A. Hepatitis B assessments among the Tibetan refugee population
Hepatitis B, in the form of Chronic Hepatitis B infection and its complications (i.e. liver damage and liver cancer), continues to place a heavy burden on the Tibetan Community in Exile. A rapid qualitative assessment was carried out in Ladakh in collaboration with University of Rochester and University of Hawaii. The study results included cultural notions of Hepatitis B around diet, transmission and alcohol, genetics and that people with Hepatitis B infrequently report stigma. The findings and the recommendations should help us to design behavioural change communication programs. A Hepatitis B prevalence survey, which was done at Bylakuppe settlement in 2014 with the help of Johns Hopkins University, revealed that the household prevalence was 11.9% (common prevalence of 8.9% for household, monastery, and school). The Hepatitis B screening during antenatal (pregnant women) visits from 12 Tibetan settlements (2007 – 2013) showed a prevalence of 8.82%. Among the TB patients registered in the seven hospitals of DoH-CTA between 2012 and 2015, the Hepatitis B prevalence was 8.0 % (104/1306). The prevalence of Hepatitis B is categorised into low (<2%), medium (2%-7%) and high (=>8%) endemicity. To learn more about these assessment reports, Please go through http://tibetanhealth.org/reports/
In a high endemic setting, Hepatitis B virus is most commonly spread from mother to child at birth, or from person to person in early childhood. “National strategies to prevent perinatal transmission should include providing Hepatitis B vaccine at birth i.e. within 24 hours of birth and ensuring high coverage of birth dose through a combination of strengthened maternal and infant care at birth with skilled health workers present to administer the vaccine and innovative outreach to provide vaccine for children born at home — The birth dose should be followed by 2 or 3 doses to complete the primary series” (WHO position paper 2009). Government of India (GOI) and DoH-CTA under their Universal Immunisation Program (UIP) give Hepatitis B vaccination at birth, 6, 10, and 14 weeks. Many countries have been very successful in reducing the Hepatitis B prevalence rate with this strategy but it takes decades for the impact to manifest. One approach to shorten this is to give a one-time catch up vaccination to all school going children. The combined approach of Universal Hepatitis B vaccination plus a one-time catch-up vaccination of school going children should in the long run reduce the Hepatitis prevalence rate of Tibetans living in India and Nepal to that of below 2%.
B. Universal Immunisation Program (UIP)
Under the UIP, DoH-CTA has started the free under-5 vaccination program. The Hepatitis B vaccination program for children under-5, which is a part of UIP, has been going on for some years. Many Tibetan women are delivering their infants in the Indian private sector but there are indications that at-birth Hepatitis B vaccination status is low even when factoring the under-reporting of the data from Indian private sector. Also, it is not possible in most cases to catch the new-born within 24 hours of birth to administer the Hepatitis B vaccination (for those deliveries taking place at home or Indian private sector by the DOH staffs). So, there is need to develop innovative approaches that will increase the at-birth vaccination status to 95%. This is one challenge we should take up in coming one or two years.
DOH-CTA is also offering free vaccinations and immunoglobin to new-borns whose mothers are positive for Hepatitis B (HBsAg).
C. School Hepatitis Project
Catch-up vaccination program targeting the school children between 6 and 18 years of age was implemented by DoH-CTA in various Tibetan schools, which would reduce the long latency to impact (i.e. reduction in incidence of Hepatitis B induced Liver Cirrhosis & Liver cancer and death due to chronic Hepatitis B infection). The students were first tested for Hepatitis B using the rapid antigen test, which detects the presence of Hepatitis B virus and then diagnosis confirmed by ELISA test. The unvaccinated negative students were given three doses of Hepatitis B vaccine and the positive students were further tested for HBV DNA, LFT, USG and other tests relevant to the condition of the student. A minimum of three health education sessions were given to all the students by the school nurse, medical officers, and the nurses of DoH-CTA health centres. The School Hepatitis B project has been implemented in 23 schools so far; 4379 students were tested for Hepatitis B virus and 2841 students have received three doses of Hepatitis B vaccine. The program is currently being implemented in six Tibetan schools where 442 students have been tested for the disease and 552 students have been given the first dose of Hepatitis B vaccine. We are planning to cover 2216 students from Tibetan Homes Foundation schools and Central School for Tibetan (CST) Sonada during the reminder of the current year. We are also planning for cover all TCV schools except TCV schools in Ladakh (which is already covered) in near future. By the end of 2017, we hope to cover 80% of the school going population.
D. Youth and Tibetan women: Starting from Tibetan settlers living in Ladakh and Arunachal Pradesh, Free testing of Hep B and vaccination against Hepatitis B of non-School going youth are also in progress.
E. Hepatitis B awareness:
- Mass Health awareness campaign was held at all the Tibetan settlements, schools, and monasteries during the World Hepatitis B day in July 2015 and throughout the year.
- A short video was made, stressing the importance of getting three doses of Hepatitis B prevention vaccine, which was praised by all.
- Another short movie was made to raise public awareness of the nature and mode of transmission of the disease, precautions to be taken, preventive and treatment measures to be adopted to prevent the spread of the disease.
F. Hepatitis B Training/Workshop:
- Comprehensive public health training was conducted at Tibetan Reception Centre and all the doctors and nurses of the DOH Health centres and Delek Hospital were invited to attend. Participants were trained on the epidemiology, causes, and treatment methodologies of Hepatitis B by experts from Chandigarh and Delhi.
- Two days of Hepatitis B training was held in the beginning of December 2015 with a focus on Hepatitis B awareness as well as updating the knowledge of the community health workers and nurses about the disease.
- During recent Special meeting on Prevention organized by CTA health department, Issues related with Hepatitis B and stigma were also touched. All allopathic doctors and senior nurses are distributed 2015 WHO Guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection; and latest updated Guidelines on management of chronic Hepatitis-B of AASLD (American Association for the Study of Liver Diseases).
G. Future plan
CTA DOH also plans to test and vaccinate all School going and non-school going children between 6 and 18 years old in Nepal; and also doing same for all Tibetans women of reproductive age group; monks and nuns; and Tibetan youth in Nepal and India.
Conclusion and Vote of thanks to all Donors
We are very thankful to our donors PRM, Les Amis du Tibet-Luxembourg via SARD, Yeshe Norbu Apello per il Tibet, Italy, Trentino for Tibet and Tibet Relief Fund, UK without whom such an extensive program would not have been possible.
On the behalf of CTA Health Department, We would like to request all friends and supporters for continued support to make Tibetan community free of Hepatitis B, said Health Kalon, Dr Tsering Wangchuk.