Ardila Syakriah, Jakarta – The COVID-19 epidemic is expected to put at risk Indonesia's target of eliminating hepatitis B and C by 2030 as it has interrupted screening and early-detection programs and vaccination drives and disrupted the supply chain of imported drugs.
The prevalence of hepatitis B in Indonesia is 7.1 percent, meaning that some 18 million people are infected with the viral disease, according to the 2013 Basic Health Research (Riskesdas). Half of the cases have become chronic, with 900,000 developing cirrhosis and liver cancer. Meanwhile, the prevalence of hepatitis C is 1.1 percent, about 3 million people.
The government is aiming to break the cycle of hepatitis B infection that is passed from mother to newborn infant, the major source of transmission, by 2022, before eventually eliminating hepatitis B and C altogether by 2030.
To achieve this the government has launched numerous programs, including gradually expanding access to early detection of hepatitis B among pregnant women and hepatitis C among at-risk sections of the population, access to free drugs to treat hepatitis C patients and hepatitis B vaccinations for newborn babies and children. However, it is feared the COVID-19 pandemic will stall further efforts.
"The pandemic will certainly disrupt our targets surrounding hepatitis elimination [...] We'll look into how we can catch up with programs [we might have missed]," Health Ministry disease prevention and control director Wiendra Waworuntu said in a press briefing to mark World Hepatitis Day on Tuesday.
The latest ministry data shows that the number of pregnant women undergoing early detection for hepatitis B increased between 2015 and 2019, when it covered some 2.5 million women.
But January until June this year saw a 41 percent decline from the same period last year, Wiendra said. The number of people undergoing early detection for hepatitis C among the at-risk population between January and June this year also declined by 60 percent from the same period last year.
So far, reports received by the ministry show that 44 percent of provinces still have not reached a target of a minimum of 85 percent of cities and regions conducting hepatitis B early detection.
Indonesian Association for the Study of the Liver (PPHI) chairman Irsan Harsan said that patients' fears over contracting COVID-19 had been the "biggest disruption" in hepatitis-eradication campaigns because they refrained from undergoing screening and treatment at health facilities.
"Some tried to consult via telemedicine platforms, but it is not easy to consult virtually for hepatitis treatment. [...] Imagine if [medical workers] do not screen pregnant women [for hepatitis B] or do not give newborn babies [hepatitis B] immunoglobulin, the babies can become infected too," he said.
The problem was that detected hepatitis cases were only the "tip of the iceberg", Irsan said, saying that in the United States, for instance, only 50 percent of hepatitis C cases were detected –18 percent of these are treated, with only 9 percent fully recovering. The figures were much lower in Indonesia, he said.
"What needs to be addressed is how we can find new cases that mostly lie beneath the surface: people who do not know they have it and who do not show symptoms," he said. "Nine of 10 people do not realize they have hepatitis B and C; and one out of four is at risk of dying from liver cancer or liver failure. That is why we dub it a silent killer."
On top of that, experts also have difficulties in deliberating medical guidelines for hepatitis B and C treatments due to mobility restrictions and social distancing during the COVID-19 pandemic, he said.
Caroline Thomas, a program manager at hepatitis support group Peduli Hati Bangsa, said stocks of daclatasvir – one of the direct-acting antiviral drugs (DAAs) to treat hepatitis C patients provided by the government – had run out since February.
The government has since 2017 provided the DAAs to 5,361 patients for free. The DAAs have a higher cure rate compared to the pegylated interferon the government used before switching to DAAs.
Such a stock shortfall was commonplace, usually lasting three to four months, Caroline said, but it had been particularly long this year as a result of mobility restrictions to contain the COVID-19 pandemic disrupting drug imports from India.
"There's nothing [patients] can do apart from waiting. Those in early stages of hepatitis C can wait, but those in late stages just can't. We are racing against time and losing lives," Caroline said.
Even without the pandemic, the number of drugs provided by the government was still far from what experts recommend if Indonesia wants to eliminate hepatitis C by the targeted time, Caroline said.
A 2019 study by University of Bristol researchers published in the Liver International journal showed that for Indonesia, hepatitis C elimination by 2045 was "the most feasible path to scale-up", and that it would prevent 739,000 new infections and avert 158,000 hepatitis C virus-related deaths.
Many patients could not afford to purchase the "pricey" drugs on their own, Caroline said, adding that they might cost patients between Rp 11 million (US$755) and Rp 18 million for three months' supply.