Parallel Session: Service Delivery and integrationDecentralization of care Long distance to services associated with: –Poor uptake –Poor adherence ... Hepatitis Prevention & Control

Presenter:

Parallel Session: Service Delivery

and integration

Mazuwa BandaDepartment of HIV/AIDS & HepatitisWorld Health Organization

Similar, yet different…. Epidemiology and

Treatment

HIV HCV HBV

Main transmission route Sexual Parenteral Perinatal

Prevalence of infection 36.9 m (2014) 170-185 m 350-400 m

Deaths per year 1.2 million 350,000 500,000

No of drugs licensed/pipeline >30/10 5/26 8/18

% infected requiring treatment over

lifetime

95% 60-80% 15-40%

Treatment duration Lifelong 12-48 weeks Cure Lifelong/3-5 years

WHO treatment guidelines 2002, 2006, 2010, 2013 2014 2015

As of March 2015, 15 million people living with HIV were accessing

antiretroviral therapy, up from 13.6 million in June 201

Actual and projected numbers of people receiving

antiretroviral therapy in low-and middle-income

countries, and by WHO Region, 2003–2015

Unprecedented scale-up of HIV services has curbed the epidemic

0

500 000

1 000 000

1 500 000

2 000 000

2 500 000

3 000 000

3 500 000

4 000 000

4 500 000

5 000 000

0

2000000

4000000

6000000

8000000

10000000

12000000

14000000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

People receiving ART in low- and middle-income countries

People dying from AIDS-related causes globally

New HIV infections are declining globally

Lessons from scaling up HIV services

Lessons from scaling up HIV services

• Programme planning

• Simplification

• Task-shifting

• Decentralization

• Integration

• Partnership

Programme planning

Approach used in HIV

• Models (e.g. Cost of expanded ART coverage

(Spectrum/ Futures Institute) to:

– update estimation of resources needed for

HIV care

– support countries to prioritize the most

effective interventions

• HIV Program M&E framework

– Global AIDS Response Progress Report

– Standardized patient monitoring system

• Standardised comprehensive surveillance systems

Approach used in HIV

• Models (e.g. Cost of expanded ART coverage

(Spectrum/ Futures Institute) to:

– update estimation of resources needed for

HIV care

– support countries to prioritize the most

effective interventions

• HIV Program M&E framework

– Global AIDS Response Progress Report

– Standardized patient monitoring system

• Standardised comprehensive surveillance systems

Relevance to HCV/HBV

• Planning manual developed

• Need for models tailored to HCV/HBV

• Strengthen surveillance to provide country-

level data on burden of disease to inform

planning and monitoring of uptake of

HCV/HBV treatment

Relevance to HCV/HBV

• Planning manual developed

• Need for models tailored to HCV/HBV

• Strengthen surveillance to provide country-

level data on burden of disease to inform

planning and monitoring of uptake of

HCV/HBV treatment

Simplification

Task-shifting

Country Doctors (100,000

population)

Nurses (100,000

population)

WHO minimum standard 20 100

USA 256 937

UK 230 1212

Malawi 2 59

Lesotho 5 62

Mozambique 3 21

South Africa 77 408

Health worker distribution

Task-shifting

Task-shifting

PLHIV on ART in South Africa after adoption of NIMART*

*Nurse Initiated Management of ART

Decentralization of care

Long distance to services associated with:

– Poor uptake

– Poor adherence

– Loss to follow-up

Integration

Integration

Partnership

Thank you !

Dr Amandua Jacinto,

Commissioner Clinical Services

Ministry of Health,

UGANDA

Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 18

Situation Analysis ..... Uganda (1) Uganda is highly endemic for HBV, with 52%

life time exposure.

3.5 million (10%) population living with CHB infection.

Highest infection rates in Karamoja (23.9%), Northern Uganda (20.7%), West Nile (18.5%), and Western Region (10.0%).

Lowest infection rates in Central Region (6%) and South-Western (3.8%).


Sero-prevalence of hepatitis B virus in Uganda


Situation Analysis ..... Uganda (2) HBV is responsible for 80% of liver cancers in Mulago hospital

HCC forms 2% of the admissions at the Uganda Cancer Institute (UCI Report 2012).

Hep B prevalence among blood donors high in Gulu (4.2%) and Arua (5.78%).

Improved selection of donors has led to reduction in trend of HBV among blood donors :3.8% in 2007/08 to 1.9% in 2012/13 (UBTS).


Situation Analysis ..... Uganda (3) A lot of fear and panic in

the population about hepatitis.

