Progress towards elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission update

Expert consensus and recommendations on the live attenuated hepatitis A vaccine and immunization practices in India

While Hepatitis A Virus (HAV) vaccination in global immunization programs has shown a virtual elimination of the disease within few years of the vaccination program, changing epidemiological landscape in India underscores the need for evidence-based, updated guidance on immunization practices. In May 2024, a panel of 15 distinguished opinion leaders and an organizing committee convened for an intensive, face-to-face advisory board meeting on high burden of HAV infection among adults, increased mortality rate in adolescents, symptomatic presentation in children, and evolving landscape globally and within India. Extensive comparable deliberations on long-term follow-up data from India and data from country of origin advocated immunogenicity, tolerability, and long-term protective effects of single-dose live attenuated HAV vaccine in children. Finally, a consensus was achieved on recognition of increased global attention toward HAV prevention through vaccination coverage. The need for a single dose of live attenuated HAV vaccine was an important outcome of this meeting.

Characteristics of hepatitis B virus surface protein and occult hepatitis B infection in infants with immunoprophylaxis failure from Indonesia

Perinatal hepatitis B virus (HBV) infection carries a significant risk of chronicity and complications while making infected people reservoirs for further transmission. Hepatitis B immunization in infants, with or without hepatitis B immune globulin (HBIG), has proven effective in preventing mother-to-child transmission. Nevertheless, some newborns of mothers with high viremia testing positive for hepatitis B e antigen (HBeAg) may not benefit from HBV immunoprophylaxis. Nineteen (10.2 %) of 186 infants born to HBV-infected mothers were HBV DNA-positive. HBV genotypes, serotypes, and hepatitis B surface antigen (HBsAg) sequences were comparable in most mother-cord blood-infant sample pairings, indicating that the infants' HBV strains originated from their mothers. Three (15.3 %) infants had overt HBV infection, whereas 16 (84.2 %) had occult HBV infection (OBI). The HBV isolates from infants exhibited 26 mutations: 38.5 % in the 'a' determinant and 61.5 % in the rest of HBsAg. Mutations were identified in B-cell and T-cell epitopes, impairing humoral and cellular responses to detect or neutralize the virus. This rendered immunoprophylaxis and diagnostics ineffective while inducing tolerance to the infection. HBV strains with these mutations can persist and cause complications, but they can be transmitted undetected by HBsAg tests commonly used in community healthcare. This study reveals the risk of HBV transmission from HBsAg mutant-infected mothers to newborns despite having received the birth dose with HBIG and complete hepatitis B vaccination.

Coinfection of hepatitis B, tuberculosis, and HIV/AIDS in Beijing from 2016 to 2023: a surveillance data analysis

BACKGROUND

Hepatitis B (HB), tuberculosis (TB), HIV infection and AIDS (HIV/AIDS) are the major public health threats in China. The existing domestic research shows significant regional differences in the coinfection of HB, TB, and HIV/AIDS and mainly focused on two diseases. This study aims to analyse the coinfection of HB, TB, and HIV/AIDS patients in Beijing from 2016 to 2023.

METHODS

We obtained data on cases diagnosed with HB, TB, or HIV/AIDS between 1 January 2016 and 31 December 2023 in Beijing from the National Notifiable Disease Reporting System (NNDRS). After removing duplicate cards with the same disease, we compared the demographic, temporal, and spatial characteristics between coinfections and mono-infections and among coinfections with different diagnostic sequences using chi-squared test. We also explored the risk factors for coinfection by multivariate logistic models.

