13 Years to Eliminate Morbidity and Mortality due to Viral Hepatitis- Global Partners Believe It Can Be Done!

The liver processes nutrients, helps to fight against infection, and aids in cleaning the blood in our bodies. Inflammation of the liver is generally known as hepatitis. Although hepatitis can be caused by autoimmune disorders, occur as a result of excessive alcohol consumption, or become induced after a toxin is introduced into the liver, the hepatitis of most concern has a viral origin. While there are 5 main viruses (Hepatitis A-E), Hepatitis C Virus (HCV) and Hepatitis B Virus (HBV) are responsible for the majority of morbidity and mortality cases associated with viral hepatitis infections globally- this is comparable to HIV/AIDS and TB, killing 1.34 million people a year. Hepatitis can either be acute (i.e. a short-term illness within 6 months of infection) or chronic. 75-80% of individuals infected with HCV will develop a chronic infection. The likelihood of HBV becoming chronic largely depends on the age at which infection occurs. According to the Centers for Disease Control and Prevention (CDC), 90% of infants, 25-50% of children between 1-5 years of age, and 6-10% of individuals over 5 years of age will develop chronic HBV. Although the majority of individuals are diagnosed at a young age, younger age groups are less likely to show symptoms.

Currently, there are 240 million people living with chronic HBV and 130-150 million people with chronic HCV around the world.

Risk factors for HBV and HCV include:

According to the World Health Organization (WHO), there are differences in global burden of disease trends for HCV and HBV:

  • HCV: Affects all regions although there are significant differences between and within countries. The WHO Eastern Mediterranean Region and the European Region have the highest reported prevalence of HCV.
  • HBV: Mostly affects the WHO African Region and the Western Pacific Region

The number of cases of hepatitis that are diagnosed increases every year as well as deaths, which have increased by 50% over the past 20 years. Even worse, most people with hepatitis are asymptomatic in the acute stage and the beginning of the chronic stage- those with symptoms may have fever, jaundice, loss of appetite, grey stools, dark urine, and abdominal pain.  Although a vaccine is only available to protect against HBV, effective treatment options exist for both chronic HBV and HCV. This is an important reality since therapy and proper case management can reduce the risk of complications such as cirrhosis, liver cancer, and premature death that are caused by chronic hepatitis infection. Access strategies supported by the WHO in 13 countries have helped more middle-income countries receive necessary medications such as Directing Acting Antirals (DAA). These drugs have a cure rate of over 95% within a 3-month timeframe, for HCV, and less side effects than other drugs- but 80% of HCV cases still have difficulties accessing the treatment and case management they need because it can be expensive. The WHO released the report, “Global Report on Access to Hepatitis C Treatment: Focus on Overcoming Barriers,” which discussed the importance of political mobilization, advocacy, and pricing negotiations on increasing access to necessary medications in low-middle income countries. Local, more cost-effective medications have even been manufactured in a few countries. In order to address the 80% of people still in need of help, in May 2016, at the World Health Assembly, 194 countries adopted the Global Health Sector Strategy on Viral Hepatitis with the goal of eliminating hepatitis by 2030. DAAs were also added to the List of Essential Medicines.

Information from the global strategy is incorporated into World Hepatitis Day activities. World Hepatitis Day occurs on July 28th every year and is focused on raising awareness about the global burden of viral hepatitis as well as the prevention and treatment options that exist. Watch these short videos to learn more about the WHO’s global strategy and the theme for this year!

International Group B Strep Awareness Month: What Should I Know About GBS Disease?

July is International Group B Strep Month. This blog post gives an overview of the illness and its impact on pregnant women around the globe.

Group B Streptococcus bacteria (GBS), also known as Streptococcus agalactiae, typically colonize the gastrointestinal and genitourinary tracts, the throat, and the skin. GBS disease is caused when bacteria enter a normally sterile site such as the blood, bone, or spinal fluid. Both children and adults can develop GBS disease. The disease usually develops in infants that are 0-90 days old and adults that are 60 years of age and older with underlying chronic illnesses. There is currently no vaccine for GBS disease.