Ministry of Health has taken hepatitis as a formidable epidemic.

Affects the poor more.

Most affected patients present with advanced complications.


Uganda’s Response Resolution WHA67.6 on

hepatitis, adopted by the WHA in May 2014, called for an intensified and expanded global hepatitis response and for the WHO Secretariat to examine the feasibility of elimination of hepatitis B and C.

Structure of National Plan for the Control of Hepatitis

Prevention

Care and Treatment

Health Education and Promotion


Political Leadership and Commitment The Minister of Health has

issued two Statutory Instruments on HBV: - The Public Health

(Declaration of Hepatitis B as a Formidable Epidemic Disease) Order, 2014 [SI No 104].

The Public Health (Vaccination of Health Workers against Hepatitis B Virus) Rules, 2014 (SI No 105].


Funding• Parliament allocated USD 2.8 million for HBV activities for the FY 2015/16.

• The funds will be used for: -

– Procuring vaccines and injection materials.

– Procuring antivirals and lab reagents.

– Programme development and activities.


Vaccination …. 1: Target GroupsTarget Groups

Massive turn up for screening

To continue with Penta-valent vaccine since 2002.

Introduce birth dose.

Vaccinate all adolescents and adults above 14 years beginning with health workers, students and armed forces.

To cover about 16.5 million people.


Vaccination …. 2: LaunchVaccination Programme launched by the President on World Hepatitis Day 2015

Strategy

4 regions over four years.

Begin with 30 most endemic districts in Northern Uganda

Integrated testing for HIV, HBV, Syphilis, Malaria. HCV to be added later.

Positive cases will be enrolled into care and treatment.


Vaccination …. 3: National Roll Out Plan .

Phase 1: Northern Uganda (30 districts).

Phase 2: Western Uganda (26 districts).

Phase 3: Eastern Uganda (32 districts).

Phase 4: Central Uganda (24 districts)


Vaccination …. 4: Grouping of Population

No Phase Particulars

1 Phase 1 Health workers

2 Phase 2 Students in all secondary and tertiary institutions at entry

3 Phase 3 Armed forces (army, police and prisons)

4 Phase 4 Other high risk populations (prisoners, STI clinics, sex workers, MSM,

travelers)

5 Phase 5 General population


Antivirals ….1: Introduction• Procurement of antivirals for patients legible for treatment.

• Currently two clinics:

– Mulago Hospital: Two sites – Gastroenterology (GE) & STI clinics.

– Arua Hospital.

– HIV co-infected patients to general HIV clinic.

– Cases with complications to specialist clinics such as GE.


Antivirals ….2: Unit costsNo Formulation Pack size Price per pack

(USD)

1 Tenofovir 30 7

2 Entecavir, 0.5 mg 30 33

3 Entecavir, 1 mg 30 66


Antivirals ….3: Target for Treatment

Infected patients: 3.5 million.

Legible for treatment is 30% 0f 3.5 million which is 1,050,000

Patients for FY 2015/16: 350.

First line treatment for adults: Tenofovir.

Second line treatment for adults and first line treatments for children: Endecavir.

QCL/Cipla to manufacture of Tenofovir and Entecavir.

Possibility to manufacture Sofosbuvir for HCV.


Manufacture: Cipla Uganda: …. 1


Manufacture: Cipla Uganda: …. 2)

Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland

34

The manucufuring plant can make: -

• Anti-malarials, anti-retrovirals,

•Antivirals (Tenofovir, entecavir, Sofosbuvir)

•Antifungals, antibiotics, etc.

•WHO accredited centre.

•Potential to supply East, Central and

Southern Africa with essential vital

medicines.

Lab Reagents and consumables Screening tests for HBV

Monitoring of patients for treatment and toxicity.

Centralized HBV DNA quantification using PCR.

Non-invasive liver tests.

Lab consumables: gloves, syringes, swabs, etc.


Programme Development…. 1: Implementation Plan

National Steering chaired by DGHS.

Committees for various activities.

Quarterly reports.

Operational treatment centres in all NRHs and RRHs, to be cascaded to lower HFs.

Partnership involvement.


Programme Development …. 2: Committees Policy, leadership and

systems development

Care and treatment

Laboratory services

Surveillance

Preventive services

BCC and advocacy

Research and ethics

Monitoring and evaluation

Supply chain management

Infrastructure

Human resources

Resource mobilization


Programme Development …. 3: Tools Guidelines

Policy

Care and Treatment

Vaccination

Laboratory

IEC materials

Registers

Revise all HMIS tools to include HBV.

