Teboota Kiabo is 19 years old. Born and raised on Kiritimati (Christmas) Island in Kiribati, he moved to the capital South Tarawa in 2014 to complete secondary school.
He is one of many young adults in Kiribati to know first-hand the terrible human cost of chronic hepatitis B infection.
Over the past few years Teboota suffered from episodes of abdominal pain, even vomiting blood on one occasion. In August 2015 he was admitted to Tungaru Hospital in South Tarawa with another episode of severe abdominal pain. A blood test revealed that he has chronic hepatitis B, and an ultrasound scan showed cirrhosis – severe scarring of the liver – as well as an enlarged spleen. No one else in the family is known to have hepatitis B, but Teboota’s mother died when he was young, and as far as his step-mother and eldest brother know, none of Teboota’s eight siblings have been tested or vaccinated for hepatitis B.
Hepatitis B is endemic in Kiribati. Immunization has protected many children from infection, but studies show that 15–20% of the adult population is chronically infected, the vast majority through mother-to-child and early childhood transmission prior to the immunization programme commencing. , Today, diagnosis commonly occurs through screening for visas, work or antenatal care, but most people are unaware they are infected until they develop serious complications.
Health care in Kiribati is free, though services are limited by the remoteness of the nation, with atolls spanning 3000 kilometres across the Pacific ocean. Outside the hospitals, health care is provided by nurses and more senior medical assistants in 105 clinics across the country. Resources are stretched, with more than 100 patients seen per day in South Tarawa clinics by only one medical assistant and one or two nurses. Only 40 clinics have functioning vaccine fridges. In the outer islands there are no facilities for blood tests, most women give birth at home, resulting in the hepatitis B birth dose failing to reach many newborns. Even running water is not available in many remote clinics.
Since his admission to hospital, Teboota has been treated symptomatically and given pain relief. He still suffers from bouts of severe abdominal pain. He and his family are unsure whether Teboota will be able to stay in South Tarawa to return to school. Although Teboota would surely benefit from hepatitis B treatment, there is currently no access to lifesaving hepatitis B antivirals in Kiribati, so his therapy is limited to symptom control, seeing doctors when he has pain and intermittent hospital admission when this cannot be managed at home.
With no other options to treat hepatitis B, clinicians often suggest that patients seek treatment from local healers, who use a combination of massage and juices from local plants to ease symptoms of cirrhosis.
Without treatment, Teboota has a high chance of deterioration and complications. People with severe hepatitis B cirrhosis who have had an episode of bleeding relating to liver disease are estimated to have a 14–35% 5-year-survival without antiviral therapy, while 8% of people will develop liver cancer annually.
Outpatient clinic medical assistant Benete Tokanang sees patients with hepatitis every day. She says "follow-up of patients is not routinely done, as there is no access to treatment. Some patients come back for retesting after seeing a local healer, hoping they have been cured."
With care provided only at the end of life, patients spend the last weeks of their lives on the ward. Medical ward nurse Bwenateti Teauoki, a dedicated clinician who sees the end-stage of hepatitis B related liver disease, captured the frustration of many: “Hepatitis is a death sentence in our country”.
Antiviral treatment for hepatitis B with tenofovir or entecavir is safe, well-tolerated, can reverse liver scarring and markedly reduce the risk of primary liver cancer (hepatocellular carcinoma). It is also relatively cheap at less than US$ 50 per patient per year. Early in 2015, WHO released guidelines for the prevention, care and treatment of people with chronic hepatitis B. The guidelines recommend all patients with cirrhosis receive immediate antiviral therapy as a priority.
WHO and the Kiribati Ministry of Health and Medical Services are working to address hepatitis beyond immunization. First steps include a review of the national viral hepatitis situation and a technical meeting of stakeholders in August 2015 in South Tawara. The meeting's recommendations focused on ensuring access to treatment, in addition to developing a national hepatitis action plan. In October 2015, the Government of Kiribati, along with all Member States in the Region, endorsed the Regional Action Plan for Viral Hepatitis in the Western Pacific 2016–2020.
Kiribati Ministry of Health and Medical Services has now identified hepatitis B as a priority issue. Access to treatment may not be far away for Taboota, though it cannot come soon enough.
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Across the Western Pacific Region, 1500 people die every day from hepatitis related liver cancer and cirrhosis – higher than the combined deaths from HIV/AIDS, tuberculosis and malaria. Liver cancer is the third most common cause of cancer death in the world, and chronic hepatitis accounts for close to 80% of all liver cancer cases globally.
WHO works with governments to ensure policy-making for hepatitis is on the right path, so that clinical practice can be more effective, and ultimately more lives can be saved through prevention and access to treatment. In the Western Pacific, WHO is leading the fight against hepatitis through partnerships with governments, experts and affected communities.