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•Regional Workshop on Hepatitis Strategic planning, Kintele, Brazzaville , Congo
.
Olufunmilayo LesiWHO Regional Office for AfricaCOLDA, Cairo, September 6-8, 2019
Needs for research and advocacy for Hepatocellular carcinoma in Africa
Outline
• Introduction & background
• Global Health Sector Strategy on viral hepatitis
• Defining research priorities and opportunities for advocacy- Using available evidence
• HCC surveillance and research
• Improving advocacy
Liver cancer/Hepatocellular carcinoma
• The global burden of hepatocellular carcinoma (HCC; primary liver cancer) is increasing
• HCC is often unaccompanied by clear symptomatology-patients often unaware of their disease and present late
• Lack of recognition that 20-30 years delay between hepatitis infection and development of HCC
• Moreover, effective treatment for those with advanced disease is lacking
• As such, effective surveillance and early detection of HCC are essential
Hepatitis mortality is increasing1.34 million deaths estimated in 2015
Sources Mortality increased by 22% between 2000 and 2015
0
0,5
1
1,5
2
2000 2005 2010 2015
Mill
ion
s o
f d
eath
s
Year
Hepatitis
Tuberculosis
HIV
Malaria
96% hepatitis deaths from HBV and HCV (cirrhosis and hepatocellular carcinoma)
Global Hepatitis report, 207, WHO Global Health Estimates, 2015
Fraction of hepatocellular carcinomaattributable to HBV and HCV infections,
by WHO region, 2015
Sources – WHO Global Health Estimates
Source: WHO Global Health Estimates, in collaboration with the International Agency for Research on Cancer (IARC),Lyon, France
Over 250,000 liver deaths estimated in Africa in 2015 (mostly cancer & cirrhosis)
An underestimated death toll due to poor surveillance
Distribution of Cirrhosis/ liver cancer deaths in the WHO African region,
according to the cause
Hepatitis A &EHepatits B
Hepatits C
Alcohol
(CDA, 2019)
Other causes: NAFLD, Alcohol, etc
Global Strategy for viral hepatitis
The World Health Assembly pledged to reach elimination by
2030
Proposed global targets for elimination• From 6-10 million infections (in 2015) to
900,000 infections (by 2030)• From 1.34 million deaths (in 2015) to under
500,000 deaths (by 2030)
Mortality is an impact indicator used to define elimination
Shared Goal: …eliminate viral hepatitis as a major public health threat by 2030
(link: http://www.who.int/hepatitis/strategy2016-2021/portal/en/)
2030 targets
Elimination is defined by impact indicators
A. Incidence -90%
B. Mortality -65%
Modelling suggests that taking 5 core interventions to sufficient coverage will achieve impact
1. Three dose hepatitis B vaccine (childhood)
90%
2. HBV PMTCT 90%
3. Blood and injection safety
100 % screened donations
100% safe injections
4. Harm reduction 300 injection sets/PWID/year
5. Testing and treatment 90% diagnosed
80% eligible treated
Eliminating hepatitis by 2030:
A package of interventions with high impact
PMTCT: Prevention of mother to child transmission
PWID: Person who injects drugs
WHO Region for AfricaHepatitis Score card
Documents burden of infection and
performance ahead of the 2020 deadline
Defining research priorities and opportunities for advocacy using available evidence
There is limited data for action• The incidence of HCC is generally underestimated
as many liver-related deaths are not identified as HCC and many known HCC-related deaths are miscoded in medical records and/or not noted on death certificates
• Tumor registries can be misleading with regard to actual incidence as the quality and completeness of registries vary
• Lack of national surveillance recording and reporting
• Limited research funding and partnerships
Promoting a global standardized framework for HBV and HCV
WHO has recently developed consolidated strategic information guidelines for viral hepatitis
– for planning and tracking progress towards viral hepatitis elimination targets
Context
17ADDITIONAL
indicators from
other
programmes
(A.11-A.27)
Inputs Output & outcomes Impact
Epidemic System Elimination
Cascade of care
Prevent
Test Treat Heal
C1. Prevalence
C2. Testing facilities
C3. Vaccine
coverage
C4. Needle syringe
for PWID
C5. Injection
safety
C.9 Incidence
C.6 People diagnosed
C.7 Treatment coverage / initiation
C.8 Viral supression (HBV) or
cure (HCV)
C.10 Mortality
from HCC,
cirrhosis
Framework for monitoring and evaluation of the hepatitis response
Global Reporting System for Viral Hepatitis [GRSH]: A seamless system to report the cascade of care From the in-country DHIS2 module to the GRSH
13
Single reporting requirements (20 data points) from health
facilities to WHO
WHO
Member
state
Health care
facilities
NGOs
Private
sector
Member
states
Global dashboard
Single log-in
Using the 10 core viral hepatitis indicators:
Cameroun Surveillance Workshop, May 2019
.
