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.
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.
Between 2006 and 2008, this program demonstrated the feasibility and successful implementation of:
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
A hepatitis B education program incorporated into the school curriculum.
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.
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.
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.
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:
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.
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.
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.
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.
Education and training play an important role in improving health practices and reducing discrimination.
Chronic hepatitis B infection is a high-prevalence, life-threatening disease caused by the hepatitis B virus (HBV).
China has the greatest burden of chronic HBV infection and liver cancer in the world.
1 in 10 Chinese have chronic hepatitis B.
More than 40% of the worldwide deaths associated with HBV infection occur in China.
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.
In 2007, the World Health Organization Western Pacific Regional Office (WPRO), released a detailed plan for hepatitis B control through immunization. Strategies begin with a focus on immunization of infants and children through timely administration of the birth dose of hepatitis B vaccine (i.e., within 12 hours of birth) and catch-up vaccination programs (i.e., targeting children not vaccinated at birth). In adult populations, high-risk groups such as healthcare workers are named as the highest priority.
The Asia and Pacific Alliance to Eliminate Viral Hepatitis (APAVH) and the Asian Liver Center at Stanford University developed an innovative online training and education tool called “Know HBV” to help improve healthcare workers’ knowledge and practice about hepatitis B.
There are two versions of the online course: one for Chinese healthcare workers developed in Chinese and one for a global audience developed in English. The initial development of the Know HBV online training course began in partnership with the Shandong Province Health Department and the Shandong Center for Disease Control, with the pilot launch of Know HBV occurring in Shandong Province and involving over half a million healthcare workers.
Improve the quality of health care and education for HBV patients through healthcare provider education.
Develop an effective training tool specifically for healthcare providers in China to improve their knowledge and practice related to hepatitis B.
Demonstrate to policy makers at the national and provincial levels the impact and effectiveness of this intervention.
The online training tool aims to:
Increase health care provider knowledge and practice regarding hepatitis B and liver cancer prevention.
Protect healthcare workers from being infected by HBV in work settings
Improve knowledge and awareness about the hepatitis B virus, liver cancer, and its prevention among doctors, pregnant women, and the general public
Increase routine checkups of those chronically infected with the hepatitis B virus
Reduce discrimination against those chronically infected with hepatitis B
The online training will consist of three core modules:
General HBV knowledge, including impact and routes of transmission
Injection and blood safety
A pilot study in Shandong Province has been completed in April 2011 in partnership with the Shandong Province Health Department and Shandong Center for Disease Control.
Implementation and Replication
Further replication of this training tool is already under way and we plan to expand it to Myanmar, India and Korea.
ASIA & VIRAL HEPATITIS: Learning from China to Enhance Prevention & Control Efforts in Asia
Hong Kong | April 28, 2010 | Convened by the Asia and Pacific Alliance to Eliminate Viral Hepatitis (APAVH)
To examine the successes and challenges of hepatitis B prevention and control activities that demonstrate China’s leadership role in the Western Pacific Region; and
To determine how APAVH can provide support and contribute to the efforts to meet control and elimination goals for hepatitis B in the Western Pacific Region.
Inaugural Partners Meeting of the Asia and Pacific Alliance to Eliminate Viral Hepatitis
San Francisco, California, United States | November 2, 2008 | Convened by the Asia and Pacific Alliance to Eliminate Viral Hepatitis (APAVH)
To establish a new public-private partnership to eliminate viral hepatitis worldwide