reflexed and tested for HDV-RNA.
Advantages of reflex testing include the automatic addition of testing, the fact that active infections can be confirmed using one sample, the streamlining of the diagnostic process without needing additional patient visits, reduced diagnostic delays, increased linkage to care, improved patient outcomes and enhanced efficiency in laboratory and clinical workflows.
The advantages of reflex testing have also been evidenced in primary literature. In a retrospective 2023 study by Nathani and colleagues published in the Journal of Viral Hepatitis, more than 11,000 HBV patients were studied for five years, and 12.9% of patients were subsequently screened for HDV infection. Researchers confirmed that 18% of the patients who were found to be positive for HDV would have been missed if the researchers had followed risk-based screening guidelines.
The European Association for the Study of the Liver published clinical practice guidelines on HDV in 2023 in which it recommended that all HBV patients should be screened for anti-HDV antibodies at least once, due to evidence that reflex testing of anti-HDV in HBV-positive patients resulted in a five-fold increase in HDV diagnoses. Overall, reflex testing can be useful for generating prevalence estimates and finding undiagnosed individuals.
US Tariffs are shifting - will you react or anticipate?
Don’t let policy changes catch you off guard. Stay proactive with real-time data and expert analysis.
By GlobalDataAnother strategy to close the gap of undiagnosed individuals living with viral hepatitis is opt-out testing, a proactive screening system. This strategy was tested in London hospitals, in which any patient who entered the emergency department and had a blood draw was automatically tested for bloodborne viruses. In two years (April 2022 to March 2024), almost 2,000 HBV infections, more than 760 HCV infections and almost 400 HIV infections were newly diagnosed. Closing the gap of undiagnosed individuals is clinically important to link patients to the appropriate care, and also offers epidemiological importance to reduce the transmission of these infections.
One particular challenge in eliminating viral hepatitis is reaching populations that may experience obstructions in accessing proper healthcare services. These hard-to-reach populations include people who inject drugs, prisoners, immigrant communities, homeless individuals, individuals with mental health disorders and racial and ethnic minorities. Particular strategies for reaching these populations can include integrating hepatitis care into existing healthcare, expanding access to screening and treatment, expanding harm reduction services, and addressing stigma and lack of awareness. Altogether, effective hepatitis management and elimination strategies require a collaborative and multidisciplinary approach involving the community and healthcare professionals.
