Stopping the silent epidemic: my summer internship with the WHO
Saturday, September 24th, 2016
Viral hepatitis has been historically under-recognised and under-addressed in the global health community. This is despite causing a serious disease burden worldwide due to chronic liver disease, cirrhosis, and liver cancer. The World Health Organization (WHO) has been involved on a global and regional level in the response to the epidemics of hepatitis B and C. A summer internship with the WHO Regional Office in Manila provided insights into modelling techniques to estimate the disease burden and treatment strategies to combat this silent epidemic. With effective antiviral treatments to cure hepatitis C and suppress hepatitis B, the prevalence, complications, and high costs of these diseases can be dramatically reduced.
“Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity .” No prizes to guess whose definition of health this is (pun intended). You’ve probably recited it word-for-word at some point in your medical studies. We look to the World Health Organization (WHO) for leadership in global health. The WHO provides technical guidelines, responds to health and humanitarian emergencies, and advocates and coordinates engagement across health, policymakers, and civil society . What goes on behind the public face we see – the guidelines, press releases, and targets? How does the organisation operate on a global, regional, and country-level? How does the WHO respond to communicable threats such as polio, HIV, and viral hepatitis? What does it take in the quest to achieve the highest attainable quality of health for all?
Curious to understand and experience the well-oiled bureaucratic machine that is the WHO, and specifically to contribute in a small way to its response to viral hepatitis, I undertook a summer internship with the WHO at the Regional Office for the Western Pacific (WPRO). This Regional Office bridges Headquarters in Geneva and the 37 Member States under its care; a diverse belt of countries spanning down East and South-East Asia, the Pacific Islands, Australia, and New Zealand. For 8 weeks, I experienced life as an intern in the HIV, Hepatitis and Sexually Transmitted Infections Unit, within the Division of Communicable Diseases.
I also had a glimpse into life in Manila, the bustling metropolitan capital of the Philippines, where colonial powers and local revolutionaries have crossed for control of the island nation, and where for me, crossing the road proved to be a regular, life-threatening exercise. My first impression of Manila was stepping out of the airport into its balmy, honking embrace. From thereinafter I was accompanied in every waking moment by the cacophony of taxis, jeepneys, and motorcycles. There was not a moment of silence. Which, as it happens, is the exact opposite of the description of viral hepatitis.
The silent epidemic
Viral hepatitis is a silent epidemic in every sense of the word. The majority of people living with chronic infection, mostly hepatitis B and C, don’t know they have the disease. Left untreated, years of asymptomatic infection can lead to the deadly sequelae of liver cancer or cirrhosis. The dearth of testing services available also contributes to the “silence” around chronic hepatitis, especially in resource-limited areas where the highest burden lies. About half of the 218,000 people in Australia with hepatitis B aren’t aware they are infected . This is even higher globally, 70-80% in the United States and more than 90% in many Asian countries (except Japan) . In Europe, only 10-40% of people with hepatitis C are diagnosed . That is to say, there are those who are living with chronic hepatitis, those who know their infection status, and those who are receiving treatment. In between, there are broad gaps, disparities in testing and treatment across both higher and lower income countries.
Whilst viral hepatitis has been unrecognised in the past, its burden is substantial. Hepatitis B and C, the biggest contributors to mortality and morbidity from the group of diseases caused by hepatitis viruses, are endemic in parts of South East Asia, Sub Saharan Africa, and South America. The Western Pacific Region, which includes Australia, bears over a third of global mortality from hepatitis – this translates to 1500 deaths every day . Viral hepatitis is the seventh leading cause of mortality worldwide, according to the Global Burden of Disease Study in 2010 . The WHO estimates that 2 billion people – 1 in 3 people globally – have been exposed to hepatitis B during their lifetime . With 1.3 million deaths each year , the mortality from viral hepatitis is on par with those of better-known infectious diseases associated with poverty such as HIV, tuberculosis, and malaria.
Yet, in comparison to these conditions, hepatitis has received little to no public health and political attention. Of the 240 million people worldwide living with chronic hepatitis B , and the 80 million living with chronic hepatitis C , only a small proportion have access to life-saving antiviral treatment. Highly effective antiviral regimens are now available but high costs, local clinical trial requirements, import licensing, and a lack of drug procurement systems and treatment programs keep them out of reach for millions. Diagnostics and laboratory capacity are also challenging: hepatitis serology, DNA viral load testing, and liver function biochemistry are costly and not widely available.
How has WHO responded to combat this silent epidemic? In 2010, the World Health Assembly made a statement to the world in the form of a resolution on viral hepatitis (WHA63.18). This resolution urged member states to act through prevention, control, and management . This was followed by another resolution (WHA67.6) four years later calling for more rigorous technical guidance and strategies linked to measurable targets . In the Western Pacific Region, there has been significant progress over the last decade, especially in vaccination. Supporting immunisation programmes for the birth dose and triple dose, as well as catch-up vaccination, has helped to reduce childhood prevalence of hepatitis B. Global hepatitis B vaccination coverage reached 82% in 2014, and over 90% in the WHO Region of the Americas and the Western Pacific Region . Indeed, as of January 2016, 13 of the 20 countries in the Western Pacific Region had achieved the target of less than 1% hepatitis B childhood prevalence by 2017. This has substantial public health benefits: from 2011–2020, hepatitis immunisation efforts in 73 countries are estimated to avert a total of 4.9 million deaths .
Whilst prevention through immunisation has laid important groundwork, the next challenge and opportunities lie in upscaling treatment. With the advent of new, highly effective antiviral medications that can cure hepatitis C and control hepatitis B, we are reaching a new tipping point in the response to viral hepatitis. The transition to inclusion of treatment in public health programmes is both logical and necessary.
