Hepatitis B in the DPRK: A serious health problem
Dr. Alice Lee, a gastroenterologist and hepatologist from Australia, visits a teenage patient at Kaesong #2 Hepatitis Hospital (May 2015). Dr Lee led Christian Friends of Koreas’s efforts to begin a hepatitis B survey and vaccination project among health care workers at CFK’s supported facilities in the DPRK[2].
Hepatitis B is a viral infection that attacks the liver and can cause both acute and chronic disease. It is a major global health problem which can cause chronic infection and puts people at high risk of death from cirrhosis and liver cancer.
The virus is transmitted through contact with the blood or other body fluids of an infected person. For this reason hepatitis B is an important occupational hazard for health workers.
An estimated 240 million people worldwide are chronically infected with hepatitis B. More than 780,000 people die every year due to complications of hepatitis B, including cirrhosis and liver cancer.
There is still limited access to diagnosis and treatment of hepatitis B in resource-constrained settings, such as the DPRK, and many people are diagnosed only when they already have advanced liver disease. Liver cancer progresses rapidly, and since treatment options are limited, the outcome is in general poor. In low-income settings, most people with liver cancer die within months of diagnosis.
However, hepatitis B can be prevented by a currently available safe and effective vaccine. The vaccine against hepatitis B has been available since 1982. It is 95% effective in preventing infection and the development of chronic disease and liver cancer due to hepatitis B. Unfortunately, many ‘at risk’ people in the DPRK, particularly health care workers, are yet to be vaccinated.
Hepatitis B is endemic in the DPRK. It is an important public health problem because of its high prevalence combined with the often deleterious chronic course noted above that leads to both physical impairment and suffering of the patients as well as causing a huge socio-economic burden[3].
It is assumed that the transmission of hepatitis B in the DPRK occurs mostly from mother to child at birth (perinatal transmission) or through horizontal transmission such as reuse of needles in health-care settings or exposure to infected blood. The latter is often from an infected child to an uninfected child during the early years of life. Sexual transmission of hepatitis B may also be an important factor[1][3].
Obtaining epidemiological data on diseases or health related problems in the DPRK is difficult so the prevalence of hepatitis B can onlybe estimated. The World Health Organization (WHO) calculated a prevalence of 4.5% in 2003. Anecdotal evidence and unpublished data from a survey among North Korean refugees in South Korea, suggests that a prevalence of 9% is more realistic. Given the high natural incidence of hepatitis in East Asia of up to 20%[4], and the North Korean deficits in vaccination, the true prevalence can be assumed to be even higher[3].
The management of hepatitis B in the DPRK has been very limited despite an extensive state-funded health care structure with specialized “Hepatitis Hospitals” in each governmental district. The current treatment of hepatitis B and its complications, such as liver cirrhosis and liver cancer, has consisted of traditional herbal medicine. Effective antiviral agents have been available for many years outside of the DPRK, as well as drugs to treat liver disease complications, but they are known to relatively few physicians in the coutntry and those have no experience with these treatments[3].
One reason hepatitis B became endemic in the DPRK was because there was no comprehensive vaccination programme in the country until 2004. That is when the national immunization program included nationwide hepatitis B vaccination of newborn. However, this still left a gap of 3.8 million unvaccinated children born before 2004.
As part of a bi-modal strategy to deal with hepatitis B and its associated problems in the DPRK, Caritas Germany worked with the Ministry of Public Health of North Korea (MoPH) to close this huge gap of unvaccinated children by vaccinating more than 3.7 million North Korean children aged from 6 to 16 during the period 2010 to February 2012. According to the MoPH, this catch-up vaccination campaign covered 99.3% of the unvaccinated children in the DPRK[4].
Caritas catch-up vaccination programme in the DPRK (July 2011)[6]
A notable feature of this vaccination campaign was its funding by South Korea who provided vaccines worth US$2.37 million to Caritas. It was interrupted twice as tensions between North and South escalated and the vaccinations only continued after heavy lobbying of South Korean politicians by the German NGO[5].
The hepatitis B vaccine remains the mainstay of hepatitis B prevention. The vaccine has an excellent record of safety and effectiveness. WHO recommends that all infants receive the hepatitis B vaccine as soon as possible after birth, preferably within 24 hours. The birth dose should be followed by 2 or 3 doses to complete the primary series[1].
