[Paleopsych] Pol.Sci.Q: Albert B. Knapp: The HBV and HCV Pandemics: Health, Political, and Security Challenges

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Albert B. Knapp: The HBV and HCV Pandemics: Health, Political, and
Security Challenges
Political Science Quarterly 120.2 (2005): 243-251

[First, the summary from CHE, 5.7.21
The Chronicle of Higher Education: Magazine & journal reader
http://chronicle.com/prm/daily/2005/07/2005072101j.htm

    A glance at the summer issue of Political Science Quarterly: Ignoring
    the dangers of hepatitis B and C

    Hepatitis B and hepatitis C infect nearly 2 billion people worldwide,
    but HIV, which affects 30 million individuals, gets much more
    attention, writes Albert B. Knapp, an associate clinical professor of
    medicine at New York University.

    If officials do not try harder to curb the spread of hepatitis, it
    could increasingly harm underdeveloped nations, which do not do as
    comprehensive a job of preventing and treating the virus as Western
    countries do, writes Dr. Knapp.

    Both hepatitis B and hepatitis C, if left untreated, cause chronic
    liver infection, which could result in death. Hepatitis C, for which
    no vaccine exists, is more difficult to treat than hepatitis B, which
    does have a vaccine.

    "If left unaddressed, by the end of the decade, these viruses could
    pose a greater danger than the HIV epidemic, not only as a
    public-health problem, but for the alarming political and security
    threats they present," writes Dr. Knapp.

    Hepatitis could weaken developing nations politically and financially
    by diverting money from economic development and cutting the size of
    their work force and military, Dr. Knapp writes. Those countries
    should try to raise public awareness about hepatitis, he says.

    Western countries and large, multinational pharmaceutical companies
    should develop and donate cheaper therapies to underdeveloped nations
    to reduce the viruses' impact there, Dr. Knapp writes. They should
    also increase efforts to make a hepatitis-C vaccine and a
    longer-lasting hepatitis-B vaccine.

    "What we lack ... is both a clear political focus and a collective
    political will, without which the consequences for everyone may be
    catastrophic," Dr. Knapp writes.

    The article, "The HBV and HCV Pandemics: Health, Political, and
    Security Challenges," is available online to subscribers and for
    purchase at [54]http://www.psqonline.org

    --Jamie Schuman

[I do not know why Adobe "Professional" omitted spaces between word in part of 
what follows.]

ALBERT B. KNAPP is an associate clinical professor of Medicine 
(Gastroenterology & Hepatology) at the New York University Medical School as 
well as an attending physician at both the Lenox Hill Hospital and the NYU 
Hospitals Center. He is the author of over 15 peer-reviewed research 
publications as well as a textbook on Gastroenterology and Hepatology.


Hepatitis B (HBV) and hepatitis C (HCV) infect nearly 2 billion people 
worldwide, but only recently have health officials in the developed world begun 
to recognize them as a serious health, political, and security challenge. If 
left unaddressed, by the end of the decade, these viruses could pose a greater 
danger than the HIV epidemic, not only as a public health problem, but for the 
alarming political and security threats they present.

Although HBV and HCV are two very different viral entities, both can result in 
chronic liver infection with eventual progression to cirrhosis, liver cancer, 
and death. HBV and HCV are found worldwide, with the highest number of cases 
clustered in sub-Saharan Africa, Egypt, and East Asia. Therapy has improved 
dramatically during the past thirty years, but both cure and worldwide 
eradication remain elusive goals. I will briefly review the distinctive 
pathophysiology of both HBV and HCV before addressing the public health, 
political, and security implications of these two pandemics.

Hepatitis B Virus

HBV is a large and complex DNA-based virus first identified in 1967.1 More than 
1.5 billion people are believed to be infected worldwide, and the highest 
levels are in sub-Saharan Africa and East Asia, where infection rates of up to 
20 percent are common. Viral spread can be either vertical (mother-to-child) or 
horizontal (early child-to-child contact or through risky sexual behavior). 
Infection from improperly sterilized intravenous needles (such as among IV drug 
users) and contaminated blood or blood products account for a smaller but 
important percentage of cases worldwide.

