World Hepatitis Alliance Viral Hepatitis: Global Policy
World Hepatitis AllianceViral Hepatitis: Global Policy
ForewordForewordThe World Hepatitis Alliance is a non-governmental organisationthat represents approximately 280 hepatitis B and hepatitis Cpatient groups around the world. It is a global voice for the 500million people worldwide living with chronic viral hepatitis B or C,all of whom are affected by the policies and practices of nationalgovernments and international agencies.This report summarises the results of a study undertaken by theAlliance for the World Health Organization (WHO) across all 193Member States. It examines their policies and programmes aimedat preventing and controlling viral hepatitis and the areas in whichthe WHO might assist with this. 135 countries responded to thesurvey, many of them taking significant amounts of time andtrouble to do so, for which the Alliance is very grateful. What wasespecially impressive was the number of countries that managedto respond even in the middle of wars or other major politicalupheavals.The responses reveal widely varying situations from countriesthat have not yet begun to tackle viral hepatitis to those withcomprehensive policies for both hepatitis B and C that areintegrated into their health systems. What clearly emerges is thelack of a co-ordinated global strategy.In a world in which there is so much migration it is hard to see howthese two highly prevalent, infectious diseases can be effectivelyprevented and controlled without a more unified approach. This isa view now widely shared and it is no coincidence that this reportis being published exactly one month prior to the start of the 63rdWorld Health Assembly at which the first comprehensive resolutionon viral hepatitis will be discussed.The resolution, agreed by the WHO Executive Board in January,begins by explicitly acknowledging the ‘seriousness of viralhepatitis as a global public health problem’. It calls for a broadrange of action across surveillance, awareness, prevention,diagnosis, care and access to treatment. If adopted at theAssembly, it would represent a major step forward in addressingthe needs of the one-twelfth of the global population currentlyinfected and preventing the ongoing transmission to millions moreevery year.This report provides compelling evidence to support the needfor this timely initiative by the Member States of the WHO. It alsoshows the crucial role that Member States want the WHO to playin order to be able to deliver effectively the actions called for in theresolution.Charles GorePresidentOn behalf of the World Hepatitis Alliance2Viral Hepatitis: Global Policy
Executive SummaryThis report provides an unprecedented analysis and overview ofcountries’ policies and programmes that determine prevention andcontrol of viral hepatitis. Collected through a survey of Ministriesof Health across all WHO Member States, these describe the workalready underway, the areas in which further action is needed andwhere assistance is wanted.The unambiguous message that emerges from the study is theimportance now being given to viral hepatitis on national healthagendas. Of the 135 countries that responded to the survey, 80%said that they regard hepatitis B and/or C as an urgent publichealth issue. In the Western Pacific and Eastern Mediterraneanregions the figure was 90% and in Africa closer to 100%. And,overall, the results underscore that, while very effective policy andprogramming exists in some areas, there is huge variation and inmuch of the world it is either not yet in place or requires significantstrengthening.Hepatitis prevention and control programmes are multi-facetedand may involve immunisation, blood screening, injectionsafety, public health awareness and education, sexual healthprogrammes, surveillance, drug and alcohol services, and bloodtesting and treatment access. Strategic planning and coordinationare therefore essential. 70% of countries report having a nationalstrategy for the prevention and control of viral hepatitis and 71%national goals. However, from further detail supplied it is clear thatsome strategies are more a series of uncoordinated programmesthan a cohesive strategic approach. That the majority of countrieswhich do, as well as of those which do not, already have goals inplace want help from the WHO developing these suggest that manyexisting goals do not comprehensively address this issue.Much progress is being made in protecting the next generationfrom hepatitis B; vaccination policies are in place in almost everycountry and almost all of these policies include infants. However,other risk groups are often not covered, particularly in lowerincome countries. 