Office equipment and transport

Computers, printers and stationary

Transport

Consumables

Maintenance of equipment and vehicles


Programme Development…. 4: Human Resources

Training of various health care workers.

Integration into other relevant programmes: HIV/AIDS, STI/STD, MCH/RH, NTDs, NCDs, etc.

Coordination.


UN Agencies and PartnersUN Agencies Partners

WHO

UNICEF

UNFPA

CDC

USIAD

CHAI

GF

GAVI


Civil Society and CBOs Several CSOs working

with GOU e.g. NOPLHB, NUSEHI, NACAS, etc.

Active in advocacy, raising awareness, client support, screening programme, etc.

Represented on National Steering Committee and TWG


Challenges New area: little expertise.

Takes time to build structures

Guidelines from WHO still in development.

Pressures from public

Still not priority to many partners.

Huge problem!


Thank You!

The Work

Continues


Hepatitis Prevention & Control in Myanmar

Dr.Toe Thiri Aung

Deputy Director (Epidemiology)

Department of Public Health

World Hepatitis Summit,4th September, 2015

Outline

• Responses to Hepatitis in line with Global Framework

• Epidemiological data for action

• Primary, secondary & tertiary prevention

• Comprehensive approach

• Limitations and challenges for Hepatitis prevention and control

• Future Road Map

• Conclusion

Current responses to Hepatitis

Epidemiological data for actionEpidemiological data for action

Primary PreventionPrimary Prevention

Secondary and Tertiary PreventionSecondary and Tertiary Prevention

Comprehensive approach Comprehensive approach

Epidemiological data for action

• Liver research at Clinical Research Division at Burma Medical

Research Institute since 1972

• Liver Research Unit at RGH in 1973

• Hepatitis B vaccine research in early 80’s

• Plasma derived HB Vaccine development started in 1991

Recombinant HB Vaccine plant (DMR/ LM) constructed in 2002

• Small studies and research on Hepatitis for different sub

populations

• Ongoing National Prevalence Survey of hepatitis B & C started

in May, 2015 by collaborated efforts of Dept of Medical

Research and Dept of Public Health. 12 out of 16 sites have

been accomplished.

Hepatitis Prevalence Burden estimates indicate:

• HBV Prevalence – males and females under 10yrs – 7.25 and 10.81%

• Prevalence among adults – males and females - 15.4 and 10%

• IV drugs users - dual infection (both HBV & HCV) 6.7% (2007 study)

• National Blood Centers , anti-HCV - 0.21% (Yangon) 2.08% (Myitkyina) 0.5% (Mandalay)

• Among HIV patients• HIV + HBsAg : 8.7%

• HIV+ HCV 5.3 %

• Triple infection 0.35%

HBsAg sero-positivity in Injecting Drug Users(IDU) attending the Registered Drug Treatment Centers (2007)

Aung Thu, Aung Thaw, Khin May Oo, Aye Aye Lwin, Ohmar Lwin, Aung Zaw Myint ,San San Oo,Pyaw Phyo Ag, Aye Hnin Phyu , Myanmar Health Sciences Research Journal,Vol.20,No3,2008

Anti- HCV seropositivity in Injecting Drug Users(IDU) attending the Registered Drug Treatment Centers (2007)

Aung Thu, Aung Thaw, Khin May Oo, Aye Aye Lwin, Ohmar Lwin, Aung Zaw Myint ,San San Oo,Pyaw Phyo Ag, Aye Hnin Phyu , Myanmar Health Sciences Research Journal,Vol.20,No3,2008

Analysis of HCV genotypes from blood donors in Yangon, Myanmar, 2004

Shinji.T, Acta Med Okayama,2004,53(s),135-42

3532%

5247%

2321%

genotyope 1

genotype 3

genotype 6

• Blood donor screening since 2000

• Promotion and expansion of immunization of

Hepatitis B (including birth dose) since 2003

• Introduction of Pentavalent vaccine in 2012

• Training of health professionals on Infection control

• Awareness raising

• Health Education

• IEC Materials

• World Hepatitis Day

Primary Prevention of Hepatitis

• World Hepatitis Day has been held since 2009 by GI &Liver Society in selected cities

• With the initiative from Liver Foundation since 2013

• In 2014, Liver Foundation held WHD in coordination withMinistry of Health and WHO SEARO

