Analyzing Subnational Immunization Coverage to Catch up and Reach the Unreached in Seven High-Priority Countries in the Eastern Mediterranean Region, 2019-2021.

Yearly national immunization coverage reporting does not measure performance at the subnational level throughout the year and conceals inequalities within countries. We analyzed subnational immunization coverage from seven high-priority countries in our region. We analyzed subnational, monthly immunization data from seven high-priority countries. Five were Gavi eligible (i.e., Afghanistan, Pakistan, Somalia, Syria, and Yemen); these are countries that according to their low income are eligible for support from the Global Alliance on Vaccine and Immunization, while Iraq and Jordan were included because of a recent decrease in immunization coverage and contribution to the regional number of under and unimmunized children. DTP3 coverage, which is considered as the main indicator for the routine immunization coverage as the essential component of the immunization program performance, varied monthly in 2019-2021 before reaching pre-pandemic coverage in the last two months of 2021. Somalia and Yemen had a net gain in DTP3 coverage at the end of 2021, as improvement in 2021 exceeded the regression in 2020. In Pakistan and Iraq, DTP3 improvement in 2021 equaled the 2020 regression. In Afghanistan, Syria and Jordan, the regression in DTP3 coverage continued in 2020 and 2021. The number of districts with at least 6000 zero-dose children improved moderately in Afghanistan and substantially in Somalia throughout the follow-up period. In Pakistan, the geographical distribution differed between 2020 and 2021.Of the three countries with the highest number of zero-dose children, DTP1 coverage reached 109% in Q4 of 2020 after a sharp drop to 69% in Q2 of 2020. However, in Pakistan, the number of zero-dose children decreased to 1/10 of its burden in Q4 of 2021. In Afghanistan, the number of zero-dose children more than a doubled. Among the even countries, adaptation of immunization service to the pandemic varied, depending on the agility of the health system and the performance of the components of the expanded program on immunization. We recommended monitoring administrative monthly immunization coverage data at the subnational level to detect low-performing districts, plan catchup, identify bottlenecks towards reaching unvaccinated children and customize strategies to improve the coverage in districts with zero-dose children throughout the year and monitor progress.

Engagement of private health sector in communicable disease and immunization programmes in Pakistan.

Background: In Pakistan, where the burden of communicable diseases remains high, the private sector accounts for 62% of health care provision. Aim: To describe the role of the private sector in communicable disease management in Pakistan and inform a more effective engagement towards achieving Universal Health Coverage. Methods: We searched the literature and available documents on policies, regulations and experiences in private health sector engagement in Pakistan. We interviewed policy level experts regarding the formulation of national health policies and plans and a sample of private providers using a structured questionnaire to assess their awareness of and engagement in communicable disease programmes. Results: Published reports described initiatives to engage the private sector in improving coverage for a package of care and programme-specific initiatives. Pakistan did not have a national policy for structural engagement, and regulations were limited. Policy level experts interviewed perceived the private sector as market-driven and poorly regulated. Thirty-nine percent of private sector providers interviewed were aware or had been trained in procedures or guidelines, and 23% of them had had their performance monitored by government. Conclusion: We recommend that the Ministry of Health provide overall vision for the operations of the public and private health sectors so that both sectors can complement each other towards the achievement of Universal Health Coverage, including for communicable diseases.

A pediatric HIV outbreak in Pakistan.

Background: Following reports of an outbreak of HIV infection among children in Larkana District, Pakistan, an international team investigated the extent and cause of the outbreak between April and June 2019. Aims: To investigate the incidence of HIV among children in Larkana District, Pakistan and describe the distribution of cases by time, place and person. Methods: Self-referred persons were tested for HIV using the national testing protocol. Local epidemiology of HIV was reviewed to generate hypotheses. An infection prevention and control (IPC) team conducted site visits and reviewed IPC practices. Results: Between 25 April and 27 June 2019, a total of 30 191 persons were tested for HIV in Larkana District, and 876 of them tested positive. Of those who tested positive, 719 (82%) were children aged <15 years. Traditional skin piercing procedures and transmission from high-risk populations to children were ruled out during the investigation. Informative interviews with parents or guardians of a convenience sample of 211 children aged <15 years showed that 99% of children had an injection or infusion for medical treatment within the past 12 months. Our investigation identified lack of HIV prevalence data for the general population including tuberculosis patients and those who attended antenatal care services. Conclusions: Investigations indicate that unsafe healthcare practices in formal and informal healthcare settings as the most likely cause of the 2019 outbreak of HIV infection in Larkana, Pakistan. Measures should be taken to improve IPC practices at the facility level, especially in pediatric and antenatal care clinics.

Region-wide assessment of National Immunization Technical Advisory Groups (NITAGs) using the NITAG Maturity Assessment Tool (NMAT) - Experience from the Eastern Mediterranean Region of the World Health Organization, 2023.