40% of countries would like assistance withthe delivery of vaccination, highlighting the need to widen andstrengthen vaccination policies and programmes.Access to testing and treatment is very variable and across someregions both are extremely limited. Just two in five people livein countries where testing is accessible to more than half of thepopulation and only 4% of low income countries report that testingis accessible. More than half of the population lives in countrieswith no provision for free testing and 41% in countries where nogovernment funding exists for treatment of hepatitis B or C. Fourout of five low income countries and almost one in three highincome countries would welcome assistance to increase accessto treatment.Executive SummaryChronic viral hepatitis is highly prevalent globally, with some fivehundred million people estimated to be currently infected withhepatitis B or C. These two diseases are the cause of significantglobal mortality and morbidity with approximately 1 million deathseach year attributable to them and their sequelae, liver disease andprimary liver cancer.In addition to access to testing, improving diagnosis requiresawareness of risks and routes of transmission among thosewho may have been exposed to hepatitis B or hepatitis C. This isalso crucial for prevention. However, government-funded publicawareness work is rare. Many innovative examples were providedthat show how effective this can be in improving prevention andcontrol of viral hepatitis and some two-thirds of governmentswould like assistance in initiating or improving awareness raisingactivities in future, including the majority of those that report havingalready undertaken some.The diverse components required for effective prevention andcontrol mean that effective programming can be very complex.Although challenging, this complexity also offers opportunitiesboth to integrate viral hepatitis into existing programmes andto introduce new policies that may positively impact other highpriority public health issues such as HIV/AIDS and intravenous druguse, therefore serving to strengthen the health system as a whole.In light of the many dimensions to prevention and control, it isperhaps not surprising that the majority of governments do notchoose to tackle hepatitis alone: almost three quarters reportcollaborating with non-state organisations. Of the 60 countries thatgave details on this, 44 report working with the WHO and morethan 9 out of 10 would like further assistance. This underlines theimportance of the WHO’s technical expertise to an effective globalresponse to viral hepatitis.This report clearly shows the disparities that currently exist acrossthe world and therefore how much work needs to be done to beginaddressing viral hepatitis in a coordinated global manner. It alsoshows, however, that there is widespread agreement on the needto start this process and that the political will exists for this to bedone.The lack of accurate prevalence data on hepatitis is widelyrecognised as inhibiting more effective prevention and controlat both international and national levels. 82% of countries reporthaving hepatitis B and/or C surveillance measures in place,although the components of these differ considerably; one-third ofcountries report having no prevalence data available and more thantwo-thirds request assistance with surveillance.Viral Hepatitis: Global Policy3
IUNUNAIDSUNODCUSAIDWHOWPROViral Hepatitis: Global PolicyAfrica Regional Office of the WHOAcquired Immune Deficiency SyndromeCommunity-Based OrganizationCentre for Disease ControlDisability-Adjusted Life YearDiphtheria, Tetanus, Pertussis, Hepatitis B vaccineDiphtheria, Tetanus, Pertussis, Hepatitis B, Haemophilus influenzae type B vaccineEastern Mediterranean Regional Office of the WHOExpanded Programme on ImmunisationEurope Regional Office of the WHOThe Global Alliance for Vaccines and ImmunisationGross Domestic ProductGross National IncomeGenito-Urinary MedicineHepatitis B Immune GlobulinHepatitis B ‘e’ AntigenHepatitis B surface AntigenHepatitis B VirusHepatocellular CarcinomaHepatitis C VirusHealthcare WorkerHepatitis B vaccineHuman Immunodeficiency VirusHealthy Life ExpectancyInjecting Drug UserJapan International Cooperation AgencyMinistry of HealthMen who have Sex with MenNational Immunisation ProgrammeNon-Governmental OrganisationPan-American Health Organization (Americas Regional Office of the WHO)Post-Exposure ProphylaxisPublic HealthSouth-East Asia Regional Office of the WHOSexually Transmitted InfectionUnited NationsUnited Nations program on HIV/AIDSUnited Nations Office on Drugs and CrimeUnited States Agency for International DevelopmentWorld Health OrganizationWestern Pacific Regional Office of the WHO
Contentspage 6Methodology , Limitations and Responsespage 8Global results overviewpage 12ContentsIntroductionRegional results overviewAfrican Regionpage 22Region of the Americaspage 25Eastern Mediterranean Regionpage 28European Regionpage 31South-East Asia Regionpage 34Western Pacific Regionpage 36Country summaries (A-Z)page 39Appendix 1: Definitionspage 179Appendix 2: Surveypage 180Viral Hepatitis: Global Policy5
