Disclosures Name - Dr Khin Pyone KyiNo conflicts of interests

Monitoring: Finding the Missing Millions-HBV Best Practice Talk - Myanmar

ByDr Khin Pyone Kyi

MBBS, DBact, MMedSc (Micro), PhD (Micro), FRCP (Edin)President

Myanmar Liver FoundationDirector General (retired)

Department of Medical Research, Ministry of Health

Finding the missing millions

This is the theme of World Hepatitis Day July 28, 2018 by World Hepatitis Alliance (WHA)

- a nod to the 290 million men, women and children

globally that live with Viral Hepatitis without even knowing

it.

- WHA estimates that 9 ot of 10 people living with Viral

Hepatitis are unaware that they are infected

- Launched a 3 year awareness and advocacy campaign to

progress towards WHO’s elimination target of a 30%

diagnosis date by 2020.

Find the missing millions (cont)

The campaign aims to tackle barriers to diagnosis by

1. Increasing public knowledge of the disease

2. Promoting easily accessible testing

3. Removing stigma and discrimination

4. Reducing out-of-pocket costs to the patients

Global burden of viral hepatitis

- 5 types of VH namely A, B, C, D and E – recognized as global public health problem.

- Approx: 240 million are chronically infected with HBV and 150 million with HCV

- Estimated 1.4 million deaths per year from VH and its related complications such as cirrhosis, liver failure & HCC

- Of these deaths 47% are attributable to HBV and 48% to HCV

Burden of Viral Hepatitis in Myanmar

The National sero-survey for HBV and HCV by DMR, DPH and MLF in 2015- conducted to cover all the 14 States and Regions -

HBV – 6.5% (average)

Range is wide – 5% to 12.3%, highest in Yangon

HCV – 2.7% (average)

The highest occurrence found in Mawlamyine 10.34%

Hepatitis B prevalence in Myanmar

12.3%

7.84%9.15%

7.5%

7.3%

7.1%

7.1%6.8%

6.5%

6.3%

6.2%

5.7%

5.%

0%

2%

4%

6%

8%

10%

12%

14%

Maw

lam

yin

e

Man

dal

ay

Lash

io

Tau

ngg

yi

Myi

tkyi

na

Pat

hei

n

Kal

e

Yan

gon

Tach

ileik

Nay

Pyi

Taw

Sitt

we

Pya

y

Loik

aw

Daw

ei

Mag

way

Hp

a-an

Bag

o

Hak

ha

HBsAg

HCVAb

HBsAg and Anti HCV-Ab prevalence in 18 townships

Burden of Hepatitis B by Population

Prevalence Population Prevalence rate

Mono-infection of HBV

**General Population (2015) 6.51%

**Adult Males 8.95%

**Adult Females 5.47%

**PWID 7.3%

Among blood donors (2015) 2.3%

Co-infection of

HBV & HCV

^ PWID (2007) 6.7%

^ PWID (Myitkyina) (2007) 9.5%

^ PWID (Moegaung) (2007) 8.5%

WHO Elimination Goal for viral hepatitisIn November 2014, the establishment of the National Hepatitis Control Program (NHCP) was initiated after the WHO resolution to improve the prevention, diagnosis and treatment for Viral Hepatitis at the 67th

World Health Assembly (WHA). The National Strategic Plan was finalized and the National Treatment Guideline for Viral Hepatitis C was approved. The NHCP was established in 2015.

The 69th WHA adopted the Global Health Sector Strategy on Viral Hepatitis (2016-2017)- the global goal to eliminate VH as a public health threat by 2030 with specific targets to fulfil by 2030. In April 2016, Regional Action Plan for Viral Hepatitis in the SEAR was approved by Member States.

Myanmar has adopted the WHO Global Hepatitis Strategy into prevention and control strategies that are tailored to specific conditions at the national and subnational levels.

Products of NHCP

The National Hepatitis Control Program, MOHS, with assistance from WHO, CHAI and related experts produced and distributed the following documents (in book form) during 2015-2018.