Although GBS may come from unknown sources, one out of four pregnant women are carrying the bacteria in their vagina or rectum and can vertically transmit an infection to their newborns. Infections occur during labor (“early-onset disease” or EOD) or within the first week of life through three months of age (“late-onset disease” or LOD). Symptoms can be difficult to distinguish from other infections and range from fever, difficulty breathing, lethargy, and “blue” skin. Severe symptoms that can develop in newborns and infants include sepsis and pneumonia. Meningitis is more likely to occur in infants or newborns with LOD. Complications from GBS disease may result in preterm delivery and lead to developmental disabilities or death. According to the Centers for Disease Control and Prevention (CDC), risk factors for pregnant women include:

  • Testing positive for group B strep bacteria late in the current pregnancy (35-37 weeks pregnant)
  • Detecting group B strep bacteria in urine (pee) during the current pregnancy
  • Delivering early (before 37 weeks of pregnancy) 
  • Developing a fever during labor
  • Having a long time between water breaking and delivering (18 hours or more)
  • Having a previous baby who developed early-onset disease

Since 1970, GBS disease has been a topic of concern in health care, research, and public health circles. In 1989, the death of three newborns from GBS disease led to the development of public awareness campaigns that called for improved education, detection, and preventive resources in the U.S. Furthermore, around this time, data collected by the CDC revealed that GBS disease was the leading cause of death in newborns. Parents and advocacy groups actively demanded guidance that would allow for routine screening and the development of an effective vaccine for pregnant moms, globally. Below is a timeline of how advocacy efforts led to research, policy change, and the implementation of effective interventions:

Brief Timeline of GBS Disease Awareness, Education, and Prevention Efforts

  • 1990 Group B Strep Association US/International is created. Its primary goals are to:
    • Educate the public about GBS infections.
    • Promote prevention of neonatal GBS infections through routine prenatal screening.
    • Promote the development of a GBS vaccine.
  • 1991 GBS researchers awarded a 5-year grant to begin research on a vaccine for  GBD disease
  • 1992 American College of Obstetrics and Gynecology and American Academy of Pediatrics publish position papers for members
  • 1996 CDC Call for Content on GBS Prevention Protocol in (January MMWR)
  • 1996 CDC, ACOG, AAP published first consensus statement on GBS National Prevention Guideline in June
  • 1997 Group B Strep Association launches its first website
  • 2002 The National Consensus Guidelines recommending routine screening for all pregnant woman was published
  • 2008 The CDC Active Bacterial Surveillance Core published data that showed an 80% drop in GBS neonatal morbidity and mortality
  • 2014 WHO convened the first meeting of the Product Development for Vaccines Advisory Committee (PDVAC); GBS and RSV identified as pathogens that cause a large burden of disease

Globally, it is estimated that EOD makes up 60-90% of GBS disease cases. The mean incidence of GBS disease in infants 0-89 days old is estimated to be .53 cases of GBS infection/1000 live births. The highest incidence of cases is reported to be in the continent of Africa, however, additional studies need to be conducted in low-income countries to better assess the true burden of disease. Prevention methods worldwide include providing prophylactic treatment (antibiotics) to women that are either high-risk or have tested positive for GBS, during labor. With treatment, there is only a 1/4000 chance of the baby becoming infected compared to a 1/200 chance if no treatment is given. In order to identify those who qualify for treatment, a culture-based method can be used to screen all pregnant women between 35-37 weeks for vaginal or rectal colonization of GBS. On the other hand, a risk-based method identifies pregnant women with risk factors for EOD such as fever, preterm delivery, and being in labor for 18 or more hours.

Although the administration of antibiotics during labor reduced EOD from .75 cases of GBS infection/100 live births to .23 cases of GBS infection/100 live births, GBS disease morbidity in infants and mothers is still significant and likely underreported. Antibiotic treatment and GBS disease education are more accessible to pregnant women in high-income countries than those in low-middle income countries. It is likely that challenges related to access to care and health system deficiencies limit the use of antibiotic treatment in low-middle income countries. As a result, the development of a cost-effective vaccine may be able to help bridge an awareness gap.

