Oct 2024 Hepatitis B Free & Australian Doctors for Africa Trip Report
30 September to 12 October
HBF (Alice Lee, David Hilmers and Sue Huntley) accompanied ADFA (lead by Digby Cullen) returning to Madagascar for the second time to continue support for the hepatitis B program. Previous discussions during the 2023 visit concluded with a proposal for a pilot study in the Prevention of Mother to Child Transmission (PMTCT) in Antananarivo. Progression has been difficult due to staff changes/shortages.
The main goal of this return trip was to determine HBF/ADFA could support potential gaps in Madagascar’s hepatitis programs. ADFA’s well established partnerships throughout the country provided the networking opportunities to faciliate this.
Travelling by road (14 hrs), avoiding pot holes of various sizes, large vehicles converging from opposite directions on narrow roads, Zebus and pedestrians, we arrived at Fianarantsoa where Prof Helio, Dr Faly and his team warmly welcomed us. After 4 days of meetings and site visits, a way forward was proposed. Site visits included:
Centre Hospitalier Universitaire Andrainjato. Activities at this teaching hospital included direct patient care (consultations, endoscopy, Fibroscan, and ultrasound), lectures, and development of a pilot project in collaboration with hospital staff.
Regional Health Director for Finanarantsoa. A presentation of the pilot project was made with hearty endorsement of the serosurvey and advised to seek approval from Ministry of Health for the PMTCT.
Obstetrician at the Finanarantsoa Maternity Hospital. Collaboration with obstetricians will be essential in order to include pregnant women who present for antenatal care and delivery to this hospital. The program was discussed with hospital staff.
CSB 1 and 2. This is the designation for local clinics where antenatal care is performed and well-child visits occur for vaccinations. These clinics will be a focal point for hepatitis B testing of mothers and their children.
President of the Midwives Associations. The majority of antenatal care and deliveries are performed by midwives. Their contribution of testing women early in their pregnancy and referring them for antiviral prophylaxis will be a critical part of the PMTCT. The team was encouraged by their enthusiastic response.
PIVOT. This is a US-based organization that has been providing health care support to communities in the region. Having made previous efforts with PMTCT, they were valuable partners in advising on potential pathways of procuring supplies as well as challenges/solutions. There is hope to collaborate at a later date with open lines of communication planned.
Under the leadership of Professor Helio and Dr. Faly, a local hepatitis B program team, including a physician and 2 support nurses, was formed. A pilot, demonstration project focused on integration and decentralisation will be at the core of this partnership.
After return by auto to Antananarivo, the team flew to Toamasina to visit the hospital of Professor Tovo and his program partners. Activities included visits to:
Centre Hospitalier Universitaire Morafeno. Activities at this teaching hospital included direct patient care (consultations, endoscopy, Fibroscan, and ultrasound), lectures, and discussions about pilot projects. In addition to hepatitis B serosurveys, there is consideration for a hepatitis C treatment program in which patients presenting for endoscopy at the hospital would be tested for hepatitis C antibody. The use of the hospital’s GeneXpert machine for hepatitis C viral load will be explored (currently under the tuberculosis program). Acquisition and importation of low-cost, pan-genotype antivirals could lead to a significant reduction in hepatitis C cases. Preoperative screening for hepatitis and C is standard of care and data in the private labs (where tests are done), is being sought.
Tomasina Maternity Hospital (CHU Anala Kininina). The team met with the obstetrician (Dr Rivo) and head midwive. This hospital manages about 3000 deliveries each year. Many of the patients are sent from local clinics for complicated pregnancies and often arrive near term and without hepatitis B testing. Twenty-three women tested positiveover the past 16 months for hepatitis B, but the total number tested was unknown. Positive mothers are advised to self fund birth dose vaccine or purchase antiviral therapy. Babies born to positive mothers are followed up by paediatricians. A small number are able to fund this. Most are untested. Agreement was reached that there is an urgent need to address gaps in hepatitis care. Paediatrician (Prof Todisoa will also be engaged.
Regional Director (Toamasina). The director who attended the hospital to site the new endoscopy services was supportive and keen to support the hepatitis program under the advise of Prof Tovo.
Mercy Ship. While in Toamasina, the team was given a tour of a Mercy Ship anchored in harbor. Work done there was impressive.
