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Eliminating hepatitis from the Eastern Mediterranean Region

Editorial

Mahmoud Fikri¹

¹Regional Director, WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt.

As we mark World Hepatitis Day on 28 July, our attention naturally focuses on the relentless battle to eliminate viral hepatitis from populations suffering under the heavy toll of this communicable disease. The theme for World Hepatitis Day this year is “Eliminate Hepatitis”. Currently an estimated 325 million people worldwide are living with chronic hepatitis B or hepatitis C virus infection. In 2015 alone, viral hepatitis caused 1.34 million deaths, while 1.75 million people were newly infected with hepatitis C (1). It would appear on the face of it that eliminating hepatitis is an insurmountable task, but substantial attention and resources have been directed to promoting hepatitis prevention and treatment, and with heartening results.

The Eastern Mediterranean Region (EMR) continues to have the highest prevalence of viral hepatitis C globally. WHO estimates that more than 15 million people in the Region are currently chronically infected with hepatitis C, and 21 million with hepatitis B (1). 80% of the regional burden of these infections lies in Egypt and Pakistan (1). Unfortunately, many people in the Region acquire hepatitis B and C in the place where they least expect it, namely health care settings due to sub-optimal infection control and prevention, unsafe injection practices and inadequately screened blood transfusions. Mother-to-child transmission is the primary cause of hepatitis B among children (2). Furthermore, many people who are at risk of HIV are also at risk of hepatitis B and C infections, due to high-risk sexual practices or shared syringes and paraphernalia by people who inject drugs.

The World Health Organization (WHO) has given special priority to hepatitis B and C prevention, diagnosis and treatment, both at the regional and global levels. Following a resolution adopted at the 67th session of the World Health Assembly (3). WHO developed the Global Health Sector Strategy for Viral Hepatitis. This strategy is rooted in the global commitment to the Sustainable Development Goals (SDGs) and to universal health coverage, and sets out a vision towards eliminating viral hepatitis globally by 2030, and potentially avert 7.1 million deaths (4,5). To guide implementation of the Global Health Sector Strategy within the Eastern Mediterranean Region, a Regional Action Plan for the hepatitis response was developed as part the EMR Roadmap 2017–2021 (6,7). Resolution EM/RC63/R.1 urges EMR Member States to develop or update national plans of action in line with the regional action plan (8).

The vision, goal and targets of the Regional Action Plan are aligned with those of the Global Strategy. Accordingly, the vision is “An Eastern Mediterranean Region free of new hepatitis infections and where people living with chronic hepatitis have access to affordable and effective prevention, care and treatment” (6). Five core viral hepatitis interventions, i.e. hepatitis B vaccination (including birth dose); injection safety; blood safety; harm reduction services for people who inject drugs; and treatment of chronic hepatitis infection, are essential to achieve the elimination of viral hepatitis B and C (9).

In this respect, it is important to acknowledge the efforts of Member States in the Region. Within the span of around 2 years, over 1 million people in Egypt have been treated with direct-acting antivirals for hepatitis C. In addition, a number of other countries with varied endemicity levels have set up their multi-sectoral strategies to address viral hepatitis aiming at eliminating viral hepatitis B and C by 2030.

Furthermore, the successful price negotiation and generic licensing agreements between the ministries of health and the pharmaceutical industry resulted in major price reductions making medicines more affordable. For example, in Egypt the price for a 28-day supply of generic sofosbuvir was as low as US$ 51 in 2016. In Morocco, the price for a 28-day supply of a generic formulation of daclatasvir dropped to US$ 120, and down to US$ 7 in Egypt in 2016 (9). Similarly in Pakistan, the price of 28-day supply of sofosbuvir through generic companies has reached as low as US$ 15 (9). These prices are substantially below the originator prices in low-income countries and the price in high and upper-middle income countries that fall outside the generic licensing agreements.

Nevertheless, weaknesses remain in the hepatitis responses of several regional Member States. Blood transfusion safety, infection control and prevention as well as injection safety continue to face many challenges in countries like Somalia, Yemen, and Pakistan (1). In several countries, birth-dose vaccination against hepatitis B is either not adopted or implemented at a low coverage level. Although harm reduction services for people who inject drugs are well established in the Islamic Republic of Iran, such services still remain at a very low scale in most countries of the Region (1).

WHO continues to support and work closely with Member States and other partners to implement and scale up all interventions for viral hepatitis control. This includes providing birth-dose vaccination against hepatitis B, enhancing prevention strategies and ensuring equitable access to quality diagnosis and treatment, until hepatitis is eliminated from the Region. As we observe World Hepatitis Day, it is reassuring to know that real progress is being made to prevent and control hepatitis and that many lives can be saved.