HBV HCV
Prevalence 913,000
(8.3%, 2017)
113,300
(1.03%, 2011)
Testing (serology/NAT) 3,634 / 5 3,634 / 5
Prevention 3-dose vaccine coverage 79% (2018) Not applicable
Birth dose / PMTCT No policy Not applicable
Injection safety 97.5% safe injections (DHS 2011)
Harm reduction (NSP) No intervention
Care and
treatment
Proportion diagnosed 37,965
(4%, 2018)
6,453
(5.6%, 2018)
Treatment coverage among
diagnosed
3,094
(8%, 2017)
827
(12%, 2017)
Treatment effectiveness 90% >98%
Impact Incidence 1.9% -
Mortality 2,524 2,528
Baseline estimates for the 10 core indicators, Cameroun, 2019
15
Reference method Alternative option Rapid assessment
technique
No data
Usually statistical sampling Non statistical sampling Expert opinion
Global reporting; Estimating HBV and HCV associated mortality-Cameroun, 2019
2016 GLOBAL HEALTH ESTIMATES FROM WHO
1. NATIONAL MORTALITY
STATISTICS / CANCER REGISTRIES
2. ATTRIBUTABLE FRACTION IN CENTRES OF EXCELLENCE IN
HEPATOLOGY
6,400 deaths from cirrhosis 800 deaths from HCC
52% HCC from HBV 22% cirrhosis from HBV36% HCC from HCV 35% cirrhosis from HCV
5,352 deaths from viral hepatitis in 2016
Mortality envelope
HBV HCV OthersHBV HCV Others
Modelling the Impact of hepatitis.
another method to provide evidence useful to identify research gaps and
promote advocacy
Modelling of impact – Mozambique
7.5% 7.2% 6.9% 6.7% 6.5% 6.2% 6.0% 5.8% 5.6% 5.4% 5.2% 5.0% 4.8% 4.6% 4.4%
-
500,000
1,000,000
1,500,000
2,000,000
2,500,000
HBsAg Prevalence
Preliminary results show an estimated 2 million infections and 3000 new cases of liver cirrhosis and cancer every year.
Increasing incidence of HCC, liver cirrhosis and deaths (HBV & HCV)
The COST of NO ACTION CDA Foundation, 2017, USA
Careful mortality measurement are needed to generate data before and during elimination efforts
Mortality is an impact indicator used to define elimination
• Sentinel surveillance in sites of
excellence can fill this gap
• WHO has developed a protocol
to aid surveillance and promote
the use of standardized
reporting format for uniform
reporting
Sequelae surveillance protocol:Overview
1. Population under surveillance: Patients with cirrhosis or hepatocellular
carcinoma in Liver/GI centres
2. Investigators: Sentinel sitesClinicians functioning as investigators
3. Case definitions: ICD-10 codes
4. Data collection: Interview and review of patients’ records
(case report form).– Part of normal clinical practice
– Data on outcome (Cirrhosis / HCC)
– Data on exposure (hepatitis and other causes of CLD)
https://apps.who.int/iris/bitstream/handle/10665/280097/WHO-CDS-HIV-19.4-eng.pdf
Developing a research agenda
• Identifying priority HCC research in Africa – Implementation research (testing & treatment, service
delivery)
– Promoting early diagnosis- blood and urine biomarkers
– Innovations in treatment- potential curative therapies and
– Prevention research
• Strategic planning of the use of limited human and financial resources
• International / regional consortia to promote collaborative research.
Prioritizing research in an effort to reduce HCC burden
Intensifying actions towards Hepatitis advocacy
Generating political and community commitment
Collaborating with the African Union and promoting the endorsement of a Regional declaration on viral hepatitis --catalyst for government leadership
African Hepatitis Summit, Uganda, June 2019Endorsed by Government of Uganda and declared open by the Vice President
Launching HCV investment case in Rwanda, Dec 2018
In Summary
• Reducing mortality from hepatitis related HCC is an impact indicator for the elimination of viral hepatitis by 2030
• Development of a national database can accelerate data generation and facilitate regional and global documentation
• There is a need for countries to prioritize HCC and develop an appropriate research agenda.
• Collaboration and global partnerships are important in developing research capacity
• Evidence based advocacy can accelerate dialogue with policy makers, mobilize political & community action for change
Conclusion
• Hepatitis is still a problem, undiagnosed, poorly researched, poorly funded, and poorly linked to viral hepatitis.
• There are huge research gaps in hepatitis and HCC research and advocacy and national surveillance can be a first step to data generation
• Each and everyone of us has a role to play
With gratitude and appreciation to all partners, Ministries of Health, and to all WHO country/regional staff
www.who.int/hepatitis hepatitis@who.int
Thank you!
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