IntroductionIntroductionChronic viral hepatitis is highly prevalent globally, with some fivehundred million people estimated to be currently infected withhepatitis B or C. These two diseases are the cause of significantglobal mortality and morbidity and approximately 1 million deathseach year are attributable to them and their sequelae, liver diseaseand primary liver cancer. Although not spread homogenouslythroughout the world, hepatitis B and C are an important challengein all regions. Furthermore, since these diseases are infectious andsince in some areas there is considerable migration between highand low endemic countries, control and prevention of viral hepatitisis important nationally, regionally and globally.Surveillance of viral hepatitis varies widely from country to countryand is generally inadequate. However, it is accepted that the highestrates of hepatitis B are found in South-East Asia, Sub-Saharan Africaand parts of the Pacific Basin and Amazon Basin.1 Here 70-90% ofthe population will be infected by the time they are 40 and many areinfected under the age of five, which brings a much higher likelihoodof developing chronic infection, liver cancer and cirrhosis. In Westernand Northern Europe, North America, some parts of South Americaand in Australia prevalence rates overall are believed low. Prevalenceof hepatitis C also varies across the world and is estimated to behighest in Africa and the Middle East and, again, lowest in muchof Western Europe and the Americas.2 The proportion of peoplewith hepatitis B and hepatitis C can vary considerably between,and within, countries and therefore, even in areas of low overallprevalence, rates in certain sub-populations can be very high.3Both hepatitis B and hepatitis C are efficiently transmitted throughcontact with infected blood and can survive for prolonged periodsoutside the body. Hepatitis B can remain infectious even in driedblood for several weeks4 and hepatitis C for up to 16 hours onenvironmental surfaces and up to 4 days’ in blood samples.5 Thescreening of blood for transfusion and use of sterile medical andinjecting equipment are of particular importance to the preventionof hepatitis B and C as well as other infections in healthcare settings.Blood transfusions were until recently a significant route oftransmission. While improved screening techniques havesubstantively reduced transmission through blood transfusions,many do still occur and an estimated 6 million units of donated bloodwere not screened for hepatitis B or C (or HIV or syphilis) in 20002001.6The use of unsterile syringes and needles accounts for an estimated23 million new hepatitis B and hepatitis C infections worldwide eachyear.7 6.7 billion unsafe injections are estimated to be administeredannually in low income countries; the highest rates of needle reuse have been found in the Eastern Mediterranean, South-East Asiaand Western Pacific regions and many of these injections are notmedically necessary.8 Use of auto-disable syringes, which cannot bereused, is increasing and 62% of non-industrialised countries usedthese in routine immunisation programmes in 2004, a 20% increaseon 2001.9 Significant progress remains to be made, however; only38% of these countries exclusively used auto-disable syringes forroutine immunisation in 2004 and adoption outside of immunisationprogrammes remains low.106Viral Hepatitis: Global PolicyUnsafe injecting practices among intravenous drug users (IDUs) arealso a major contributor to the global incidence of hepatitis B and Cand are associated with most hepatitis C infections in developed andtransition economies.11 They are transmissible through the sharing ofneedles as well as injecting paraphernalia and hepatitis C prevalencerates of up to 96% have been found in IDU populations even incountries with prevalence rates under 2% overall.12The most effective method of prevention for hepatitis B isvaccination; no vaccine exists for hepatitis C. Vaccines for hepatitisB have been available for almost thirty years. Although initiallythese were expensive and adoption was slow, to date 88% of WHOMember States have introduced the vaccine for at least some of theirpopulation.13 Infant vaccination programmes, the most widespreadapproach, are protecting the next generation from hepatitis B. Thisstill leaves many people exposed to hepatitis infection. As hepatitisB can be transmitted through body fluids other than blood, high riskgroups include the family and partners of people with hepatitis B, sexworkers and victims of sexual assault as well as healthcare workers,IDUs and others likely to be exposed to blood and blood products.Whereas infection with hepatitis C usually becomes chronic, whetherthis happens with hepatitis B infection is dependent on the ageat which the infection occurs: the younger a person is infected,the more likely the infection will become chronic, while adultsgenerally clear the virus after a period of acute infection. Deathsfrom acute hepatitis are relatively rare. The majority, at least 90%,of the morbidity and mortality associated with hepatitis B and Care manifested in conditions, particularly primary liver cancer andcirrhosis, that develop slowly during chronic infection. More than onein every forty deaths worldwide is caused by these two conditions,and the great majority of these result from hepatitis B or C infection.14Globally, 57% of cirrhosis and 78% of primary liver cancer isattributed to hepatitis B and C