According to the World Health Organization (WHO), developing a vaccine for maternal immunization is a priority when it comes to GBS disease. In 2016, the WHO Product Development for Vaccines Advisory Committee held a technical consultation to discuss vaccine development. Ultimately, the committee determined that the global burden of GBS disease cases that result in stillbirths needs to be assessed. In addition, standardized antibody assays need to be developed in order to find correlates of protection. Vaccine targets such as the type III capsular polysaccharide (CPS) and proteins on the GBS bacterial surface have also been identified. As new vaccine development ideas for GBS disease are being discussed, here are some foundational components that the Group B Strep Association (US/International) and Group B Strep Support (UK/EU) groups feel have an important role to play in the introduction of the vaccine to pregnant women across the globe:

  • Standardized definition of disease worldwide.
  • Standardized monitoring of disease worldwide.
  • Routine prenatal care widely available in which a vaccine can be delivered.
  • Education of health professionals and parents and expectant parents about group B Strep and the vaccine.

Check out these CDC podcasts, if you want to learn additional information about GBS disease during International GBS Awareness Month!

Global Health in Conflict: A Weightier Commitment

It is important for early-career professionals interested in pursuing a career in global health to be aware of the realities of working internationally. Although stories of setting up vaccination clinics or fighting Ebola may stir up feelings of excitement, being a part of the action may require additional education and training in conflict resolution and institution building. This is especially true when it comes to conflict-affected areas and fragile states that are the most in need of health care/public health services as a result of the local health system infrastructure being weakened. A different kind of public health professional, one that is willing to risk their life and invest in the indigenous health system, is required in our world today.

I currently work as an epidemiologist at a regional health department in Texas. We serve two main roles for the 30 counties we cover. One of our roles is to function as a local health department and deliver a diverse range of services to 23 counties. The other main role is to serve as an extension of the state health department and provide surveillance/investigation guidance for the reportable conditions that health care providers, schools, and community members are mandated to report. This relationship is seen especially when we work with the 7 counties in our region that have their own local health departments. Before beginning this job, I actually worked at one of these local health departments and was on the receiving end of the interaction described above.

For most of my life, I’ve been interested in pursuing a career in global health or humanitarian work. When I was younger, I thought the only way I could pursue this dream was by being a physician (especially if I wanted to be able to support myself financially). I also believed this to be a great way to help communities that were dying from preventable illnesses. My introduction to public health helped me see that there were many other ways to help achieve the goal of combating deaths due to preventable illnesses. I focused in on epidemiology as a way to combine my science/laboratory background with my desire to serve and entered into an MPH program after completing my B.S. in Biology. Most of my MPH program was spent working hard to obtain tangible experiences in public health practice and deciding which skills would be most necessary for me to have before entering into the workforce. While pursuing my MPH from 2014-2015, some of the hot topics in public health were Ebola, antimicrobial resistance, bioterrorism, anti-vaccination movements, hospital-acquired infections, opioid abuse, tuberculosis trends related to travel, maternal and child health gaps, and continued efforts to end polio and AIDS, to name a few. Towards the end of my program, I began to hear more about the dangers of humanitarian work and global health as stories involving health care and humanitarian workers being targeted in conflict-affected areas/fragile states were highlighted in various media outlets. I also knew of at least one faculty member at the university I attended whose global health team was attacked shortly after the individual returned to the US (after working in the field for a number of years).

When I entered into the public health workforce in 2016, Zika was just becoming a hot topic in public health circles in the U.S. But there were other things for me to learn at my local health department. I received an introduction to the Immunization team and programs such as Texas Vaccines for Children which enable young people in Texas to receive affordable immunization coverage (there is an adult vaccine program too). I also received an introduction to the statewide ImmTrac system that stores vaccine records and learned about some of its strengths and challenges. Ultimately, I was able to see the importance of public health collaborating with healthcare providers, schools, and community members to ensure that a community has adequate herd immunity or, in the case of outbreaks, can deliver effective interventions in response to infectious disease threats. Something else I learned about was the role of immunization clinics or point of dispensing units (PODS) during natural disasters, such as floods, and other public health emergencies.

