How do you cure a disease with no vaccine?

No Vaccine, No Cure for Decades — and Now, Almost Gone

Here is the strange part. England is on the edge of eliminating hepatitis C — a disease for which no vaccine exists. That should not be possible. Vaccines are the instrument of elimination — smallpox, polio, measles. Remove the vaccine and you are supposed to be stuck.

Yet in 2025, England is targeting the end of hepatitis C as a public health threat, five years ahead of the World Health Organization's 2030 global deadline. Dr. Sema Mandal at the UK Health Security Agency has said England is closer than ever before to fully defeating the disease. That is not a press release boast — it is a measurable, verified position on a trajectory.

Now hold that thought, and consider the scale of what this is pushing against. In 2022, roughly 50 million people worldwide were living with chronic hepatitis C. That same year, complications from the virus — liver cancer, organ failure, cirrhosis — killed approximately 240,000 people. Those numbers do not shrink easily, and they do not shrink without a vaccine.

England found a different instrument. Not a shot in the arm but a pill, a commercial deal, and a decision to go looking for people who did not know they were sick. The contrast between England's trajectory and the global picture is so sharp it demands an explanation. The explanation, it turns out, is genuinely strange and genuinely instructive.

The Quiet Tenant: How Hepatitis C Spends Decades Remodelling a Liver

Most people who acquire the hepatitis C virus feel nothing. No fever worth remembering, no jaundice, no signal dramatic enough to send them to a doctor. The acute infection — a short, sharp immune skirmish — simply passes without announcement. Here is the strange part: that silence is the whole problem.

Roughly 75% of acute cases do not resolve on their own. Instead, the virus quietly crosses into chronicity, settling into liver cells where it begins, with extraordinary patience, to remodel the tissue around it. Chronic infection is not inert — it is slow chemistry. Year after year, the immune system mounts a low-grade inflammatory response, and the liver responds by replacing damaged cells with fibrous scar tissue, a process called fibrosis.

The virus itself is a moving target. HCV is classified into six main genotypes and over 80 subtypes — a genetic diversity that made early treatment a guessing game, because the drugs available before the 2010s worked reasonably well against some variants and poorly against others. Genotype was destiny, in the worst sense.

Now hold that thought, and fast-forward thirty years of silent remodelling. The liver's architecture, slowly replaced by scar tissue, eventually reaches a threshold: cirrhosis, a liver so thoroughly remodelled it can no longer perform its basic chemistry. Beyond that threshold waits hepatocellular carcinoma — primary liver cancer — one of the most difficult cancers to treat. The disease announces itself, loudly and late, only after decades of quiet construction work. That lag between infection and consequence is precisely what makes hepatitis C so epidemiologically dangerous. Most carriers do not know they are carriers.

Eight Weeks. Ninety-Five Percent. The Drug That Rewrote the Rulebook.

For most of its history, hepatitis C was treated with interferon — a drug that felt, to many patients, roughly as bad as the disease it fought. The old regimen ran for up to a year, triggered flu-like misery, depression, and anaemia, and cured somewhere between half and two-thirds of people who could tolerate it at all. "Tolerate" is doing a lot of work in that sentence. Many couldn't.

Then came direct-acting antivirals, or DAAs. The name is almost too plain for what they do: these are small oral molecules that reach directly into the virus's replication machinery and shut it down. Take a pill, or a combination of pills, once a day. Do this for eight to twelve weeks. In more than 95% of cases, the virus becomes undetectable and stays that way.

That last part has a clinical name: Sustained Virologic Response, or SVR. In practice, SVR means cured. Not managed, not suppressed — cured. That word sat unused in hepatitis C medicine for decades. Now it fits.

Here is the strange part. The drug isn't the only miracle. The scale of deployment is. Since 2015, more than 100,000 patients in England have received treatment through the NHS. That is 100,000 people who, a generation earlier, would have faced either a brutal interferon regimen or none at all. Now hold that thought alongside the 95% figure, and the arithmetic becomes almost uncomfortable in its optimism.

The rulebook, to be precise, wasn't rewritten gradually. It was replaced in about a decade — which, in the history of medicine, is practically overnight.

A Billion Pounds and Unlimited Doses: When Medicine Is Priced Like a Streaming Service

Picture the moment someone at NHS England sat down with representatives from Gilead, MSD, and AbbVie and proposed something genuinely unusual. Not: we will pay you per patient treated. Instead: we will pay you one billion pounds, and in return you will supply us with as many courses of treatment as we need, for as long as we need them. A fixed national price for unlimited volume.

It is, structurally, a streaming subscription. You pay Netflix once a month and you can watch as many films as you like; Netflix has no incentive to hope you watch fewer. The NHS deal worked the same way. Once the contract was signed, the pharmaceutical companies had no financial reason to see fewer patients treated, and the NHS had no per-patient cost standing between a sick person and a cure. The barrier that quietly rations medicine in most healthcare systems — the unit price — was simply removed.