infections.15 Hepatitis B causes 30%of cirrhosis and 53% of primary liver cancer and hepatitis C 27% ofcirrhosis and 25% of primary liver cancer.Treatment has been shown to be highly effective but is currently oflimited availability in many parts of the world.16 Effective treatmentand management of chronic infection can substantially reduceor eliminate much of the morbidity and mortality that result fromhepatitis B and C infections. HIV/AIDS co-infection and alcoholconsumption are both believed to increase the likelihood of thedevelopment of liver cancer and cirrhosis in people with chronic viralhepatitis. Of the at least 33 million people estimated to have HIV/AIDS worldwide, 2-4 million are estimated to be co-infected withhepatitis B and another 4-5 million with hepatitis C.17 Alcohol useis a growing global public health problem and a leading risk factorin global morbidity.18 Some areas, such as parts of Eastern Europeand Africa, see high levels of alcohol consumption, viral hepatitisinfection and HIV /AIDS in the same geographical area, although todate little research has examined the impact of the three together.Awareness of viral hepatitis is low. This is important becauseknowledge of the risks and routes of transmission is essential toprevent continuing transmission. This is particularly relevant forhepatitis B and C, which are often asymptomatic for many years
IntroductionEffective control and prevention is often complex, requiring avariety of components including immunisation programmes, bloodscreening, injection and needle safety, services for intravenous drugusers, public health awareness and education programmes, sexualhealth programmes, disease surveillance, and blood testing andtreatment access. This may be one of the reasons that aggregateinformation on viral hepatitis policies is scarce at national and, evenmore so, at international level.This research project was initiated in 2009 in order to map existingnational government policies and programmes for viral hepatitis aswell as to determine those areas where governments would liketechnical assistance from the WHO. The data generated provide anoverall view of what is currently in place, together with gaps andneeds, and thus will be able to inform planning at regional andglobal level, as well as providing governments with useful insightsinto how viral hepatitis can be addressed in different contexts.Additionally, drawing together data on the many elements necessaryfor effective control and prevention offers opportunities to ensurethat interventions are coordinated and integrated so as to strengthenhealth systems overall.This report provides an overview of the main dimensions of countries’viral hepatitis prevention and control programmes and policies,summarised at global and regional level and on a per-country basis.The first section sets out the methodology used in the study andthe limitations of the data collected. Most prominently this highlightsthat the data, collected through a survey of governments, have notbeen validated and that the existence of a policy or programmecannot be taken as testament to its implementation, effectivenessor comprehensiveness. For example, 97% of responding countrieshave a vaccination policy and yet 40% feel they would benefit fromtechnical assistance from the WHO in vaccination delivery.included a short overview of indicative health, economic andhepatitis-related mortality and morbidity data for each country atthe beginning of each country profile. These data are provided asrelative indicators, intended to provide a degree of context for thedata collected in this study and to facilitate comparison, and shouldnot be taken as official figures for the area or country. Accurate andcurrent prevalence data for hepatitis B and hepatitis C is not oftenavailable.Introductionwith the result that globally the majority of those infected areundiagnosed. Not only does this increase the likelihood that theywill unwittingly infect others; in preventing them from accessingtreatment or making lifestyle changes such as moderating alcoholintake, this greatly contributes to the significant global mortality andmorbidity that result from hepatitis B and hepatitis C.Lavanchy, D. Hepatitis B virus epidemiology, disease burden, treatment, and current andemerging prevention and control measures. Journal of Viral Hepatitis, 2004, 11 (2): 97-1071Lavanchy, D. Chronic Viral Hepatitis as a Public Health issue in the World. Best Practice &Research Clinical Gastroenterology, 2008, 22 (6): 991-10082Ibid.3Alter, M. Epidemiology of viral hepatitis and HIV co-infection. Journal of Hepatology, 2006, 44:S6-S94Kamili, S, K. Krawczynski, K McCaustland, X Li and M Alter. Infectivity of Hepatitis C virus inplasma after drying and storing at room temperature. Infection Control and Hospital Epidemiology,2007,28: 519-5245Lavanchy, 2008. op cit.6World Health Organization. Viral Hepatitis: Report by the Secretariat, WHO EB126/15, 2009b7Lavanchy, 2008. op cit.8World Health Organization. Immunization Safety: Accomplishments, 2005 (http://www.who.int/immunization safety/ispp/ispp