The Global Movement to Eliminate Viral Hepatitis. John W Ward, MD Task Force for Global Health CDC, Atlanta, Georgia, USA

Transcription

1 The Global Movement to Eliminate Viral Hepatitis John W Ward, MD Task Force for Global Health CDC, Atlanta, Georgia, USA

2 Infection and Disease Control, Elimination and Eradication Control Below acceptable levels ( e.g., flu) Elimination Zero cases in an area (e.g., measles) Below a certain rate ( e.g., TB) A proportional decrease (e.g. malaria) As a public health threat (LF, Chagas) Eradication Zero cases globally e.g., smallpox Prevention Interventions Ongoing Ongoing Cease 2

3 Guiding Principle - Health equity Disease Elimination and Eradication Goals Achievement of time limited goal for improvement in health Strengthening of existing health systems Purposes Set time limited targets Create a sense of urgency Set goals for accountability Attract stakeholders Hinman A NY State J of Med 1984; Dowdle W, Bull WHO 1998; Dowdle W, Cochi S, Vaccine

4 4 GlobaI Concern Regarding he Increases in Viral Hepatitis Related Mortality World Health Assembly resolutions Sustainable Development Goal Combat hepatitis 4

5 Eliminate Hepatitis B Virus and Hepatitis C Virus as Public Health Threats by 2030 Prevent 7.1 Million Deaths Countries encouraged to develop national goals 5

6 HBV and HCV Meet Criteria for Disease Elimination Public health importance- 1.28million deaths /year Biologic feasibility- Humans required for replication, no intermediate hosts, or propagation in the environment Technical feasibility- Prevent transmission- Hepatitis B vaccine Prevent parenteral blood exposures and sexual contact (HBV) Testing and treatment Prevent mortality - Testing, care and treatment Global endorsement World Health Assembly International Task Force for Disease Eradication 6

7 7 Regional Plans

8 8 Global Awareness Campaigns

9 Global Elimination of HBV and HCV as Public Health Threats by 2030 SDG: Sustainable development goals nationalacademies.org/hmd/reports/2017.aspx 9

10 Elimination of Transfusion-associated HBV and HCV Transmission Blood Bank Screening (HBsAg, anti-hcv, PCR testing) 99% reduction in transmission since 1980s 7-14% risk to 1/488,000 (HBV) and 1 /1,200,000 (HCV ) 97% of all donations globally are screened for HBV and HCV Meets elimination performance targets for 2020 (95%) Quality of testing ( i.e. HCV virologic testing ) remains an issue Dodd R, Transfusion C Lee, BMJ 2006; H Zhang Hepatology 2014; CDC.gov/Hepatitis

11 Large Reductions in Blood borne Transmission in Health Care Settings Improvements in injection safety and infection control 88% decrease in the proportion of injections administered with non-sterile equipment 91% reduction in HBV transmission 83%% reduction in HCV transmission 5% injections continue to be given with reused equipment HBV HCV Hauri A, nt J STD AIDS Jan;15(1):7-16;.Pepin JPLoS One 2013;e HCV 2010

12 The Greatest Challenge to HBV Elimination Hepatitis B Vaccination of Newborns Perinatal transmission Increasing attributable fraction of new HBV infections Only 43% of newborns receive HepB vaccine; lowest coverage is in Africa Certain strategies increase coverage Scale up to 80% prevents 18.7 m infections by 2030 GAVI support for newborn Hep B vaccination for purchase and technical assistance for administration Investment case improved Final board vote June 2019 Cambodia 12 WHO global hepatitis report Shimakawa Y Gut Dec;65(12): Nigeria

13 Western Pacific Region Achieved Goal of <1% of Children with HBV by 2017 Western Pacific Region Strategic information to guide planning Plans with time limited goals Implementation platform and tools Accountability Strategic information to monitor progress 13 Verified (19) Programme improvements required (6) Serosurvey with <1% but not submitted (3) Serosurvey planned (6) Awaiting results of serosurvey (1) Under review for verification (1) Data not available (1) Certification process to document achievement of goal Wiesen E, Diorditsa S, Li X. Vaccine May 27;34(25):

14 Key Attributes of Successful Disease/Elimination Programs Political will/ community support (advocacy) Agreement on time limited goals and action plan Adequate public health/ clinical infrastructure Implementation of feasible, cost effective interventions Data for monitoring progress and program improvement Hinman A NY State J of Med 1984; Dowdle W, Bull WHO 1998; 14

15 Greatest Challenge to Elimination of HCV Transmission Prevention Services for Persons Who inject Drugs Drug treatment+ safe injection equipment reduces transmission risk by 71% HCV testing/ treatment reduces risk by 90% Only 93 of 176 countries have prevention programs New cure as prevention studies in progress Safe equipment Coverage Eastern Europe (18/18) Western Europe (23/27) East and SE Asia South Asia (6/9) Central Asia (5/5) Latin America (5/18) Canada & US (2/2) Australia & NZ (2/2) Middle East & N Sub-Saharan Africa Global (82/151*) Needles/syringes distributed per PWID per year Drug treatment Coverage Eastern Europe (16/18) Western Europe (25/27) East and SE Asia (7/16) South Asia (5/9) Central Asia (2/5) Latin America (2/18) Canada & US (2/2) Australia & NZ (2/2) Middle East & N Africa Sub-Saharan Africa (4/16) Global (70/151*) Recipients of drug treatment per 100 PWID * (Number of countries reporting implementing OST, of those with injecting drug use identified) Larney S, Lancet Glob Health. 2017

