Hepatitis B and C surveillance and screening programmes in the non-EU/EEA Member States of the WHO European Region: survey findings from 10 countries, 2012.

The hepatitis B virus (HBV) and hepatitis C virus (HCV) epidemics warrant a comprehensive response based on reliable population-level information about transmission, disease progression and disease burden, with national surveillance systems playing a major role. In order to shed light on the status of surveillance in countries of the World Health Organization (WHO) European Region outside of the European Union and European Economic Area (EU/EEA), we surveyed 18 countries in Central and Eastern Europe. Among the 10 countries that responded, the common features of many surveillance systems included mandatory surveillance, passive case-finding and the reporting of both acute and chronic HBV and HCV. Only some countries had surveillance systems that incorporated the tracking of associated conditions and outcomes such as cirrhosis and liver transplantation. Screening programmes for some key populations appeared to be in place in many countries, but there may be gaps in relation to screening programmes for people who inject drugs, prisoners, sex workers and men who have sex with men. Nonetheless, important components of a surveillance structure are in place in the responding study countries. It is advisable to build on this structure to develop harmonised HBV and HCV surveillance for all 53 Member States of the WHO European Region following the example of the system recently instituted in EU/EEA countries.

Policy responses to viral hepatitis B and C among people who inject drugs in Member States of the WHO European region: a sub-analysis of the WHO 2013 global hepatitis policy survey.

BACKGROUND: Unsafe injections, through infectious bodily fluids, are a major route of transmission for hepatitis B and C. Viral hepatitis burden among people who inject drugs is particularly high in many Member States of central and Eastern Europe while national capacity and willingness to address it varies greatly. METHODS: The initial survey included 43 questions covering awareness, data, prevention, and screening and treatment. It was sent in five languages to identified national focal points. This sub-analysis included 11 questions and 53 Member States in the WHO European Region. Descriptive analyses of national activities are presented. As a secondary outcome bivariate analyses of differences between Member States of the European Union (EU) and European Free Trade Association (EFTA) compared to those not in said grouping are presented. RESULTS: Forty-four of the 53 Member States responded to the survey (response rate of 83%). More than three-quarters reported offering publicly-funded treatment for HBV or HCV (82% and 80%, respectively), with a significantly higher proportion of EU/EFTA Member States (P=0.004 and P=0.010, respectively). Half of Member States (53%) reported the existence of a national policy for hepatitis prevention and control; however less than one-third (27%) reported having written national strategies. Under half of the responding Member States reported holding events for World Hepatitis Day 2012. One-fifth reported offering hepatitis B and C testing free of charge, with less than one-third reportedly conducting regular serosurveys among people who inject drugs. CONCLUSIONS: Findings highlight key gaps requiring attention in order to improve national policies and programmes in the region and ensure an adequate response to injection drug use-associated viral hepatitis. Further studies are required to assess quality and impact of national policies and services.

Treatment of chronic hepatitis B virus infection in resource-constrained settings: expert panel consensus.

Most of the estimated 350 million people with chronic hepatitis B virus (HBV) infection live in resource-constrained settings. Up to 25% of those persons will die prematurely of hepatocellular carcinoma (HCC) or cirrhosis. Universal hepatitis B immunization programmes that target infants will have an impact on HBV-related deaths several decades after their introduction. Antiviral agents active against HBV are available; treatment of HBV infection in those who need it has been shown to reduce the risk of HCC and death. It is estimated that 20-30% of persons with HBV infection could benefit from treatment. However, drugs active against HBV are not widely available or utilized in persons infected with HBV. Currently recommended antiviral agents used for treatment of human immunodeficiency virus (HIV) infection do not adequately suppress HBV, which is of great concern for the estimated 10% of the HIV-infected persons in Africa who are co-infected with HBV. Progressive liver disease has been shown to occur in co-infected persons whose HBV infection is not suppressed. In view of these concerns, an informal World Health Organization consultation of experts concluded that: chronic HBV is a major public health problem in emerging nations; all HIV-infected persons should be screened for HBV infection; HIV/HBV co-infected persons should be treated with therapies active against both viruses and that reduce the risk of resistance; standards for the management of chronic HBV infection should be adapted to resource-constrained settings. In addition, a research agendum was developed focusing on issues related to prevention and treatment of chronic HBV in resource-constrained settings.