• World Hepatitis Alliance President sent congratulatorymessages

• Celebrities performed an exciting 10 minutes HealthEducation humorous play

• Speeches, donations and free HB vaccination to studentnurses and blood donors

• Still need to organize nation-wide World Hepatitis Day

World Hepatitis Day

Secondary & Tertiary Prevention of Hepatitis

• Management Guidelines on Hepatitis B 2013 and Chronic Hepatitis C 2014 were developed by Gastrointestinal and Liver Society with the support of Roche Myanmar

• Simplified Treatment Guideline for Hepatitis C Infection has been endorsed in June 2015

• Education and counselling of patient

• Harm reduction

Comprehensive Approach for hepatitis

• Commitment to provide comprehensive services for

hepatitis

• National consultation meeting on Hepatitis in November

2014 to advocate policy makers for development of Road

map of National Hepatitis Program

• National Consultation on finalization of simplified

treatment guideline in June 2015

• Planning to conduct the preparatory meeting for

National Strategic Planning in September 2015

• Strategic directions will be developed after NSP

• Nation-wide prevalence survey for Hep B and C

Partnership

• WHO, UN agencies

• Local and International NGOs

• Liver Foundation in Hepatitis networking • Global networking & collaboration with World Hepatitis Alliance

• Clinton Health Access Initiative

• MSF

• Others

Limitations and challenges

• ? Magnitude of public health burden of HCV and HBV

• Limited epidemiological data for accurate

prevalence/incidence; geographic spread/risk groups

• National program and strategic directions have not

developed yet

Limitations and challenges Contd.

• Screening & diagnosis

• Limited availability of test kits for HBV &HCV screening

• Molecular assay in private labs, limitedcapacity in public sector (only in nationalreference labs, Research institutes)

• Prevention

• Hepatitis B vaccination coverage (pocket areas)

• Risk Communication

Limitations and challenges Contd.

• Treatment

• Limited HR specialized in treatment of Chronic Hepatitis

• Treatment for Chronic Hepatitis could not be affordable: Equity

• Donor interest for hepatitis is currently limited to co-infection

• Capacity Building

• No systematic training program on complicated Hepatitis Treatment for medical officers

Future Road map

Overall goal of road map is to be in line with WHO Global Hepatitis ProgramOverall goal of road map is to be in line with WHO Global Hepatitis Program

Myanmar National Hepatitis Program will adopt a health system framework with public health approach to reduce viral transmission (prevention) and reduce morbidity & mortality (treatment) due to viral hepatitis

Myanmar National Hepatitis Program will adopt a health system framework with public health approach to reduce viral transmission (prevention) and reduce morbidity & mortality (treatment) due to viral hepatitis

The Government will provide treatment to both mono-infection and co-infection and hold central patient registry for treatment and centralized drug procurement

The Government will provide treatment to both mono-infection and co-infection and hold central patient registry for treatment and centralized drug procurement

National Programme

• Simplified programmatic approach will follow 4 recommended key axes

• Axis 1: Increasing awareness for policy makers, health professionals, donors and stakeholders

• Axis2: Evidence based policy and advocacy

• Axis 3: Prevention of transmission: Primary, Secondary & Tertiary

• Axis 4: Screening, care and treatment

Future Road Map (Immediate)

• National prevalence survey of hepatitis B & C: Ongoing

• National guidelines on management of Hepatitis : Ongoing

• National Strategic Plan for formulation of national policy &

strategies for viral hepatitis prevention & control: Ongoing

• Set up international procurement and importing mechanism for

hepatitis drugs and diagnostics

Road Map (Mid-term)

• Standard operating procedures for screening

• Establish monitoring & evaluation systems – develop standardized

reporting format, mechanism and record keeping

• Establish network of quality public sector Hepatitis B and C clinics (free

medication, standardized investigation tools, trained care providers)

Conclusion

• Hepatitis prevention and control in line with

global framework

• Comprehensive approach

• Stronger partnership among stakeholders

• Working together to achieve the targets of

road map

Thank you

Kenya :Hepatitis Situation World Hepatitis Summit

Glasgow

Dr. P. Santau Migiro,

Ministry of Health Kenya

Introduction

• Population; 40 million

• Key Indicators

• Under Five mortality rate:52/100 (KDHS 2014 preliminary)

• Maternal mortality rate estimated at 414/100,000 (KDHS 2008/9)

• Immunization coverage with 3rd dose of pentavalent is 90% (KDHS 2014)

Kenya’s Burden of disease and disability

Burden of Hepatitis Disease

• Data is not adequate but from screening of 40,657 blood units found :• HBsAg - 3.3%,

• anti-HCV – 1%,

• anti-HIV – 1.2%,

• syphilis – 0.19%

• Unknown numbers of injecting drug users

• Screening during WHD IN 2014 found 2% HBsAg positive(n=2198)

Year Study population

No. of

samples

Anti-HCV

seroprevalen

ce HBsAg

Mwangi JW et.al.. Viral markers in a

blood donor population. East Afr Med J.