Returning to Antananarivo, meetings included those with:
Director of Communicable Diseases. The proposed pilot projects were presented. Discussion included mention of a serosurvey program that is being rolled out in Madagascar to determine the prevalence of HIV and syphilis in pregnant women. Over 20,000 women are expected to be enrolled. Funding is being sought to include hepatitis B testing but has yet to be secured. A data management system is being established to include provision of tablets and a centralized data base that will record results from across the country. It is anticipated that blood samples will be stored in a central repository, and these samples could be tested for hepatitis B at a later date.
WHO (Dr. Richard Mbumba Ngimbi). Personnel at the Antananarivo WHO office have been actively supporting work on integrating birth dose hepatitis B vaccines into the national immunization schedule. They are also supporting epidemiological studies. They report discussions with GAVI about acquiring vaccines have begun. They were in agreement with the proposed pilot, demonstraton project on PMTCT.
Professor Luc Samison (head of the University Lab- Merieux foundation supported). Fruitful discussions ensued concerning possible collaboration with laboratory support including viral load testing of hepatitis B positive pregnant women. Dr. Samison has a PhD student whose thesis topic will be hepatitis B. They have the capability to perform viral load testing using classic PCR techniques but are currently performing a limited number of samples using GeneXpert. Donating the hepatitis B GeneXpert cartridges would potentially reduce costs (less customs tax). A tour of their impressive BSL 2+ laboratory facility was given.
Pasteur Institute Director Voahangy. A possible collaboration (in vaccine procurement) in social sciences research was briefly discussed whilst attending the conference on schistosomiasis.
Ministry of Health departments (Ministry of Public Health Ambohidahy Antananarivo). Listed below are those in attendance *. This meeting provided an opportunity to better understand the current hepatitis program as delineated in the recently endorsed National Hepatitis Strategic Plan, the application to introduce birth dose hepatitis B vaccination, and seroprevalence studies. The Ministry stated that their potential partners include GAVI, CDC Africa, the Egyptian government, the Hepatitis Fund, USAID, and European agencies. The following proposals were presented to the Ministry of Health:
A pilot demonstration for PMTCT, using a central and decentralized model of care, to be undertaken at the capital and in two regional sites (Fianarantsoa and Toamasina). The proposed project will provide free testing of all pregnant women, antiviral therapy for those found to be positive for PMTCT, birth dose hepatitis B vaccine for all babies, and testing of babies born to positive mothers. These projects will help guide the rollout of a national program and pathways to access test kits, vaccines and medications. Staff upskilling and capacity building will be concomitantly developed.
Seroprevalence studies of women who have children under the age of 5 will be rolled out. The target population will be women who present for post natal care, those bringing their children in for childhood vaccinations, or those presenting at delivery. For mothers who test positive, their children aged 9 months to 5 years will also be tested. This will help to estimate the transmission rate of hepatitis.
Serosurvey of women presenting for delivery at CHU Anala Kininina will be offered followed by testing infants born to positive mothers. A record of self selecte interventions (including birth dose vaccine and antiviral treatment) will be made.
After discussion, the Ministry of Health requested a signed ‘convention’ or framework before a formal endorsement of the pilot studies can be given. It was emphasized that all components of the proposed studies are consistent with the goals outlined in the National Hepatitis Strategic Plan.
We hope that through these activities, a pathway to ignite hepatitis B care can be paved. There will be multiple challenges, many competing priorities and severely limited resources, but the will is strong to implement these proposals and achieve the goals of the National Hepatitis Strategic Plan. We were encouraged by the enthusiasm expressed at all levels, from the Ministry of Health officials to the mum fearful to test her children due to the possibility of a positive result to the sick who are dying from the consequences of this insidious disease.
Attendees at the Ministry of Health meeting
Doctor Ramarolahy Rija Director General of Healthcare Provision (DGFS)
Doctor Rakotonavalona Rivomalala Director General of Preventive Medicine (DGMP)
Doctor Andriamino Brusa Director of Communicable Diseases
Doctor Tsivahiny Paubert, Director of the Expanded Program on Immunization
Doctor Rajaonarivony Virginie Head of the Viral Hepatitis Program
Doctor Nely Alphonse José Head of the Communicable Diseases Department
Professor Alice Lee Director of Hepatitis B Free
Professor David Hilmers Chief Medical Officer of Hepatitis B Free
Doctor Digby Cullen Member of Australian Doctors for Africa
Doctor Ralaizanaka Faly, Gastroenterologist, CHU Andrainjato Fianarantsoa
Doctor Rakotozafindrabe Rina, Gastroenterologist, CHUJR Befelatanana
Professor Razafimahefa Helio Gastroenterologist, CHU Andrainjato Fianarantsoa