The complete vaccine series induces protective antibody levels in more than 95% of infants, children and young adults. Protection lasts at least 20 years and is probably lifelong[1]. Being able to maintain its national immunization program of the newborn, including the hepatitis B vaccination, is of vital importance to the DPRK if it is to ever overcome the endemic health problems of tuberculosis and hepatitis B.
For the less than 1% of immunized children who later develop chronic hepatitis B, and those of older, unvaccinated, generations who have developed acute hepatitis B, there is no cure. Treatment options depend on the severity of the disease.
There is no specific treatment for acute hepatitis B. Therefore, care is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids lost from vomiting and diarrhoea[1].
Chronic hepatitis B infection can be treated with drugs, including oral antiviral agents. Treatment can slow the progression of cirrhosis, reduce incidence of liver cancer and improve long term survival. In most people, the treatment does not cure hepatitis B infection, but only suppresses the replication of the virus. Therefore, most people who start hepatitis B treatment must continue it for life[1].
The oral anntiviral agents rarely lead to drug resistance as compared with other drugs, are simple to take (1 pill a day), and have few side effects so require only limited monitoring[1]. They are “finally within the reach of the DPRK”[2], according to the U.S. based charity, Christian Friends of Korea (CFK). However the need for life-long treatment has obvious implications in countries like the DPRK, where treatment continuity will be extremely vulnerable to disruption, as happened with the 2010-2012 hepatitis B vaccination catch-up programme described earlier.
CFK has been working in the DPRK for some years in close collaboration with the country’s Ministry of Public Health (MoPH). The charity’s original focus was on the clinical aspects of tuberculosis (TB), helping the country to improve its treatment and testing facilities, including providing equipment and ongoing training for the National TB Reference Laboratory. Some years ago it was invited to also provide general support for hepatitis care centres. The initial support included greenhouses, water systems, supplemental food and medicine, tractors, blankets, etc. Starting in May 2015, CFK began addressing the more clinical aspects of hepatitis B prevention and teatment in the DPRK[2].
It immediately identified a need for a hepatitis B vaccination programme among health care workers who staff the approximately 150 sanatoriums around the country treating tuberculosis and hepatitis B patients. These care workers were born well before 2004 and were too old to be included in the 2010-2012 vaccination catch-up programme for 6-16 year olds.
For North Koreans already infected by the hepatitis B virus, CFK’s plans for the future could offer some of the medical support we take for granted in Europe: “In the near term, we hope to start a pilot project to support anti-viral therapy, while also strengthening diagnostic and treatment capability by expanding emergency intervention, nutritional support and palliative care to people already suffering from more advanced liver disease. A proposal and negotiations for a new hepatitis prevention and care plan was approved and signed by the Ministry of Public Health.
“This is a long-awaited and urgent priority that promises to bring hope and healing to many lives. From this beginning, we will negotiate a fuller Memorandum of Understanding on a future visit that will guide our efforts going forward”[2].
CFK’s committment to the DPRK is commendable. It should be inspiring other humanitarian NGOs, particularly those specialising in health care, to follow CFK’s example. However, without long-term support from major international donors and other aid organisations, leaving a single U.S. based donor with the responsibility for essential treatment, supplies, training and operational expertise, creates the risk that programmes, supply lines, testing and treatment will be interrupted.
NOTES
[1] WHO Fact sheet No. 204 (July, 2015). http://www.who.int/mediacentre/factsheets/fs204/en/#
[2] CFK Newsletter. (June 2015). http://cfk.org/wp-content/uploads/2015/06/June-2015-Newsletter-Final-PROOF.pdf
[3] Fighting hepatitis B in North Korea: Feasibility of a bi-modal prevention strategy. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4630473/
[4] Hepatitis B infection: Current concepts and future challenges. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259419/
[5] Yonhap News Agency (2013). Nearly 4 million N.K. children vaccinated against hepatitis B. http://english.yonhapnews.co.kr/northkorea/2012/03/13/21/0401000000AEN20120313001700315F.HTML
[6] Caritas (2011). http://www.caritas.org/where-we-are/asia/korea/
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