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Treat Patients with Life-Saving Hepatitis B Meds

by Hepatitis B Free
Treat Patients with Life-Saving Hepatitis B Meds

Hepatitis B Free Project Report.  August, 2019.

Our volunteers continued their work across the Pacific during the past 3 months and we are happy to report the progress that has been made.  With your support and generous donations anti-viral medications purchased by Hepatitis B Free have been shipped to Fiji and Papua New Guinea.

Vanuatu and Fiji.  Dr. Alice Lee visited the island nation of Vanuatu in July to explore the implementation of a hepatitis B treatment program with members of the Ministry of Health.  There appears to be enthusiasm for a new program in Vanuatu, and we are investigating grant opportunities. Dr. Lee continued on to Fiji where she delivered a number of lectures to local physicians.  Anti-viral medications that were purchased by Hepatitis B Free have arrived and patients will soon be started on treatment.

Kiribati.  In July, Sue Huntley and Aidan Foy went on their second trip this year to Kiribati.  They were happy to meet the new Hepatitis Project Officer. They found that a number of their recommendations from the previous trip had been adopted, including increasing hepatitis clinic time and the addition of a dedicated hepatitis clinic nurse.  The clinics that they attended were functioning smoothly, and more patients have been referred for treatment. The trip corresponded to World Hepatitis Day, and the Kiribati Health Promotions Department organized activities including health fairs in which hepatitis information booklets were distributed, question and answer sessions were conducted, and point of care hepatitis testing was performed.  Patients testing positive were referred to the hepatitis clinic for treatment.

Sue and Aidan were able to visit one of the neighboring islands, Abiang, for the first time.  It is about two hours by speed boat from the main island of Tarawa. They evaluated the health care facilities on the island to see if a hepatitis B treatment program can be supported in the outer islands.  The local health care providers are very enthusiastic about starting such a project. 

Papua New Guinea.  We were pleased to have an infectious disease physician from the United Kingdom, Dr. Luke Mair, spend three months volunteering in Popondetta.  He was an extremely valuable asset to both the local clinics and to Popondetta General Hospital. Shortly after Luke left PNG, anti-viral medications purchased by Hepatitis B Free arrived in-country, and patients who have already been screened will be started on life-saving therapy.  A return trip by our volunteers is scheduled for later this year.

North Korea.  Drs. Alice and Lee and David Hilmers will be traveling to North Korea in October to continue the work of Hepatitis B Free there.  We currently are working in clinics in five different cities and have nearly 2000 patients on therapy with more being added on each trip.

Once again we thank you for your tremendous support of our work.  We can see the difference that your generous contributions are making in the lives of those to whom we reach.

May 20-22, 2019

Written by Dr Alice Lee on behalf of trip team Drs Alice Lee, David Hilmers & Thao Lam.

The HOPE C project in Yangon is about to be completed. One hundred ninety-three patients have started hepatitis C treatment, with 18 remaining to start at Myanmar Liver Foundation (MLF). There are enough medicines left to treat 40 people. With this first cohort of patients about to finish, we have been asking, what next for the program? This is where Putao comes in. Putao, Myanmar had been proposed by MAM (Medical Action Myanmar) as a potential site to expand our work in hepatitis C treatment.

Putao is a city in the northernmost part of Myanmar, only accessible by air. It is home to 60,000 people, who are mostly farmers, miners and mountain herb gatherers. It is cold in winter and surrounded by mountains. MAM have worked in Putao since 2012, where they provide care for a community, many of whom are “persons who inject drugs” (PWID). This region has one of the highest rates of PWID in Myanmar. There is no hepatitis treatment here, and the closest treatment centre is more than 14 hours away by bus.

Thao, David and I arrived in Yangon on Saturday 18th May. At 5:30 am the next day, we went back to the airport to fly to Putao with Dr. Thet Myat, the hepatitis program officer at MAM. This was also her first trip to Putao. It was a four-hour flight with two twenty-minute stops along the way. We worked on the talks for the day and tidied up our laptops. I tried to mentally prepare for what needed to be done. I needed to get a good handle on this, have realistic expectations and develop some relationships.Putao represents many challenges. First, we needed to assess whether it was feasible to work here. But at the same time, is this not why we organized Hepatitis B Free in the first place? -- to work in areas where it seems too hard, whatever the reason may be and to help those who are least likely to get help.

