No country has eliminated viral hepatitis yet, but all eyes are on Pacific island country Niue as they attempt to reach this ambitious goal through the “Cure-a-Country” viral hepatitis elimination programme.
Niue, a tiny island nation located in the South Pacific, is home to about 1600 people. The country’s small population count has placed them in a unique position to demonstrate the possibility of eliminating viral hepatitis as a public health threat, led by Niue’s Ministry of Social Services and the Health Department together with partners.
“The Niue Health Department started this programme in 2019 in partnership with Global Health New Zealand and Otago University,” explained Dr Edgar Akau’ola, Niue’s Chief Medical Officer and Director of Health. “Our target population was those who were above 18 years old – 900 adults out of the total population in Niue.”
Multiple partners came together to support the initiative. Non-government organization Global Health New Zealand contributed resources and commodities for the programme, the University of Otago provided technical support and a knowledge survey, and the World Health Organization (WHO) provided further advice and supported coordination with the Health Department.
“Many people, when they hear something is a new idea, or means being the first in the world to do something, will shy away and wait for someone else. But in Niue they listened, saw the opportunity and showed great leadership,” said Hazel Heal, Global Health New Zealand Co-Founder and herself a survivor of hepatitis C.
L-R: Global Health New Zealand Co-Founder Hazel Heal, Director of Health Dr Edgar Akau’ola, and Director-General for the Ministry of Social Services Mrs Gaylene Tasmania. Note that Niue is one of the only countries in the world to have never experienced a case of COVID-19. Photo supplied by Hazel Heal.
Hepatitis B and C are inflammation in the liver caused by viruses. Both hepatitis B and C can result in serious lifelong disease including liver cirrhosis and liver cancer, or even death.
“Viral hepatitis is an emerging priority in the Pacific as many countries have high burden of chronic hepatitis B, sometimes up to 1 in 5 people infected and most are unaware of their infection. Earlier treatment can reduce progression of disease and development of liver cirrhosis and liver cancer,” explained Dr Mark Jacobs, Director of Pacific Technical Support and WHO Representative to the South Pacific.
WHO has been working with partners to scale up the national comprehensive hepatitis response in Pacific island countries and territories, such as in Niue, Fiji, Kiribati, Solomon Islands, Tonga, and Vanuatu. In 2016, WHO and its Members States globally agreed on a roadmap to eliminate viral hepatitis B and C as a public health problem by reducing new hepatitis infections by 90% and deaths by 65% by 2030.
To make the vision of hepatitis elimination a reality in Niue, the plan involved widescale testing of their target population, engaging and communicating with communities to make them aware about the initiative, providing treatment where needed, and implementing an ethics-approved study.
However, during the planning and coordination for the “Cure-a-Country” viral hepatitis elimination programme, the COVID-19 pandemic hit. The pandemic disrupted their well-laid plans.
“Initially we wanted to travel to Niue, bring doctors and nurses and run testing days, because we did not want to be extractive or demanding of the limited health staff resources. The closed borders meant this was impossible,” explained Hazel of Global Health New Zealand.
The Health Department team in charge of the hepatitis elimination programme. Photo: Niue Health Department
Instead, the Niue government and partners redesigned their plan and resources were added to support in-country capacity, which enabled the government to begin the programme including the vital part of offering hepatitis testing.
But as they organized the testing, they faced another obstacle: “Another challenge we faced was people in the eligible age group did not turn up for the screening,” said Dr Edgar.
The government of Niue and its partners creatively turned this challenge into an opportunity by leveraging pandemic preparedness efforts to widen their reach.
“During the rolling out of our COVID-19 vaccination programme, we used that opportunity to screen those that missed out before when they came in for their vaccination. We completed 857 tests out of 900 and found only 8 positive hepatitis B cases and no hepatitis C cases.” shared Dr Edgar.
“By the time of the second vaccination dose, they were able to run testing alongside vaccination rollout, a wonderful achievement and an efficiency that could be repeated in other nations. Over 90% of the over 18 population had been rapid tested for both hepatitis B and C by World Hepatitis Day, 28 July 2021, a world first,” explained Hazel. “The redesigned plan, empowering the local health team to carry out the testing is in fact much more repeatable, a real demonstration of what can be done throughout the Pacific.”
The eight individuals who tested positive – making up 1% of the eligible population screened – will be provided with treatment and care by the government and its partners.
“We are working closely with our partners to treat these 8 positive cases; all expenses covered by our partners. We can’t thank them enough for this because Niue Health does not yet have the resources and funding for this project,” added Dr Edgar.
To bring their goal to the finish line, Niue’s Health Department is working closely with partners to seek validation of elimination of viral hepatitis as a public health problem in the country. WHO has shared interim guidance for country validation for hepatitis elimination and will support Niue in the process.
“With the right commitment, creativity, and support from partners, Niue is now on track to reach the goal of eliminating viral hepatitis. Their all-out national effort for the hepatitis elimination initiative during the pandemic is commendable and something that other Pacific island countries can potentially replicate,” said Dr Jacobs. “We look forward to working with the Niue government in the validation of elimination of hepatitis B and C in the country.”