I’ve shared some of my experience working at the local level because it gave me a tangible picture of how public health functions in stable environments or areas that are not weakened by natural disasters. In conflict-affected areas or fragile states, public health efforts may be fragmented at best. For example, in August 2015 Nigeria was removed from the World Health Organization’s list of countries with endemic Wild Polio Virus (WPV). This was the result of global efforts aimed at eradicating polio through targeted immunization campaigns. Nigeria went two years without WPV cases before, in August 2016, two cases were reported in Borno-a conflict-affected state. Two additional cases were reported in September 2016. The cases were from inaccessible areas of the state with limited security and indicated that prolonged transmission had gone undetected as a result of armed conflict. Although the number of areas held by insurgents, and therefore without access to vaccines, eventually decreased, the conflict in Borno prevented timely vaccination campaigns and posed a risk to Nigeria as a whole. Specifically, migration between Internally Displaced People (IDPs) camps and refugee communities resulted in a higher potential for WPV cases to be reported in states not directly tied to the conflict. A similar trend was noticed with the Ebola outbreak that occurred in West Africa from 2014-2015. The disease posed an increased risk in fragile states and areas affected by conflict. For example, prior civil wars in Liberia and Sierra Leone severely weakened the countries’ infrastructure in the 1990s. The conflicts also affected surrounding countries and resulted in millions of displaced people. In some of instances, countries had the resources needed to respond to public health emergencies caused by conflict. However, groups of people or areas deemed to be inaccessible as a result of conflict continued to undermine the effectiveness of immunization clinics and infectious disease response efforts.

A comparative analysis conducted by Bourdeaux et al. in 2015 assessed the effect of conflict on health systems in Haiti, Kosovo, Afghanistan and Libya.  Health systems were defined as, “the organized network of institutions, resources and people that deliver health care to populations” and was based on the World Health Organization’s (WHO) Framework for Action (2007). The framework highlights financing, leadership/governance, information, medical products/vaccines/technologies, health workforce, and service delivery as essential components of effective health systems. When this organized network is destroyed as a result of armed conflict, high levels of morbidity and mortality occur and can have negative effects that persist even after the conflict is over. The analysis found that the building blocks most affected by conflict and security forces were “governance, information systems and indigenous health delivery organizations.”  In order to address these gaps, a suggestion provided by the authors is to deploy Health Security Teams comprised of individuals with training in public health and institution building to conflict-affected areas and fragile states. The teams would support indigenous health systems instead of creating parallel or temporary systems, and not be involved in serving military interests. Additionally, these teams would know how to guide security forces as they engage with health systems in diverse political climates.

At this point in time in my career, most of my work is done in an office on a phone or computer. When I started my journey in public health, I pictured something different. I still have the long-term goal to work internationally (or financially support myself while volunteering internationally). However, I am sobered by the fact that if I want to serve those who are truly in need (especially as it relates to conflicted-affected areas and fragile states) I will have to be at peace with laying my life on the line. I will also have to be prepared to navigate the challenges presented above. This includes learning as much as I can about conflict resolution and negotiating to protect health systems. In general, I feel that public health has much to do in terms of educating and re-assuring those we serve (both domestically and internationally). As a result, part of my journey in public health will include developing skills as a connector of people and someone that can see both sides of an issue. I think that all public health professionals interested in working in a global health or humanitarian worker capacity should consider this. At the same time, immigrants or refugees that have left their homes due to conflict or in search of better opportunities can also develop the skills needed to resolve conflict and rebuild institutions. The success of the suggested Health Security Teams could depend on this.

 

Photo: Diane Budd, M.D.

conflict

#Polio eradication in @CDCMMWR: Are we finally on the cusp of that elusive dream?

Note: This was cross-posted to my own blog.


I came across a very encouraging article in last week’s MMWR (the CDC’s Morbidity and Mortality Weekly Report) this morning about polio eradication. After several reappearances in 2013, cases are down again this year and, if things continue to go well, the end may be in sight:

Four of six WHO regions have been certified as free of indigenous WPV, and endemic transmission of WPV continued in only three countries in 2014. In 2013, the global polio eradication effort suffered setbacks with outbreaks in the Horn of Africa, Central Africa, and the Middle East; however, significant progress was made in 2014 in response to all three outbreaks. Nonetheless, the affected regions remain vulnerable to WPV re-importation from endemic areas and to low-level, undetected WPV circulation. Continued response activities are needed in these regions to further strengthen AFP surveillance and eliminate immunity gaps through high-quality SIAs and strong routine immunization programs.