RESULTS

Overall, 104,141 cards from 103,595 cases in Beijing were included in this study. The number of cases infected with HIV/AIDS, HB, or TB alone was 20,884 (20.12%), 23,853 (23.03%), and 58,357 (56.33%), respectively. Furthermore, 47 cases (0.05%) were diagnosed with HIV/AIDS and HB, 153 (0.15%) with HB and TB, and 336 (0.32%) with HIV/AIDS and TB. And only five cases were diagnosed with all three diseases. 0.22% HB and 1.58% TB were coinfected among HIV/AIDS patients; 0.64% TB and 0.20% HIV/AIDS were coinfected in HB patients, and 0.26% HB and 0.57% HIV/AIDS in TB patients. Differences in demographic characteristics, residential areas, and diagnosis years were found between coinfected patients and those with a single disease. In contrast, almost no significant difference in characteristics and diagnostic time intervals was found among comorbidity patients with the same diseases but different diagnostic sequences. The multivariate logistic model shown that males were more susceptible to be coinfected (ORs ranged from 1.50 to 27.81). Compared with the cases aged 60 and above, younger TB patients were more likely to be coinfected with HIV/AIDS (OR = 2.76[95%CI:1.59-4.77], 5.36[3.16-9.07]and 2.75[1.62-4.65] for those aged 15-29, 30-44 and 45-59), while younger HB or HIV/AIDS patients were less likely to be coinfected with TB (OR = 0.37[0.18-0.73], 0.34[0.20-0.59], 0.63[0.40-0.98] for younger HB and OR = 0.27[0.15-0.48],0.46[0.26-0.81],0.59[0.33-1.03] for younger HIV/AIDS). Compared with TB patients in urban areas, suburban patients are less likely to be infected with HIV/AIDS (OR = 0.63[0.50-0.79] for inner suburbs and 0.33[0.16-0.72] for outer suburbs). Patients infected with TB or HIV/AIDS living in outer suburbs were more likely to be coinfected with HB (OR = 2.65[1.62-4.34] for TB and OR = 4.04[1.18-13.85] for HIV/AIDS). Patients coinfected with TB and HB had longer diagnostic intervals than those infected with HIV.

CONCLUSIONS

The incidence of comorbidity of HB, TB, and HIV/AIDS was low and showed a declining trend in Beijing. Among various types of coinfections, HIV/AIDS coinfected with TB has the highest incidence. Males should be considered as the primary target population for preventing coinfections. In addition to promoting the development of information technology and integrating data from multiple sources, it is essential to conduct thematic investigations, enhance education among key populations, and intensify the tracking of close contacts of existing patients to prevent and control the spread of these diseases.

Cost-Effectiveness of Screening and Treating Chronic Hepatitis C Virus Infection in Zimbabwe

BACKGROUND

The aim of this study was to assess the cost effectiveness of a screening and treatment intervention approach for chronic HCV infection in Zimbabwe.

METHODS

Using a decision tree and a validated Markov model, we estimated the lifetime costs and health effects of screening for and treating HCV infections from a healthcare perspective. We evaluated three screening strategies, namely the following: i. no screening; ii. screening among the general population; and iii. screening among high-risk groups. Incremental cost effectiveness ratios were calculated for the strategies that were not dominated. We used deterministic and probabilistic sensitivity analyses to explore the impacts of parameter uncertainty on cost effectiveness outcomes.

RESULTS

The strategy of screening among high-risk groups and treating with sofosbuvir/velpatasvir had an incremental cost of USD 1201 and incremental quality-adjusted life years (QALY) of 2.01, yielding an incremental cost effectiveness ratio (ICER) of USD 604 per QALY gained as compared to no screening. The ICER was below the 0.5 times the gross domestic product per capita parameter (USD 796), making the intervention potentially cost effective. The strategy to screen among the general population was dominated, because it costed more and resulted in fewer QALYs than its comparators.

CONCLUSIONS

Screening for HCV among high-risk populations followed by treatment using sofosbuvir/velpatasvir is cost effective under the assumptions made in this study.

Burden of five major types of gastrointestinal cancer in the Eastern Mediterranean Region

OBJECTIVE

We provide an overview of the latest estimates of five gastrointestinal (GI) cancers in the Eastern Mediterranean Region (EMR) countries to guide cancer control policy.

METHODS

We extracted the number of cases and deaths for oesophageal, gastric, liver, colorectal and pancreatic cancers from the GLOBOCAN database produced as estimated by the International Agency for Research on Cancer for the year 2022. Age-standardised incidence and mortality rates (ASR) per 100 000 person-years were estimated for the 22 EMR countries, cancer site and sex.

