Caption: RBC DG providing free HEP C drugs

BY LYDIA ATIENO

Every year on 28 July, the world marks World Hepatitis Day (WHD). Last year, in Rwanda, the WHD included a vaccination campaign for about 2,000 individuals and an HBV and HCV screening for 500 people in Kigali.

This year, Rwanda will join the rest of world in marking WHD, carrying out a series of activities for prevention, access to testing, treatment and care.

This year’s WHD in Rwanda will bring together  stakeholders such as civil society, government institutions, partners and the general public to boost the global awareness  of VH.  A massive campaign such as this can evoke real change at national level.

Objectives of this year WHD campaign is to; Increase awareness among the Rwandan population on HBV and HCV and the availability of services in the country, Mobilization of national and international stakeholders for HBV and HCV control in Rwanda,  Increase the access to preventive, diagnostic, treatment and care services of HBV and HCV for those in need in Rwanda.

About hepatitis

Nowadays, viral hepatitis has been recognized as a major contributor to the global disease burden, causing serious illness and death from acute hepatitis infection, liver cancer, and cirrhosis. The burden is particularly significant among individuals co-infected with the human immunodeficiency virus (HIV).

Co-infection of HIV with Hepatitis B (HBV) or C (HCV) viruses is associated with less spontaneous clearance, higher chronicity, and more rapid disease progression. This is further compounded by the higher than average prevalence in this population given the shared routes of transmission and the interaction between the viruses.

In July last year, Rwanda was one of the first countries  in the region to launch a national viral hepatitis control programme, with the commitment from the government to scale-up screening and treatment throughout the current national guidelines. 

The goals of this year campaign include; massively scale-up access to preventive, diagnostic, treatment and care services of HBV and HCV for those in need in Rwanda including in HIV people, Increase awareness of the Rwandan population on HBV and HCV and the availability of services in country, as well as Mobilize national and international stakeholders for HBV and HCV control in Rwanda.

Activities to be carried out

This year WHD planned activities, will be carried out with the aim of achieving the National Operational Plan’s strategies.

To accomplish these objectives the Ministry of Health (MOH), will carry out activities such as, screening of HBV and HCV in high- risk groups, HBV immunization for the general population including those who will be screened negative for HBV antigens during the WHD screening activity, Provision and linkage to care for confirmatory testing and treatment, monitoring and evaluation of the activities will be conducted.

During the campaign, approximately 250,000 individuals are expected to be screened for HBV and HCV and 400,000 to be vaccinated against HBV.

To reach as many high-risk groups and people, at the same time, screening and vaccination will take place at 30 District hospitals and 15 prisons’ health dispensaries.  Individuals, who will be screened positive for HBV and/or HCV antigens will be referred for care as recommended by the National Guidelines for the Prevention and Management of Viral Hepatitis B and C. 

Caption: People turning out for free Hepatitis vaccine

Treatment will be offered to all People living with HIV (PLHIV) HCV+ confirmed cases , as well as patients who will be screened anti-HCV positive during the 2017 WHD campaign and confirmed HCV+.  HBV and HCV treatments options provided will follow the recommendations indicated in the national guidelines. 

Also, data will be collected to ensure proper monitoring and evaluation. This will ensure adequate supervision and surveillance of the campaign by the central level and members of the viral hepatitis technical working group. 

The 2017 WHD campaign budget is primarily covered by the government of Rwanda which will provide all screening commodities, therapies and ensure hospitals operational costs.

Problems associated with hepatitis

Infection with either Hepatitis B (HBV) or C (HCV) viruses is among the leading causes of liver inflammation, prone to cause chronic infection. In 2015, HBV and HCV resulted to respectively 887,000 and 399,000 deaths mostly from complications (cirrhosis and hepatocellular carcinoma) (6), adding significantly to the global disease burden.

The national prevalence of HBV and HCV infection in Rwanda is not well documented, and the mortality related to these infections is poorly characterized. Current estimates compiled from a variety of different studies provided an HBV surface antigen (HBsAg) prevalence ranging between 1.9% and 7%, while HCV studies have suggested an antiHCV seropositivity varying between 0.8% and 5.7% % (7,8,9,10).

In recent screenings performed in Rwanda, 117,258 HIV-positive individuals were screened for the presence of HBsAg and anti-HCV. The prevalence of HBsAg and anti-HCV were 4.3% and 4.6% respectively. 182 (0.2%) HIV+ individuals were co-infected with both HBsAg and anti-HCV. The prevalence was higher in males; HBsAg, 5.4% vs. 3.7%; and anti-HCV, 5.0% vs. 4.4 %(11). Moreover, it increases with age, 17,8% in people aged  65 years; and varied geographically.

The situation in Rwanda

Access to screening, care, and treatment, in Rwanda, has been limited due to multiple reasons, including the high costs, the complexity of therapy, and limited access to diagnostics services. Also, the lack of adequate information or misrepresentation about HBV and HCV may have had severe consequences for patients and their families as well as other contacts.