More recently, the Sustainable Development Goals (SDGs), adopted by the United Nations in 2015, calls for the elimination of hepatitis in goal 3.3: “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases .” Whilst only committing to ‘combat’ and not to end the scourge of viral hepatitis, this is still in progress: hepatitis did not receive even a mention in the Millennium Development Goals (MDGs) . Part of the reason why hepatitis was not included in the MDGs was the misconception that its global burden was not as significant. Contrary, whilst the burden was high, there was limited research demonstrating prevalence and incidence, and also the link between viral hepatitis and liver cancer . This was compounded by inclusion of only acute hepatitis, which accounts for only a minor proportion of mortality from viral hepatitis, and not including deaths from liver cancer and cirrhosis that were related to hepatitis B or C . The SDGs present a new opportunity for public health, clinicians, policymakers, and civil society to galvanise behind the cause towards the goal of eliminating viral hepatitis. It is a promising step in the right direction, but much more is needed to tackle the epidemic.
What if? Modelling future disease burden of hepatitis
Understanding the enemy is one important facet of the response. Analysing the current burden of hepatitis, predicting future trends, and implementing prevention and treatment strategies to reduce morbidity and mortality are part of the solutions. In public health terms, this may typically start with gathering surveillance data. However, the underreported and underserviced nature of viral hepatitis has resulted in limited national data in many severely affected countries. Whilst addressing these issues in surveillance is a priority, alternate methods must be used in the interim to build the epidemiological picture of hepatitis in each country.
Disease burden modelling is successfully being used to estimate disease burden of hepatitis B and C and propose public health strategies for countries across the Western Pacific Region. The methodology uses a mathematical model created and operated by the Center for Disease Analysis (CDA) in the United States, responsible for hepatitis disease burden analysis in over 65 countries worldwide . The model simulates a country’s populations (using baseline demographic statistics) and develops a baseline picture of the burden of hepatitis (using local epidemiological information), and also the costs of diagnostics and treatment. It then predicts the future trends in prevalence, complications, and mortality using the natural history of hepatitis through stages of fibrosis to cirrhosis, liver cancer, and death/liver transplantation. The information is drawn from a variety of sources including national surveys and surveillance data (where available), hospital data, unpublished studies, and local clinician consensus. As such, the process is always a collaborative effort between the CDA, local health authorities, researchers, and clinicians, as well as the WHO.
Once a baseline picture of prevalence and future disease burden is established, the model simulates various treatment strategies. It is important to emphasise that the the focus is on upscaling treatment, as many countries are on track with immunisation, however, older populations with high rates of asymptomatic carriers will be at future risk of disease and death if left untreated. The strategies may involve starting treatment programmes where none have previously existed, or replacing older antivirals with new highly effective regimens. The treatment ‘scenarios’ can be also be goal-driven, for example by increasing treatment to reduce mortality, or to achieve elimination of hepatitis by 2030. By simulating these treatment strategies, the model can predict how many lives can be saved by diagnosing and treating more people for their disease.
The disease burden analysis, together with economic analysis, transforms the case into an advocacy tool to present to policymakers. Whilst the economic analysis involves various processes, one noteworthy financing strategy (not unique to hepatitis treatment programmes) is the use of public-private co-payment. This is where the costs of treatment are shared between the public health budget, health insurance (for example, in the social security budget), and the individual patient. This is modelled at a rate that ensures that patients are able to afford care and treatment without being sent into impoverishment due to catastrophic health expenditure. The cost-effectiveness – even cost-saving – outcomes of these treatment strategies makes a strong case for investment. The reality is that treating complications of cirrhosis and cancer is very expensive. In addition to medical costs is the loss of productivity of a substantial amount of the working population, due to years lived with chronic, disabling illness. Treating earlier not only saves lives, but minimises the population progressing to those end-stage complications. The message has been clear: treating now saves lives.
Before my internship with the WHO, I was somewhat apprehensive and sceptical about the practical impact of “epidemiology” and “policy” in public health, and specifically, global health contexts. On some level I knew they were important, but their tangible effect was a mystery. Coming away from this experience, I realise that epidemiology and disease burden modelling have a specific and powerful role in bridging the divide between public health challenges and ways for policy-makers to enact change. Presented in the right way, data becomes a case for investment, which if solidified as policy and action, can transform millions of lives through treatment and other public health measures.
Whilst at times I felt swallowed up within the intense WHO environment, I learnt a lot about the structure of the organisation and gained an appreciation for the amount of ongoing work required to keep it going. One can also feel disillusioned by the constant stream of meetings and seemingly menial details in editing and chasing publications, a sentiment shared by many an intern. Whilst my contribution during the internship was minor in the grand scheme of things, it was incredibly humbling to have a small but tangible role to play in the emerging field of hepatitis with the WPRO. I was able to meet clinicians and public health professionals dedicated to reducing the burden of hepatitis in the Philippines, the Western Pacific, and globally. This was both from day-to-day work at the WPRO as well as during a technical advisory meeting in Ha Noi, Viet Nam where experts met to discuss current challenges and strategies affecting the region. The experience showed me in ways I had never known about the impact of hepatitis on people’s lives, as well as on entire populations. I left without a doubt as to the absolute necessity of the world to listen and act. We are starting to break the silence around viral hepatitis, but it can’t stop there. Much more needs to be done if we are ever to end the epidemic and ensure that no one need suffer from this preventable disease.
The WHO offers internships from 6 – 12 weeks in duration in a variety of locations worldwide. See the website for more details http://www.who.int/employment/internship/interns/en/.
The author wishes to acknowledge the support and guidance of WPRO HIV, Hepatitis, and STI Unit, particularly Dr Nick Walsh who supervised and mentored her through the internship.
Conflicts of interest
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