Putao felt immediately different from Yangon. China is to the east, and India to the west, a 7 day walk over land and 6 hours or so by car to the other side. I was told that there are no real check points at the border, but the soldiers on the Indian border will shoot to kill. We were met by customs officers who scrutinised our passports. We need special government permission to be anywhere but in the town. We were picked up by the program medical coordinator in Putao. (This is his fifth day on the job). We checked into a local hotel and made our way to the MAM office where we were greeted enthusiastically by the Medical Director and the Organisational Director. They came to Putao ahead of us with the Global Fund audit team. We get to know each other and plan the one and a half precious days we have here so as to make the most out of our time.

We arrive at the MAM clinic and are met by a very young but enthusiastic group of doctors. The success of a new hepatitis program will rely on them. These doctors come from all over Myanmar, the most junior having graduated only 2 months prior and the most senior 4 years ago. We spend the afternoon chatting and getting to know each other. They are excited to have us here. David runs a hands-on ultrasound training session, with local doctors as models. There is a palpable excitement in their desire to learn, quickly replacing my reservations about the youth of the group.

The clinic lies at the end of a long driveway of dirt and gravel. Chickens roam freely. There is a needle exchange box at the entrance of the driveway; gates are closed for security; the staff house on the left has laundry hanging over the fence and wherever there is space. It seems fitting for a house for young men. The clinic has two medical and two counselling/consulting rooms, a dispensing area, a waiting room, reception, a data room, a lab, and a kitchen. Apart from the ultrasound, there is a small nebulizer, one sphygmomanometer and a small pulse oximeter. The doctors would like a little more. This is the better equipped of the two MAM clinics.

We had dinner with Ye Aung, Thet Myat and Yan Lin Aung at the dining pavilion at the hotel. We sit in a hexagonal room with a bar at one end, one of just two tables of people in the restaurant. Deer heads feature in the centre, looming over the drinks. The menu includes dried venison, and lots of garlic, onions, chillies and salt on top of piles of white rice. Discussions bounce between sharing stories of our journeys to date, what we would like to do here and the challenges that lie ahead. I don’t imagine for a moment that any of us sitting together are naïve as to the task that lies before us. I am reminded of the goal of Hepatitis B Free – to help and provide services where it seems impossible. Putao seems like the perfect fit.

The next day we start with a local breakfast of noodle soup, sticky rice, toast, “two in one” (tea, coffee and powdered sugar/milk), and walnuts. At the opposite end of the dining hall is a team from Canada here to train local pastors. Christianity is the most common religion in this area – many cross the border to India to study, then return to set up a church. Some villages have more than 2 churches.

Our first stop is the methadone clinic at the Putao hospital. It is nothing more than a small stand-alone building with 3 small spaces, including a waiting room, consult room and a dispensary. Two ladies in uniform sit behind a barred window and dispense cups of methadone. More than 200 people come each day. In just 30 minutes, at least 10 people come by, mostly on bike to collect their daily dose. No fuss. Next door is the back entrance to the hospital, a square building surrounding a central courtyard. We glimpse into the wards and see the windows without glass frames, metal beds with minimal bedding, and no flow of air. Patients are lying on their beds, and some have a person sitting nearby, presumably a caretaker. In one corner of the hospital, the doctor rounds with the nurses. Otherwise, it is a quiet area with very little activity.

We make a short visit to the lab. The power is unreliable and there is little here, rapid tests remain the basis of most laboratory assessments. Machines including fridges are plugged in, but none are on and most are empty. One patient waits in the corner, the kindly lab technician looks on as we walk around. The ART clinic is one room with a curtained space for consults with the doctor and a table with the meds for dispensing. Discrimination and privacy are not major concerns here.

