By Savanna Henderson, Humanitas Global
This is part two of a two-part post on hepatitis B and C (HBV and HCV). This post is focused on the obstacles in prevention and how we overcome such obstacles to prevent further infection and death related to viral hepatitis. Part one can be found here.
The health burden of hepatitis has been compared to that of HIV, yet awareness-raising outreach, policy changes, and funding for hepatitis prevention and treatment has fallen short in comparison. This lack of attention is problematic because of the sheer numbers of infection and death related to viral hepatitis but also because the hepatitis B virus alone is 50 to 100 times more infectious that HIV. Prevention was the key message of this year’s World Hepatitis Day but there are a number of barriers that stand in the way. Fortunately, these obstacles are all passable, especially when utilizing the health-care system as a preventative environment.
Access to high-quality blood screening equipment
As explored in the previous post, unsafe injection practices, poor infection control, and use of unscreened blood are prime contributors to the ongoing transmission of HBV and HCV. In many LMIC’s it is not mandatory that blood banks screen for HBV and HCV. The most successful testing mechanism is nucleic acid testing (NAT), which can detect the virus earlier than other tests and has the added benefit of resolving false positives. But, it is expensive for LMIC’s; it requires rapid processing of blood, cold storage of samples, expensive instruments, trained technicians and the expense of the test itself, resources and infrastructure that may not be in place. These resource-limited regions unfortunately suffer from higher prevalence rates of transfusion-transmitted infections and would benefit greatly from NAT screening. One study found that NAT screening in India could prevent 2,019 infectious blood donations out of 6 million donations versus 3,000 out of 400 million donations not using NAT screening. While an expensive endeavor, NAT testing is highly successful in detecting the hepatitis virus and should be a focus for policy makers and planners to contribute to the prevention of hepatitis.
Promotion of safe injection practices in healthcare settings
While infection is common among drug users who share or re-use needles, infection can also occur in clinical settings. Worldwide, the re-use of syringes and needles in health care systems contributes to transmission of 33% of new HBV infections and 42% of HCV infections. There are also a significant proportion of injections given outside the health sector, by traditional and unlicensed practitioners that risk transmission of hepatitis through improper sterilization and re-use of equipment. Reasons for unsafe injections range from lack of quantities of needles and syringes, lack of sterilization equipment or fuel to operate equipment, high patient demand for injections, and a lack of understanding on the true risk of unsafe injections. A study in India found a cost-effective solution to unsafe injection by introducing and promoting universal adoption of auto-disposable syringes. Acknowledging and responding to the reasons unsafe injections are given is critical to providing universally safe injections.
Prevention of mother-child infection transmission
Perinatal and contact with infected blood in early childhood are the most common routes of HBV transmission in high endemic regions, like central Asian republics, Southeast Asia, sub-Saharan Africa, and the Amazon basin. While there is a vaccine for HBV with a 95% success rate, adoption of global childhood vaccination has been held up by lack of infrastructure, high cost, and low rates of hospital births. Support and funding for increased infrastructure and vaccines in high-risk areas is a key step in preventing transmission of HBV to children. Because the vaccine is administered within 24 hours of the child’s birth, children born at home lack access to the preventative vaccine. Interventions have been conducted in Indonesia where trained birth attendants are taught to administer the vaccine to babies born at home using a single-use, pre-filled injection device. Similar interventions should be explored throughout high-risk areas where rates of home-births are greater than hospital births.
Lessons learned from the global HIV response
Finally, the global reaction to HIV provides practical lessons and tools to address viral hepatitis today. More than a decade ago, HIV treatment alone cost up to US $10,000 per person a year. Today, diagnosis and treatment has dwindled to US $200 per person a year and HIV screening tests are now less than US $1 in low-income countries. Overall availability and accessibility of HIV screening and treatment today, can be attributed to mobilization and involvement of civil society in advocacy and awareness, policymaking and programming. National strategies were developed to address and resolve barriers to screening and treatment that led to established HIV treatment programs in many LMICs. These programs can utilize their workforce and lab resources to screen and treat infected and co-infected individuals. Social marketing programs were developed and implemented in over 50 countries to raise awareness of the disease and have made condoms available, affordable, and acceptable. This contributed to increased awareness and behavioral changes leading to preventative behavior and an increase in screening and treatment of HIV. Similar social marketing initiatives could be developed to create awareness and understanding of HBV and HCV, risk behaviors and available resources, increase voluntary screening and follow-ups, and treatment.
Prevention is critical to eliminating the spread of hepatitis and related deaths. Increased awareness and understanding of how hepatitis is transmitted should coincide with the mobilization of resources to stop preventable transmissions. Incorporating the HBV vaccine into national recommended childhood immunizations and adopting auto-disposable syringes are great examples of how to prevent further infection utilizing existing infrastructure and tools. Treatments should be more affordable, for nations and individuals to access, and integrated into screening sites. Over one million deaths from viral hepatitis are unacceptable when prevention is possible.