Myanmar has a population of 51 million people. A recent national survey estimated that 3.5 million people are living with hepatitis B and another 1.1. million are living with hepatitis C. The country faces some major challenges in providing adequate screening and treatment for hepatitis.
- Lack of resources
Hepatitis services are seriously under-resourced. This is a particular problem in the public sector, in which only six hepatologists work. There is no public budget for hepatitis C therapy. Standard imaging is available, including ultrasound and CT scan. However, there are few qualified radiologists in Myanmar and there is no MRI available in the public system. Liver biopsies are not routinely done and antenatal screening is not available.
The private sector offers better services but it is usually US$5-10 for a single consultation. In the private sector, lab services support basic biochemistry, haematology and serology for viral hepatitis. Viral load and genotype is also available, costing up to US$200 for genotype. Even the rapid point of care testing kits (US 50 cents-$2) and liver function tests (around US$20 each) used to diagnose hepatitis are significant expenses for most of the population, whose average income is less than US$50 per month.
- Availability of drugs
For hepatitis C, the availability of drugs is a significant barrier to treatment. Only sofosbuvir is currently registered in Myanmar; no other hepatitis C drugs are registered. There is access to generic Harvoni (ledipasvir/sofosbuvir) and daclastavir via the black market, with uncertain product quality. Sofosbuvir is US$300 per month, Harvoni US$500 per month and daclastavir US$150 per month. These prices are inaccessible to the majority of the population.
Most of the antiviral therapies for hepatitis B are available in Myanmar and have been registered. They range in cost from US$5 for lamivudine and around US$20 for tenofovir or entecavir. Nevertheless, these are imported generics from India, and hence the effectiveness and purity of these agents is not well-established.
- National vaccination programs
Although the childhood hepatitis B vaccination programme has been implemented for 10 years, including birth doses where possible, there are challenges to implementation. There is likely low coverage of the birth dose, particularly in the rural setting where cold chain may not be available. In addition, there are no current national policies or vaccination programmes for high risk groups including health care workers, catch up programmes for children, vaccination of those with HIV, and those living in institutions such as orphanages.
- Individual vaccinations
Vaccines cost around US$5-10 per dose and hence are out of the budget for most of the population. Some hospitals have offered ad hoc vaccinations for doctors and nurses at various time points, but most other hospitals remain unvaccinated. Although many NGOs provide a free screening test and some provide vaccination, scope for this is limited by costs.
- Immunisation programs
A range of immunisation programmes are currently being implemented using privately donated funds; however, the capacity of these projects is limited due to the high costs of vaccines and testing kits. Other NGOs, such as Medical Action Myanmar (MAM), continue to screen and where appropriate provide vaccines. These efforts are also limited due to the significant costs of the tests kits and vaccines in a setting of limited funding and competing needs.
During our most recent trip to Myanmar, Hepatitis B Free took part in teaching, investigative and collaborative work to assess the situation of hepatitis in Myanmar and lay the groundwork for future programs.
Dr Alice Lee gave lectures to about 100 people, delivered hands-on endoscopy training, ward rounds and case discussions, and talked with colorectal surgeons and hepatology professors to further understand current needs in both the public and private sectors. We also held discussions focused on the needs and status of hepatitis programs with the Myanmar Liver Foundation (MLF), which has provided over 100 000 vaccinations to date, and Medical Action Myanmar (MAM), an NGO with strong programs in HIV and malaria. There is strong potential for future collaboration with both organisations.
In the short-term, Hepatitis B Free plans to study the effect of vaccine delivery outside of the cold chain, and to bring together local NGOs to deliver effective screening and treatment for hepatitis. We hope to collaborate with MLF and MAM to test and vaccinate at-risk groups: those with HIV, children in orphanages, children attending MAM clinics and health care workers.
We plan to engage with local partners to establish and support training modules and resource development for both government and non-government hepatologists; gastroenterologists and other relevant specialists; primary health care providers, nurses including community health workers, midwives, traditional birth attendants; and the general public. We will facilitate training and resource development for Endoscopic Retrograde Cholangopancreatography (ERCP), radio frequency ablation and liver biopsies.
We will also advocate for changes to primary prevention using screening and vaccination.
Test kits: We will advocate for the global community and relevant partners to provide access to rapid point of care tests that are more affordable. The majority of the work done by WHO is undertaken using the Alere Kits, which cost up to US$2 per test.
Vaccines: We will advocate for access to cheaper vaccines to immunise at-risk populations, in line with the aims of the WHO Global Vaccine Action Plan 2011- 2010. Vaccines procured by UNICEF are as low as US 30 cents but are not currently available for purchase by NGOs without the collaboration of the Ministry of Health in Myanmar.
Treatment: We will continue to assist local partners to establish locally relevant guidelines for treatment of hepatitis B and C. Dialogue is already underway with local partnerships and with pharmaceutical companies.
Internationally: We will explore opportunities and facilitate access to more affordable antiviral therapy for hepatitis B and C, such as the Gilead scheme reference. We also hope to explore and advocate for cost- appropriate lab services with international partners and facilitate technical resources and expertise.
Research: We hope to support research activities and provide resources and technical expertise in the design, execution and publication of locally relevant studies.