Africa: The War Against Hepatitis B And Coronavirus-2

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Viral hepatitis affects adults, adolescents and children in this region and also occurs as a co-infection in people with non-communicable and communicable diseases. Among people living with HIV, globally 4 million people have HIV-hepatitis co-infection. Undetected and untreated, these patients are also at risk for liver disease undermining the gains of the HIV response.

In Africa, HBV is predominantly transmitted in the perinatal and childhood period and from mother to child; whilst unsafe injection practices both in health facilities and community account for the majority of hepatitis C infection. Intravenous drug use is an emerging concern for HCV transmission in Africa.

According to the most recent estimates of the Global Burden of Disease, (2) viral hepatitis was responsible for approximately 1.5 million deaths in 2015. Every day, more than 3,600 people die of viral hepatitis-related liver disease, liver failure and liver cancer. The death rate from hepatitis B and C have increased by 22% in 2015 from the baseline in 2000.

The available evidence suggests that over two million Africans with chronic HBV and HCV may develop progressive liver disease in the next few decades if no intervention is deployed. Viral hepatitis mortality is becoming a bigger global threat than death from HIV/AIDS (1.3 million), malaria and tuberculosis (TB) [0.9 million and 1.3 million, respectively].

It is clear that viral hepatitis has become an emergency. The availability of highly effective generic antiviral therapy for hepatitis B that cost $30 a year and the rapidly declining cost of generic curative HCV medication make universal access to viral hepatitis screening and treatment feasible.

The benefits of hepatitis elimination beyond health outcomes include averted medical costs and reduced time spent in sickness. These savings accrue to improvement in education, economic growth and in accelerating poverty reduction in families’ communities and nations.

A coordinated public health response in Africa is needed. Government leadership and community collaboration are pivotal to providing an enabling environment for collaboration and partnership in addition to mobilising funding, training and the successful implementation of a country-specific hepatitis response.

The African Response to the Global Health Sector Strategy for Viral Hepatitis and
The WHO Global Health Sector Strategy (GHSS) for viral hepatitis elimination was endorsed by the WHO Member States during the 2016 World Health Assembly (WHA 69.22).

The strategy set ambitious targets for elimination of viral hepatitis as a public health threat by 2030 and promotes universal access to hepatitis preventive, screening and treatment services. It also promotes synergies between viral hepatitis and other health issues and positions the viral hepatitis response within the context of universal health coverage.

The African Regional Framework for hepatitis Prevention, Care and Treatment (2016-2020), guides the WHO Member States to implement the Global Health Sector Strategy on viral hepatitis (2016-2021) and proposes priority actions such as developing evidence-based and costed national plans, strengthening hepatitis prevention and developing strong and funded hepatitis screening and treatment programmes.  The national hepatitis response should be guided by a national plan with a clearly defined governance and management structure that can ensure a coordinated and efficient response and clear accountability.

In the Africa region, the hepatitis response is lagging behind other all other regions. The scorecard summarises some of the progress made in implementing the core priorities for Africa. Currently, 27 countries have developed a national action plan for viral hepatitis, but only 13 countries (30%) have officially endorsed and launched it. Strong progress has been made in hepatitis prevention, but coverage of timely hepatitis B birth dose is only 10%. As shown in the scorecard only 11 countries have established timely hepatitis birth dose for the control of perinatal and mother-to-child infection (see #1 in the scorecard).

Screening and treatment programme to identify the 71 million Africans with chronic infection are vital to reduce the morbidity and mortality of viral hepatitis and reaching the WHO impact targets. Of the 30 highest-burden countries, only eight have established screening and treatment programmes most of which are small scale implementation projects in specialist centres.

Despite the availability of highly effective generic antiviral therapy for hepatitis B and C, only three countries are implementing a government-led public health approach and making significant progress towards the GHSS 2020 and 2030 target. Some of the significant barriers to mounting an effective African response to viral hepatitis include poor community and political awareness, inadequate data for decision making and advocacy, limited access to affordable diagnostics and drugs and inadequate financing and lack of trained health workforce.

This scorecard takes a closer look at the progress of countries in Africa towards these targets.

Since 2015, the WHO Regional Office for Africa has also contributed to advancing the regional hepatitis response with the ultimate goal to save the lives of 6 million people living with viral hepatitis in the region by 2030. Some of the achievements to date include providing support tailored to the needs of individual countries and includes promoting the development of evidence-based national action plans aligned to country characteristics, development of normative guidance and treatment guidelines and coordinating hepatitis surveillance and data to facilitate regional and global hepatitis reporting.

WHO is also promotes regional awareness by supporting national commemorations of World Hepatitis Day (July 28), capacity building and high-level meetings such as the African Hepatitis Summit.

In addition, there is a dearth of information on the burden and patterns of the disease. This is despite a 2014 World Health Assembly resolution that urged member states to develop and implement coordinated multi-sectoral national strategies for the prevention, diagnosis and treatment of viral hepatitis based on local epidemiological context.

