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In Philly’s push to eliminate hepatitis, a ‘silent infection,’ how many have it remains a big unknown

A national push to eliminate two types of hepatitis is hindered by too little information about who's infected.

Staff and volunteers from the Hep B United Philadelphia staff conducted hepatitis B screening at the Chinese Health Fair, in partnership with the Northeast Philadelphia Chinese Association, at 1919 Cottman Ave. on Sept. 18.
Staff and volunteers from the Hep B United Philadelphia staff conducted hepatitis B screening at the Chinese Health Fair, in partnership with the Northeast Philadelphia Chinese Association, at 1919 Cottman Ave. on Sept. 18.Read morephoto provided by the Hepatitis B Foundation

Philadelphia health officials are taking aim at two infectious diseases known as silent killers.

The Philadelphia Department of Public Health aims to eliminate hepatitis B and C by 2030. These two infections of the liver, which can lead to cirrhosis and liver cancer, kill about 325 city residents a year.

This will require health officials to address the thousands of infections from the viruses that they know about, with more than 2,000 new cases just in 2019, as well as identify the many more that are currently uncounted. Getting an accurate count of who is affected citywide represents a major obstacle.

“I don’t even have an educated guess,” said Danica Kuncio, viral hepatitis program manager for the health department.

Hepatitis B and C are different viruses, but both can be spread through needles when using drugs, and hepatitis B can be spread through sex. Hepatitis C can be cured, and B is treatable.

National health experts estimate about 40% of the 2.5 million Americans with chronic hepatitis C don’t know they’re infected. Between 860,000 to 2 million are infected with hepatitis B, according to the CDC. Even when the disease isn’t lethal, liver inflammation from infections can create a host of other health problems.

More than half of all hepatitis C cases are reported in Black and Latino Philadelphians, who often have less access to routine health care.

In Philadelphia, outreach to the Asian and African American immigrant community about hepatitis B will also be critical. In the United States, most infants are vaccinated for the virus, but that’s less common in other countries, making screening and vaccination critical for immigrants of some Asian and African nations and their families.

» READ MORE: Language barriers, bias, and cultural differences hinder access to health care for Asian Philadelphians

The city health department expects to release in early 2023 a plan for eradicating hepatitis B and C within eight years. Kuncio called the push “a steep goal” that’s in line with a multibillion-dollar initiative of the Biden administration, according to Stat, a health news website.

“We certainly can make a lot of progress in that time,” she said.

Hard to track ‘silent infections’

The city announced its goal to eliminate the two forms of hepatitis in July. Hepatitis cases appear to have declined in Philadelphia in 2020 and 2021, but health officials say that is almost surely inaccurate.

A problem, Kuncio said, is that hepatitis can do damage without causing noticeable symptoms. This is why it is known as a “silent infection.”

In chronic hepatitis cases, the viruses can damage livers for decades without causing noticeable symptoms, and doctors often don’t know to look for it. Stigma associated with both illnesses makes people reluctant to get tested.

During the COVID-19 pandemic, restricted in-person services and shuttered doctors’ offices made it hard for people to get tested.

Public health leaders suspect they are undercounting infections among many vulnerable populations. In addition to Asian and African American immigrants, these include people experiencing poverty or drug addiction, because they are less likely to be tested.

But getting accurate data is complicated. The health department is notified of positive cases, but not how many tests for the two viruses are administered. This means public health workers can’t calculate a “positivity rate” for the city’s testing, which would allow them to gauge how widespread the viruses are. The department is working with providers to find ways to gather better data about testing, Kuncio said.

“That’s what we really want to be able to use this data for,” Kuncio said, “to inform areas of the community that need specific resources.”

Deaths, too, are probably undercounted, Kuncio said. Cirrhosis or cancer are more likely to be recorded as the causes of death than the viral infections that led to them.

» READ MORE: How the COVID-19 pandemic is affecting another epidemic among teens: STDs | Expert Opinion

Difference between hepatitis B and hepatitis C

Hepatitis B and C both affect the liver, but are very different. Hepatitis B is often passed from mother to child during birth, though in the U.S. most infants are vaccinated against the virus.

Hepatitis C is primarily transmitted through exposure to infected blood, and those at risk include people who use injected drugs and Americans who had blood transfusions before screening methods improved in 1992, according to the CDC. It can also be passed from a mother to an infant.

The stigma that can be associated with both viruses stems from their association with drug use, and hepatitis B’s potential to spread through sex. Health experts said combating the viruses must include improving access to clean syringes for people with opioid addiction.

“Harm reduction and syringe service access is a really important tool for hep C,” she said.

» READ MORE: As activists rally in Harrisburg to legalize needle exchanges, a fight to keep them open continues in N.J.

To reduce case rates, public health workers will need to improve their approach to screening, treatment, vaccination, prevention, and education.

Hepatitis C became curable about a decade ago, a major medical accomplishment that federal health officials say too many with the virus don’t know about. The eight to 12-week regimen of treatment is also much cheaper than when it first debuted.

There is also a vaccine and effective treatment for hepatitis B, but lack of insurance or poor access to health care often prevents people from getting care they know they need.

“There’s a lot of barriers for people to even get the treatment because our health-care system doesn’t make it simple,” Kuncio said.

Some help may come by next year from the federal government. The Centers for Disease Control and Prevention is considering recommending universal testing for hepatitis B for all adults, which is already recommended for hepatitis C.

Currently, doctors must take the initiative to broach the topic of testing with patients. Some may not be aware of which patients are at greater risk, while others may not want to offend patients by suggesting they get tested.

Universal testing would avoid the complications of both obstacles and would be “a huge win,” said Catherine Freeland, associate director of public health research at the Hepatitis B Foundation, a Pennsylvania-based nonprofit promoting testing and treatment of the virus. Still, she said, it’s unclear how soon the recommendation could take effect.

The city health department is also hoping for more funding, with a White House push for hepatitis C eradication. The city currently relies on a $601,228 CDC grant to support its hepatitis initiatives, and it’s not enough.

“Given the proportion of cases we have and the people we know are living undiagnosed with B and C,” Kuncio said, “there’s a lot of funding that’s needed.”