Hepatitis at a national level: government perspectives

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1 Hepatitis at a national level: government perspectives Presenter: Dr Shin Young-Soo Regional Director WHO Western Pacific

2 Panel The Honourable Dr. David Sergeenko Minister of Health, Labour and Social Affairs. Republic of Georgia The Honourable Omar Sey Minister of Health The Gambia Professor Imam Waked Professor of Medicine at the National Liver Institute Cairo, Egypt and Representing the Minister of Health and Population of Egypt Dr. Henry Mwebesah Director of Health Services Ministry of Health Uganda and Representing the Minister of Health, Uganda Ms. Laurence Caté Head of the HIV, STI s and Hepatitis Office, Ministry of Social Affairs, Health and Women s Rights, France Dr. Neeraj Dhingra Deputy Director General, Department of AIDs control, Ministry of Health and Family Welfare, India Professor John Watson Deputy Chief Medical Officer for England, Department of Health, United Kingdom Dr. Yanhong GUO Deputy Director, Bureau of Medical Administration, National Health and Family Planning Commission, China Mr. LU Ming Consult Director, Expanded Programme on Immunization Division, Bureau of Disease Control and Prevention, National Health and Family Planning Commission, China

3 Progress Towards Hepatitis C Elimination in Georgia Dr. David Sergeenko Minister of Labour, Health and Social Affairs of Georgia

4 Disease Burden Prevalence among general population 6.7% (Tbilisi populationbased survey, ) Prevalence among different population groups: IDUs: 50-92% (various studies ) TB Patients: 21% (Lomtadze et al, 2013) MSM: 17.3% (BSS in Tbilisi, 2010) HCV Genotypes in Georgia Genotyp General pop* IDU (2012)** HIV Co-infected*** e HCV 1 43% 22% 42% HCV 3 37% 66% 35% HCV 2 20% 20% 18% Source: * Georgian Infectious Diseases, AIDS and Clinical Immunology Research Center data for ; **Bouscaillou, J., et al. (2014). : Int J Drug Policy; ***Karchava, et al: Georgia Medical News: 2009 Dec; (177): 51-55

5 Recent progress against HCV in Georgia 60% Discount program for civilians is started Negotiations with the US partners and Gilead: possible HCV elimination 1 st National workshop 1 st phase of elimination program is launched State Program - Free of Charge Hep C treatment for prisoners 2 nd National workshop Free of Charge Hep C treatment started for HIV/HCV co-infected patients with Peg/Riba by GF National Commission Development of longterm elimination plan for Government negotiated for additional 10,000 treatments with price reduction for civil population HCV elimination perspectives were discussed during the annual meeting of the EASL in London Memorandum of Understanding between Georgian Government and Gilead, April 21

6 Current Major Activities Population-based survey for the prevalence of HCV infection, National Program Phase I of Elimination Program (April Ongoing) Completed Long-term national plan on HCV elimination ( ) In Progress

7 Population-based Seroprevalence Study of Hepatitis B and C in Georgia Primary objective: Estimate the prevalence of hepatitis C and B in general population, by age group/region/district. Secondary objective Assess the risk factors for transmission Describe the circulating genotypes Assess the knowledge and perception

8 92.5%/92.5% Coverage by regions, Interview/blood sample Zemo Svaneti 93.6%/90.4% 93.3%/88% 95.5%/93.5% 96%/91.6% 95%/92% 87.8%/89.3% Total Interview (90.7%) Blood (86.3%) Refusal - 5.7%

9 2015 National Program for Shortterm/urgent Measures (Phase I) of Hepatitis C Elimination Action Plan Goal Reduce HCV-related morbidity, mortality and prevalence by gradually providing accessibility to prevention, diagnostics and introduction of new antiviral drug (Sofosbuvir/Harvoni) for treatment of the disease

10 1 st Phase of elimination program Preliminary results (1) Treatment of Approximately 5000 patients with F3 and F4 is planned As of August 27, patients registered in the program and 3022 already started treatment with Sofosbuvir. 12 service provider clinics are operating in 6 cities of Georgia 1343 patients (44%) are on 12-week regimen with Interferon, Sofosbuvir and Ribavirin, 806 patients (27%) are on 24-week regimen with Sofosbuvir and Ribavirin

11 1 st Phase of elimination program Preliminary results (2) According to the data from two clinics with the highest number of patients, among 979 patients who completed 1 month of treatment, concentration of virus dropped to 0 unit in 80.3% and dropped to <25 in additional 14%. Among 125 patients who completed the 12-week regimen and the results of monitoring are available, concentration of virus dropped to 0 in 122 patients (98%).