1 Those who have a scientific background may wish to refer to the excellent 
review article focusing on the molecular biology of HBV by Donald Ganem and 
Alfred M. Prince, "Hepatitis B Virus Infection--Natural History and Clinical 
Consequences," New England Journal of Medicine 350 (March 2004): 1118-1129.

Most people infected with HBV show no symptoms of the disease. Ten to twenty 
percent of cases progress insidiously over a twenty- to thirty-year span, 
leading to cirrhosis, liver cancer, and, ultimately, death. Detection requires 
expensive individual blood-screening studies as well as vigilant monitoring of 
the nation’s blood supply. Consequently, the likelihood that someone with the 
infection will be diagnosed and treated depends on both geography and 
socioeconomic status. Patients in developed countries with access to medical 
care usually are diagnosed earlier in the infectious cycle and are better 
candidates for costly but effective oral antiviral therapy. Those, however, in 
either underserved areas of the West or in the developing world usually get 
medical attention at a more advanced stage of the disease, by which time, even 
if available, antiviral therapy is less effective. At that point, treatment 
generally is palliative but, given the massive number of patients, even this is 
costly for those countries with meager healthcare infrastructures and budgets.

Hepatitis C Virus

HCV is simpler in molecular design but far deadlier than HBV. It is a close 
cousin of both the dengue and yellow fever viruses. HCV initially was 
characterized in 1989.2 As with HIV, the genetic material of HCV is RNA, and 
this results in a high degree of genetic instability, or mutability, rendering 
the virus not only more infective and adaptive but exceedingly difficult to 
treat. At least 250 million people worldwide are estimated to have contracted 
HCV. But, unlike HBV, the incidence of chronic infection with ineluctable 
cirrhosis, liver cancer, and death far exceeds 50 percent. HCV is spread 
horizontally, in most cases, through improperly sterilized needles used by IV 
drug users or as the result of a contaminated blood supply. Maternal 
transmission and sexual promiscuity are other important risk factors. Low 
socioeconomic status plays a role in the likelihood of infection, but experts 
don’t quite understand the link.

On the basis of some very elegant epidemiological research, HCV is thought to 
have originated as a zoonotic (animal-to-human) mutation somewhere in the 
Pacific Theater during the Second World War. HCV insidiously infected large 
numbers of Japanese troops in China and Southeast Asia, and they eventually 
repatriated the virus.HCV reached the West in a circuitous fashion via infected 
French and American veterans of the Indochinese conflicts. Worldwide 
dissemination ensued from contamination of the blood supply in both Western 
Europe and the United States, and from a surge in infected IV needles shared by 
drug users or, in the case of at least one country, by lax sanitary controls 
during a massive national vaccination program.

2 For further in-depth details, please see G.M. Lauer and B.D. Walker, 
"Hepatitis C Virus Infection," New England Journal of Medicine 345 (July 2001): 
41-52.

Unlike HBV, treatment forHCVis not only costly but also most unsatisfactory at 
any stage of the disease. Overall therapeutic success is reported at 60 
percent, but this is misleading, because those patients with the most-common 
variant of HCV have response rates of only 40 percent. The economic impact of 
the disease is extraordinary. Antiviral treatment for one year can exceed 
$25,000 per person in the United States, but the actual cost is far higher due 
to both frequent drug side effects and co-morbidity issues. Patients who do not 
respond to treatment may require liver transplantation. In the West, HCV 
infection is currently the most common reason for such transplants. In fact, 
nearly 6,000 were done in the United States in 2004, at an individual price 
conservatively estimated at $150,000. This excludes the requisite lifetime cost 
of the expensive, but mandatory, immunosuppressive drug therapy and specialized 
medical care that all transplant recipients must receive.

Meanwhile, drug therapy and surgery are simply out of reach for most people in 
the developing world because of costs and lack of sophisticated medical 
support. Consequently, in underdeveloped nations, the average patient receives 
basic palliative therapy, languishes, wastes away, and dies.

Public Health Challenges

HBV and HCV present important challenges for the world healthcare establishment 
in detection, therapy, and containment strategies. Overall success varies from 
nation to nation, depending on the underlying quality and sophistication of a 
particular state’s medical infrastructure as well as its ability and political 
will to commit vast sums of money to combating the virus. Let us review each of 
the key challenges for fighting these infections.

