"We have a real opportunity here to push back hepatitis B. With the right approach, we can free a generation of children in Myanmar from this debilitating and deadly virus.”
Seven years ago, Khin Aye went for a routine prenatal check-up while pregnant with her first child. The hospital staff conducted a blood test. “When the test came back, they told me I had hepatitis B.”
While the diagnosis was a shock, with health implications for the rest of Khin Aye’s life, it meant that her newborn daughter received the birth dose hepatitis B vaccine within the crucial 24-hour window after delivery and is hepatitis B negative.
An estimated 3.5 million people in Myanmar are living with the hepatitis B virus (HBV). The disease is often referred to as the “silent killer” as many people are unaware that they are infected. Those who remain untested and untreated face a significantly higher risk of contracting liver disease, including cirrhosis and liver cancer.
In Myanmar (and Southeast Asia), HBV is most commonly transmitted from mothers to children during childbirth. Home births are still relatively common, and access to affordable prenatal and postnatal care, including HBV testing, remains out of reach for many pregnant women. This has contributed to an invisible epidemic, with national HBV prevalence estimated to be 6.5% in Myanmar, and 12% in Yangon Region where Khin Aye lives.
Community Partners International (CPI) is working with the B. K. Kee Foundation and the Myanmar Liver Foundation to establish an effective testing and treatment model to prevent the transmission of HBV from mothers to children during childbirth. The "Stop Hep B @ Birth Project" is focusing on two township suburbs of Yangon - South Dagon and Dagon Seikkan - that have high inward migration and large areas of densely populated slums.
“We are looking to develop a treatment and prevention model that works well in this peri-urban context, and can be replicated in other similar contexts in Myanmar,” explains Dr. Eindra Htoo, a Research Coordinator with CPI who leads the Stop Hep B @ Birth Project.
“The key here is access to prenatal and postnatal care,” affirms Dr. Eindra Htoo. “Early in pregnancy, women need a blood test to determine their HBV status and check for co-infections. If they test HBV positive, and if their viral load exceeds 200,000 units per millilitre, they need to take antiviral medication from 5 months after conception to one month after delivery to help reduce their viral load during delivery and early breastfeeding.”
“For all HBV positive pregnant women, their newborns need to receive the birth dose vaccine within 24 hours of delivery and then follow up vaccinations at two, four, and six months. For women with high viral loads, we also recommend that their babies receive HBV immunoglobulin, or antibodies, at birth to further strengthen their immunity. Under the project, we are providing all of this for free.”
With this relatively simple approach, the evidence shows that prevention of mother-to-child transmission can be achieved in 95% of cases or more.
However, the lack of awareness of HBV is a significant barrier. “From my own experience, around 80% of the pregnant women that I encounter have little or no understanding or awareness of HBV or how it is transmitted,” reveals Dr. Eindra Htoo. For this reason, the Stop Hep B @ Birth project conducts regular HBV awareness sessions in communities in South Dagon and Dagon Seikkan.
Khin Aye is one of 110 women that the project, launched in June 2018, will enroll during the five-year project lifetime. When she became pregnant with her second child in late 2019, she disclosed her HBV status while visiting her local urban health center for prenatal care. The health center referred her to the B. K. Kee Clinic in South Dagon, that is the base for care provision under the Stop Hep B @ Birth Project. The clinic would be the focal point for Khin Aye’s prenatal and postnatal care from that point on. At the clinic, she underwent a blood test which indicated that her HBV viral load was low enough to not require antiviral medication.
During her pregnancy and the postnatal period, Khin Aye also received support from Thida Khaing, an outreach worker with the Stop Hep B @ Birth Project, who provided regular phone support and a home visit. During the home visit, Thida Khaing drew blood from Khin Aye’s family members to screen them for HBV, checked on the health of the mother and baby, and provided counseling.
Khin Aye emphasized the importance of the counseling she has received, both at the B. K. Kee Clinic and from Thida Khaing. “I heard a lot of false information from people in the community about hepatitis B, for example, that it can be passed on through sweat. This made me anxious. So, it really helped me to get accurate information and understand how I can prevent transmission and protect my baby and family.”
One of the key challenges that Thida Khaing encounters in her outreach work is social stigma. “Many community members are reluctant for me to visit them in their homes. They fear that their neighbors will find out their HBV status and will discriminate against them,” she explains. “I have to fix an appointment time with them that makes them feel as comfortable as possible. But the fear of stigma makes it difficult for them.”
With the arrival of the COVID-19 pandemic in Myanmar in March 2020, the Stop Hep B @ Birth project has had to adapt to minimize infection risks for HBV positive clients, their families, and health workers. The project immediately suspended home visits and, instead, focused on providing phone support.
“I called my clients regularly during lockdown to provide counseling on reproductive health and remind them to attend prenatal check-ups at the clinic. I also made sure that those taking antiviral medication are adhering to the treatment,” explains Thida Khaing. In the early days of the pandemic, the B. K. Kee Clinic reduced opening times to three days per week with a reduced staff. The clinic is now open seven days per week, but reduced staffing and caseloads have been maintained to ensure physical distancing.
With COVID-19 now seemingly under greater control in Myanmar, Thida Khaing has resumed home visits, wearing full protective equipment including a surgical mask and gown, face shield and gloves supplied by the project. “It’s strange for clients and their families to see me in this equipment,” says Thida Khaing. “It makes it more obvious that I am a health worker, which creates a greater risk of social stigma.”
An additional challenge created by COVID-19 has been the disruption of the national Expanded Program on Immunization (EPI) which provides children under five with free access to key immunizations, including the HBV vaccine. “Many of the newborns enrolled on the project cannot get the follow-up vaccines on time now because of the disruption,” Dr. Eindra explains. “But the most important ones are the birth dose vaccine and immunoglobulin, and we can still make sure that newborns receive those in time.”
As Khin Aye’s delivery date approached, her health status created a dilemma. “I was very nervous about giving birth in a hospital because of COVID-19. I didn’t know which option was best.” Hospital births in Myanmar have become more accessible to women in the last few years as they are now technically free, although there remain hidden costs that are a barrier for some.
In June, Khin Aye gave birth to her second child, a son, in hospital. As soon as the child was delivered, Thida Khaing headed to the hospital to ensure that Khin Aye’s newborn received the birth dose HBV vaccine within 24 hours. While the vaccine is provided free by hospitals in Myanmar, they don’t always have available stock, in which case the project provides it. Thida Khaing also drew blood from Khin Aye to conduct a blood test to determine her HBV viral load at the time of delivery.
“I feel like I have become needed in the community,” says Thida Khaing as she reflects on her outreach work. “The community has accepted me and I can help safeguard newborn babies against HBV.”
In May 2020, CPI expanded the Stop Hep B @ Birth Project to encompass a further six wards in South Dagon and Dagon Seikkan.
“We have a real opportunity here to push back HBV,” says Dr. Eindra Htoo in closing. “With the right approach, we can free a generation of children in Myanmar from this debilitating and deadly virus.”
The Stop Hep B @ Birth Project is made possible with support from the B. K. Kee Foundation and the Tides Foundation.
Some names have been changed to protect privacy.