Gulf Cooperation Council states: On the brink of HBV elimination.

Abstract

The global health sector strategy (GHSS) on viral hepatitis 2016-20211 set the stage for bold action to eliminate the hepatitis B virus (HBV) and hepatitis C virus (HCV) as public health threats by 2030. The strategy provided a roadmap setting out tangible targets on diagnosis, prevention and treatment. Recently, the World Health Assembly approved the development of a new global health sector strategy on viral hepatitis for 2022-2030. The new strategy comes at a critical time as countries need to make a strong push to eliminate HBV and HBC by 2030. Despite substantial progress, numerous challenges remain to HBV elimination across policy and practice.2 Here, we reflect on the successes and challenges towards HBV elimination in the six Gulf Cooperation Council (GCC) states: Bahrain, Kuwait, Oman, Qatar, the Kingdom of Saudi Arabia (KSA) and the United Arab Emirates (UAE). We also set out how the new health sector strategy can drive the field towards achieving the 2030 targets. At the turn of the twenty-first century, GCC states had high to medium endemicity of HBV. Over the following decades the burden fell, and in 2016 the prevalence of HBsAg in the Middle East and North Africa region was estimated at 2.1% (1.6-2.6). Within GCC states the prevalence varied; Bahrain and the UAE had the lowest estimated prevalence at around 1%, while Oman had the highest at 2.5%.3 Successful HBV vaccination programmes have driven much of the progress. GCC countries incorporated the HBV vaccine into their national immunisation programmes around 1990-1991, with progressive increases in the coverage over time. Data from the World Health Organization (WHO) vaccine monitoring system show that in recent years over 90% of children received an HBV birth-dose and the required three doses of HBV vaccine before the age of 5 years in all six GCC states.4 The viral hepatitis GHSS set the target of reducing the incidence of new cases of HBV by 30% between 2015 and 2020 and 90% by 2030, the latter being equivalent to a prevalence of 0.1% HBsAg among children.1 GCC states have already taken great strides to meet this target and in 2016, Bahrain, Kuwait, KSA and UAE had already achieved the goal, while Oman and Qatar had a prevalence of 0.2%.3 Despite successes in driving down the prevalence of HBV in GCC states, numerous challenges remain to its elimination, from a lack of resourcing to the absence of national and regional disease registries. Here we outline three priorities for achieving the goal of HBV elimination in GCC states by 2030. A lack of public knowledge of HBV and the social stigma associated with the condition have been long-standing barriers to elimination. Recently we engaged YouGov to conduct an online survey exploring public knowledge and perspectives of HBV amongst 1003 people in the KSA (698 Saudi, 305 expatriates) and 1022 in the UAE (118 Emirati, 904 expatriates). The survey employed a close-ended self-administered quantitative questionnaire in both English and Arabic. Just over half of the people surveyed in both countries were aware of HBV, while around a quarter knew that HBV results in serious health consequences. Less than 1 in 5 people reported knowing how HBV can be transmitted or prevented (Table 1). The lack of knowledge around HBV, including on the risk factors and consequences of the disease, coupled with social stigma which prevents people from seeking advice and care, present major barriers for diagnosing people and linking them to care. Globally, only 10% of people living with chronic HBV are diagnosed, and only 22% of these receive treatment.5 In the GCC states, in 2016 the percentage of people with HBV who received a diagnosis varied from 18% in Qatar to 3% in Bahrain and the UAE.3 United Arab Emirates n (%)a Kingdom of Saudi Arabia n (%)b Increasing the general public's awareness and knowledge and tackling social stigma should be at the centre of efforts to scale up prevention programmes and improve HBV diagnosis and treatment. Targeted approaches, including in high-risk groups for transmission, are likely to be most effective. Yet, in GCC states, policies and strategies focusing on vulnerable or marginalised groups, including people who inject drugs, remain suboptimal.6 These challenges are not limited to the Gulf region. In Europe, WHO policy recommendations targeting the most vulnerable are less requently in place and where they are in place, are more often poorly implemented.7 Sustained efforts to increase awareness and improve knowledge, including HBV risk factors and the consequences of chronic liver disease, will be important. These efforts must be directed not just to the community at large, but also towards primary care physicians. At-risk groups should also be prioritised for health education, including on the benefits