Once the contract was signed, the pharmaceutical companies had no financial reason to see fewer patients treated, and the NHS had no per-patient cost standing between a sick person and a cure.

Here is the strange part: this also turned out to be the fiscally conservative option. Liver transplants are extraordinarily expensive procedures. Hepatocellular carcinoma — liver cancer driven by decades of viral inflammation — requires years of oncology care. When you run the arithmetic, curing someone in eight weeks with antivirals is vastly cheaper than managing their organ failure a decade later. Since the deal was struck, demand for liver transplants caused by hepatitis C has fallen by 52%. Deaths from HCV-related disease, including cirrhosis and cancer, have dropped 35 to 37 percent.

A billion pounds, on that ledger, starts to look less like a health budget line and more like an infrastructure investment. You pay once. The liver wards empty. The numbers hold.

What Sixty-One Percent Down Actually Looks Like in Practice

Numbers at this scale need translating. In 2015, roughly 129,000 people in England were living with chronic hepatitis C — a silent reservoir, most of them unaware. By 2024 that figure had fallen to an estimated 50,200. A 61.1% reduction. To put it another way: for every five people who were chronically infected a decade ago, only two remain so today.

Compare that to virtually any other chronic infectious disease campaign in modern memory, and the pace is startling. HIV prevalence has not fallen by anything close to that margin. Tuberculosis in England has declined, but over generations, not a single decade. Here is the strange part: hepatitis C achieved this without a vaccine, without herd immunity, purely through finding people and curing them one by one.

The sharpest single shift happened among people who inject drugs. In 2015, 28.6% of that group tested positive for the virus. By 2024 the figure was 5.2%. That is not a rounding error; that is the entire landscape redrawn. Opt-out testing — where a blood test happens automatically unless the patient specifically refuses — drove much of this, deployed in prisons, emergency departments, and drug treatment centres, the three places where the hardest-to-reach patients most reliably pass through a door.

Now hold that thought, because one gap remains stubbornly visible. As of 2024, approximately 84.6% of infected individuals in England have been diagnosed. Progress, certainly. But the WHO target is 90%, and that last stretch is almost always the most difficult. The people still missing are, by definition, the ones the system has not yet managed to find.

The People Still Hiding in the Numbers — and Why Some of Them Are from Estonia

Here is the strange part. England has treated more than 100,000 people, cut its chronic case count by 61.1%, and watched liver transplant demand drop by half. And yet, as of 2024, roughly 84.6% of infected people in the country have actually been diagnosed. That leaves 15.4 percentage points between England and the WHO's 90% diagnosis target. In a disease that kills quietly, that gap is exactly where survival hides.

The undiagnosed remainder is, almost by definition, hard to count. Many carriers have no symptoms at all — the virus settles in, damages the liver slowly, and announces itself decades later as something far worse. So the 50,200 figure is an estimate, not a census. Somewhere inside it are people who have never had a reason to ask for a test.

UK health officials have specifically called for testing among people from Eastern Europe, including Estonia. The reason reaches back to 1991. Before the collapse of Soviet-era healthcare systems, sterilisation standards for medical and dental instruments were inconsistent across the region. A blood test, a dental extraction, a minor surgical procedure — any of these could, in the wrong clinic on the wrong day, have passed the virus silently from one patient to the next. The exposure happened decades ago. The infection has been waiting since.

For the reader sitting in Tartu or Tallinn with a parent who had surgery before 1991, this is not a historical footnote. It is a reason to make a phone call. The 15.4% gap will not close itself.

A Blueprint for Hepatitis C Elimination — and Fifty Million People Still Waiting

The WHO set 2030 as the global elimination deadline because it seemed, a decade ago, like an ambitious but achievable horizon. England may cross that line five years early. The world is watching.

Here is the strange part. The English model works partly because the NHS is the English model: a single buyer, a single deal, unlimited doses at a fixed price. That structure is politically and structurally impossible in fragmented healthcare systems where the cost of each pill flows through insurers, middlemen, and competing incentives. You cannot photocopy a billion-pound subscription contract and paste it onto a country that doesn't have a single counter to walk up to.

Gaps remain even in England. The exact count of undiagnosed, asymptomatic carriers is, by definition, an estimate. The funding architecture once the bulk caseload clears is still an open question. The precise scale of hepatitis C in Estonia remains poorly measured.

Now hold that thought, and widen the frame. Globally, roughly 50 million people were living with hepatitis C in 2022. England's hepatitis C elimination does not shrink that number by much. What it does is prove the thing was doable. Whether the rest of the world finds its own path to that proof, we still don't know. That, honestly, is the best part of the story — it isn't finished.