Conflict-Driven Migration Increases Hepatitis Burden as Production Costs Fall

Researchers of studies on the effect of conflict-driven migration on rates of hepatitis indicate that mass migration from high-burden countries has significantly increased the prevalence of both hepatitis C virus (HCV) and hepatitis B virus (HBV) infection in the host nation. The cost of pharmaceutical ingredients used to cure hepatitis continues to fall, making the global initiative to eliminate hepatitis feasible. The results of this research was presented at American Association for the Study of Liver Diseases’ The Liver Meeting, held November 8-12, 2019, in Boston, Massachusetts.

In 2 separate studies, researchers analyzed recent changes in HCV and HBV prevalence in Sweden as a result of conflict-driven migration.¹ Researchers obtained demographics on the total migrant population between 2014 and 2018 from the Swedish government’s national databases, the investigators determined migrant contributions to national HCV¹ and HBV² prevalence. Country-of-origin disease burden was obtained for nations including Syria, Somalia, and Iraq and compared with Swedish population-wide HCV and HBV outcome data.

Valles and colleagues found that of 701,302 documented migrants, 5046 were HCV positive (4289 of whom had a chronic infection). This increased Sweden’s HCV burden by 13.2%. Investigators estimated that without treatment interventions, 1287 cases of cirrhosis, and 52 cases of hepatocellular carcinoma in the coming decades. Migrants from Syria accounted for the majority of new HCV cases (n=4006), followed by migrants from Somalia (n=842). 

Prasai et al found that the number of migrants with HBV over the last 5 years was estimated to be 11,376; this increased the national burden by 58%. The investigators projected an additional 228 new cases of HBV-related cirrhosis and 34 cases of hepatocellular carcinoma, lacking proper intervention. Results demonstrated that Syria accounted for the majority of new HBV cases (n=133,538), followed by migrants from Iraq (n=18,573) and Somalia (n=17,177). 

Mass-migration from conflicted regions has significantly increased the prevalence of both HCV and HBV in Sweden over the last 5 years, consequently increasing the disease burden, including long-term outcomes of cirrhosis and hepatocellular carcinoma, which disproportionately affect individuals from migrant communities. Effective screening and management strategies should target individuals from these high-burden nations.

Initiatives to improve screening for HCV — resulting in an increase of patients who need treatment with direct-acting antivirals (DAAs) — were the focus of a separate study that analyzed the cost of production for HCV DAAs compared with prices in low-, middle-, and high-income nations.³ The investigators in this study sourced prices on active pharmaceutical ingredients exported from India and multiplied the price by per-unit dosage to derive the cost per HCV DAA tablet. To estimate a cost-based generic price, assumed conversion cost ($0.01 per unit), profit margin (10%), and margin for tax (27% on profits) were added; the target price was then compared with sales data and current lowest DAAs prices in 11 countries.

Results demonstrated that from 2014 to 2019, the cost of sofosbuvir decreased by 90%, and the cost of daclatasvir decreased by 88%. The investigators suggested that generic sofosbuvir can be profitably manufactured for $28 per 12-week cure, sofosbuvir/daclatasvir for $32, sofosbuvir/ledipasvir for $60, and sofosbuvir/velpatasvir for $89.

For comparison, sofosbuvir/daclatasvir costs $41 per cure and sofosbuvir/velpatasvir costs $93 in India, whereas sofosbuvir/daclatasvir costs $78 per cure and sofosbuvir/ ledipasvir costs $90 in Ukraine.3 Over the last 5 years, cumulative sales of HCV DAAs were $87 billion; however, the investigators project that the cost of manufacturing HCV DAAs to cure worldwide HCV infection (67 million people) is just $2.8 billion.

Although conflict-driven migration has increased the burden of hepatitis infection in host countries, screening and treatment strategies now benefit from the decreasing costs of HCV DAAs, whereby cures may be purchased for a little over $40 per person, just above the $32 cost of profitable production.³ National health departments should be aware of these costs and negotiate lower prices for HCV elimination programs.

Reference

1. Valles KA, Prasai K, Inzunza A, Roberts LR. Conflict, refugees, and the evolving hepatitis C burden: human migration and shifting disease landscapes. Poster presented at: American Association for the Study of Liver Diseases: The Liver Meeting; November 8-12, 2019; Boston, MA. Abstract 0544.

2. Prasai K, Valles KA, Inzunza A, Roberts LR. Hepatitis B disease prevalence and the effect of mass-migration on shifting disease burden. Poster presented at: American Association for the Study of Liver Diseases: The Liver Meeting; November 8-12, 2019; Boston, MA. Abstract 0955.

3. Hill AM, Barber M, Khwairakpam G, Gotham D. The road to elimination of hepatitis C: costs per cure fall to US $32 per person. Poster presented at: American Association for the Study of Liver Diseases: The Liver Meeting; November 8-12, 2019; Boston, MA. Abstract 0559.