1. National treatment guideline for viral hepatitis C.

2. National treatment guideline for viral hepatitis B.

3. Myanmar National Action Plan for Viral Hepatitis Response 2017-2020

4. Myanmar National Strategic Plan on Viral Hepatitis

2016- 2020

5. National Monitoring and Evaluation Plan for Viral

Hepatitis Myanmar 2017-2020

National Strategic Framework

Goal: To work within a health system framework and use effective public

health approach within the premises of Universal Health Coverage

Target: Reduce the incidence of viral hepatitis

Reduce mother to child transmission of HBV

Reduce the mortality due to viral hepatitis

Reduce the socioeconomic impact of viral hepatitis at individual,

Community, and population levels

Framework for action: Universal Health Coverage, Continuum of Care and

Public Health Approach

Vision: To free from viral hepatitis by halting transmission while those living

with hepatitis has access to safe, affordable, and effective treatment

StrategicDirection 1

Prevention of Transmission

Of ViralHepatitis

StrategicDirection 2Diagnosis,

Clinical CareAnd

Treatment

StrategicDirection 3Workforce

Development

StrategicDirection 4Surveillance

and Research/Strategic

Information

Strategy Implementation: Leadership, Partnership, Accountability,

Monitoring and Evaluation

Mo

nit

ori

ng

an

d E

va

lua

tio

n

CONTEXTANDNEED

Epidemicpattern,stigma

andpopulations

in need

CONTEXTANDNEED

INPUTS OUTPUTS & OUTCOMES IMPACT

Policy,Laws,healthsystem

inputs andfinancing

Cascade for care (HBV) and cure (HCV)

Prevention TestingCare&

treatment Cure

Strategic information framework: minimum set of 10 core indicators to monitor and evaluate the health sector response to hepatitis B and C along the result chain

1.Prevalence

2.Infrastructure

for testing

3.VaccinationCoverageHepatitis

B:-newborns

-infants4.

Needle-syringeDistribution

5.Facility-level

Injection safety

6.People

Diagnosed

7.Treatmentcoverage/initiation

8.Cure(HCV)

or viralsuppression

(HBV)

Newinfections,

deaths,equity

9.Incidence

10.Attributable mortality

HCC and cirrhosisand chronic liver

diseases

National targets for viral hepatitis response in Myanmar for 2030

Core intervention IndicatorMyanmar

2015Myanmar

2020Myanmar

2030Global2030

ChildhoodVaccination

Hepatitis 3rd doseVaccination coverage

76% 80% 90% 90%

Prevention ofMother-to-child transmission of hepatitis B

Hepatitis timely birth dose vaccination coverage

15% of institutional

deliveries 2% of all delivers

75% of all deliveries

80% 90%

Safe injectionsProportion of safe injections in health care facilities.

To be determined in

2017

To be determined after

the injection safety

assessment

To be determined after

the injection safety

assessment

90%

Harm reductionNumber of needles/ PWID/year

222 300 365 300

TestingPercent of persons withchronic HBV and HCV infections diagnosed

<1% 25% 50% 90%

Chronic HBV infection treatment

Percent of treatment eligible persons with chronic HBV infection treated

<1% <1% 50% 80%

Chronic HCV infection treatment

Percent of treatment eligible persons with chronic HCV infection treated

<1% 30% 50% 80%

Public Sector -For control of hepatitis B

The Government takes the leadership role for the prevention, diagnosis, control and treatment of Viral Hepatitis. There are 5 Liver Speciality Units in Public Hospitals in Myanmar with approximately 25 Hepatologists.

- Effective vaccine for Hepatitis B- immunization is the central strategy for Myanmar to reduce the HBV burden.

- Screening of blood and blood products at Blood Banks.

- Sterile needles and syringes distribution.

- The major stumbling block is the low awareness of VH both in

general and key populations. Knowledge of various risks &

transmission routes is central to prevention of spread.

Hepatitis B Vaccination ( EPI and high risk groups)

Hepatitis B vaccine – introduced into EPI in 2003 and 3 doses given at 2, 4 and 6 month schedule with other EPI vaccines for all newborns in Myanmar

Plasma-derived hepatitis B vaccine was developed at the Department of Medical Research (DMR)(1991 – 1997) and produced on a large scale for use in the community, after certification by the NYBC ( WHO/UNDP Project)

Recombinant Hepatitis B Vaccine Plant - under DMR and HB vaccine was developed (2003-2004)

Production was started for use in the community (Korea EDCF Loan)

DTP-Hib-HepB3 coverage in Myanmar -2015

Hepatitis B testing and vaccination among PWID, PWUD (Jan 2017 -Jun 2018)(high risked groups)

• As the vaccination is counted only with the completion of the third dose, some of the clients showing as a “gap” who are in the ongoing vaccination processes.