1999 Jan;76:35-7.

blood donors1.80% 3.90%

Ilako FM et al.. The prevalence of

hepatitis C virus antibodies in renal

patients, blood donors and patients with

chronic liver disease in Kenya. East Afr

Med J. 1995 Jun;72(6):362-4.

renal patients,

chronic liver

disease,

blood donors

6.3%

2.6%

0.9%

Atina JO et al. Prevalence of hepatitis A,

B, C and human immunodeficiency virus

seropositivity among patients with acute

icteric hepatitis at the Kenyatta National

Hospital, Nairobi. East Afr Med J. 2004

81:183-7.

patients with

acute,

icteric hepatitis

84 7.10% 26.20%

Karuru JW(1), Lule GN, Joshi M, Anzala O.

Prevalence of HCV and HCV/HIV co-

infection among in-patients at the

Kenyatta National Hospital. East Afr Med

J. 2005 Apr;82(4):170-2.

HIV (+) in-patients,

HIV(-) in-patients

458

518

3.7%

4.4%

Muasya T et al. Prevalence of hepatitis C

virus and its genotypes among a cohort

of drug users in Kenya. East Afr Med J.

2008 85:318-25.

drug users333 22.20%

Muriuki BM1, Gicheru MM, Wachira D,

Nyamache AK, Khamadi SA. Prevalence

of hepatitis B and C viral co-infections

among HIV-1 infected individuals in

Nairobi, Kenya. BMC Res Notes.

2013;6:363.

HIV cohort in

Nairobi

300 10.30% 6%

Stevens W et al. Baseline morbidity in

2,990 adult African volunteers recruited

to characterize laboratory reference

intervals for future HIV vaccine clinical

trials. PLoS One. 2008 Apr 30;3(4):e2043

HIV cohort:

Kangemi

HIV cohort: Kilifi

Medical staff in

KNH- Nairobi

396

367

204

1%

7.6%

0%

3.3%

10.4%

2%

Current situation on prevention

• Childhood immunization with pentavalent began in 2001

• All blood is screened for hepatitis viruses

• Auto disable syringes used for immunizations

• Immunization policy advocates for vaccination of at risk populations such as health workers.

• All patient on dialysis are vaccinated against Hep B

Childhood Vaccinations (KDHS 2014)

97 98 9690

97 9481

87

71

94 9185

68

2

Percent of children age 12-23 months vaccinated

Pentavalent Polio Pneumococcal

Policies

• Policy Goal:

• To promote safe injection practices and proper management of medical waste

National Policies which address prevention.

Service delivery

• Health services are delivered at 6 levels starting from the community, then dispensaries, health centres, 1st level referral, 2nd level referral and tertiary.

• Services at lower levels like MCH services are integrated.

• There is no regular program for screening of hepatitis

• At national level issues of hepatitis are found in several departments spanning the continuum (prevention-treatment)

• Treatment guidelines for Hep B and C available and were developed by MOH with leading specialists.

Partnerships

• Public sector services are at about 50% and the rest by private, NGOs, FBOs.

• The ministry provides vaccines to public, private and other facilities.

• Health data is collated from all facilities

• The ministry’s role is to provide leadership to the health sector by coming up with policies, strategies and guidelines in collaboration with stakeholders

Challenges and opportunities

• Challenges• Inadequate data on burden of disease• Data collection tools do not capture details on hepatitis• Inadequate resources to vaccinate all at risk populations• Over use of injections especially in rural areas

• Opportunities• Robust research institute (Kemri)• National Blood Transfusion Service• Availability of MoH departments which can work together to push agenda

forward• Greater awareness of the disease both at global, regional and national level

through World Hepatitis Day and other similar campaigns• Committed professional associations

Next steps

• Need to have data on disease burden (target samples from KAIS and MIS)

• Provide guidelines and relevant policies.

• Coordination of various stakeholders to work on national strategy to respond to the issue

• Awareness creation on hepatitis by increasing visibility of world hepatitis day activities..

• THANK YOU

• ASANTENI SANA

Documents

Parallel Session: Service Delivery and integrationDecentralization of care Long distance to services associated with: –Poor uptake –Poor adherence ... Hepatitis Prevention & Control