Detection

Detection is based on blood screening. Given that both HBV and HCV are 
clinically undetectable for a major part of their destructive cycles, universal 
screening of all citizens, and especially of the blood supply, is the ultimate 
approach. However, realistically, only a small percentage of a nation’s 
population is likely to be effectively screened--even in the most motivated and 
sophisticated of societies. Therefore, public health planners have refined 
their strategy toward screening of all "high risk" individuals, but even so, 
their success in detecting the virus is limited. In the United States, 
officials estimate that they have identified only about 50 percent of those who 
have HCV, despite an aggressive national healthcare campaign. On the other 
hand, public health officials have succeeded brilliantly in detecting and 
eliminating both viruses from the blood supply in the developed world. What is 
more, despite the prohibitive cost of the viral detection kits, some inroads 
have been made in ensuring the safety of blood supplies in developing 
countries, also.

Treatment

Treatment strategies vary between the West and developing nations. Earlier 
viral detection in developed countries means that patients get treatment at an 
earlier stage of the infection, with good success at curing HBV and improving 
results in treating HCV. The story in the underdeveloped world is starkly 
different; typically, the average infected patient seeks treatment in the later 
and more debilitating stages of either disease. Successful outcomes are rare, 
and the cost of even simple supportive care is relatively quite high and 
strains alreadylimited healthcare budgets. In reaction, many poorer nations, 
encouraged by tactics learned during the HIV struggle, have begun to demand 
significant discounts, rebates, or frank allocations of medications from the 
major manufacturers, while requesting increases in dedicated foreign financial 
aid to combat the viruses. In addition, several Western and non-Western 
pharmaceutical concerns have begun to develop cheaper antiviral medications 
based on chemical synthetic processes with lower research and development 
costs.

Containment Strategies

Containment strategies of different degrees of efficacy and expense have been 
developed for both the West and the developed world. These include 
encouragement of universal condom use and prophylactic HBV vaccination. Condoms 
have gained broader social acceptance during the past two decades as an 
effective means of preventing the spread of HIV. Condoms also have been shown 
to help seriously curtail HBV transmission in several large epidemiological 
studies of gay men in New York City. We suspect that condom use should have a 
similarly salutary effect on curbing HCV transmission. But because sexual 
spread is a secondary route for this virus, the anticipated decrease may be 
minor.

Vaccination indeed represents the optimal containment strategy and has been the 
most effective tool in eradicating other communicable diseases worldwide. Dr. 
Edward Jenner pioneered this technique in England at the end of the 18th 
century in an attempt to curb smallpox outbreaks. Vaccination, however, has 
several drawbacks: It is currently available only for HBV prevention (although 
an effective HCV vaccine is now in development and could be ready by the end of 
this decade). Furthermore, inadequately supervised vaccination programs using 
reusable but improperly sterilized needles or syringes may unintentionally lead 
to the massive spread of other communicable diseases.

HBV vaccination has become mandatory for young school children in the West 
since the early 1990s, after it was shown to dramatically decrease viral 
incidence. The ultimate example is Taiwan, where, following a ten-year 
mandatory vaccination program for all children, the measurable incidence of HBV 
plummeted from more than 10 percent to less than 1 percent in this cohort.3 A 
universal HBV vaccination program for children in the United States, 
underwritten and signed into law by then-President Bill Clinton in 1993, will 
probably rank as one of his most important legislative contributions. The only 
flaw in universal vaccination programs is that the present HBV vaccine is 
thought to have an effective life of only five to ten years and, therefore, 
must be supplemented by regular booster shots. Although logistically possible 
in preschool and high school populations, regular booster programs for adults 
present a logistical nightmare.

3 For more details on this fascinating study, see M-H. Chang, C-J. Chen, M-S. 
Lai, et al., "Universal Hepatitis B Vaccination in Taiwan and the Incidence of 
Hepatocellular Carcinoma in Children," New England Journal of Medicine 336 
(June 1997): 1855-1859.