These were to be supported by targeted health promotion and prevention actions and appropriate and effective viral hepatitis surveillance systems. The absence of evidence-based policy actions continues to limit the establishment of effective responses.

For example, women continue to present at maternity centres for the delivery without ever having been screened for hepatitis B. The worry is that some are symptomatic, as a recent study from Uganda showed.

The hepatitis B vaccine has been available since 1982 and immunization is an effective strategy. But poor uptake and coverage in the region persist. This is despite various strategies to ensure full vaccination coverage.

Global vaccination coverage – the proportion of the world’s children who receive recommended vaccines – has remained the same over the past few years.

During 2019, about 85% of infants worldwide (116 million infants) received three doses of diphtheria-tetanus-pertussis (DTP3) vaccine, protecting them against infectious diseases that can cause serious illness and disability or be fatal. By 2019, 125 Member States had reached at least 90% coverage of DTP3 vaccine.

 A summary of global vaccination coverage in 2019 follows.

Haemophilus influenzae type b (Hib) causes meningitis and pneumonia. Hib vaccine had been introduced in 192 member states by the end of 2019. Global coverage with 3 doses of Hib vaccine is estimated at 72%. There is great variation between regions. The WHO Region of South-East Asia is estimated to have 89% coverage, while it is only 24% in the WHO Western Pacific Region.

Hepatitis B vaccine for infants had been introduced nationwide in 189 member states by the end of 2019. Global coverage with three doses of hepatitis B vaccine is estimated at 85%. In addition, 109 Member States introduced one dose of hepatitis B vaccine to newborns within the first 24 hours of life. Global coverage is 43% and is as high as 84% in the WHO Western Pacific Region, while it is only estimated to be at 6% in the WHO African region

Human papillomavirus (HPV) is the most common viral infection of the reproductive tract and can cause cervical cancer in women, other types of cancer, and genital warts in both men and women. The HPV vaccine was introduced in 106 member states by the end of 2019, including three countries with an introduction in some parts of the country.

This is the strongest year on year increase in HPV introductions (+15%) since the HPV vaccine came to market in 2006.  However, since many large countries have not yet introduced the vaccine and vaccine coverage is suboptimal in many – global coverage with the final dose of HPV currently is estimated at 15%.

Nearly a third of these member states (33) have also started to vaccinate boys.

Meningitis A is an infection that is often deadly and leaves one in five affected individuals with long-term devastating sequelae. Before the introduction of MenAfriVac in 2010 – a revolutionary vaccine developed in collaboration with Serum Institute of India through the WHO and PATH Meningitis Vaccine Project – meningitis serogroup A accounted for 80–85% of meningitis epidemics in the African meningitis belt.

In 2012, MenAfriVac became the first vaccine to gain approval for use outside the cold chain during campaigns – for as long as four days without refrigeration and at temperatures of up to 40°C. By the end of 2019 almost 350 million people in 24 out of the 26 countries in the meningitis belt had been vaccinated with MenAfriVac through campaigns.

To sustain the dramatic effect of these campaigns, Ghana and Sudan were the first two countries to include the MenAfriVac in their routine immunization schedule in 2016, followed by Burkina Faso, Central African Republic, Chad, Mali and Niger in 2017, Côte d’Ivoire in 2018 and Gambia and Nigeria in 2019.

Measles is a highly contagious disease caused by a virus, which usually results in a high fever and rash, and can lead to blindness, encephalitis or death. By the end of 2019, 85% of children had received one dose of measles-containing vaccine by their second birthday, and 178 member states had included a second dose as part of routine immunisation and 71% of children received two doses of measles vaccine according to national immunisation schedules.

Mumps is a highly contagious virus that causes painful swelling at the side of the face under the ears (the parotid glands), fever, headache and muscle aches. It can lead to viral meningitis. Mumps vaccine had been introduced nationwide in 122 member states by the end of 2019.

Pneumococcal diseases include pneumonia, meningitis and febrile bacteraemia, as well as otitis media, sinusitis and bronchitis. The pneumococcal vaccine had been introduced in 149 member states by the end of 2019, including three in some parts of the country, and global third dose coverage was estimated at 48%.

Polio is a highly infectious viral disease that can cause irreversible paralysis. In 2019, 86% of infants around the world received three doses of polio vaccine. In  2019, the coverage of infants receiving their first dose of IPV in countries that are still using OPV is estimated at 82%.

Targeted for global eradication, polio has been stopped in all countries except for Afghanistan and Pakistan. Until poliovirus transmission is interrupted in these countries, all countries remain at risk of importation of polio, especially vulnerable countries with weak public health and immunisation services and travel or trade links to endemic countries.

Rotaviruses are the most common cause of severe diarrhoeal disease in young children throughout the world. Rotavirus vaccine was introduced in 108 countries by the end of 2019, including three in some parts of the country. Global coverage was estimated at 39%.