We head to the MCB clinic, about a 30-minute ride from the hospital. Two physicians ride ahead of us on their motorbikes – the deputy project medical officer and the preventative doctor – and three ride in the back of the car with the back wagon flipped down. David offers to ride in the back but we know it is useless. It is unusually hot and humid today. There are mountains every direction we look, green pastures and lots of cows. There is little traffic, just the occasional truck, army vehicle, car or motor bike.

Waiting for us at the MCB clinic is the team leader doctor, who has just graduated two months ago from medical school. He now leads a clinic that cares for over 1000 patients and also covers the nearby hospital when the local township medical officer is away. Sleeping in a room on the second floor of the clinic, his job is his life. He must look forward to the weekends when he can head back to the main clinic to socialize (drink and smoke) with his fellow medics from clinic #1. Despite his seemingly extreme youth and inexperience, he had identified a young 24-year old woman who came to his clinic soon after giving birth to her second baby with abdominal pain, low grade fever and a mass. Local physicians had diagnosed a liver cancer based on ultrasound findings, and he wanted us to review her case. Her husband was a PWID, and she was found to have a positive hepatitis C antibody test, but otherwise she was well. She was back to her usual routine, attending to the farm and caring for her two young children, one now 2 months old. Hearing her story, examining her and completing an ultrasound, we wanted her diagnosis to be anything but a liver cancer, but an alternative diagnosis seemed less and less likely. With no blood tests, no pathology, no other imaging, we needed to come up with a reasonable action plan. As best as we could, we tried to explain what we thought. Her response was unexpectedly calm, without hysteria or tears, simply, “I would prefer it out of me if possible.” We all hoped this would be possible. However, the reality was that we needed to do further tests and at best, if she could have an operation, it would cost over $1000 USD. This was well beyond anything that was within her family’s reach. A 24 year-old lady with a possible life-saving intervention at that price….we thought. MAM would have a policy and we needed to ensure that we were not crossing boundaries.

In the afternoon we travelled down the main road and off a short dirt track to a village. MAM signs and a needle sharing box identified our destination, a simple structure with a palm roof, bamboo floors and windows framed with colourful cotton curtains. It was both home and clinic to the community health workers (CHW) who had been providing first-line care to her village for nearly two years, and she lived here with her three children and husband. PWIDs come to the clinic for needle exchange and general health needs. Her main concerns are that the needles are not returned and that they steal her chickens. We promised to look into that. Outside we saw just one chicken roaming around with her chicks. Three patients were invited to come and share their story. The first was a 34-year old opium turned heroin addict who has now been abstinent for 5 months. He tested positive for HIV and HCV. He was unaware of his status, but happy that he can support his family. He would do whatever the doctors recommended to stay well. The next two were women, both hepatitis B positive. The first lady had three children, all under the age of six, and her husband is a PWID. She gave birth in hospital, and her baby was vaccinated. The second women was found to be hepatitis B positive before the delivery of her youngest baby – one of five children. Although she delivered in the village, her baby received the birth dose hepatitis B vaccine. Having been advised of its value, her husband took the baby to the hospital within 24 hours of delivery to have their first dose. However, none of her children nor her husband have been tested.

There is much to do in Putao, and a lot of it is very simple. Sitting on the floor of the clinic room, in a circle with the local doctors, my head spun in a million and one directions, trying to process it all and form a strategy. I felt a sense of familiarity in this space, so similar to Papua New Guinea in its physicality, but different in people and culture. The team was waiting back at the main clinic at the promise of a training session. The heat was finally subsiding, replaced by wind and a sudden welcome downpour. We narrowly escaped getting soaked. The projector was set up in the waiting area, wooden benches lined in row, an open-air teaching space against the backdrop of tall bamboo trees. Over the next two hours, eyes were glued to the projector, and despite my computer screen blacking out with power cuts, the doctors interrupted with questions along the way and not a single head nodded off in a nap. I am pleased to share what I can and wished we had more time together. As we closed the session, we wanted to encourage and say that we will do whatever we can. I wanted them to know that they are not alone in this. We promised to train and be back, no matter what, and this promise we know we can keep. I just hope that some of these doctors will still be here.

