December 2023 Kiribati Trip Report
07-20 December 2023
HBF team: Sue Huntley and Thomas Russell
Local team support: MHMS Executive, Department Heads, and Administration Staff
The primary goal of the trip was to:
Evaluate program to date, ways to improve, support and expand with particular focus on: Prevention of Mother to Child program, expansion of the hepatitis treatment program (test and treat) to the outer islands and ongoing adherence for those on treatment.
Better understand and negotiate a pathway for the evaluation and assessment of patient with coinfection with hepatitis D, utilizing the data available from testing done by VIDRL.
A summary of the key discussions/findings is listed below:
DFAT – met with High Commissioner Karen Bray, and members of the local team. Discussions included current trip expectations, a summary of achievements for 2023 and future planning for 2024.
WHO – Met with Country team leader Wendy Snowdon. A summary of this visit and primary goals outlined. Wendy outlined WHO and local key challenges including supply chain as well as addition freight costs related to the remote setting
PEARL – Met with Jeremy Hill, discussions on the current process for screening and upcoming EPIC Program. The projected number of patients that would result from additional screening would equate to an additional 40-50 patients per year being referred to existing hepatitis services at the main hospital.
MHMS – Met with Department Heads from Laboratory Services, Medical Information, Pharmacy and Hepatitis Clinic staff.
Laboratory Services, Rosemary Tekoaua – discussions on VIDRL HDV results. Key items to match test results to patients to allow linkage to care by accurately identifying those with coinfection and ensuring assessment. Outcome: assistance offered to identify and supply details for reconciliation of results.
Medical Information Services, Kantaake Corbett – offered services of staff to assist with reconciliation of existing data against clinic lists. Worked closely with Tibwataake Baiteke to confirmation information and accurate numbers of those seen in clinic and outer islands.
Pharmacy Services, Moannara Benete – review of ordering process and requirements for projected number of patients for 2024. The cost of medications was included and introduction emails to companies who HBF uses was offered and accepted.
Hepatitis Clinic, Atataa Binataake – Current workload for this role is currently covered by 1 full time staff member who also covers infection control. The hepatitis program coordinator role remains vacant (since Mid-2023). It is clearly not possible for one staff to complete all the tasks in managing the hepatitis clinic. These issues were highlighted and discussed with the MHMS.
MSF – Program lead Alison Jones reached out to HBF to share current goals of programs and continue open communication channels. Thomas Russell and Sue Huntley met with MSF Field officer Sue and Project Medical Coordinator Misato who outlined current project and how it has evolved from the initial country presence for COVID to now assisting with maternity project on Tarawa and outer islands. They are working with MHMS to include all of Kiribati in the program which will initially be trailed for 2 years with assessments. Where relevant, hepatitis programs (particularly antenatal screening for hepatitis B and linkage to care) pathways will be strengthened between the organizations and communication ongoing.
Hepatitis B program assessment, identifying key gaps and potential solutions and support by HBF.
Challenges:
Health Care Worker Capacity – one person cannot do it all
Challenges in adherence to antiviral therapy. Since the commencement of the program, more than 700 patients have started on therapy. At present, only 171 continue to regularly attend clinic for assessment, review and ongoing medical therapy.
Regular follow up of patients who are hepatitis B positive but not on treatment is not being done. A list of patients who have tested positive is not available for recall (and even if available, there is inadequate resources to make this happen). Some of these patients will need treatment and are at risk of disease progression.
Pregnant women – large number of births and not many referrals. What is available to follow up post-delivery to babies with vaccination and testing of babies at 9-12 months. Explore better pathways for linkage to care for positive mothers and follow up after delivery.
HDV – data clean up under way, with the primary goals of ensuring that all patients who are coinfected are linked to care.
Cost of medications through existing contracts with MHMS (current costs are more than HBF costs)
Vaccination of MHMS staff (not consistently undertaken)
HBF technical support follow up (still remains adhoc).
Suggested solution:
Fill Program Coordinator position
Add a second full time nurse to assist increased referrals from the EPIC program.
Expansion of the hepatitis clinic. Review the clinic model with upskilling of nursing staff so assessments can be made by clinic nurses (nurse lead clinics in addition to doctor’s clinics) who are assessing patients and doctor reviews can be tailored to meet the need.
Follow up of patients who have been treated and encourage them to return to clinic for assessment. Additional support for adherence (community champions to be identified- supported and trained)
Follow up of patients who have tested positive for HBsAg and who need to return to clinic for assessment. (collate all results and ensure that access to results by key staff is made available)
Follow up of those who commenced treatment post-delivery and assess if babies can be booked in for POC testing for HBsAg at 9-12 months. All women will need follow up either way.
Review of VIDRL data of patients who have tested positive for HDV and if they have attended the hepatitis clinic. If not, refer to Hepatitis clinic for assessment and possible treatment.
Introduction to other reputable pharmaceutical companies who meet the Good Manufacturing Practice guidelines – completed during visit with Introduction emails to Viatris, Hetero and Stride, cc Acting Chief Pharmacist.
All MHMS staff to be screened and offered vaccination in line with WHO recommendation of 3 injections for vaccination. A register to be kept so it can be followed through for all staff approached. Add testing for HBsAb to ensure that protective titres have been achieved.
HBF to attend Hepatitis Task Force quarterly meeting via Zoom. Sue Huntley offered to send out invitation so this could be achieved
Training session – A DFAT/WHO/SPC training session was held for South Tarawa Medical Assistances, RMO and Public Health Nurses, Program Nurses and Pharmacists attended. This was positively received by all who attended. The comprehensive program was delivered primarily by Thomas Russell, supported by Sue Huntley. It was deemed to be a program that could be run on a biannual program as a refresher and or initial delivery. Training for medical officers was also undertaken. This will require ongoing support also.
Conclusion: The above item identified under point 6 & 7 was presented at the Exit Meeting. It was acknowledged that although gaps were identified, the ongoing support of DFAT, MHMS and WHO was vital for the program for it to continue to expand and become robust.
All parties were thanked for their assistance and support.