Meanwhile, developing countries have yet to benefit from this containment 
effort, because the vaccines are very expensive. Recently, several newer and 
less-costly alternatives have been developed with poorer nations in mind. 
Immunological relief for those countries may yet be in sight.

It bears noting, also, that vaccination programs are not risk free. If 
administered improperly, a large program, however well intentioned, can 
actually serve as a vector of transmission for another infectious agent. Such 
is the case in Egypt, a nation that presents a cautionary tale of good 
intentions and poor execution that produced disastrous results. The parasite 
schistosomiasis, endemic to the entire Nile River Valley and first described 
during the time of the Pharaohs, has been a major cause of debilitating liver 
and bladder disease in large numbers of villagers in both Egypt and the Sudan. 
From 1958 through 1982, the Egyptian government undertook a massive 
anti-schistosomal campaign to eradicate this scourge. Tragically, the reusable 
needles and syringes used in the public health effort were improperly 
decontaminated, and many of the vaccines became co-infected with HCV. 
Subsequently, HCV infection rates surged in the vaccinated group, making 
Egypt’s infection rate the highest in the world: More than 20 percent of the 
Egyptian population has evidence of HCV infection. By comparison, in 
neighboring Sudan, which is just as hard hit by schistosomiasis but which did 
not pursue a campaign of mass vaccination, the rate of HCV is only 4 percent.4

4 For a thorough review of this distressing topic, see C. Frank, M.K. Mohamed, 
G.T. Strickland, et al., "The Role of Parenteral Anti-schistosomal Therapy in 
the Spread of Hepatitis C Virus in Egypt," Lancet 355 (March 2000): 887-889.

Political and Security Issues

There is no evidence that HBV and HCV have been used as weapons of bioterror. 
From the point of view of today’s terrorists, neither HBV nor HCV would be 
considered as prime bioterror agents, given their relatively slow spread, the 
twenty- to thirty-year effective lag time before the appearance of significant 
symptoms, and the relative invulnerability of most nations’ blood supplies. 
Nevertheless, if left untreated, HBV and HCV pose significant longterm social 
and financial threats to political stability. HBV, for example, has already 
brought disaster, despair, and chaos to large swaths of sub-Saharan Africa, 
where billions of dollars were diverted from critical economic development 
efforts to fight these pandemics. If not checked, HBV and HCV risk imperiling 
the entire African continent.

The West has successfully controlled both infections with only minimal 
financial, political, and security concerns. In contrast, the pandemics are 
likely to further enfeeble the economies of those nations least equipped to 
cope with the huge economic toll they could exact.

Individual citizens of any nation typically look to their governments to ensure 
their healthcare security. That security hinges on the ability of the state to 
protect its citizens from contracting either virus, either through preventive 
programs, such as HBV vaccination, a secure blood supply, and condom campaigns, 
or by aggressively treating the disease with antiviral medications and liver 
transplantation. The wealthier the state and the more sophisticated the 
healthcare system, the more its citizens expect of their public health 
programs.

To meet those expectations, governments are coming under increasing political 
pressure to redirect public spending into such preventive measures as 
education, research, and healthcare infrastructure. Such moves should include 
widespread HBV vaccination, condom usage, and safeguarding of the blood supply, 
because multiple epidemiological studies attest to their overall effectiveness 
and relative lack of expense. And, to a large degree, wealthier nations have 
done just that. In doing so, these societies have averted wholesale epidemics 
with the attendant societal and political disruption they threaten. Indeed, the 
eradication of both HBV and HCV from the Western world’s blood supply is to 
date, among their greatest public health successes. In the United States, the 
chances of contracting either HBV or HCV from contaminated blood have fallen to 
1:63,000 and 1:130,000, respectively. Although impressive, these results pale 
in comparison to HIV prevention, where the rate of accidental contraction is 
1:493,000. Clearly, further work, in the sense of even more-sensitive HBV and 
HCVblood detection technology, is needed, and this should be driven by 
enlightened public policy. HBV vaccination and universal condom usage in the 
West have also been effective and must be encouraged and expanded.