final report accomplishments/en/, accessed 22 March 2010)9Ibid.10Shepard, C, L Finelli, and M Alter. Global epidemiology of hepatitis C virus infection. LancetInfectious Diseases, 2005, 5: 558-6711Lavanchy, 2008. op cit.12World Health Organization. Viral Hepatitis: Report by the Secretariat, WHO EB126/15, 2009b13Ibid14Perz, J.F, G. Armstrong, L Farrington, Y Hutin, B Bell. The contributions of hepatitis B virus andhepatitis C virus infections to cirrhosis and primary liver cancer worldwide. Journal of Hepatology,2006, 45: 529–53815Shepard, C, L Finelli, and M Alter. Global epidemiology of hepatitis C virus infection. LancetInfectious Diseases, 2005, 5: 558-6716Alter, 2006, op cit.17World Health Organization. Global Health Risks: Mortality and burden of disease attributable toselected major risks. Geneva, Switzerland, World Health Organization, 2009a18Following the description of the methodology used, the responsesreceived are outlined by geographical location and income group.The global and regional analyses then present the data collectedunder six themes: policy, awareness and education, surveillance,testing, treatment, and care and civil society engagement. The finalpart of each summary examines the areas in which countries wouldwelcome assistance from the WHO.The second section provides short descriptive summaries of theinformation received from each country that provided informationto this study. Summaries of the data received from each countryare set out according to the same themes used in the global andregional analyses, with the areas identified for WHO assistanceseparated out for ease of reference. Need as well as resources forthe many dimensions of prevention and control for viral hepatitisvary considerably across countries and regions. We have thereforeViral Hepatitis: Global Policy7
MethodologyMethodologyThis study was conducted from July 2009 to March 2010 bythe World Hepatitis Alliance in partnership with the World HealthOrganization (WHO).The information used in this report was gathered through a surveyof all WHO Member States. The survey was drafted by a projectteam at the World Hepatitis Alliance in consultation with the WHO. Aglossary of working definitions of the terms used in the survey wasalso developed to be provided alongside it for reference. The surveywas piloted across three WHO Member States and the resultingcomments and amendments incorporated into the final version.The study aimed to gather basic information on the policiesand programmes that exist across WHO Member States for theprevention and control of hepatitis B and hepatitis C, focusing ongovernment-sponsored education and awareness programmes,screening and testing programmes, disease surveillance,programme monitoring and evaluation and collaboration acrosssectors and with international and local organisations. Whilerespondents were asked to provide additional comment anddocumentation wherever possible, the core survey was designedto capture this basic set of data without requiring excessive detail.Responses to the survey were sought from the identified focal pointfor viral hepatitis at the Ministry of Health in each WHO MemberState. These were identified both through direct communicationwith Ministries and through WHO international, regional andcountry offices. Contact was made via WHO offices whereappropriate. The survey was made available online as well as indocument form and every effort was made to encourage Ministrieswhich did not initially complete the survey to respond. Althoughthe survey was written and distributed in English, responses andsupporting documentation were accepted in other languages.The global, regional and country profiles were developed usingthe completed survey responses supplemented by any additionaldetail, comments and documentation received. Policies andstrategies provided were examined and their content analysedaccording to a pre-defined set of variables. These had beenidentified a priori and agreed by the project team as constitutingthe major components for each type of policy and strategy. Wheredocuments had been submitted in languages other than English,they were analysed directly from the original by a member ofthe project team familiar with that language or working withtranslators.8Viral Hepatitis: Global PolicyFor analysis, countries have been grouped according to their WHOregion and by income group according to the 2009 World BankCountry Classification, based on Gross National Income (GNI).Those countries without this classification were allocated a groupbased on their GNI for the purposes of this study. Additional datahave been included to give an overview of the context in whichpolicy and programme development takes place. These includedata on health spends, life expectancy and population, all of whichwere drawn from the WHO Statistical Information System (WHOSIS)published database using the most recent data available. Inaddition, estimates of the mortality and morbidity associated withhepatitis B and hepatitis C and their sequelae from the WHO GlobalBurden of Disease 2004 study have been included.