RESULTS

The estimated 173 000 new cancer cases and 139 000 deaths from the five GI cancers corresponded to 22.2% of the incidence and 28.7% of the mortality burden in the EMR. Across all cancers (for both sexes combined), colorectal cancer ranked third (6.9%; ASR 8.9), followed by liver cancer (6.2%; ASR 8.4) in terms of incidence, while liver cancer (9.6%; ASR 8.1) and gastric cancer (6.4%; ASR 5.5) were the third and fourth leading causes of cancer-related mortality in the region, respectively. Marked differences in cancer incidence and mortality rates were observed between the 22 countries, particularly the 10-fold variations seen in liver cancer incidence.

CONCLUSION

GI cancers currently account for an important fraction of the cancer burden in the EMR; the present analysis seeks to inform tailored decision-making according to the country-specific GI cancer profiles.

HBV and HCV testing outcomes among marginalized communities in Italy, 2019-2024: a prospective study

Background

The health of the marginalized populations is crucial for public health and inequalities. The World Health Organization (WHO) Global Hepatitis Report 2024 stated that over 304 million people were living with Hepatitis B Virus (HBV)/Hepatitis C Virus (HCV) infection in 2022. We performed HBV/HCV screenings among marginalized communities to reveal hidden infections and link-to-care positive participants.

Methods

From January 2019 to May 2024, finger-prick tests were used to conduct on-site screenings at non-profit organizations in Tuscany, Italy. Positive participants were referred to the closest outpatient clinic.

Findings

Eighty/1812 (4.4%) participants were Hepatitis B surface Antigen (HBsAg)+, mostly men (p < 0.001) and non-Italian natives compared to those HBsAg- (p < 0.001). Fifty-two/1812 (2.9%) were anti-HCV+ with a higher proportion of Italians (p < 0.001) and lower education level (p < 0.01) compared to the anti-HCV-. Intravenous drug use was an independent factor for being anti-HCV+ (p < 0.0001). Among the HBsAg + individuals, 66.3% (53/80) were linked and 90.4% (48/53) retained in care (treated/monitored). Of the anti-HCV participants requiring clinical evaluation, 37.8% (14/37) were linked to care, and all the 11/14 (88.6%) viremic patients were successfully treated.

Interpretation

We found higher HBV/HCV positivity compared to national prevalences. Participation and linkage to care were successful. The young mean age (33.6 yrs) of HBsAg + individuals, primarily from regions with low vaccinal adherence, indicated geographical origin as a key risk factor. HCV positivity was associated with extreme marginality. The results stress the need to implement marginalized groups screening to target HBV/HCV hidden infections, reducing disparities in healthcare and advancing towards the WHO 2030 elimination goal.

Funding

Gilead Sciences; Fondazione Cassa di Risparmio di Pistoia e Pescia; Regione Toscana.

Successful Amendment of an Existing Hepatitis B Screening Programme by a Guideline Recommended Hepatitis D Screening in the Primary Care Setting

BACKGROUND

Despite European guidelines recommending anti-hepatitis D virus (HDV) screening for all hepatitis B surface antigen (HBsAg)-positive cases, screening rates remain insufficient.

AIMS

We analysed anti-HDV screening rates in primary care and implemented prospective HDV screening in HBsAg-positive cases identified in the preventive medical examination from the age of 35 ("Check-Up 35+").

METHODS

From 2012 to 2021, we reviewed anti-HDV and HDV RNA test rates in HBsAg-positive patients at 11 sites of a large German laboratory group. From 2022 to 2023, we prospectively screened HBsAg-positive samples from the "Check-Up 35+" for anti-HDV. Anti-HDV positive patients were then contacted again for HDV RNA testing.

RESULTS

Retrospectively, 2792/13,905 (20%) HBsAg-positive cases were tested for anti-HDV, with 142/2792 (5.1%) being positive. HDV RNA was tested in 57/142 (40%) anti-HDV-positive cases, with 26/57 (46%) being positive. In the prospective screening, 1159/225,901 (0.51%) individuals were HBsAg-positive. Of these, 700 (60%) were tested for anti-HDV, with 18/700 (2.6%) positive test results. 4/18 (22%) were successfully contacted again for HDV RNA analysis, with one case testing positive. Neither the HBsAg nor the anti-HDV positive result was known prior to screening in these cases. Anti-HDV testing could not be performed in 459/1159 (40%) HBsAg-positive cases, primarily due to insufficient blood sample volume (310/459 cases, 68%), with others missed due to logistical errors.