16 Greatest Challenge to Elimination of Pre-mature Mortality Testing and Early Treatment of HBV and HCV Infection HBV 257 million Global: Diagnosed 9%; on treatment 1% HCV 71 million Global: Diagnosed: 20%; Treated 4% Sources WHO (Center for Disease Analysis ) cdc.gov/hepatitis

17 Elimination Programs Improve Access in Country of Georgia ~150,000 HCV RNA+ persons; 5.4% prevalence Goal: 90% diagnosed; 95% treated; 95% cured by 2020 >50,000 HCV RNA+ persons treated Key tools National planning Data to guide and evaluate program Health system strengthening Political support Partnerships Gilead, Abbott, CDC, State, WHO, 17 Nasrullah M, Nat Rev Gastroenterol Hepatol Jul

18 HCV Elimination Programs- Egypt, Iceland Iceland 1200 infected; 0.3 % HCV prevalence National plan- 80% reduction in incidence by 2025 Multidisciplinary public health model focus on PWID Social mobilization e.g. letters to all households 50-70% of persons diagnosed treated for HCV Concern- Sustainability Egypt - 6 M infected; 6.4% prevalence Goal- Reduce to < 2% from HCV treatment centers; over 1 million persons treated In Feb. 2018, President Al Sisi s set goal to free country of HCV by In October, launched campaign to test all persons age In November, government announced HCV testing of eight million persons 18 Olafsson S J Int Med March 2018; El Kassos M. Exp Rev infect Ther March 2018

19 Mera J, personal communication MMWR Morb Mortal Wkly Rep May 13;65(18):461-6 Routine Testing of All Adults in the Cherokee Nation HCV Elimination Program Program launched elimination program in 2015 Moved from birth cohort to universal HCV testing for patients yrs. Training and electronic tools to prompt testing Care managed by mid-level providers (e.g., pharmacists) 8/2015 Screening Evaluation Treatment 55% 75% 71% 85% 10/2018 Health system strategies to pay for testing and treatment Contact tracing to identify new HCV infections Cure 96%

20 HCV Burden of Disease, HCV Testing Fig 1. HCV seroprevalence in different age groups. and Treatment Cost- Thailand Total HCV infected 356,670 > 30 yrs of age 343,698 (96%) 52% have advanced liver disease Focus testing on persons > 30 yrs, born before 1983 HCV treatment cost $250 per course HCV diagnosis HCV monitoring $79 (anti-hcv, PCR) $ (PCR) 20 Wasitthankasem R, Vichaiwattana P, Siripon N, Posuwan N, Auphimai C, et al. (2018) Birth-cohort HCV screening target in Thailand to expand and optimize the national HCV screening for public health policy. PLOS ONE 13(8): e

21 Micro-elimination Diverse settings Clinical care systems- eg. US VA system Corrections Communities- e.g San Francisco, Punjab, India Co-infected populations- e.g. HIV Are field studies of elimination Need time limited numerical targets Design to guide large scale implementation 21

22 Countries Represented Albania Iceland Sierra Leone Australia India Singapore Belgium Ireland Spain Cameroon Italy Switzerland Canada Myanmar Taiwan Congo Nepal The Netherlands Egypt Nigeria Tunisia France Pakistan Ukraine Georgia Poland United Kingdom Germany Romania United States Ghana Rwanda Greece Russia 22

23 A Community of Practice to Support Viral Hepatitis Elimination

24 Examples of Communities of Practice Supporting Disease Elimination Best practices information and operational research Technical assistance, operational research, program monitoring and evaluation, partnership development Global Polio Eradication Initiative Alliance for Malaria Prevention Training and expert technical assistance through distance-based channels and in-country missions Tools and library; research, advocacy materials, financing Differentiated Care for HIV Models of HIV care; global and local guidance; resource library; and implementation tool kits, target partners 24

25 Why A Community of Practice for Viral Hepatitis Elimination? Prevention of transmission and disease is complex Resources are precious Elimination programs are new and often disconnected from others Key information is fragmented or not available Technical assistance for programs is limited or not available Few opportunities for operational research to improve performance 25

26 Elimination program funding Standing stakeholders Funders of PROVE WHO World Hepatitis Alliance Rotating stakeholders Elimination programs Technical experts Civil society Executive Board Program for the Elimination of Viral Hepatitis Community of practice Trusted evidence base (HEPEXPERT) Technical assistance Operational research Global advocacy Collaborative partnerships Information sharing Operational research Information resources Technical assistance Operational research Implementing partners: elimination and prevention initiatives Scientific advisory committee IT development partner Information hub/ PROVE website Customizable digital tools and IT services for implementing partners Public dissemination of evidence, tools and information

27 27 Viral Hepatitis Elimination Programs Locations and Activities 27

28 Summary HBV and HCV elimination are rare opportunities for major improvements in health The progress toward elimination is substantial Model programs provide examples of best practices Collaboration and information sharing can help current and new program achieve elimination goals 28

29 29 Let s Work Together to Eliminate Viral Hepatitis