But the prognosis for poorer nations, lacking both the financial base and 
medical infrastructure, in combating HBV and HCV is far less sanguine. These 
nations must make both prevention and containment strategies high priorities 
and summon the political will to raise public awareness of the diseases to the 
same degree they already have achieved in the HIV campaign. Implementing the 
same preventive measures already in place in the West is critical to the poorer 
states’ future economic and political health. Failure to protect the population 
will result in skyrocketing rates of infection, with many of the same political 
and security repercussions many poorer nations already have suffered from the 
faster-acting HIV epidemic. As the pool of HBV-HCV-infected citizens widens, no 
segment of the population will be safe, with the disease spreading to include 
farmers and workers, as well as the middle and upper classes. With so many 
layers of society swept up by the pandemics, nations will be hobbled 
byanever-worseninglaborshortage,aswellasasteadydecline 
inindividualworkerproductivity.Lowerexportswilltriggeralossofforeign 
currency,andforeigninvestmentislikelytodryupaswell.Asaresult,already 
economicallyvulnerablenationswillseetheireconomiesdeteriorateeven morerapidly.

Atthesametime,wideninginfectionratesamongtheranksofthemilitary,
oftenthesocietalbackboneofadevelopingnation,alsoexacerbateinternal 
andinternationalsecurityconcerns.Theendresultforthestateisoverwhelming
poverty,socialunrest,anddangerouspoliticalinstability.Inaddition,
poorerstateswillhavetomakethehardbutrealisticchoicetoforegoexpensive
antiviralandtransplantationtreatmentsandconcentrateonthebascpreventive
programs.Ultimatelythough,giventhecostsofthesecheaperalternatives,
itwillstillbeuptotheWestandthelargemultinationalpharmaceutical
companiestodevelopandthendonatecheaperantiviraltherapiesortheir
alternatives.

BesidestheadditionaleconomiccoststotheWest,developednations,
particularlytheUnitedStates,wouldfaceadditionalpoliticalandsecurity
challenges,including

o bordercontrol,tofendoffpossiblecarriersofthedisease;

o unusualbusiness,foreignpolicy,andeconomicdevelopmentconstraintsin
dealingwithnationswhereinfectionratesarehigh;

o theexplodingHCVcrisisintheprisonpopulation;

o thecontroversialquestionofestablishingarationalneedleexchangepro-
gramforIVdrugusers.

BorderControl

Therelativelyporousbordersofourglobalizedsocietypromotethespreadof
diseasethroughtourismandmigration.IftheHBV-HCVpandemicsexpand,
theUnitedStatesandotherdevelopedcountriesmaycurtailorbaroutright
tourismorimmigrationfromseverelyaffectedareas--withpoliticalfriction
hereandabroadalikelyconsequence.Worseyet,iftourismdropsoffinnations
hardhitbytheviruses,itwillbringthemevenmorecripplingeconomicdisruption
andworseninginternationalrelations.

Foreign Policy Implications

ThespreadofthesediseasesalsohastroublingimplicationsforfutureU.S. 
foreignpolicy.Forexample,forfearofexposingU.S.troopsorgovernmentpersonnel 
toinfectioninendemicareas,thegovernmentmayavoidinvolvementincertain 
regionalconflictsorinpeacekeepingendeavors.TheIndochineselinktothes 
preadofHCVtotheWestisasoberingreminderoftherisk.Inaddition,businesses 
andmultinationalinvestorswillbemorelikelytocurtailtheiractivitiesin 
diseasehotspots, creating 
acatch-22forthesenationsbyfurtherweakeningtheirfinancial
stabilityanddeprivingthemofcriticalcapitaltohelpfundtreatmentand
containmentefforts.

HCV in U.S. Prisons

TheHCVepidemicintheU.S.prisonpopulationhasbecomebothasignificant
domesticpoliticalissueandaninternaleconomicandsecuritythreat.
Accordingtoa2003reportfromtheDepartmentofJustice,slightlymore
than2millionpeopleareincarceratedinstateandfederalprisons.Many
inmateshavehistoriesofIVdruguse,andseverallocalandnationwidestudies
suggestthatatleast20percentofallprisonersareinfectedwithHCV.
Manycasesgoundiagnosedanduntreated,andformaneverexpandingHCV
reservoir,currentlyestimatedat400,000cases.Amplifyingthedanger,
paroledprisonerscanunwittinglyinfectothersinthegeneralpopulation.
Aggressiveeducationandearlytreatmentprogramsmustbeimplementedinour
nation’sprisons,notonlytocontrolthisgrowinginternalsecuritythreat,
butalsotoavoidtheprohibitivehealthcarecostsoflaterandmoreextensivetreatment.