Rubella is a viral disease which is usually mild in children, but infection during early pregnancy may cause fetal death or congenital rubella syndrome, which can lead to defects of the brain, heart, eyes, and ears. Rubella vaccine was introduced nationwide in 173 member states by the end of 2019, and global coverage was estimated at 71%.

Tetanus is caused by a bacterium which grows in the absence of oxygen, for example in dirty wounds or the umbilical cord if it is not kept clean. The spores of C. tetani are present in the environment irrespective of geographical location. It produces a toxin which can cause serious complications or death. Maternal and neonatal tetanus persist as public health problems in 12 countries, mainly in Africa and Asia.

Yellow fever is an acute viral haemorrhagic disease transmitted by infected mosquitoes. As of 2019, yellow fever vaccine had been introduced in routine infant immunization programmes in 36 of the 40 countries and territories at risk for yellow fever in Africa and the Americas. In these 40 countries and territories, coverage is estimated at 46%.

In 2019 14 million infants did not receive an initial dose of DTP vaccine pointing to lack of access to an immunization and other health services and an additional 5.7 million are partially vaccinated. Of the  19.7 million more than 60% these children live in 10 countries: Angola, Brazil, the Democratic Republic of the Congo, Ethiopia, India, Indonesia, Mexico, Nigeria, Pakistan and the Philippines.

Monitoring data at subnational levels is critical to helping countries prioritize and tailor vaccination strategies and operational plans to address immunization gaps and reach every person with life-saving vaccines.

 WHO is working with countries and partners to improve global vaccination coverage, including through these initiatives adopted by the World Health Assembly in May 2012.

IA2030 sets an ambitious, overarching global vision and strategy for vaccines and immunization for the decade 2021–2030. It was co-created with thousands of contributions from countries and organizations around the world, and will come into effect by the end of 2020 after WHA endorsement. It draws on lessons from the past decade and acknowledges continuing and new challenges posed by infectious diseases (e.g. Ebola, COVID-19).

 Through collective endeavour, countries and partners will achieve the vision for the decade: A world where everyone, everywhere, at every age, fully benefits from vaccines for good health and well-being.

 The strategy intends to inspire and align the activities of community, national, regional and global stakeholders. IA2030 will become operational during 2020-21 through regional and national strategies, a mechanism under development to ensure ownership and accountability and a monitoring and evaluation framework to guide country implementation.

(https://www.who.int/immunization/immunization_agenda_2030/en/)

In 2020 will WHA adopt the global strategy towards eliminating cervical cancer.  In this strategy, the first of the three pillars requires the introduction of the HPV vaccine in all countries and has set a target of reaching 90% coverage.  With introduction currently in 55% of Member states and average HPV vaccination coverage at only 54%, in the next 10 years, large investments towards introduction in low and middle-income countries will be required as well as programme improvements to reach the 90% coverage targets in low and high-income settings alike will be required to reach the 2030 targets.

 The hepatitis B vaccine coverage in Sub-Saharan Africa is estimated to be at six percent compared to the global coverage of 43%. And the immunization schedules in this region remain a challenge since it’s often difficult to get babies vaccinated within the first hours or days after birth.

These challenges are further compounded by weak health systems with limited healthcare budgets that make diagnostics and treatment unavailable to the wider population. All these challenges have been further expanded by the COVID-19 pandemic.

Closing the gaps

In the journey to a hepatitis free future, several actions are needed.

There needs to be more deliberate action to screen all pregnant women. More targeted efforts need to be implemented to reach women, especially those in marginalized and far-flung areas, to ensure that they get antenatal care.

Governments also need to allocate resources for epidemiological studies to inform country-level control strategies.

And there’s an urgent need to increase uptake and coverage of both new and old vaccines. For example, estimates show that between 2021 and 2035, Nigeria could prevent between 0.3 and 1.2 million deaths if sufficient investments were made for the inclusion of the hepatitis B vaccine as part of the birth dose round of immunisations.

Innovations to ensure continuity of care including access to vaccine services are needed. These could involve the use of technology and mobile clinics.

Taking lessons from the HIV/AIDS control measures is invaluable. Co-opting hepatitis B into the HIV/AIDS prevention and treatment messages would also help register quick gains as the viruses have similar routes of transmission.

Success in attaining a hepatitis B free future also requires strengthened partnerships between the WHO, governments and funding agencies.

The additional recent WHO recommendations, informed by additional evidence on the safety and efficacy of tenofovir (an antiviral drug), is increasing its use.

All pregnant women who test positive for hepatitis B infection and have a high viral load can be given preventive treatment with tenofovir from the 28th week of pregnancy. The other change is that, in contexts where hepatitis B viral load testing is not available, HBeAg, a low-cost test, can be used to determine eligibility for preventive antiviral treatment.

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