Cambodia: Simplified, decentralized, but effective hepatitis C management

27 Jul 21

Epidemiology has shown that simplified, decentralized hepatitis C care can be integrated into public and rural health services in resource-limited settings, while maintaining high rates of patient follow-up, treatment efficacy and safety. This proof-of-concept by Médecins Sans Frontières (MSF) and Epicentre in Cambodia, where a parallel hepatitis C virus (HCV) seroprevalence study was conducted, therefore supports the extension of this model of care to other countries or regions.

Hepatitis C

Hepatitis C occurs as a result of infection with HCV, which is transmitted mainly through the bloodstream.

A client at the Mith Samlanh Drop-In Centre, which offers medical support, food and a resting area. Many clients are battling addiction to injectable drugs, and connected problems such as Hepatitis C. Cambodia, 2017.

The disease can remain silent for many years.

If not diagnosed and treated in time, it can lead to cirrhosis (scarring of the liver) and even liver cancer.

Today, there are combinations of direct-acting antivirals (DAAs) that block the replication of the virus and are over 95 per cent effective in the general population.

Patients wait for their appointment at the MSF Hepatitis C clinic at Preah Kossamak Hospital in Phnom Penh, Cambodia, 21, April 2017.

As part of a program with the Cambodian Ministry of Health, MSF has set up a hepatitis C screening and treatment program first in Phnom Penh and then in Battambang province.

Evaluate the incidence to define adapted programs

Epicentre epidemiologist Emily Lynch also conducted a study in this rural northwestern province of Cambodia to assess the rate of HCV infection and risk factors.

The blood sample of a villager is tested for Hepatitis C during a morning of active case finding in a village in Moung Ruessei district in Cambodia. Active case finding helps identify patients with Hepatitis C before symptoms develop. 2019.

She looked for signs of the virus in 5,098 people in 3,616 households.

Antibodies indicating the presence of the virus were detected in 2.6 per cent of people over 18 years of age and in 5.1 per cent of those over 45 years of age.

The nurses Prak Vichhuta and Ty Chhunnly test blood samples of villagers for Hepatitis C during an active case finding campaign in a village in Moung Ruessei district in Cambodia. 2019.

It was the first study of this magnitude in Cambodia.

The survey showed that HCV seroprevalence increases with age and is inversely proportional to education level.

Khen Sophea carries out information and education activities during an active Hepatitis C case finding campaign in a village in Moung Ruessei district in Cambodia. 2019.

This particularly high HCV seroprevalence among people over 45 years of age is most likely the result of medical care such as injections, surgery, blood donation and transfusion, or dental care before wider access to disposable medical equipment.

This study also shows screening programs need to target people over 45 years of age.

Sol Rasy, nurse supervisor, explains the means of transmission of Hepatitis C and the course of the disease to villagers in Muang Roussei district in Cambodia. 2019.

A proven, simplified model of care

In Cambodia, 76 per cent of people live in rural areas with limited access to medical care. Existing health centers provide primary healthcare, most often by nursing staff.

MSF Doctor Theresa Chan discusses a patient with MSF doctor Hang Vithuneat at the MSF Hepatitis C clinic at Preah Kossamak Hospital in Phnom Penh, Cambodia, 21, April 2017.

From 2016 to 2018, Médecins Sans Frontières (MSF), working with staff at the government-run Preah Kossamak Hospital in Phnom Penh, set up a simplified model of care for people with HCV.

"This model is based on the use of rapid diagnostic tests, fewer follow-up visits and biological tests, and the transfer of many clinical tasks from physicians to nurses and pharmacists," says Mickael Le Paih, MSF's head of mission in Cambodia.

MSF Volunteer Nurse Ron Bora Ron performs a fibroscan at the MSF Hepatitis C clinic at Preah Kossamak Hospital in Phnom Penh, Cambodia, 21, April 2017.

This model, which had a priori never been used elsewhere, was then evaluated by Meiwen Zhang, an epidemiologist at Epicentre, to determine its effectiveness.

Of the 540 HCV patients followed up between March 2018 and January 2019, 98.7 per cent received an initial medical consultation.

A monk waits for his appointment at the MSF Hepatitis C clinic at Preah Kossamak Hospital in Phnom Penh, Cambodia, 21, April 2017.

Of these, 530 people started DAA treatment at a health center (for 485 of them and at a referral hospital, for the other 45).

Care at the community health centers was provided by nurses.

A client at the Mith Samlanh Drop-In Centre, which offers medical support, food and a resting area. Many clients are battling addiction to injectable drugs, and connected problems such as Hepatitis C. Cambodia, 2017.

A total of 466 patients completed treatment, with a sufficiently low viral load in 98.5 per cent of patients that they were considered cured.

The epidemiological analysis showed the highly simplified and decentralized model of care developed by MSF in a public and rural health system can ensure good patient follow-up without compromising the effectiveness and safety of treatment.

A Patient holds their meds at the MSF Hepatitis C clinic at Preah Kossamak Hospital in Phnom Penh, Cambodia, 21, April 2017.

"We are confident that this model can be replicated in other resource-limited settings to improve access to care for people with HCV. Its model should help reduce the barriers to care for the estimated 58 million people* living with HCV worldwide, and thus contribute to reducing the impact of hepatitis C," says Le Paih.

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