Needle Exchange Controversy

Spreadofthediseasescouldbecheckedbycontroversial,buthighlyeffective,
voluntaryfreeIVneedleexchangeprograms.Thesecarefullyadministeredprograms
arewidelysuccessfulinwesternEuropeandarecreditedwithstemmingingreat
partthefurtherspreadofbothHBVandHCVintheIVdrug-
usingpopulation.Nevertheless,intheUnitedStatesin1988,Congressprohibited
theadoptingofsimilarvoluntaryexchangeprograms.Theoriginalintentatthetime
wastowaituntilafuturesecretaryofhealthandhumanservices(HHS)couldprove
throughpilotstudiesthattheIVneedleexchangesforestalledthespreadof
diseasewithoutencouragingdruguse.Compellingevidenceconfirmingthe
beneficialeffectsoffreeneedleexchangeprogramswaspresentedtoHHS
SecretaryDonnaShalalain1998,butthebanwasnotlifted,
fordomesticpoliticalreasons.Itisimperativethatthepresent
administrationreviewthispressingquestionandliftthebaninordertostem
furtherinfectioninthissubpopulatin.

Solutions

AsuccessfulworldwideeradicationcampaignforbothHBVandHCVmustfocuson
universalHBVvaccinationand,eventually,HCVvaccination,aswellasthe
safeguardingoftheentireworld’sbloodsupply.TheWesthasmadeexcellent
progressincurtailingandtreatingbothinfectionsinthegeneralpopulation.
Nevertheless,glaringdeficienciesremain,suchasthesoaringrateofHCVinthe
U.S.prisonpopulation,whichrequirespromptattention.Thefailuretoimplement
thecongressionallysanctionednationalIVneedleexchangeprogramistragic,
becauseithasbeenshowninmultiplestudiestocurtailthespreadofbothviruses
intheIVdrug-usingpopulation.TheEuropeanexperienceinthisareahasbeenvery
positive.Thisisanotherstickypoliticalsituation,
but legislators must summon the needed courage to implement this important
and rational program. The economic costs of not interceding, combined with
the potential social chaos and political turmoil threatening portions of 
sub-Saharan Africa, should galvanize the West to aggressively pursue

o medical funding for research and development of cheaper and longer-lasting 
HBV vaccines;

o development of an HCV vaccine that would be available by the end of the 
decade and that would complement these other protective measures;

o more-effective and less-costly anti-viral medications;

o more-sensitive blood detection technology for the screening of both highrisk 
individuals and the blood supply.

In the interim, the West should make a collective decision to fund HBV 
vaccination, blood supply screening, and HBV antiviral programs for those 
nations deemed at risk. It is ironic that HIV, a virus affecting 30 million 
people worldwide, commands far more attention, both politically and research 
dollar- wise, than both HBV and HCV, which together afflict nearly 2 billion 
people. President George W. Bush’s 2004 State of the Union speech pledge of $10 
billion (USD) for treatment of HIV in Africa deserves both praise and support. 
But we should bear in mind that worldwide deaths as a result of HCV alone 
surpassed those of HIV in 2000 and are expected to rise sharply, according to 
an unclassified national intelligence estimate published during the last year 
of the Clinton administration.5 Efforts should be made to expand President 
Bush’s program in order to includeHBVand HCV. The European Economic Community 
and Japan should be encouraged to share the additional financial burden.

5 See: www.aegis.com/news/boc/2000/BC00093.html.

The world has the potential to severely curtail or even rid itself outright of 
both HBV and HCV within the next generation. We find ourselves closer than we 
think to major breakthroughs in antiviral therapy, screening, and vaccination 
technology and, given our prior experience with smallpox and HIV, we possess 
the requisite logistical expertise to mount a successful worldwide viral 
eradication campaign. What we lack, however, is both a clear political focus 
and a collective political will, without which the consequences for everyone 
may be catastrophic.