•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!