For these reasons and given the recent statistics obtained among the HIV positive population, scaled-up access to comprehensive viral hepatitis (VH) screening and care is required to prevent significantly morbidity and mortality associated with these two diseases.

The Rwandan Ministry of Health (MoH) has identified viral hepatitis as a serious public health concern and has shown commitment to scaling up screening and treatment throughout national guidelines. In 2015, the National Guidelines for HBV and HCV Prevention and Treatment were updated to include recommendations for treatment of HCV with direct-acting antiviral (DAAs) and implementation of the HBV birth dose vaccine.

The MoH and the Rwandan Biomedical Center (RBC) developed the National Operational Plan for 2016/17, which outlined the costs and potential impact of the national program.

The national guidelines lay out the service package that should be available at each health facility level. These levels include referral, provincial, district hospitals and, health centers. All these facilities should be offering different HBV/HCV services integrated within existing HIV services countrywide.

Caption: The turn out of people during implimentation of activity for week 5-9 2017

Screening Campaign of HBV&HCV the 2017 WHD campaign will focus on an active detection of HBsAg and anti-HCV in the targeted and high-risk population.

This national screening campaign will initiate and encourage people to know their VH status, identification of VH cases national-wide and assist in linking them to care. 

Targeted group

People aged 45 years and above, Health Care Providers (HCPs) Medical, nurses and laboratory technician students, Prisoners as well as other risk groups such as female sex workers and injection drug users, are the targeted group.

The staff from National level (RBC /HIV/STIs and OBBI Division, members of the VH technical working group) will organize and coordinate this activity - The Local administration will be involved in facilitation, security, and mobilization of the population.

The District hospitals (DHs) will be in charge of the storage of Elisa tests and will offer screening tests to the population whereas, the health centers will communicate results and inform patients on next steps as the community health workers will sensitize the targeted people in the villages to be tested.

Considering a prevalence of 4.3% for HBV (based on the screening of PLHIV 2016), about 8,170 people are expected to be positive for HBV and will need to be referred to care and treatment as recommended by the national guidelines. About 181,830 people are projected to be negative. HBsAg negative with no documentation of previous HBV vaccination will be encouraged to undergo immunization.

For HCV, the prevalence is 4.7% (based on the screening of PLHIV in 2016), meaning that approximately 8,930 individuals are expected to be HCV antibodies positive, whereas 181,070 individuals HCV negative.

Regarding prisoners, the screening will take place directly at the prisons’ health dispensaries. If tested negative, inmates will receive the vaccine directly at the prison’s health clinic. Currently, there are about 62,000 prisoners, which will use about one-fifths of the available screening tests. 

During the campaign, all patients inclusive of inmates will receive post-test counseling on HBV/HCV preventive behaviors and associated screening tests. 

Where to get the services

Thirteen testing sites will perform the Elisa tests during the screening campaign: NRL, Kabgayi DH, Kibuye DH, Centre Hospitalier de Butare (CHUB) ,Ruhengeri DH, Kibungo DH, Nyagatare DH, Rwamagana DH, Nemba DH, Gisenyi DH, Gihundwe DH, Bushenge DH and Kabutare DH.

At the ELISA testing sites, samples will be tested for the presence of HBV surface antigen (HBsAg) and the HCV antibody (anti-HCV). All results, positive or negative, will be recorded on the LRFs and communicated back to the hospitals, from where the samples originally came and, after sent to the health centers selected by the patients during screening as close to their residential area.

There, patients will be contacted to collect results and informed about next steps. If patients are screened negative for HBsAg, they will be referred to vaccination. In cases, where the patients are screened negative for HCV, the patient will receive information on HCV transmission, so as to prevent future infections.

The distribution of commodities to screening and testing sites will be performed through the existing channels. The necessary products and quantities will be prepared at Medical Production and Procurement Division (MPPD) and distributed through distrVaccination Vaccination is a significant contributor to infection control.

Routine administration of the HBV vaccination schedule for infants is already in place since 2002, and nationally almost all one-year-olds have received three doses of the HBV vaccine (~93%)(13).

Given that infant vaccination is relatively new to the routine practice, it will take some decades before all persons are vaccinated against HBV. Thus, vaccination of adults will be an essential element in effective infection control.

Importance of immunization 

Targeted immunization of populations at high- risk of infection will have the greatest impact on transmission of the disease, and as such, vaccination of such groups should be prioritized. These include pregnant women, People Living with HIV (PLHIV), Health Care Workers/Community Health Workers (CHWs), and other high-risk groups.

People will be informed of the vaccination campaign and the location through the usual media channels; mainly the radio and Whatsapp messages. These messages will notify the public about the activity in general; the sites and people within the high-risk groups as stated above will be strongly encouraged to participate in the vaccination.

This campaign will target each administrative district. The same hospital chosen from the screening will also offer vaccination as the selection is based on accessibility and available of laboratory, nursing personnel as well as equipment. For an overview of the chosen health facilities.