CONCLUSIONS

Retrospective data show insufficient anti-HDV screening in clinical routine. The prospective anti-HDV screening provides a blueprint for using existing hepatitis B virus screening programms for population-based HDV double reflex testing, provided that adequate logistical prerequisites are established.

TRIAL REGISTRATION

German Clinical Trial Register: DRKS00029180.

Epidemiology of liver diseases: global disease burden and forecasted research trends

We assessed the global incidence, mortality, and disability-adjusted life years (DALYs) associated with various liver diseases, including alcohol-related liver disease (ALD), hepatitis B/C virus infections (HBV or HCV), liver cancer, metabolic dysfunction-associated steatotic liver disease (MASLD), and other chronic liver diseases, from the 2019 Global Burden of Disease study. Additionally, we analyzed the global trends in hepatology research and drug development. From 2000 to 2019, prevalence rates increased for ALD, MASLD and other liver diseases, while they decreased for HBV, HCV, and liver cancer. Countries with a high socio-demographic index (SDI) exhibited the lowest mortality rates and DALYs. The burden of liver diseases varied due to factors like sex and region. In nine representative countries, MASLD, along with hepatobiliary cancer, showed highest increase in funding in hepatology research. Globally, the major research categories in hepatology papers from 2000 to 2019 were cancer, pathobiology, and MASLD. The United States (U.S.) was at the forefront of hepatology research, with China gradually increasing its influence over time. Hepatologists worldwide are increasingly focusing on studying the communication between the liver and other organs, while underestimating the research on ALD. Cancer, HCV, and MASLD were the primary diseases targeted for therapeutic development in clinical trials. However, the proportion of new drugs approved for the treatment of liver diseases was relatively low among all newly approved drugs in the U.S., China, Japan, and the European Union. Notably, there were no approved drug for the treatment of ALD in the world.

The Disease and Economic Burden of HBV and HCV in Ethiopia

As the second most populated country in Africa, Ethiopia needs public health measures to control diseases that impact its population. The goal of this study is to analyse disease burdens of HBV and HCV, while also highlighting their estimated associated costs for the country. A literature review and a Delphi process reflecting input of Ethiopian experts and the National Viral Hepatitis Technical Working Group were used to complement mathematical modelling to estimate HBV and HCV disease and economic burdens. Two scenarios were created for HCV: 2023 base and WHO elimination. For HBV, three scenarios were created: 2023 base, WHO elimination and universal birth dose. Using current country costs, each scenario was also examined through an economic lens. There were an estimated 7.6 million HBV infections in 2023. To impact transmission, a universal birth dose and pregnant women screening program would allow Ethiopia to vaccinate approximately 3.9 million infants annually, with a budget of $4.68 million USD, meeting the WHO prevalence elimination target (≤ 0.1% in ≤ 5-year-olds) by 2043. Ethiopia had an estimated 690,000 HCV infections in 2023. To achieve HCV elimination, the country would need to expand screening and treatment to 74,000 individuals annually with a peak budget of $12 million USD per year until 2032, decreasing to less than $2 million USD in 2035. Ethiopia can begin making steps towards elimination of HBV through expansion of birth dose vaccination. However, larger investments will be needed to scale-up treatment and diagnosis interventions for both diseases.

Global Elimination of Hepatitis C Virus

Hepatitis C virus (HCV) is predominantly transmitted through parenteral exposures to infectious blood or body fluids. In 2019, approximately 58 million people worldwide were infected with HCV, and 290,000 deaths occurred due to hepatitis C-related conditions, despite hepatitis C being curable. There are substantial barriers to elimination, including the lack of widespread point-of-care diagnostics, cost of treatment, stigma associated with hepatitis C, and challenges in reaching marginalized populations, such as people who inject drugs. The World Health Organization (WHO) has set goals to eliminate hepatitis C by 2030. Several countries, including Australia, Egypt, Georgia, and Rwanda, have made remarkable progress toward hepatitis C elimination. In the United States, the Biden-Harris administration recently issued a plan for the national elimination of hepatitis C. Global progress has been uneven, however, and will need to accelerate considerably to reach the WHO's 2030 goals. Nevertheless, the global elimination of hepatitis C is within reach and should remain a high public health priority.