12 Hepatitis C Elimination Strategy and Action Plan, Goal Elimination of HCV by ensuring prevention, diagnostics and treatment of the disease

13 4 Strategic Priority Areas 1. Partnership, resource mobilization and communication 2. Evidence-based policy 3. Prevention of transmission 4. Screening, Care and Treatment

14 TARGETS By % of people living with HCV are diagnosed 95% of those diagnosed are linked to HCV care 95% of those linked to HCV care are treated 95% of those treated are cured

15 Targeted Cascade of HCV Care 100% 80% 100% 95% 90% 86% 81% 60% 40% 20% 0% 95% 95% 95% 95% HCV Infected Diagnosed Linked to care Treated Cured

16 Identification of People Living with HCV Universal HCV Screening (difficult to achieve) OR Targeted HCV Screening among: People who inject drugs (PWID) Men who have sex with men (MSM) Sex workers (SW) HIV/AIDS patients TB patients STI patients Patients on hemodialysis Patients with hemophilia Patients with onco-hematologic disorders Blood donors Pregnant women Healthcare workers Law enforcement personnel Prisoners Students Several mass screening campaigns have already been conducted during past 3 months and more than 12 thousand people in the whole country received free HCV screening. During 2015 free HCV screening of 70 thousand people is planned.

17 Acknowledgements US CDC CDC South Caucasus Office Gilead WHO HQ & WHO Euro

18 Thank you

19 World Hepatitis Summit Prevention of HBV infection and chronic carriage in The Gambia Hon. Omar Sey Minister of Health and Social Welfare

20 Situational Analysis Presentation Format Hep B vaccination schedule The Gambia Hepatitis Intervention Study (GHIS) strategy Discussions/Comments

21 Situational Analysis Total Population: 1,782,764 Birth Cohort (newborns/yr): 86,308 Surviving Infants: (34/1000 IMR) 79,921 WCBA: 192,720 HepB Birth Dose Coverage (2014): 98% Penta3 Coverage 2014: 96%

22 Hep B vaccination Schedule in The Gambia: Hepatitis B given as a Four dose series Hep B Mono given at birth/soon after Penta 1 given at 2 months Penta 2 given at 3 months Penta 3 given at 4 months

23 GHIS strategy: the prevention of primary liver cancer through HBV vaccination at infancy Infection and CC? Chronic hepatitis CANCER Phase 1 Phase 2 Phase 3 HepB Vaccination Evaluation (short term) Evaluation (long- term) ? Cancer Registration Case identification Record linkage

24 PHASE 1 GHIS design: a stepped wedge design for introducing HepB into EPI Vaccination team No Usual EPI vaccines Usual EPI Vaccines + HB vaccine Time (years) Since start of program Start of HB Vaccination program Countrywide coverage

25 The Gambia : Most common cancers in men Site(ICD-10) CIR % ASIR Liver Lung Prostate Stomach Lymphoma ALL CANCERS

26 The Gambia: Most common cancers in women Site(ICD-10) CIR % ASIR Cervix Liver Breast Ovary Lymphoma ALL CANCERS

27 PHASE 2 Vaccine Efficacy (VE) against infection and chronic carriage

28 Phase 3: Long-term follow-up Initially estimated to last for slightly over 35 years on the basis of several assumptions (Cancer Res, 47:5782, 1987) Includes three core components: 1. Nationwide cancer registration 2. Active surveillance for cases of HCC and cirrhosis and other types of liver diseases 3. Extensive efforts to determine if cases belong to the GHIS cohort for final evaluation of the project Whether complete population enumeration, sample surveys, or a case-control approach is to be adopted this now needs careful review by all stakeholders.

29 : Cross-sectional survey 40 villages from Central River Region selected at random All children born since introduction of HBV vaccination (1990) screened for HBsAg Blood samples taken from carriers and carriers mothers ( for further serology to mainly monitor perinatal transmission)

30 Prevalence of HBV chronic carriage: Status Number Percentage HBsAg HBsAg- 4, Total 4,

31 Comments on the survey: Decline over time in HBsAg positivity is significant and encouraging Perinatal transmission does not appear to be important, unlike elsewhere in Asia Is The Gambian EPI eradicating HBV?

32 Effect of vaccination on HBV infection and chronic carriage before age 15 (adapted from published studies, before and after the GHIS strategy)

33 Global impact of the GHIS Partnership (MoH&SW, MRC and IARC-WHO) Tremendous improvement of the Gambian EPI with >90% coverage for HepB and DTP-OPV vaccines Improvement of the country clinical diagnostic capacity (Initiation of histopathology service, introduction of U/S service) Model for other African and non- African countries for the introduction of new efficacious vaccines Opportunities and support for research projects on aetiology, molecular pathology and treatment of chronic hepatitis, cirrhosis and of HCC (e.g. PROLIFICA project on investigation of treatment modalities against chronic hepatitis B in adults in the prevention of liver fibrosis and cirrhosis in The Gambia and elsewhere in West Africa) Potential new relations ( e.g. Partnership for aflatoxin control in Africa (PACA) of the AU (AFLATOXIN STUDY).

34 Thank You

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