November 4, 2013

Global Burden of Liver Disease Substantial

Medscape Medical News > Conference News

Miriam E. Tucker

November 04, 2013

WASHINGTON, DC — Total deaths worldwide from cirrhosis and liver cancer rose by 50 million per year over 2 decades, according to the first-ever World Health Organization (WHO) study of liver disease mortality.

"Viral hepatitis specifically and liver disease in general have been underrepresented in the policy and the funding table," presenter Benjamin Cowie, PhD, told Medscape Medical News. "We're now increasingly recognizing that this is a substantial contributor to global mortality."

Dr. Cowie presented the liver disease-specific findings from the WHO Global Burden of Disease Study here at the Liver Meeting 2013.

"Certainly here in the United States, the number of people dying from liver disease and viral hepatitis is increasing quite steadily and concernedly rapidly," said Dr. Cowie, an infectious disease physician and epidemiologist at the Royal Melbourne Hospital in Australia.

Session comoderator Robert Fontana, MD, told Medscape Medical News that "there need to be better studies of viral hepatitis around the world to get better data. This is really a global health problem. We've been talking about AIDS and tuberculosis for a long time, but liver disease is also here. It's not coming, it's here already."

This is a substantial contributor to global mortality.

"We need to test people so we can treat them," added Dr. Fontana, who is from the University of Michigan Health System in Ann Arbor. "If you wait until they get liver cancer, the efficacy of everything we do is poor."

The report, supported by the Bill and Melinda Gates Foundation, was a collaboration of 486 researchers from 50 countries. The Institute for Health Metrics and Evaluation at the University of Washington led the work, which examined 291 diseases and injuries and 67 risk factors from 1990 to 2010 by region and country.

The report first listed hepatitis B as a leading cause of global death from infectious disease," but initial data did not include deaths from secondary infectious causes, such as liver cancer, cirrhosis, and other chronic diseases (N Engl J Med. 2012;366:454-461).

Cirrhosis and Liver Cancer on the Rise

"The morbidity and mortality of viral hepatitis is underrepresented in previous estimates because cirrhosis and cancer weren't included, but when you aggregate them, it moves up. I think that's a really important point," Dr. Fontana said.

As the number of annual liver cancer and cirrhosis deaths rose by 1.25 to 1.75 million from 1990 to 2010, an increasing proportion was due to liver cancer. In 2010, hepatitis B virus was associated with 45% of liver cancer and 30% of cirrhosis deaths, whereas hepatitis C and alcohol each caused about 25% of liver cancer and cirrhosis disease deaths.

In all, 1.3 million deaths worldwide are due to chronic viral hepatitis, which is comparable to the burden of HIV/AIDS, tuberculosis, and malaria, Dr. Cowie noted.

These proportions varied by country and region. In the United States, which had an estimated 19,500 liver cancer and 49,500 cirrhosis deaths in 2010 — an increase of 25,000 total liver disease deaths over 20 years — hepatitis C was a primary cause, accounting for 41% of liver cancer and 40% of cirrhosis deaths. Alcohol and hepatitis B were less common causes.

In China, by contrast, hepatitis B caused 54% of liver cancer and 46% of cirrhosis deaths in 2010. There were 370,000 liver cancer and 110,000 cirrhosis deaths in 2010. Those represented half the entire global burden of liver cancer deaths, but only 11% of the total deaths due to cirrhosis, Dr. Cowie noted.

Hepatitis B–associated cirrhosis was also more common in sub-Saharan Africa, where it accounted for 47% of liver cancer and 39% of cirrhosis deaths. The region also had a disproportionate burden of other cirrhosis deaths.

In Australia, cirrhosis deaths predominate, but liver cancer from hepatitis B is increasing relatively rapidly. There, hepatitis B is associated with 41% of liver cancer deaths and alcohol is responsible for 38% of cirrhosis deaths.

Dr. Cowie told Medscape Medical News that the recent baby boomer screening recommendations from the US Public Health Services Task Force and the Centers for Disease Control and Prevention are a step in the right direction.

"It's good to see the United States taking a leadership role from a clinical perspective, but there's still a lot to be done," he said. "Beyond diagnosis, what about access to care? In Australia, less than 5% of infected people have access to treatment."

Advancing Progress in Liver Diseases

Advancing progress in liver disease could follow the model of the HIV/AIDS movement, Dr. Cowie suggested. "That's one of the really encouraging messages from the Global Burden of Diseases project. HIV mortality has been falling since 2006 on a global basis. That's such a wonderful testament to what we can achieve when we harness our collective political will and donor funding and partnership responses with affected communities," he noted. "We can transform what was — and still is — a very substantial burden, but we're actually turning it around. That's so encouraging. We need to take those lessons and translate them into other areas that have been neglected, like viral hepatitis and liver disease."

Dr. Cowie pointed out that in poor countries, programs such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the US President's Emergency Plan for AIDS Relief (PEPFAR) have brought lifesaving drugs to people in need. "In poor countries with HIV, there was a recognition that this was a substantial and evolving health emergency. As a consequence, the Global Fund and PEPFAR have transformed the lives of millions of people. Why can't we do that for liver disease?"

Dr. Cowie says he anticipates that the project will help many different diseases that have previously been underappreciated as major causes of morbidity and mortality. "All data are freely available on that site. It's an absolute treasure trove. It's not just about viral hepatitis or about any particular country. It's about all causes of human disease in an accessible format."

Dr. Cowie has disclosed no relevant financial relationships. Dr. Fontana reports receiving research support from Gilead and Vertex, and being a consultant for GlaxoSmithKline and Tibotec.

The Liver Meeting 2013: American Association for the Study of Liver Diseases (AASLD). Abstract 23. Presented November 3, 2013.

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