Hepatitis B Free Team in Popondetta, PNG
Hepatitis B Free Team in Popondetta, PNG

We would like to thank you for your continued support and update you on the latest activities of Hepatitis B Free.  As you can see below, our team of volunteers has been very active in several countries.

Myanmar

One of our team members, Carrie Lee, spent a month in Myanmar at one of our clinical sites as a rotating medical student.  Hepatitis C virus (HCV) infection is a major public health issue in Myanmar, affecting 2.65% of the population. New medications for HCV called directly acting antivirals (DAA) can cure up to 95% of people with HCV and with minimal side effects. However, in Myanmar these treatments have not been widely available to date.  Hepatitis B Free has been a partner in a treatment program for 200 people in the city of Yangon with local NGOs – Medical Action Myanmar and Myanmar Liver Foundation – since 2017 with these new DAA medications.  In December 2018 Carrie spent four weeks at Medical Action Myanmar learning about this HCV project. MAM is dedicated to providing healthcare for the most vulnerable people in Myanmar and specializes in HIV treatment and care.  Carrie says that she has been involved with the HCV project from a distance for some time, so it was rewarding for her to see how the project ran in real life as well as seeing the impact it is having on the lives of individuals. She was able to sit with the doctors and see patients at various stages of treatment, from diagnosis, the middle of treatment, and the end of treatment. One patient shared his story about how he became infected with HCV following a car accident seven years ago. It was the middle of the night and he needed an urgent blood transfusion, but with none immediately available, one of the doctors donated his own blood – unfortunately without time to screen the blood for blood borne viruses. The patient expressed his concerns about his family, and his relief that he received treatment at MAM for no cost and with no side effects. Sadly, this is a common story for people in countries with limited blood bank screening.  Carrie also worked on a report about the HCV program that was submitted to the Myanmar Ministry of Health in January 2019. Hepatitis B Free is currently working with MAM staff to explore expanding HCV treatment to other, more remote, regions of Myanmar.

North Korea (DPRK)

Due to sanctions and changes in US State Department policies, our team has been unable to travel to the DPRK for the past six months.  Fortunately, the State Department gave approval to our American partners to travel, and we plan to return to North Korea for 8 days in late March.  Currently, there are over 1200 patients on life-saving treatment for hepatitis B and many more should be added on the upcoming trip.  Additionally, we will be opening a fourth clinic and initiating plans for a fifth one.  Through a generous donation we have been able to obtain funding for a GeneXpert machine which will give us the capability to measure hepatitis B and C viral load.  This will greatly improve our diagnostic capabilities and allow us to treat hepatitis C as well as B.  It will potentially give us the ability to treat hepatitis B-infected pregnant women in order to reduce the risk of passing the virus to their babies.

Kiribati

Work continues in Kiribati despite the absence of some key local personnel due to maternity leave and illness.  We now have nearly 100 patients on treatment.  We are pleased to have a new volunteer, Dr. Aidan Foy, join Hepatitis B Free.  Aidan is an experienced gastroenterologist who has a special interest in working in Kiribati.  He will travel in late March with one of our board of directors, Sue Huntley, to provide training, see patients, and give administrative support to the local team.

Papua New Guinea (PNG)

In February three team members went to PNG to train local health professionals, identify patients to start treatment for hepatitis B, and to finalize arrangements for the delivery of hepatitis B medications.  Thirty-six patients with chronic hepatitis were seen and labs drawn.  Approximately ten of these will need to be started on treatment.  Clinics were set up at Popondetta General Hospital and Siroga Clinic, and lead physicians have been designated.  Team members met with the governor of Oro Province, members of Parliament, and the CEO of New Britain Palm Oil Company, and we are hopeful after these meetings that there will be sustained funding of the project with expansion in the future.  We also are welcoming a new Hepatitis B Free volunteer from the UK, Dr. Luke Mair, who will spend 3 months at Popondetta, working in clinics and leading efforts on a study to determine the prevalence of hepatitis B in the province.