16.369

12.41512.041

8.666

-

2.000

4.000

6.000

8.000

10.000

12.000

14.000

16.000

18.000

JD2017 JJ2018 (half)

Hepatitis B testing

Hepatitis B Vaccination

Hepatitis B vaccination among PWID by States/Regions (Jan-Jun 2018)

1.686 1.738

1.047

2.040

39%

79%

66%

85%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

-

500

1.000

1.500

2.000

2.500

Kachin Mandalay Sagaing Shan

HBV test (PWID)

HBV vaccinated (PWID)

Vaccination % JJ2018

• As the vaccination is counted only with the completion of the third dose, some of the clients showing as a “gap” who are in the ongoing vaccination processes.

Hepatitis B Screening at Blood Banks

- One of the main modes of transmission for HBV and HCV is by transfusion of contaminated blood & blood products.

- Transmission is preventable by screening all blood and blood products in all transfusion services

To implement blood safety and testing strategies:

- Test all donated blood for HBV, HCV and HIV ( Lab QC)

- Prevent unnecessary blood transfusions by establishing

policies and practices that promote rational use of blood

- Strengthen national blood screening policies & strategies

Mandatory tests for VH at Blood BanksIn Myanmar screening for HBV at Blood Banks started in 1988 using locally produced RPHA reagents at the NHL.Started with blood banks in Yangon and then expanded to hospitals in the districts.

In 2004, Rapid tests were used for screening – ICT tests.

In 2014 ECLIA method and RDT tests were used. Also NAT Tests were applied as required .

Throughout Myanmar testing of blood for HBV is compulsory for donated blood for transfusion and for all patients as preoperative procedure (HBsAG, HIV and Anti HCV).

Screening Blood donors at Blood Banks

Overall in selected 154 blood screening sites countrywide the prevalence of HBsAg and Anti HCV among blood donors were as follows:

Year No. of donors HBV HCV

2014 313662 2.4% 0.5%

2015 379088 2.3% 0.5%

2016 397278 1.8% 0.4%

Test Kits for Viral Hepatitis

For easy diagnosis, the test kits should be of high quality and user friendly (preferably WHO pre-qualified)- Both HBV and HCV screening through Rapid Diagnostic Test Kits – available in all lab for screening of blood safety.- ELISA is available but not practical for routine diagnostic use.

( Temp sensitive reagents).- Viral Load machines at reference lab– available for confirmatory tests but limited usage due to limited reagents.- Liver Function Tests – available in tertiary hospitals, States and Regional Hospitals, District Hospitals-Ultrasonogram – available up to District HospitalGenotyping, Fibroscan for Liver staging, APRI score- limitedHBV & HCV screening – free for blood donors but not free for others.

Public Sector Awareness Raising Activities

The Department of Public Health (DOPH) has carried out VH related activities since 2014. The NHCP is under the DOPH which is responsible for awareness raising for VH.

World Hepatitis Day events – carried out in collaboration with MLF since 2013 and then as leading partners in 2017 and 2018 in two major towns each time – lectures, seminars, displays and distribution of presents and pamphlets.

NHCP collaborates with the following CSOs, NGOs and INGOs to develop and implement its VH prevention and control program – Myanmar Medical Association, Myanmar Liver Foundation, Myanmar Red Cross Society, Myanmar Maternal and Child Welfare Association, WHO, CHAI, CPI, BKKEE Foundation etc.

Public Sector facilities and limitations

Although there is a policy, a gap remains in implementation of infection control practices.

- The national policy on injection safety in health-care settings recommends single use syringes, needles and cannulas for therapeutic injections- available in all health care facilities.

- However there is no specific immunization policy for health care providers and high risk populations.

- There is a national infection control policy for all blood banks- screening for HBV and HCV for all donated blood.

- National policy for hepatitis B which includes birth dose vaccination – limited to hospital deliveries currently – due to intermittent supply of birth dose – 20-25% of hospital deliveries were covered.

- No routine surveillance for VH before, but starting now.

