August 2024 Mongolia Trip Report
Aug 23 to Aug 30
Christian Friends of Korea, Hepatitis B Free and Global Care Partners
Mongolia’s hepatitis situation
Mongolia has one of the highest rates of hepatitis B and C globally with rates close to 10% (for both B and C) of the population. Hepatitis B is further complicated by high rates of coinfection with hepatitis D (HDV/delta virus), which is associated with a much more aggressive disease leading to accelerated disease progression and higher rates of liver cancer. Liver cancer remains the second most common cancer in Mongolia.
Ministry of Health has made significant progress with a national program, referred to as the Health Liver from 2016-2019, which was preceded by a National action Plan 2022-2025. These efforts have led to screening more than 50% of those aged >15 years, with many having already completed treatment for hepatitis C. Hepatitis B therapy is much more complex, with high rates of coinfection with HDV infection. The decision to treat is hampered by the need for long-term treatment along with the funding requirements. Further, when coinfection with hepatitis D is present, treating HDV may be the priority. Testing for HDV is even more complex and less readily available. Despite this, supported by the Ministry a small cohort of patients has been started on hepatitis D treatment in Mongolia.
Hepatitis B and C are different viruses, with distinct sources of infection and prevention strategies. Hepatitis B can be prevented by vaccination and treating high-risk pregnant women while hepatitis C is mostly transmitted through health care practices (particularly shared needles in the past) with higher rates in the older population. Both can lead to liver failure and liver cancer. Treatment for hepatitis B is much more complex, requires a clinical assessment as well as lab testing before embarking on long-term treatment. For over 60% of persons with hepatitis B and D coinfection, treatment is even more complicated and access is highly limited. Hence, there have been multiple barriers to introducing treatment. On the other hand, hepatitis C treatment is highly successful with a greater than 99% cure rate after 12 weeks of tablets for most people. Treatment programs for HCV have therefore been rolled out in many Mongolian provinces.
Despite the efforts of the Ministry of Health with support from NGO’s including FIRE and the Oman Liver Centre, there are significant gaps in care delivery. The nomadic nature of the people, the vast distances, lack of financial resources (for those without medical insurance), and poor access to care means that the most disadvantaged are unable to obtain treatment.
More than 20% of the people of Mongolia live below the poverty line, both in the urban and rural setting. The resettled nomads often live in the outer districts of Ulaanbaatar in Ger communities which are well defined. Health care at the primary level is provided by family clinics where members of the community (the most disadvantaged), have already been identified and can be targeted for priority intervention.
Christian Friends of Korea, Hepatitis B Free and Global Care Partners had the privilege to visit Mongolia to follow up the CFK visit earlier this year. A partnership with a Christian ministry in Erdernet is developing which offered the opportunity to visit the second most populous city in Mongolia (about 8-10 hrs by car from Ulaanbaatar). The Orkhon Province is serviced by the central Provincial Hospital which is the referral centre where patients are reviewed and assessed for hepatitis care, which remains highly centralized. A wide range of services are provided including care of patients with advanced liver disease (with endoscopy), surgery, cardiac catheterization as well as antental care. Liver cancer is referred to Ulaanbaatar. Erdernet also houses a number of prisons where health care gaps exist. Request for support was received from the prison warden and is under consideration on how this can be implemented.
Meetings in Ulaanbaatar focused on how our partners can support the national hepatitis program. This included engagement with the key players in the hepatitis/tuberculosis programs including the Ministry of Health and meeting with NGO’s including FIRE and the Oman Foundation. Ongoing exploration of potential partnerships is in progress.
One proposal is partnership with the Ministry of Health, with possible collaboration with the other key stakeholders in hepatitis care, to provide access to care for the most vulnerable populations. The current centralized approach requires that patients travel to the centre, often at the provincial level, at times over vast distances, to register and engage with tertiary level services in order to access treatment. Our program proposes an alternative decentralised model, in which care is provided at the family clinic level supported by community liaison support staff to ensure that follow up, ongoing adherence to treatment, and follow up are optimized. Where other critical needs are identified, efforts will be made to integrate other support to the hepatitis program.
This opens a unique opportunity to integrate both hepatitis as well as tuberculosis screening and linkage to care.