Strengthening hepatitis B and C surveillance in Europe: results from the two global hepatitis policy surveys (2013 and 2014).

BACKGROUND: Hepatitis B and C are major public health threats in the World Health Organization (WHO) European Region. Viral hepatitis surveillance shortcomings have resulted in many WHO Member States having insufficient data available to guide decision-making. This study describes surveillance in the region based on a quantitative sub-analysis of findings from the 2013 WHO viral hepatitis policy report and a qualitative analysis of civil society survey responses associated with these findings. METHODS: Descriptive statistics were created from information that national government focal points for viral hepatitis in 44 countries had previously reported in response to the WHO survey. Bivariate analysis was performed to compare data from within and outside of the European Union/European Economic Area (EU/EEA). Survey responses from civil society organizations in the countries of the WHO European Region were collated, and a descriptive analysis of the comments on surveillance-related questions was performed to identify key themes. RESULTS: The response rate for the survey of governments was 83 % among both EU/EEA countries (25/30) and non-EU/EEA countries (19/23). More than 90 % of governments reported having national surveillance systems for the acute forms of hepatitis B and hepatitis C, but less than two-thirds reported surveillance for the chronic forms of both diseases. High proportions of governments reported having central registries for the reporting of deaths (96 %) and liver cancer cases (80 %), while less than half reported regularly conducting viral hepatitis sero-surveys. All responding Member States reported having adequate laboratory capacity nationally to support hepatitis outbreak investigations and other surveillance activities. Target populations for sero-surveys most commonly included people who inject drugs (27 %), the general population (25 %), men who have sex with men (20 %) and pregnant women (20 %). Few statistically significant differences were found between EU/EEA and non-EU/EEA countries. CONCLUSIONS: Study findings indicated a capacity for robust viral hepatitis surveillance across the WHO European Region, with most countries having important surveillance components in place, but notable weaknesses were also identified. There is an urgent need for countries throughout the region to strengthen their surveillance programs in order to maximize the population-level impact of advances in HBV and HCV prevention and treatment.

HIV/hepatitis coinfection in eastern Europe and new pan-European approaches to hepatitis prevention and management.

ISSUES: HIV/hepatitis coinfection in Europe; WHO European clinical protocols on the management of people coinfected with HIV/AIDS and hepatitis B or C (HBV or HCV); stakeholder recommendations for better HCV services. INTRODUCTION: The increasing availability of highly active antiretroviral therapy throughout Europe and central Asia has changed comorbidity and mortality patterns among people living with HIV/AIDS (PLWHA) as liver disease has increasingly replaced AIDS as the cause of death in PLWHA in western European countries. The average prevalence of HCV among PLWHA is 40 per cent, and much higher in countries where the HIV epidemic is driven by injecting drug use. Access to hepatitis treatment for PLWHA and IDUs is still very limited in Europe due to a lack of clear clinical management guidelines for HIV/hepatitis coinfections, high costs and a national failure to recognise hepatitis as a critical health issue. DESCRIPTION: In October 2006, the WHO Regional Office for Europe issued protocols for the clinical management of HIV/HCV and HIV/HBV coinfections. They include diagnostic algorithms adjusted for resource availability, and guidelines for the management of patients who do not yet need treatment, those who need only hepatitis or only HIV/AIDS treatment, and those who need both. Though the protocols should provide practical guidelines for physicians and assist in the development of national treatment standards, there is still a need for targeted prevention, treatment and care interventions. To expand access to hepatitis prevention and treatment, public awareness needs to be raised and national political leaders need to address hepatitis as a public health issue. Effective public health measures include price reductions for anti-hepatitis drugs; targeted testing, counselling and prevention activities; increased access to hepatitis B and C treatment and to HBV vaccination for the populations most at risk.