[Ferroptosis and liver diseases]

As the central organ of metabolism, the liver plays a pivotal role in the regulation of the synthesis and metabolism of various nutrients within the body. Ferroptosis, as a newly discovered type of programmed cell death caused by the accumulation of iron-dependent lipid peroxides, is involved in the physiological and pathological processes of a variety of acute and chronic liver diseases. Ferroptosis can accelerate the pathogenetic process of acute liver injury, metabolic associated fatty liver disease, alcoholic liver disease, viral hepatitis, and autoimmune hepatitis; while it can slower disease progression in advanced liver fibrosis and hepatocellular carcinoma. This suggests that targeted regulation of ferroptosis may impact the occurrence and development of various liver diseases. This article reviews the latest research progress of ferroptosis in various liver diseases, including acute liver injury, metabolic associated fatty liver disease, alcoholic liver disease, viral hepatitis, autoimmune hepatitis, liver fibrosis and hepatocellular carcinoma. It aims to provide insights for the prevention and treatment of acute and chronic liver diseases through targeting ferroptosis.

Obesity and risk for liver disease: a two-sample Mendelian randomisation study

The associations between obesity and liver diseases are complex and diverse. To explore the causal relationships between obesity and liver diseases, we applied two-sample Mendelian randomisation (MR) and multivariable MR analysis. The data of exposures (BMI and WHRadjBMI) and outcomes (liver diseases and liver function biomarker) were obtained from the open genome-wide association study database. A two-sample MR study revealed that the genetically predicted BMI and WHRadjBMI were associated with non-alcoholic fatty liver disease, liver fibrosis and autoimmune hepatitis. Obesity was not associated with primary biliary cholangitis, liver failure, liver cell carcinoma, viral hepatitis and secondary malignant neoplasm of liver. A higher WHRadjBMI was associated with higher levels of biomarkers of lipid accumulation and metabolic disorders. These findings indicated independent causal roles of obesity in non-alcoholic fatty liver disease, liver fibrosis and impaired liver metabolic function rather than in viral or autoimmune liver disease.

Elimination of HCV Infection: Recent Epidemiological Findings, Barriers, and Strategies for the Coming Years

Hepatitis C is a disease for which in approximately 30 years we have gone from the discovery of the causative agent in 1989, to the introduction of direct-acting antiviral (DAAs) therapies starting from 2011, and to a proposal for its elimination in 2016, with some countries being on track for this goal. Elimination efforts, in the absence of a vaccine, rely on prevention measures and antiviral therapies. However, treatment rates have declined in recent years and are not considered adequate to achieve this goal at a global level. This poses a great epidemiological challenge, as HCV in many countries still causes a significant burden and most infected people are not yet diagnosed. Consequently, efforts are needed at different levels with common purposes: to facilitate access to screening and diagnosis and to improve linkage to care pathways. In this review, we discuss the latest epidemiological findings on HCV infection, the obstacles to its elimination, and strategies that are believed to be useful to overcome these obstacles but are applied unevenly across the world.

Comparison of anti-HCV combined with HCVcAg (Elecsys HCV Duo immunoassay) and anti-HCV rapid test followed by HCV RNA analysis using qRT-PCR to identify active infection for treatment

