An understanding of the silent disease burden in Indonesia and recommendations that can offer potential guidance for policymakers in countries throughout the region and around the world to eliminate the virus.
by Dr Jack Wallace
Viral hepatitis is a devastating public health issue and unlike HIV, malaria or tuberculosis, global deaths continue to rise.
In 2015, an estimated 325 million people worldwide were living with chronic hepatitis B or hepatitis C infection; however, only 11 percent of people infected have been tested and are aware of their status. Due to the lack of symptoms caused by the infection, as well as poor public awareness and a lack of healthcare infrastructure, people who are chronically infected are often diagnosed when it is too late – when they start to get symptoms which occur when liver failure, cirrhosis or liver cancer has developed. Viral hepatitis is an issue that disproportionally affects Asia-Pacific with the majority - up to 64 percent - of global deaths due to viral hepatitis occurring in this region.
Viral hepatitis is a significant public health issue in Indonesia, the world’s fourth most populous country, with around 19 million people infected with hepatitis B and 2.5 million infected with hepatitis C. The number of deaths are still increasing from both infections. More people in Asia-Pacific die as a result of viral hepatitis than the number of people dying from HIV, tuberculosis and malaria combined; however, up until now, hepatitis has lacked the same levels of awareness and political momentum which are critical to eliminating the infections.
Indonesia has played a major role in raising awareness of viral hepatitis as a global health threat. Indonesia’s leading role in addressing the global health burden of hepatitis is illustrated by the country being a co-sponsor of the WHO resolution that called for the comprehensive prevention of hepatitis by all member states and created the annual World Hepatitis Day in 2010. It is observed on 28 July every year. Indonesia should be credited for its national response by significantly improving access to health services through the implementation of a national medical insurance scheme. Nevertheless, the nation continues to be significantly challenged by the disease. Policy implementation faces several obstacles, further complicated by the nation’s geographic and cultural spread over 17,500 islands as well as its economic context.
Because of Indonesia’s unique challenges and global involvement, the country was a natural choice for CEVHAP’s first situation analysis report which describes ways that could assist Indonesia in achieving elimination of viral hepatitis by 2030. The report was done alongside Jonathan Scrutton and Dr Suzanne Wait. The key issues in Indonesia that will either assist or impede the country’s ability to achieve the WHO and CEVHAP elimination goals were looked at. While the report provides an extensive understanding of the disease burden in the country and recommendations presented are tailored specifically to maximise results in Indonesia, they also offer potential guidance for policymakers in countries throughout the region and around the world. The elimination of the virus in this island nation by 2030 is achievable, but only through concerted action and by addressing gaps in preventive care, testing and community engagement.
Overall, awareness and access to hepatitis testing remain problematic in Indonesia. It has been estimated that, at most, only 10 percent of the infected Indonesian population are aware of their infection, so the big challenge is identifying people who are at risk of developing liver disease, and ensuring these people have access to effective medical care. The availability of tests for people to find out if they are infected with viral hepatitis varies dramatically depending on where they live, and, even when physical access is not an issue, the cost of diagnostic tests act as a significant barrier to diagnosis.
Indonesia also needs to increase health spending to better address preventative care, instead of principally providing curative services. In 2014 for example, it was estimated that just 6.6 percent of total health expenditure went to prevention and public health services, despite acknowledging that prevention is much cheaper than cure. Specifically, for viral hepatitis, there is limited availability of specialists to treat hepatitis B or hepatitis C with under 200 clinical specialists mostly located in the west of the country, which is a key concern.
Several middle-income countries, like Indonesia, are also no longer eligible for international aid or access programmes from pharmaceutical companies. This adds to the challenge and has a knock-on effect on what medications governments can reimburse or subsidise for people living with hepatitis. The report also highlights that there can be social implications related to being infected with viral hepatitis, and this needs far greater attention. More community engagement and research are required to overcome stigma, misconceptions about the condition and discrimination against people living with the infection.
Despite these challenges and concerns, there is hope that elimination of viral hepatitis is achievable in Indonesia through concerted action and by addressing key gaps, using the structure of the Global Health Sector Strategy for Viral Hepatitis. These gaps include:
- Information for focused action — – A distinct evidence based national hepatitis strategy, paired with a robust strategic information system to ensure policies to improve prevention and care are based on up-to-date data.
- Interventions for impact — – An essential benefits —package of viral hepatitis interventions, services, medicines and commodities clearly defined at the national level, to ensure greater equity in quality of care across the country.
- Delivering for equity — – Comprehensive interventions aimed at vulnerable populations who may be at higher risk of infection, and existing models of service delivery adapted to meet their needs.
- Financing for sustainability — – A mechanism to cover the —cost of diagnostic tests for the general population, as well as treatment and longer-term monitoring and care.
- Innovation for acceleration — – New innovative approaches —to improve the efficiency and quality of services and maximise impact.
The potential for eliminating hepatitis B and hepatitis C has never been greater. A readily available and effective vaccine exists for hepatitis B, and the number of new hepatitis B infections has been gradually decreasing as a result of the effective implementation of the vaccination – although there are gaps within this programme in Indonesia which need to be addressed. Additionally, while there is currently no vaccine against hepatitis C, its treatment has been revolutionised by the development of direct-acting antivirals (DAAs), which can now cure the disease in most people within months. The Indonesian government funded DAAs for 6,000 patients in 2017.
The Indonesian government led in advocating for a comprehensive global response to viral hepatitis. This leadership, through the development and coordination of a partnership between government, clinical and public health specialists, research and particularly organisations representing the people most affected by viral hepatitis, is required to eradicate viral hepatitis within Indonesia. The CEVHAP report highlights the need for urgent action and urge the government to consider the recommendations made by CEVHAP’s report, so that the country eliminates viral hepatitis as a public health threat by 2030.
Not only would taking urgent action provide relief to many Indonesians, it would cut down on long-term costs and set an example for fellow markets in the Asia-Pacific region. There is a clear and urgent need to find, test and treat the missing millions suffering from this terrible infection. Let us do what is needed to eliminate viral hepatitis.
Dr Jack Wallace is a senior research officer at Burnet Institute, Melbourne, Australia and an executive and founding member of the Coalition to Eradicate Viral Hepatitis in Asia Pacific (CEVHAP).