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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%).
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 19
Sero-prevalence of hepatitis B virus in Uganda
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 20
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).
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 21
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.
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 22
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
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 23
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].
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 24
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.
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 25
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.
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 26
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.
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 27
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)
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 28
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
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 29
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.
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 30
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
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 31
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.
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 32
Manufacture: Cipla Uganda: …. 1
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 33
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.
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 35
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.
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 36
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
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 37
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
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 38
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.
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 39
UN Agencies and PartnersUN Agencies Partners
WHO
UNICEF
UNFPA
CDC
USIAD
CHAI
GF
GAVI
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 40
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
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 41
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!
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 42
Thank You!
The Work
Continues
Thursday, 10 September 2015 World Hepatitis Summit 2015: Glasgow, Scotland 43
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 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
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
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