Hepatitis C virus (HCV) infection can cause acute and chronic hepatitis, leading to liver cirrhosis and hepatocellular carcinoma. The World Health Organization aims to eliminate viral hepatitis by 2030 through extensive screening and treatment. To achieve this goal, comprehensive and widespread screening is essential for diagnosis and treatment. This study aims to evaluate the diagnostic sensitivity and specificity of the Elecsys® HCV Duo immunoassay (Duo-assay), which simultaneously detects anti-HCV antibodies (Duo/anti-HCV) and HCV core antigen (Duo/HCVcAg) in a single sample, compared with initially antibody testing followed by quantitative real-time polymerase chain reaction (qRT-PCR). Additionally, this study aimed to evaluate a relationship between Duo/HCVcAg and qRT-PCR assay in different genotypes. A total of 769 plasma samples were tested using the Duo-assay to further evaluate the test's performance and conduct Duo/HCVcAg correlation analysis using qRT-PCR for each genotype. Among the active infection group (anti-HCV+/RNA+; n = 473), the Duo-assay showed 100% sensitivity for detecting Duo/anti-HCV and 70.6% for Duo/HCVcAg. In the resolved infection group (anti-HCV+/RNA-; n = 176), the assay showed 100% sensitivity for Duo/anti-HCV and 100% specificity for Duo/HCVcAg. In the non-infected group (anti-HCV-/RNA-; n = 120), the assay showed 100% specificity for both Duo/anti-HCV and Duo/HCVcAg. Moreover, no correlation was observed between the Duo/HCVcAg and HCV RNA tests, irrespective of genotype. These findings indicate that the Duo-assay is highly sensitive for detecting anti-HCV and specifically identifies patients with active infection. Nevertheless, cases with anti-HCV+/HCVcAg-results should undergo additional confirmation with western blot/immunoblot and qRT-PCR to ensure diagnostic accuracy, especially in Blood donation facilities.

Hepatitis B Virus-Related Cirrhosis and Hepatocellular Carcinoma Hospital Discharge Rates from 2005 to 2021 in Spain: Impact of Universal Vaccination

Background: The main consequences of chronic hepatitis B virus (HBV) infections are cirrhosis and hepatocellular carcinoma (HCC), both associated with frequent hospitalization. The aim of this study was to analyze the impact of universal HBV vaccination in Spain on chronic HBV-related hospital discharges from 2005 to 2021. Methods: Using data from the Minimum Basic Data Set of the Spanish National Health System, we calculated the hospital discharge rate ratio (HDRR) and 95% confidence interval (CI) values for chronic HBV-related discharges between 2005 and 2021. For comparative purposes, we calculated the HDRR and 95% confidence interval (CI) values for the early (2005-2013) and later (2014-2021) periods and the vaccinated compared with unvaccinated cohorts for the 20-39 age group. Results: The hospital discharge rate per 1,000,000 people was 3.08 in 2005 and 4.50 in 2021 for HCC, and 4.81 in 2005 and 1.92 in 2021 for cirrhosis. Comparing the early and later periods, values were higher for HCC (HDRR 1.13; 95% CI: 1.06-1.20) and lower for cirrhosis (HDRR 0.56; 95% CI: 0.51-0.60). The rate for the 20-39 age group was lower for the vaccinated compared with the unvaccinated cohorts overall (HDRR 0.53; 95% CI: 0.45-0.62), for HCC (HDRR 0.66; 95% CI: 0.53-0.82), and for cirrhosis (HDRR 0.41; 95% CI: 0.33-0.53). Conclusions: This study describes the important impact, after 25 years, of universal HBV vaccination in Spain: cirrhosis hospital discharge rate was reduced, and the vaccinated cohorts, compared with the unvaccinated cohorts in the 20-39 age group, had a lower hospital discharge rate of both HCC and cirrhosis.

IFNL4 genotype and other personal characteristics to predict response to 8-week sofosbuvir-based treatment for chronic hepatitis C

BACKGROUND

Shorter duration therapy for hepatitis C virus (HCV) infection might reduce treatment costs and increase the number of patients treated and cured. We determined factors associated with treatment response after an 8-week sofosbuvir-based therapy and developed a simple model to predict an individual's likelihood of treatment success.

METHODS

Among 2907 patients who received ledipasvir/sofosbuvir for 8 weeks, we determined failure rates by demographic and clinical characteristics, and IFNL4-∆G/TT genotype. We estimated the average IFNL4 genotype-related treatment failure rate in major ancestry groups by applying our IFNL4 genotype results to genotype distributions from reference populations. We created a treatment response model based on three personal characteristics.

