By Jenny Kowalczuk
The ambitious, draft WHO Global Health Sector Strategy on Viral Hepatitis 2016-21, was approved at the 69th World Health Assembly, in May 2016. A goal of the draft strategy is to eliminate viral hepatitis as a public health threat by 2030, and to contribute to the achievement of universal health coverage. The strategy therefore sets challenging targets for tackling hepatitis B and C by 2030. These targets include a 90 per cent reduction in new cases of chronic hepatitis B and C, a 65 per cent reduction in hepatitis B and C deaths, and a massive treatment goal of 80 per cent of eligible people with chronic hepatitis B and C infections.
NOhep, will be the global movement to eliminate viral hepatitis, and will be launched on WHD2016. It aims to bring people together and provide a platform for people to speak out, be engaged and take action to ensure global commitments are met and viral hepatitis is eliminated by 2030.
Given that less than one percent of all those currently infected with Hep C are receiving treatment, the goal of delivering treatment to 80 percent of all those infected by 2030 is extremely ambitious. Pharma seems willing to fully support increased access. If this is coupled with a strategy that addresses awareness building, prevention and testing, this treatment goal may be achievable but it certainly won’t be easy. It will demand high levels of patient awareness and health worker engagement to promote testing, so that those infected can be identified and treated. As well as the hard work of sustaining commitment and effort over 15 years, smart tactics will be needed to overcome the many unforeseen issues and obstacles that will threaten to derail the strategy.
India has already successfully tackled polio. South East Asia, the region encompassing India, was declared polio free in 2013. For a country with over one billion citizens, this achievement is significant. But India’s now faces another equally tough challenge, to contain another silent killer, hepatitis C. Although only a small proportion of India’s population are thought to be infected, this represents many millions of people in need of testing and treatment. In some areas, such as the Punjab, incidence is much higher than the national average. Poor blood banking systems, lack of adherence to blood transfusion standards and the reuse of unsterilized needles and surgical instruments, as well as intravenous drug users sharing needles, have all contributed to an emerging public health problem of epic proportions.
Hepatitis C has much in common with polio. Invisible and deadly for the majority of those infected, hepatitis C only makes its presence felt after wreaking havoc in the liver for decades. Although hepatitis C is bloodborne, and not waterborne like polio, there are similarities. Like polio the vast majority of cases go undetected with early symptoms easily mistaken for other less serious issues. Like polio, it is highly infectious and transmitted through contact with infected blood. Infection often happens from seemingly uneventful events such as contact with dirty razors in barber’s shops or needles used for tattoos, as well as medical sharps including needles. Like polio, without testing, infection from hepatitis C easily goes unnoticed. The consequences of hepatitis C infection are debilitating and deadly. Those infected suffer liver diseases including cirrhosis, liver cancer and liver failure, years after first infection.
Given these similarities and the scale ambition of WHO’s 2030 hepatitis goals, the long path towards polio eradication, now on the home stretch, offers hard won insight that the global NOhep campaign can put to good use. Polio eradication was first committed to in 1988. Now, with over 30 years experience built on the investment of many millions of Rotary and donor dollars, the efforts of the Global Polio Eradication Initiative (GPEI) offer deep and wide learning those aiming to end the scourge of hepatitis can benefit from.
- Prepare for the unexpected
Despite rapid reduction in the number of endemic countries and immediate reductions in the incidence of polio throughout the world, GPEI hit problems that prevented it from reaching its goal several times over. Wars and natural disasters, as well as social and cultural resistance in some of the hardest to reach geographies in the world, disrupted immunisation efforts and led to the virus spreading, reintroducing polio to countries that had successfully stopped its circulation. Polio eradication was set back time and time again. Creative social and technological solutions were slow coming, but when they did they gave access to pockets of infection some never thought could be reached. Inspired use of satellite technology, already used to track the movement of cattle for UN environment and food agencies, allowed immunisation teams to reach nomadic people in the Sahel. Opportunistic tactics were also deployed to reach those prevented from receiving immunisation by religious belief, war or displacement. Immunisation stations at border posts between India, Pakistan and Afghanistan helped deliver immunisation to children on the move, where official door to door health workers could not.
There is well-placed confidence in the range of preventive measures including immunisation, widespread testing and effective treatments for hepatitis B and C but there may be twists and turns in the journey towards containment and eventual eradication we cannot yet know. The world is an unpredictable place, conflict and social upheaval are blighting all continents. We should not expect an easy ride or assume that existing health system structures will always function, improve and grow. Any global strategy must have the flexibility and creativity to seize opportunities as and when they present. This flexibility to respond to positive as well as negative change, depends on leaders with the confidence to read the signs and change direction without hesitating. Working around unexpected challenges and capitalising on opportunity, will be as important as ongoing work of well planned steps towards the 2030 goal.
- Build strong, independent governance around delivery to keep the strategy on track
The polio global eradication goals of 2000, 2005 and 2012 were all missed. Clearly doing things the same way as they’d been done before wasn’t getting the traction needed to eliminate the virus and prevent its reintroduction. After the final missed goal, a new strategy with new operational tactics was needed if more than 25 years work towards polio eradication was to finally pay off.
The Independent Monitoring Board (IMB) set up in 2000 by the WHO, was given oversight of the work of the GPEI. The scrutiny and expertise of the IMB breathed new life into a global effort dogged by missed targets and entrenched operational issues. With their support and clarity, a new plan of action was developed that addressed both wild and vaccine-derived polio viruses and integrated IPV, the inactivated vaccine, into an endgame strategy. The IMB demanded not just activity, — previously been passed off as progress — but for every dollar spent, tactical results in line with its strategy that progressed the GPEI ever closer to their goal.
The IMB members were also prepared to ask the difficult questions and make unreasonable demands for change that those delivering the programme could not. For those delivering the hepatitis strategy, the support of an independent advisory or oversight board should be welcomed. Allowing independent and experienced experts and leaders to steer from the outset, will give the strategy a high level perspective that those engaged with delivery can never have.
- Leave a legacy greater than the goal itself
In 2012 when the previous deadline for polio eradication was approaching, the absence of transition planning caused widespread apprehension. Many were concerned that the surveillance network would be left without funding or dismantled as the case had not been formally made to support the networks and assets built up through polio eradication. The transition to a polio free world set out in the GPEI Endgame Strategy includes plans for delivering wider health and health system benefits from strategy development, delivery, process and technology of polio eradication. Legacy planning includes strengthening surveillance and immunisation systems so that new and existing vaccines can be delivered where they are needed. It plans for the transfer of technology, skills and knowledge that have been gained over the course of the polio eradication program. These and other planned benefits will ensure that the massive investment made in polio eradication will be put to use for other global health projects and that the experience and knowledge gained will be shared.
Delivering the goal to eliminate viral hepatitis as a public health threat by 2030 will expose many substantial and significant gaps in surveillance, knowledge, technology, expertise and services across the globe, and not always where they are expected. All of these shortfalls will need to be overcome If the 80 percent treatment goal for hepatitis C is to be reached. Concrete and sustainable plans to leaving the skills, structures and technology in place after 2030 will sustain investment through a period of low economic growth and shrinking donor aid budgets. Planning now for a strong legacy will pay dividends in health service delivery as increasing freedom from the burden of hepatitis is realised.