Asia and Pacific Alliance to Eliminate Viral Hepatitis

The Burden of Disease 

China has the greatest burden of chronic HBV infection and liver cancer in the world.  As of 2006, an estimated 93 million Chinese (7.3% of China’s population) live with chronic HBV infection. In addition, more than 40% of the worldwide deaths associated with HBV infection occur in China.  Based on World Health Organization (WHO) estimates from 2006, liver cancer and liver disease caused by acute and chronic HBV infection account for 263,000-300,000 deaths in China each year—a burden that exceeds the combined mortality from tuberculosis (200,000), HIV/AIDS (38,000), and malaria.  The chronic infection, if not properly monitored, can lead to death due to liver damage or cancer in one out of four patients.  Moreover, chronic infection persists, leading to the transmission of disease from generation to generation if left without intervention.

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2006-2008: Private-Public Partnership in Qinghai: The Largest Free Hep B Catch-up Vaccination and Education Program in China

Home to a large population of ethnic minorities of low socioeconomic status, Qinghai province is a remote, often neglected rural region of China with a high prevalence of chronic hepatitis B.  Since many children 5 years of age and older in Qinghai were not vaccinated against the hepatitis B virus, a private-public partnership was formed between the ZeShan Foundation, the Ping and Amy Chao Foundation, the Asian Liver Center at Stanford University, the China Center for Disease Control and Prevention, the Chinese Foundation for Hepatitis Prevention and Control, and the Qinghai government.  Using the existing provincial China CDC structure, this private-public partnership in Qinghai resulted in a unique two-part school-based immunization program to educate and provide free hep-B vaccination for all children in kindergarten and grade school within the region.

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Between 2006 and 2008, this program demonstrated the feasibility and successful implementation of:

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1. A province-wide catch-up vaccination program that reached 600,000 children in 2,200 schools with a 99.4% 3-shot completion rate, and
    

2. A hepatitis B education program incorporated into the school curriculum.

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Site Visit

At the request of the World Health Organization, the Asian Liver Center at Stanford University and the Asia and Pacific Alliance to Eliminate Viral Hepatitis (APAVH) were invited to work with the Ministry of Health in Laos to improve and reach the WHO hepatitis B goals by 2012. 

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In February 2010, the Asian Liver Center conducted an informal site visit to Lao People’s Democratic Republic (Lao PDR) to assess the progress of hepatitis B control activities in Laos, with focus on timely birth dose and routine immunization coverage.  The Asian Liver Center was invited by the World Health Organization Western Pacific Regional Office to assist the Laotian government in reaching the WHO hepatitis B goals that it was currently not on track to meet.  A WPRO representative joined the Asian Liver Center team during the site visit.

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The timely birth dose coverage and third dose coverage of hepatitis B vaccine in 2009 was 21% and 67% respectively.  Due to the special service delivery strategy using four annual special outreach rounds to deliver vaccines, it is very difficult to achieve not only high enough coverage but also timely administration of the vaccines as per the recommended schedule required for effective control of vaccine-preventable diseases.  The percentage of children who received three doses of pentavalent vaccine by 3 months of age is only 20%.  In addition, the funding for the birth dose of hepatitis B vaccine is not secure beyond 2010.  Unless and until Laos changes its service delivery strategy, it will be very difficult for it to achieve the regional goal of hepatitis B control.  The field visits to health facilities showed poor injection safety practices, with use of safety boxes for collection of used syringes and needles limited to EPI injections which account for only 5-10% of total injections.  However, a national policy on health care waste disposal does not appear to exist.  The poor injection safety will continue to contribute to high incidence of hepatitis B and C.

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After meeting with many government officials and hospital and clinic staff and conducting site visits to both the main city and provincial hospitals and clinics, our team put together a presentation of recommendations that we shared with the Ministry of Health.  Our recommendations included:

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1. New Educational Materials – Current educational materials may not be widely understood due to low literacy rates.  Posters do not clearly inform women when and where to get immunizations.  There is a vital need for educational materials to be more colorful, attention-grabbing.  Currently, immunization cards do not have a space for next visit date.
    

2. Additional notable findings included the fact that current rural campaigns are not appropriately targeting the Laotian population – many campaigns are too text heavy and many rural populations have very low literacy levels; sharps disposal and health center hygiene need major improvement; and health workers need some sort of identification.

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Current Project

The Asian Liver Center recently developed 2,000 educational banners that will arrive in Laos on April 23th to be used as part of the World Immunization Week awareness activities.  Since over 80% of births occur outside hospitals or healthcare facilities and often by untrained attendants, the banners will be used throughout the country in villages and health centers that serve 10-12 villages.  The goal is to improve awareness of the timing and benefits of infant immunization.

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Potential Future Projects

 

We are considering implementing a cell phone/text messaging campaign and continuing to improve health infrastructure support. However, much can be done concurrently to improve the health system, including training healthcare workers, such as birth attendants, and exploring ways to provide transportation for high-risk women to receive care at regional hospitals. Transportation funding and a prepaid mobile phone for each village are some of the strategies that have been discussed. The regional director of WPRO considers Laos a priority country in the region.