LimitationsWhile the data presented include information reported by themajority of WHO Member States, 58 countries were unable tosubmit the required data in time. In some cases the lack of anyfocal point or department which oversees viral hepatitis preventeda survey response from being obtained. Those countries fromwhich no response was received may therefore be those in whichless work is underway and as such the results contained in thisreport may suggest a greater degree of activity in the policy arenathan in fact exists globally.Finally, the data included here are those which have been reportedby the identified focal point from each country’s Ministry ofHealth. It was not possible to verify the data submitted prior topublication of this report. The documentation has been codedand summarised for ease of inclusion in this report and, althoughevery effort has been made to ensure that all information correctlyreflects countries’ submissions throughout, it is possible that someinaccuracies have been included. We hope that governments willalert us to these so that they can be corrected in future editions.LimitationsThere are a number of limitations to the data collected andproduced in the course of this study that should be borne in mindwhen examining its results.Furthermore, the data included in this study reflect only the extantpolicies, strategies and programmes at the national level asreported by governments and not their quality or effectiveness orindeed even implementation. It is therefore important to exercisecaution in drawing service provision and delivery conclusions fromthe data included in this report.Several linguistic and definitional considerations should also behighlighted. The survey being limited to the English language,although mitigated by many WHO country offices that providedassistance to respondents, may have affected both responserates and respondents’ thorough and clear understanding of thevariables involved. The definitions of many of the terms used inthe survey, while addressed for the purposes of the study in the(English-language) glossary, will also vary across different regionsand countries and may therefore have been interpreted in differentways.The questions included in the final survey were framed in a waythat allowed respondents to answer ‘Yes’ or ‘No’ or to select froma few predefined variables. While this may assist with responserates and mitigate difficulties for respondents with limited Englishlanguage, this approach allows less scope to capture the nuanceswithin each variable. Although further clarification, detail anddocumentation were sought, these were not always available orprovided.To give an indication of the burden of hepatitis B and hepatitisC and their sequelae and co-factors, the 2004 mortality andmorbidity estimates for hepatitis B, hepatitis C, liver cancer andcirrhosis have been included in the report. These were drawnfrom the WHO Global Burden of Diseases 2004 Update publisheddatabase. It should be stressed, however, that accurate prevalencedata on hepatitis is extremely limited especially in lower incomecountries and these estimates are therefore very difficult tovalidate. These data are provided as relative indicators, intendedto provide a degree of context for the data collected in this studyand to facilitate comparison, and should not be taken as officialfigures for the area or country. They may in many places not givea full picture of the burden attributable to hepatitis B and hepatitisC. This will be a valuable area for future research and we hope thatfuture editions of the report will benefit from more accurate andcomparable epidemiological data as these become available.Viral Hepatitis: Global Policy9
ResponsesResponsesFigure 1. Map of global responsesResponse ReceivedNo Response/Not WHO Member StateThe information contained in this study reflects data gatheredfrom a total of 135 (70%) of the 193 current WHO Member States(associate members, areas and territories were not included inthe study). These are presented in the overview sections by WHOregion as detailed below and by income group according to theirWorld Bank 2009 country classification.1 The response rate variedfrom 84% within the Europe region (including separate entries
Mar 22, 2010 · with hepatitis B and hepatitis C can vary considerably between, and within, countries and therefore, even in areas of low overall prevalence, rates in certain sub-populations can be very high.3 Both hepatitis B and hepatitis C are efficiently transmitted through contact with infected bloo
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Viral Hepatitis C: Introduction “Viral hepatitis," refers to infections that affect the liver and are caused by viruses. It is a major public health issue in the United States and worldwide. Not only does viral hepatitis carry a high morbidity, but it also stresses medical resources and can have severe
Viral Hepatitis B: Introduction “Viral hepatitis," refers to infections that affect the liver and are caused by viruses. It is a major public health issue in the United States and worldwide. Not only does viral hepatitis carry a high morbidity, but it also stresses medical resources and can have severe economic consequences. .File Size: 412KB
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Needs Assessment of People with Viral Hepatitis – China 5 Educational institutions 37 Relationships 38 Information about viral hepatitis 39 Health promotion 42 Clinical Management - Monitoring 43 Clinical Management - Pharmaceutical treatment 44 Traditional Chinese Medicine 47 Discrimination 48
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