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AROUND 70 percent of viral hepatitis deaths throughout the world occur in Asia, and the majority of these are attributable to hepatitis B or hepatitis C.
Ensuring that people living with hepatitis are diagnosed and use health services will prevent as many as 5 percent of all global cancer-related deaths.
Recently, leading medical and public health experts at the APASL Public Health Forum gathered to discuss the progress being made, and challenges remaining, to eliminating hepatitis across Asia Pacific. The meeting called for an end to discrimination against people living with viral hepatitis, highlighting this stigma as a key barrier to elimination. Speakers also emphasized the positive impact of vaccination programs, as well as the importance of better infrastructure for testing and treatment at a national level in order to achieve elimination by 2030—the goal set by the WHO in its Global Health Sector Strategy on Viral Hepatitis 2016 to 2021.
The health forum, “Towards Elimination of Viral Hepatitis by 2030: From the Clinic to Community,” was jointly organised by the Asia Pacific Association for the Study of the Liver (APASL), and the Coalition for the Eradication of Viral Hepatitis in Asia Pacific (CEVHAP), working closely with a number of multisectoral organizations, including the Hepatology Association of the Philippines, the Yellow Warrior Society of the Philippines, ZeShan Foundation, the World Hepatitis Alliance and the WHO.
APASL 2019 President Diana Payawal said, “The forum provides a platform for experts from across the region and beyond to convene, discuss key barriers to elimination, share best practices and explore solutions for the future.”
The forum is well-timed as this month an important paper by the Lancet Commission on Elimination of Viral Hepatitis identified 20 heavily burdened countries that account for over 75 percent of the global burden of hepatitis; 11 of these 20 countries are in Asia. The paper identified several major challenges in Asia: mother-to-child transmission of hepatitis B, unsterilized injection practices and poor access to direct-acting antivirals despite availability of generics.
The impact of viral hepatitis in many countries in the Asia Pacific region is stark with just over 16 percent of people in the Philippines and over 10 percent of the population of China over the age of 20 living with hepatitis B.
Stigma and discrimination—key barriers to elimination
THE impact of viral hepatitis-related stigma and discrimination is significant as these issues reduce the willingness of people to access testing and the other health services they need. Stigma and discrimination means that people with viral hepatitis are sometimes ostracized or separated from their communities, and as a result, they experience reduced access to education, employment and health services. It also restricts the ability of researchers, advocates and media to draw attention to the true social context for people living with viral hepatitis, as only a limited number of people are willing to discuss their experiences in public. To increase the uptake of testing, vaccination and clinical management, we need to eliminate drivers of stigma, such as the testing of people within workplaces or educational settings and the lack of confidentiality of viral hepatitis test results.
“The development of regulations marginalizing people with viral hepatitis in Asia Pacific has been a pernicious development in seeking to reduce transmission of these infections,” said CEVHAP Executive Committee member Dr. Jack Wallace, who spoke at the forum on stigma, discrimination and human rights. “These regulations are found in employment settings where people with viral hepatitis are routinely excluded from employment and immigration processes in which people with viral hepatitis are excluded from receiving work visas in overseas countries. Another occurrence is when people are tested and diagnosed within educational settings or other locations in which testing is not of primary benefit to the person concerned.”
Prevention and access—the keys to real progress
ANOTHER major topic in terms of viral hepatitis elimination is prevention and access to testing and treatment. Eliminating viral hepatitis, a blood-borne asymptomatic infection, requires the implementation of hepatitis B vaccination programs and national policy on testing. The preventative nature of vaccination programs directly affects the burden resulting from infection. This has been proven in many countries across the world including China and Taiwan where there was a significant reduction in the numbers of children with hepatitis B as a result of the vaccination program. The development of national testing policies will support the early detection and diagnosis of viral hepatitis, which is vital in preventing cirrhosis or liver cancer. Testing must, in turn, be linked to support, care and treatment programs. This can often be done through the use of existing services and programs, such as those already established for maternal and child health, HIV prevention and control, and noncommunicable diseases.
Dr. Rosmawati Mohamed, consultant hepatologist at University of Malaya Medical Center and cochairman of CEVHAP, said “Providing accurate information about hepatitis to healthcare professionals, employers and the public is crucial. Raising awareness about hepatitis through campaigns that convey the benefits of early diagnosis, regular monitoring and dispel myths of hepatitis transmission is also significant. While the Ministry of Health in Malaysia has a done a great job by showing strong political will and providing access to affordable hepatitis treatment, engagement of all stakeholders including hepatitis advocates can help to support, strengthen and complement Ministry of Health’s efforts in combating hepatitis and liver cancer.”
Using his years of field experience in Pakistan, CEVHAP cochairman Professor Saeed Hamid, shared a case study with the forum demonstrating that the elimination of viral hepatitis requires the development of new clinical models of care. He stated that “New models are based on going deep into the community and delivering care at their doorstep, including testing and treatment. We should strive for point-of-care diagnostics to start treatment on the first visit.”
As a region, Asia Pacific has made steady progress towards the elimination of viral hepatitis. However, this progress is not at the rate or level required to meet the goal of elimination by 2030. It is time for every country to revisit its national policy and for advocates to push for legislation that criminalizes discrimination, promotes vaccination and ensures the linkage between testing and care.
About Viral Hepatitis
VIRAL hepatitis is inflammation of the liver caused by a virus, and globally kills more than 1.34 million people every year. Ninety six percent of these deaths are attributable to infection with the hepatitis B virus and/or the hepatitis C virus. Hepatitis B and hepatitis C can only be transmitted in specific circumstances where exposure to infected blood occurs. Hepatitis B transmission, an infection preventable by vaccination, occurs primarily through exposure from mother to child at birth, and hepatitis C through the sharing of unclean injecting equipment. The WHO has established a goal of reducing hepatitis-related mortality by 65 percent with a 90 percent reduction in new infections by 2030.
There are five different hepatitis viruses—hepatitis A, B, C, D and E. Hepatitis A is transmitted mainly through ingestion of contaminated food and water and there are an estimated 1.4 million cases each year. Hepatitis B is transmitted through contact with the blood or other bodily fluids of an infected person, most frequently from mother to child at birth, and approximately 240 million people are living with chronic infections. Hepatitis C is mainly transmitted through blood-to-blood contact such as unsafe injection practices and inadequate sterilization of medical equipment. Hepatitis D is transmitted on through contact with infected blood and only occurs in people who are already infected with hepatitis B. Hepatitis E, like hepatitis A, is transmitted through ingesting contaminated food or water.
For more information, please visit www.cevhap.org, or visit APASL Official Web site: www.apasl.info.