RESULTS

Overall, 4.4% of the patients failed treatment. We observed significantly lower failure rates for persons <50 years (1.6%), females (2.6%), those carrying the IFNL4-TT/TT genotype (1.8%), those with HCV RNA <5.8 log10 copies/mL (2.0%) or HCV genotype-1B infection (2.6%). In a model based on ancestry, age and sex, the predicted probability of treatment failure ranged from 0.5% among females of East Asian ancestry <50 years of age to 8.5% among males of African ancestry age ≥65 years.

CONCLUSION

Applying this algorithm at the point-of-care might facilitate HCV elimination, especially in low- and middle-income countries.

Functional cure of chronic hepatitis B-hope or hype?

Chronic hepatitis B constitutes a substantial disease burden worldwide. The steps advocated by the World Health Organization in 2016 to eradicate hepatitis B by 2030 has failed to achieve significant progress, especially with respect to immunization coverage and linkage to care. The lack of governmental and public awareness regarding the long-term implications of hepatitis B burden cause underfunding of developmental projects. The presently approved treatment modalities have limited efficacy in complete viral eradication, hence the need for newer molecules to achieve functional cure (sustained undetectable hepatitis B surface antigen (HBsAg) and hepatitis B virus DNA in peripheral blood after a finite period of therapy). However, preliminary results from trials of novel therapies show their inadequacy to achieve this end by themselves but better performance with a low baseline serum HBsAg with nucleos(t)ide analogues (NA) treatment which need to be combined with/without pegylated interferon as an immunomodulator. Such therapy is limited by cost and adverse events and need to show incremental benefit over the standard of care (long-term NA therapy) with respect to efficacy and drug toxicities, making the development process tenuous. Thus, while such therapies continue to be tested, strategies should still focus on prevention of transmission by non-pharmaceutical measures, vaccination and increasing linkage to care.

Hepatitis C Elimination in Egypt: Story of Success

Egypt has long been overwhelmed by the hepatitis C virus (HCV) infection, and it used to be the country with the world's highest prevalence rates. The disease had been a significant public health problem, affecting millions of Egyptians and posing severe economic and social challenges. By the early 2000s, it was estimated that around 10% of the Egyptian population was infected with HCV. However, in recent years, with the availability of direct-acting antiviral therapies, the country has made enormous steps in combating this public health threat. The combination of innovative health strategies and political will enabled Egypt to establish a successful model of care for HCV management and to be the first country to eliminate hepatitis C, setting a model for the rest of the world. In 2023, Egypt became the first country to fulfill the World Health Organization's set programmatic criteria of reduction of hepatitis C incidence and mortalities to levels close to elimination of disease or achieve the "gold tier" status on the path to disease elimination.

FGL1 and FGL2: emerging regulators of liver health and disease

Liver disease is a complex group of diseases with high morbidity and mortality rates, emerging as a major global health concern. Recent studies have highlighted the involvement of fibrinogen-like proteins, specifically fibrinogen-like protein 1 (FGL1) and fibrinogen-like protein 2 (FGL2), in the regulation of various liver diseases. FGL1 plays a crucial role in promoting hepatocyte growth, regulating lipid metabolism, and influencing the tumor microenvironment (TME), contributing significantly to liver repair, non-alcoholic fatty liver disease (NAFLD), and liver cancer. On the other hand, FGL2 is a multifunctional protein known for its role in modulating prothrombin activity and inducing immune tolerance, impacting viral hepatitis, liver fibrosis, hepatocellular carcinoma (HCC), and liver transplantation. Understanding the functions and mechanisms of fibrinogen-like proteins is essential for the development of effective therapeutic approaches for liver diseases. Additionally, FGL1 has demonstrated potential as a disease biomarker in radiation and drug-induced liver injury as well as HCC, while FGL2 shows promise as a biomarker in viral hepatitis and liver transplantation. The expression levels of these molecules offer exciting prospects for disease assessment. This review provides an overview of the structure and roles of FGL1 and FGL2 in different liver conditions, emphasizing the intricate molecular regulatory processes and advancements in targeted therapies. Furthermore, it explores the potential benefits and challenges of targeting FGL1 and FGL2 for liver disease treatment and the prospects of fibrinogen-like proteins as biomarkers for liver disease, offering insights for future research in this field.