Progress in Nigeria since 2012 has brought the goal of interrupting the last known chains of indigenous WPV transmission in Africa within reach. Elimination of all poliovirus transmission in Nigeria in the near term is feasible, through intensified efforts to 1) interrupt cVDPV2 transmission, 2) strengthen routine immunization services, and 3) increase access to children in insecure areas. Similar efforts should be implemented in all countries in Africa, where 9 months have passed without a reported WPV case, and 6 months have passed since the last reported cVDPV2 case.

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Number of cases of wild poliovirus type 1 in countries with recent polio outbreaks, by territory* — January 1, 2013–March 30, 2015

*Central Africa (Cameroon and Equatorial Guinea), Horn of Africa (Ethiopia and Somalia), and Middle East (Iraq and Syria).

The eradication push has suffered major blows in the last two years. In 2013, after six years of being polio-free, a major outbreak in Somalia contributed more polio cases to the year’s tally than the rest of the world combined; meanwhile, the virus made its way back into Syria that same fall after a 14-year hiatus. Luckily, extraordinary efforts in the midst of conflict zones on the part of health workers were able to beat the virus back to the heart of the fight – the final three countries in which it remains endemic.

Number of cases of wild poliovirus type 1 among countries with endemic poliovirus transmission, by country — January 1, 2013–March 30, 2015
Number of cases of wild poliovirus type 1 among countries with endemic poliovirus transmission, by country — January 1, 2013–March 30, 2015

Most (86%) WPV cases in Afghanistan in 2014 resulted from importation from Pakistan; however, the detection of orphan viruses highlights the need to strengthen the quality of both polio vaccination and AFP surveillance (10). Efforts are also needed to increase population immunity by intensifying routine polio immunization activities to ensure high coverage among infants with at least 3 OPV doses.

Recent challenges to the secure operation and public acceptance of the polio eradication program in Pakistan are unprecedented (10). Although poliovirus transmission has been concentrated primarily in the FATA region of northwest Pakistan, transmission has continued in the greater Karachi area, and WPV cases have been reported from all major Pakistan provinces. Successful efforts to enhance security to protect health workers and increase public demand for vaccination are urgently needed.

The recent gains in control and elimination of poliovirus transmission globally must be maintained and built upon through innovative strategies to access populations during SIAs in areas with complex security and political challenges, improve AFP surveillance, and strengthen routine immunization. With the progress achieved in 2014 to interrupt endemic WPV transmission in Nigeria and polio outbreaks in Africa and the Middle East, permanent interruption of global poliovirus transmission appears possible in the near future, provided that similar progress can be made in Afghanistan and Pakistan; progress there would also reduce the risk for future importation-related outbreaks in polio-free countries.

While there have been several cases of circulating vaccine-derived poliovirus in northern Nigeria, the fact that no wild poliovirus has been seen in the country since last July is extremely encouraging – eradication in Africa may be in sight. The final stronghold will be Pakistan and Afghanistan (primarily its regions that border Pakistan) – where, as the global health community has discussed ad nauseum, militants take advantage of the lack of public trust in eradication owing to bad intelligence schemes, among other things.

Obviously, it is still too early to tell. Gaps in surveillance mean incomplete data; there are most likely more cases that have not been reported. Furthermore, ongoing conflict (not to mention the recent Ebola outbreak) has left the health systems of many countries devastated, so vulnerabilities are everywhere. Nevertheless, with continued dedication (and a little luck), we may very well get there. Here’s hoping.

Ebola: The Ripple Effects (infographic)

For better or worse, Ebola is becoming old news. Aside from the initial case in Dallas that was transmitted to two nurses, there have been no more cases here in the U.S., and panicked predictions of a massive outbreak causing mayhem and catastrophe never materialized (much like public health experts said they would not – funny how that works).

The outbreak in West Africa is ongoing and continues to be a tragedy on a massive scale that is losing public interest. We previously posted an article by Mary Anne Mercer on lost opportunities and the weaknesses in the healthcare systems that the outbreak has laid bare. Now, the MPH@GW blog has kindly provided an infographic on the outbreak and its collateral damage.

Ebola-Public-Health-Crisis-IG