By Dr Alex Lampen-Smith | Posted: Monday September 24, 2018
In 2015 the World Health Organisation (WHO) outlined the goal of removing viral hepatitis (B and C) as a public health threat by 2030
Specifically, this includes reducing new infections by 90 percent, diagnosing 90 percent of people with viral hepatitis, reducing mortality by 65 percent and treating 80 percent of eligible persons. New Zealand is one of 196 countries that are signatories of this initiative.
On July 27 this year AbbVie convened a Hepatitis C Summit as a forum to highlight the fundamental need for New Zealand to develop a Hepatitis C National Action Plan, in order to achieve the World Health Organisation goal to eliminate HCV by 2030. This cross-sector collaborative event was attended by approximately 150 participants with broad representation from across the New Zealand health sector. The agenda and presentations were determined by the sector-lead Summit Steering Committee. The members of which came from primary and secondary care, nursing, Maori health, Pacific health, pharmacy, needle exchange, laboratory, CADS and a philosophy, law and ethics expert.
Dr Homie Razavi, an international epidemiology expert from the Centre for Disease Analysis in Colorado, presented his modelling for the cost of care of people living with hepatitis C with and without any change in current practice. Including the costs of case finding +/- national screening, under optimistic (where cheaper diagnostic prices can be negotiated) and conservative cost models. The need for a national registry was also discussed and modelling addressing this was presented. Without a registry there are increased costs due to duplicate testing and the inability to monitor tracking towards achieving elimination. However, even taking that into account, screening and pan-genotypic treatment for everyone is, at worst, cost-neutral and, at best cost-saving (if diagnostic prices can be negotiated and a registry put in place).
If we do nothing it will cost more lives and dollars.
If we do something it will save lives and cost less.
Dr Catherine Stedman, of the Canterbury District Health Board, presented the strategic requirements for New Zealand to reach elimination targets. Kathryn Leafe, Executive Director of Needle Exchange NZ, presented the perspective of the vulnerable members of our community who are injecting drugs. Stigma is an ongoing issue. Current injecting drug use is not a contra-indication to DAA treatment and harm reduction policies and capabilities need to be upscaled. Dr Arlo Upton, from the Southern Community Laboratory, discussed the not insignificant issues at the laboratory interface and Prof Tim Dare discussed legal, ethical and privacy issues.
Minister of Health the Hon Dr David Clark attended briefly and spoke. He indicated the government is motivated to work towards elimination targets. The ministry recognises more work needs to be done in the health system to improve equity. Dr Clark referenced the health and disability sector review that is underway. Regarding hepatitis C, he reiterated the issue of stigma and the role of peer lead diagnosis and treatment and emphasised that partnerships are important, in particular amongst secondary and primary care, CADS and needle exchange. He acknowledged the ministry personnel present and said he looked forward to hearing the solutions and strategies the sector would identify.
At the recent Australasian Viral Hepatitis Conference, which the NZSG and the Hepatitis Foundation of NZ (HFNZ) sponsored, I was asked to present New Zealand’s position as we head towards the 2030 elimination targets. Regarding hepatitis C I presented the eight requirements, as discussed at the Hepatitis C Summit as ‘the eight pillars’.
Recent announcements from Pharmac regarding the proposal to fund the pan-genotypic Maviret, and the advertising campaign the Health Promotion Agency is preparing for launch, indicate we are meeting two of the requirements, but many others are only happening locally, piecemeal or not at all. The big-ticket items – a registry, national screening programme, monitoring and funding – must be delivered by central government. It is my opinion and that of HFNZ and some members of the steering committee that we have a long way to go.
On a brighter note, I am cautiously optimistic New Zealand can achieve the elimination targets for hepatitis B. Pharmac has lifted prescribing restrictions for entecavir and tenofovir, which will remove barriers to care for people who have difficulty accessing specialist hospital-based clinic appointments. The HFNZ has drafted a Framework for Action. This document, as well as population modelling from Dr Razavi, has been presented to the Ministry of Health, which will lead ongoing development of this work. We hope the Ministry will develop it into New Zealand’s first national strategy for hepatitis B.
Recently HFNZ has completely modernised its data and software systems. The dramatically enhanced capability means we now have a highly efficient monitoring system and national registry rolled into one. The increased interoperability with third parties will improve linkage to care for patients from diagnosis in the community, monitoring and advice for treatment in primary care or via referral to secondary care.
At the macro level, interoperability with Statistics NZ and mesh block data will allow identification of areas of suspected high prevalence for increased case finding. Advanced data analysis will allow accurate evaluation of our progress as we move towards 2030 elimination targets. We have 25,000 people in our programme and hope to increase those numbers; it is estimated 100,000 people in New Zealand are affected by hepatitis B.
Over the three-day viral hepatitis conference two prevalent themes emerged. Firstly, the role of partnerships was evident, with many projects owing their success to positive and productive partnerships between health care professionals, academics, indigenous groups, peers (persons with lived experience of the condition) and community workers. Outcomes indicate that the lived experience of the people affected must be central to any strategy considered. Secondly local and international speakers emphasised the need for quality data to guide clinical programmes and their evaluation.
Those affected with hepatitis B and C come from minority and disadvantaged groups in our society. No one size fits all. The challenge for hospital-based clinicians, such as ourselves, is to participate in novel ways to deliver health care.