Role of Private Sector in Viral Hepatitis Control

Two main organizations concerned with liver diseases in Myanmar

1. GI and Liver Society

A leading professional society under MMA

consisting of hepatologists, Gastroenterologists, doctors etc

developed Viral Hepatitis clinical management guidelines and

carry out CME activities (mainly academic)

2. Myanmar Liver Foundation (MLF)

A non profit NGO formed 6 years ago consisting of volunteers

- hepatologists, researchers, medical doctors, artistes,

entrepreneurs etc - main objective of reducing the

morbidity and mortality due to liver diseases .

Private sector- awareness raising activities by MLF

MLF has been acclaimed for undertaking notable efforts to raise awareness among policymakers and the general public through conducting public talks, regular broadcasting on radio channels, television channels on liver diseases and vaccines etc

World Hepatitis Day celebrations – annually since 2013

Radio health education talk – average 16 times a year

TV health education shows – average 24 times a year

TV news – average 20 times a year

Public (health education) Talk- average 24 times a year

Special video clip produced for public health education on VH

(MOHS, WHO and MLF), distribute IEC materials, pamphlets etc,

HE Articles and Q and A sessions in journals all year round

Media Coverage and Networking

Awareness raising- TV, FM, Displays, Booths

Vaccination programs all over Myanmar by MLF

Since 2013, MLF has carried out hepatitis B vaccination programs all over Myanmar.

(1) Hepatitis B vaccines were purchased from Vaccine

companies at a discount rate

(2) From 2015 to 2016, MLF received donated HB vaccines

from EPI Department, MOHS

From 2013 to 2018, MLF has screened and vaccinated approximately 500,000 persons with 3 doses of HB vaccines in collaboration with Civil Society Organizations in the respective towns and villages.

Hepatitis B Vaccination

Coverage by Myanmar Liver

Foundation Supported by

Donors (both local & abroad)

and Ministry of Health &

Sports

(Feb 2013 to December 2018)

14 States & Regions - Approx 500,000 personsvaccinated with 3 doses of HB vaccine

Vaccination Programs all over Myanmar

Children with blood disease, Yangon & Myitkyina, Kachin

Relevant research findings

Research data in Myanmar 35 years ago showed the prevalence of HBsAg in the general population ranging from10% to 12%. In children under 12 yrs it was around 6%.

In children, HB vaccine was introduced into the EPI in 2003 and all newborns were given 3 doses. The efficacy of the HB vaccine could be seen in the following research findings.

Year No of children tested HBsAg (+) per cent

2010 1211 (Kayin) 2.4%

2013 159 (Kaw Hmu) 1.25%

2016 1326 (Gwa) 0.6%

2018 100 ( at Charity Clinic) 0

Private sector- Free tests, Free drugs & Free consultationReducing out of pocket fees for the patients

MLF opened two Charity Clinics in two major towns, Yangon (May, 2017) and Mandalay (January, 2018).

Free services provided at the clinics include –

1. HBV and HCV tests, Hepatitis B Combo tests, Blood sugar test, Pregnancy test

2. Hepatitis B vaccination

3. Ultrasound examination

4. Fibroscan

5. Consultation with trained Medical Officers and Hepatologists (continum to care)

6. Free treatment for hepatitis B and C through donations and research projects.

Than Sitt Charity Clinic (1)

• No 33-35, Pathein Street, KyunTaw (Middle) Ward, Sanchaung Township, 11111, Yangon

• Phone: +959-964482820,964582820

ဆ ေးခန ေး -၁ (ရန ကနု ) ဆ ေးခန ေး -၂ (မန္တဆ ေး)

Number of patients obtaining free services at Than Sitt Charity Clinic (May 2017- October 2018)

(1) Hepatitis B Vaccination- 7691(2) Hepatitis B Tests – 3043(3) Hepatitis C Tests - 4520(4) B Combo Tests - 2233(5) RBS - 1957(6) Ultrasound - 2302(7) Fibroscan - 1709(8) Hepatitis C Treatment – 846 by donations

- 800 by research projects(9) Hepatitis B Treatment

1. By donations - 70 HB chronic carriers2. BKKee Research Project (recently started)

approx: 100 HB pregnant mothers and household contacts to betreated for up to 5 years as required.

3. Cost sharing basis – (hundreds)

Wishing all a success in the Viral Hepatitis Elimination Program

Thank You