Government - Executive summary
Viral hepatitis is a group of infectious diseases that aff ects hundreds of millions of people worldwide, causing serious illness and death from acute hepatitis infection, liver cancer and liver cirrhosis. Although there are eff ective tools and strategies for the prevention and treatment of hepatitis, low awareness of hepatitis has limited their impact. Given the variation in how the fi ve main types of hepatitis (A, B, C, D and E) manifest across and within countries, global prevention and control eff orts need to be transformed into national and sub-national prevention and control strategies.
In 2010, the World Health Assembly adopted resolution WHA 63.18 in recognition of viral hepatitis as a global public health problem. The World Health Organization (WHO) followed up on the resolution by crafting a strategy that addresses four axes: awareness-raising, partnerships and resource mobilization; evidence- based policy and data for action; prevention of transmission; and screening, care and treatment.
The periodic evaluation of implementation of the WHO strategy requires an initial baseline survey of all Member States. In mid- 2012, WHO, in collaboration with the World Hepatitis Alliance, conducted such a survey, asking Member States to provide information relating to the aforementioned four axes of the WHO strategy. In particular, Member States were asked whether key prevention and control activities are being conducted. This report presents the results. The fi rst chapter provides an introduction to viral hepatitis and to the global response to this group of diseases. The second chapter provides a global overview of the survey fi ndings. Chapters three through eight present fi ndings from the six WHO regions, including summaries of data from all responding countries. Additional survey data, study methodology information and the survey instrument can be found in Annexes A–E.
One hundred and twenty-six Member States submitted the survey for a response rate of 64.9%. The regional response rate varied from 26.1% for the African Region to 100% for the South-East Asia Region. Across income groups, the response rate ranged from 47.4% for low-income countries to 80.0% for high-income countries.
Implementing a national response to comprehensively address viral hepatitis is a challenge for many governments. Because of the high burden of hepatitis-related diseases and the different routes of transmission and health outcomes, they need to simultaneously implement a variety of prevention and care interventions. Additionally, government offi cials should focus on monitoring hepatitis outbreaks and disease trends while collaborating with civil society to raise awareness about hepatitis. The results of the survey indicate that some Member States are addressing some aspects of this response but that much more needs to be done.
An important step that can help Member States to identify priorities and marshal resources is to develop a written national strategy or plan that focuses exclusively or primarily on viral hepatitis. This plan could either stand alone or function as part of a broader health-planning document. Only 37.3% of responding Member States reported the existence of such a plan. Even fewer (28.6%) had a governmental unit dedicated to addressing hepatitis prevention and control. Furthermore, the number of government staff working full-time on hepatitis-related activities is small; more than half of the countries reported having no more than two employees.
Almost three fourths of responding Member States reported that they had a viral hepatitis prevention and control programme that included activities targeting specifi c populations. The populations most commonly targeted were health-care workers, including health-care waste handlers (86.0% of responding Member States within this subset), and people who inject drugs (54.8% of responding Member States within this subset).
National governments can play an important role in making their citizens aware of the importance of viral hepatitis, how to avoid getting infected and how to seek care. World Hepatitis Day (28 July), which was established in 2010 as part of the World Health Assembly resolution 63.18, is an important means of raising awareness about hepatitis. Two years after the passage of the resolution, almost 40% of responding Member States reported that they had engaged in activities to mark World Hepatitis Day. However, it is important for the remaining Member States, particularly where the burden of viral hepatitis is high, to organize World Hepatitis Day activities. Civil society organizations can play a signifi cant role in further publicizing health messages for World Hepatitis Day and throughout the year. However, less than half of responding Member States reported that they collaborated with civil society groups within their countries to develop and implement the governmental viral hepatitis prevention and control programme.
Obtaining reliable data is important for planning and monitoring the implementation of hepatitis control activities. Most Member States (82.5%) reported having a national surveillance programme that regularly collected data and reported results regarding hepatitis incidence. In only approximately half of these Member States did the surveillance system include a method for monitoring chronic hepatitis B and C, which are responsible for most hepatitis-related morbidity and deaths. To properly assess the scope of chronic hepatitis requires conducting regular prevalence serosurveys in both the general and most-at-risk populations; however, only about two thirds of Member States reported conducting such surveys.
There have been signifi cant advances in the prevention of viral hepatitis. The most important is the wide-scale implementation of universal childhood vaccination for hepatitis B. As of 2011, 180 countries included hepatitis B vaccination in their routine vaccine schedules and the coverage is approaching 80%. The survey results provide additional data concerning national hepatitis B vaccination policies. Slightly more than three fourths of Member States reported having a specifi c policy for the prevention of mother-to-child transmission which includes vaccination. This is important as infection transmitted from mothers Executive summary to their children is the principal route of transmission in many countries, particularly in Asia. Health-care workers are another group requiring special attention for vaccination in view of their high risk of infection through needle-stick injuries. Almost two thirds of Member States reported having a vaccination policy for health-care workers.
In many countries, transmission of hepatitis to patients through unsafe injection practices in health-care settings is still a problem. The majority of the responding Member States reported addressing this through a national policy on injection safety and recommending the use of single-use syringes.
With the development of reliable tests to identify hepatitis infections, transmission of hepatitis through transfusions is preventable; 94.4% and 91.3% of Member States reported screening all donated blood units for hepatitis B and C, respectively. The survey was not able to assess other recommended practices, such as the promotion of blood donations from voluntary nonremunerated blood donors or the utilization of quality control measures for laboratory testing.
Hepatitis treatment is undergoing a revolution. New medications are being developed and introduced, which will improve control and provide higher cure rates for hepatitis B and C. It is important for countries to be prepared for the anticipated scale up of treatment by training health-care providers, establishing national treatment guidelines, and including hepatitis medications in their essential medicines lists. The survey results indicate that much progress must be made in these key areas. Only half of reporting Member States indicated that they have clinical guidelines for the treatment of hepatitis, and less than half reported including key medications for the treatment of hepatitis B such as tenofovir or entecavir in their essential medicines list. Only 54.8% reported including pegylated interferon, which is the current mainstay of hepatitis C treatment. Encouragingly, approximately 60% of Member States reported having publicly funded treatment programmes. The survey was not able to assess the geographical coverage of these treatment services or their success in reaching most-at-risk populations.
One of WHO’s core functions is to help Member States in their eff orts to improve the health of their populations. In the survey, Member States were asked to indicate areas in which they might want assistance from WHO for the prevention and control of viral hepatitis. Respondents most commonly selected the following: developing a national plan for viral hepatitis prevention and control (58.1%), estimating the national burden of viral hepatitis (54.8%) and developing education/training programmes for health professionals (54.0%). In order to provide this assistance, it will be important to identify adequate resources and coordinate activities at WHO Headquarters and the regional levels.
The survey has limitations that constrain the ability to interpret the results, including a low response rate from the African Region. In addition, it was not possible to collect information concerning the quality of the programmes or their geographical scope. Nevertheless, the survey does document notable achievements, particularly in the area of prevention of hepatitis transmission. National governments still need to do much more to comprehensively address this global killer. Furthermore, in view of limited resources, it will be vital for all relevant organizations at the international, national and local levels to work together to maximize the impact of hepatitis control activities.