Once again, we thank you for your contributions to our efforts.  There is much to be done, and we are anxious to expand our efforts into other countries, such as the Solomon Islands.  Please let others know about our organization and our efforts to combat this deadly disease.

Happy holidays to our supporters, donors and friends,

 

We would like to thank you for your support and dedication to Hepatitis B Free this year.  Each one of you has played an important role in the success of our program this year.

Through your generosity we have been able to start hundreds of new patients on life-saving therapy for hepatitis, to continue training programs for health professionals, and to initiate national treatment programs in several new countries.  Our teams of volunteers have traveled every month to the countries we have served and provide education on a weekly basis through teleconferencing.

Attached is an article published in a medical journal describing our work in North Korea.

We wish you a joyous holiday season and a prosperous 2019!

Warmest regards,

The Hepatitis B Free Team

 


Attachments:
September 2018, DPRK (Hepatitis B Free & CFK)
September 2018, DPRK (Hepatitis B Free & CFK)

We continue to be grateful for the efforts of those who support our cause of eradicating hepatitis. We are pleased to provide an update on our programs with some new successes to report and continued challenges in other areas.

North Korea (DPRK)

One of our team members, Sue Huntley, travelled to the DPRK in September for the scheduled quarterly visit. The treatment program continues to enrol new patients with hepatitis B, and over 1200 individuals are now receiving life-saving therapy.

A new challenge to our efforts was the US State Department’s refusal to grant exemptions to the travel ban to the DPRK for any humanitarian organization beginning in October. Thus, American members of Hepatitis B Free and our US partners were denied permission to travel to the DPRK for the scheduled November visit. We are hopeful that this ban on humanitarian aid will soon be lifted, and we ask your assistance in expressing your concern to legislators over this policy.

A scholarly paper which describes our DPRK program was published online in the journal Gut and Liver in September.

Fiji

We are pleased to announce that a national program of hepatitis B treatment is beginning. This represents the culmination of several years of hard work on the part of HBF. Two members of the team are currently in Fiji to train local providers and to support local government health officials as this program gets underway.

Kiribati

We see steady progress in the hepatitis B treatment program in Kiribati. Turnover in local medical personnel and a lack of resources always provide challenges in these remote islands. After a successful visit in August, two members of the team are travelling to Kiribati this week for training and patient care. Regular training also takes place through teleconferencing.

Papua New Guinea (PNG)

Another significant advance to report is the approval of a hepatitis B treatment program in the Oro District in PNG. Government endorsement of the project, acquisition of drugs at a discounted price, identification of supporting clinics, and laboratory support have all been achieved. As soon as an import license is approved, treatment with antivirals can begin. The first training session of local providers was accomplished by HBF last week through teleconference. We are hopeful that the drugs will arrive, and patients will start treatment during the first quarter of 2019. A team from HBF will travel to PNG to support the rollout of the program at that time.

Myanmar

Two members of the team will travel to Yangon in December to provide technical support and patient care for patients co-infected with hepatitis C and HIV. Our partners on this project Medical Action Myanmar (MAM) have done an outstanding job of providing patient care, detailed documentation, and management of medications.

FibroTouch

A welcome addition to our clinical capabilities was the provision of a FibroTouch transient elastography machine by HI SKY corporation from Beijing, China. This device is more portable and lighter than our current equipment, and, best of all, is battery operated. This will expand our capabilities to test for liver fibrosis and cirrhosis.

We are excited about the prospects for the coming year and thank each one of you for your support and encouragement!

The Hepatitis B Free Team

Photo credit: Christian Friends of Korea (2018)

Seeing patients in DPRK
Seeing patients in DPRK

Links:

 

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Organization Information

Hepatitis B Free

Location: Linley Point - Australia
Website:
Facebook: Facebook Page
Twitter: @hepatitisbfree
Project Leader:
Alice Lee
Linley Point, Australia
$33,775 raised of $95,000 goal
 
132 donations
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