For Vietnam, where 15-17% of the population have hepatitis B or C, the global health burden has been heavy. Photograph: Hemis/Alamy
For health ministries trying to tackle hepatitis, the advice is: know your epidemic, get government on board to find a solution, educate the population and have the right policy in place
Guardian Professional, Sunday 28 July 2013 03.00 EDT
Viral hepatitis causes 1 million deaths a year in the Asia Pacific region, the equivalent of one death every 30 seconds and more than three times as many as HIV. Of the 350 million people in the world living with hepatitis B, 74% of them live in Asia, but getting the disease on the health policy agenda of some of the worst affected countries has not been easy.
"We have a vaccine for hepatitis B and new treatments for chronic hepatitis C that could save millions of lives, but none of these matter if governments fail to tackle viral hepatitis," says professor Stephen Locarnini, director of the WHO Regional Reference Laboratory for Hepatitis B at the Victorian Infectious Diseases Reference Laboratory in Melbourne and joint secretary of the Coalition to Eradicate Viral Hepatitis in Asia Pacific (Cevhap).
"What we need is for governments across the region to approach viral hepatitis in the same way that most have HIV/Aids, TB and malaria. This starts with the development of a national action plan and our expert members are ready and willing to help governments in the development of these, following the framework for global action blueprint provided by WHO."
Dr Robert Gish, Cvevhap's co-founder has been doing just that with the government in Vietnam, where an estimated 15-17% of the country's 100 million people have hepatitis B or C. "It's clear that the country needs a policy for liver health," he said.
Gish, together with colleagues in Vietnam and from UN and other international agencies has been working to get hepatitis and liver health on the Vietnamese government's health agenda.
A white paper published in 2011 in the Journal of Gastroenterology and Hepatology spelt out the rationale for a dedicated policy for liver health in Vietnam: 12% estimated prevalence of chronic hepatitis B, at least 2% prevalence of chronic hepatitis C and heavy alcohol use by men, adding up to liver cancer as the most common cause of cancer death in the country. Despite the sizeable liver cancer wards in all of Vietnam's major hospitals, a general lack of understanding of liver disease both among the public and health professionals and no systematic screening for those at risk has left the epidemic unchecked.
The white paper advocated liver disease education for the public and healthcare workers and an expansion of countrywide screening, hepatitis B vaccination and treatment of chronic hepatitis. These measures coupled with long-term surveillance for liver cancer, enhanced infection control to prevent transmission in health care settings and ongoing prevalence data analysis can help bring the epidemic of liver disease under control.
The message fell on fertile ground: in December 2012 the ministry of health set up a technical action group and by the end of this year is likely to have a draft policy in place.
Vietnam currently vaccinates approximately 60% of babies within 24 hours of birth and, says Gish, has the rural healthcare system in place to reach the WHO's revised target of 90% coverage (up from 80%).
Vaccination for adults is far less widespread but Gish and his colleagues are currently running pilot projects to test and vaccinate 20,000 adults, recruited from medical, dental pharmacology and nursing schools. "They are easy to reach and can carry the message forward to their patients, but they can only do so effectively if they themselves have been tested and vaccinated," says Gish.
But progress is stunted in parts of Asia, such as the Philippines, where hepatitis is accompanied by discrimination. Prevalence estimates range from 8% to 20% across different segments of the 96 million population and the stigma attached to hepatitis B is severe. Pre-employment tests for the disease screen out those who test positive. Overseas workers from the Philippines face similar discrimination notably in Middle Eastern countries. People with hepatitis are blatantly discriminated against," says Gish. "Workplace discrimination is a huge problem that deters people from getting voluntarily tested."
Gish has also been working with the Hepatology Society of the Philippines, which is leading the effort in the country, and also with hepatitis activist group Yellow Warriors Society Philippines to get hepatitis on the health policy agenda but, he says the contrast with Vietnam at government level has been "like night and day. The department of health has sat on a draft hepatitis policy for three years, so we're trying to revitalise a lot of activity. In Vietnam we were starting from scratch, but now the Vietnamese ministry of health is moving forward quite aggressively on its own."
Having become interested in hepatitis in Asia when treating Asian patients in his practice in San Francisco, Gish decided he could make a bigger impact on the disease by supporting colleagues to get it more widely recognised in Asia. His interest has spread to central Asia, another hepatitis hotspot, with a regional project underway in Armenia.
"Every country I've worked with has different customs and problems, but what they have in common is a need to know their hepatitis epidemic, get government on board to find a solution, educate the population and have the right policy in place."