of screening.2 Continuing education programs and awareness campaigns are important, as well as the development and adaptation of regional clinical practice guidelines.8 The role of primary care physicians, the implementation of community-based initiatives and the role of civil society in HBV education, prevention, diagnosis and management are also key considerations. The new WHO strategy should reflect the need to employ an equity lens to all HBV programmes, from public health policies to prevention, diagnosis and treatment. Building trust among impacted communities and providing opportunities for them to engage in the development of programmes for their own benefit will be key to achieving sustained impact. All stakeholders play a critical role, from government institutions, clinicians and professional associations to the private sector and civil society. In most countries, however, there is limited engagement between stakeholders or platforms for coordinating activities.6 Strengthened coordination and communication mechanisms will enable different actors to work together toward achieving shared goals. New criteria from the WHO will assist countries to validate the impact and programmatic targets set out in the GHSS. Knowledge sharing initiatives between countries can also help to ensure best practices are replicated. Reducing the burden of HBV will also require improving how people living with HBV access services along the care cascade. Receiving a diagnosis is one of the most critical steps in a patient's journey. Health professionals need to use clear, non-stigmatizing language to explain the diagnosis and set out the management plan. Continuity of care enables a patient to build a trusting relationship with their physician. The YouGov survey asked respondents how important it is for patients to express their views during different stages of their care (Table 2). Most respondents thought it was very, or somewhat important to express their views when starting or stopping a treatment, when treatment may impact their social life or when the condition is stigmatising. The results highlight the need for care providers to create space for patients to engage in critical discussions regarding decision-making processes. Point-of-care diagnostics and linkage to care following diagnosis are challenges in the Gulf, as is ensuring patients remain in care. Previous efforts to simplify models of care for HCV can deem useful models for HBV.9 The role of allied health professions, such as counsellors, should also be considered as they play an important role in helping patients to adjust to the realities of long-term treatment. Patient monitoring is an often-overlooked aspect of long-term care but is critical in HBV management; improved systems that track patients along the care pathway will help to maintain continuity of care and ensure better outcomes. Finally, integrating HBV into the continuing medical education of all health providers who will engage with HBV risk populations can help to ensure consistent quality care across the health system. While GCC states have succeeded in driving down the prevalence of HBV, particularly among children, it is important to recognise the fragility of these gains. The COVID-19 pandemic has highlighted the vulnerability of health systems with disruption to services presenting very real risks for people requiring long-term chronic disease management. There is emerging evidence of disruptions to routine childhood immunisations in GCC states which directly threaten recent progress on HBV and other vaccine-preventable diseases.10 The impact of this is likely to be uneven. Prior to the pandemic, HBV vaccination coverage in GCC states was suboptimal among the most at-risk populations.6 Now, more than ever, all stakeholders must work towards establishing and strengthening policies and strategies that directly meet the needs of the most vulnerable and ensure optimal clinical care by, for example, reducing late diagnosis. As the burden of COVID-19 subsides, health systems will face enormous challenges to address the backlog of unmet needs, including missed routine vaccinations. We urge countries to take immediate steps to develop plans and strategies to minimising the impact of healthcare disruptions, ensuring that future generations do not suffer needlessly from vaccine-preventable conditions such as HBV. In many countries, HBV elimination is a distant reality,2 yet after decades of progress GCC states are on the brink of achieving this goal. The final step in the journey may prove the hardest yet, but with continued commitment from all stakeholders an HBV-free future is a real possibility. HEM reports receiving consulting fees from ISGlobal related to this work. The remaining authors report no relevant conflict of interest. The data are available upon request from the corresponding author.