National Immunization Technical Advisory Groups (NITAGs) are independent bodies that help improve national immunization programmes in decision making on immunization policy. The new NITAG Maturity Assessment Tool (NMAT) provided an opportunity to conduct a region-wide assessment to improve NITAG capacity and foster institutional growth. We share experience of the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO) in using NMAT and the use of findings to develop improvement plans. NITAG chairs and secretariats from 22 EMR countries attended a virtual NMAT training in 2023. They self-assessed their NITAGs using the tool and developed improvement plans. An algorithm used the data to determine maturity levels for seven indicators. We consolidated results for the region by income groups. Of 22 countries (or NITAGs), 20 (91%) submitted NITAG assessment findings and 19 an improvement plan. The proportion of criteria met per indicator varied from 36% for independence and non-bias to 74% for establishment and composition. Maturity level varied by indicator. Of 20 NITAGs, less than half had an intermediate or higher-level maturity for the indicators of independence and non-bias 1 (5%), operations 3 (15%), making recommendations 4 (20%), stakeholder recognition 6 (30%), and resources and secretariat support 7 (35%). Meanwhile 11 (55%) NITAGs had an intermediate or higher maturity level for the indicators of establishment and composition and for integration into policy making process. Participants described NMAT as a concise, useful, user-friendly tool. NMAT is a practical tool that can be used by NITAGs to provide insights and strategic direction for individual countries and regionally. Prevention and management of conflict of interest is the domain that requires the most improvement in EMR. Planned activities should be implemented, monitored and a follow up assessment conducted in 2025.

Progress Toward Measles Elimination - World Health Organization Eastern Mediterranean Region, 2019-2022.

In 2015, all 22 World Health Organization Eastern Mediterranean Region (EMR) countries and areas (countries) pledged to achieve measles elimination by 2020. Despite success in several countries, most countries in the region still have not eliminated measles. This report updates a previous report and describes progress toward measles elimination in EMR during 2019-2022. During that period, estimated regional coverage with the first and second doses of a measles-containing vaccine (MCV) was 82%-83% and 76%-78%, respectively. During 2019-2022, approximately 160 million children were vaccinated during national or subnational supplementary immunization activities. Reported confirmed regional measles incidence decreased from 29.8 cases per 1 million population in 2019 to 7.4 in 2020, but then increased 68%, to 50.0 in 2022 because of challenges providing immunization services and conducting surveillance during the COVID-19 pandemic. Surveillance indicators deteriorated in 11 (50%) of the 22 EMR countries. During 2019-2022, four countries in the region were verified as having achieved measles elimination, but other countries reported immunity gaps and increased measles incidence in 2022. To achieve measles elimination in EMR, national immunization programs, especially in those countries with high measles incidence, will need to continue to recover from the COVID-19 pandemic, increase overall vaccination coverage to close immunity gaps, and maintain high-quality disease surveillance.

National immunization technical advisory groups (NITAGs) in the WHO Eastern Mediterranean Region (EMR): A decade of shaping immunization policies, 2010-2021.

In the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO), little is known on National Immunization Technical Advisory Groups' (NITAGs) outputs, including recommendations and their outcomes. We abstracted information from the WHO/UNICEF joint reporting forms and extracted implemented immunization policy decisions from the WHO immunization portal. We describe trends in establishments and functionality of NITAGs and immunization policies implemented in EMR from 2010 to 2021. In 2013, all 22 EMR countries had a NITAG, although only 20 remained active in 2021. The number of countries meeting six NITAG process indicators increased from 7 in 2010, to 14 in 2019, then reduced to 12 in 2021. In 2021, the proportion of countries with a functional NITAG decreased with income level, from 83% in high-income countries, to 55% in middle-income countries and 20% in low-income countries. From 2010 to 2021, there were 103 new vaccine introductions, 31 vaccine switches, and 28 schedule changes implemented across all 22 countries, irrespective of income groups. While NITAGs are established and making recommendations in countries, their functionality decreases with income level. Governments should continue to invest in NITAGs, including on strengthening processes and ensuring that recommendations made are based on evidence to decision frameworks.

Preparations for sustainability and transition from Global Fund support in the Eastern Mediterranean Region.

Background: HIV, tuberculosis and malaria (HTM) services receive financial support from the Global Fund and need to plan for sustainability and transition from external funding. Aim: To recommend actions for addressing key sustainability and transition issues in 15 countries receiving Global Fund grants in the WHO Eastern Mediterranean (EMR) Region. Methods: We reviewed documents, interviewed key informants, and conducted case studies in Sudan and Tunisia to highlight key considerations for sustainability and transition from Global Fund that is tailored to the EMR and the health system building blocks. Sustainability considerations should align with the health system building blocks, including governance, financing, service delivery, workforce and health product management, with the addition of considerations for key and vulnerable populations because of their particular importance for HIV and tuberculosis services. Conclusion: While hoping for economic growth and reduction of the burden of HTM, EMR countries need to prepare for transition from Global Fund support. Proactive steps that are tailored to the health system building blocks and address the needs of key and vulnerable populations should progressively increase national capabilities as well as resources dedicated to HTM.

Immunization in the Eastern Mediterranean Region: some signs of post-COVID-19 recovery, but more work ahead.

Every year, WHO and UNICEF estimate the immunization coverage for 195 Member States, based on reported data and independent coverage surveys (1,2). These estimates indicate progress in reaching children with life-saving vaccines while identifying coverage gaps (3). The 2022 estimates were much awaited, given that the COVID-19 pandemic caused a setback in coverage (1). Overall, there are encouraging signs of recovery in the WHO Eastern Mediterranean Region (EMR). For example, coverage of the third dose diphtheria-pertussis-tetanus containing vaccine (DTPcv3) and the second dose measles containing vaccine (MCV2), both almost restored or exceeded their 85% and 76% pre-pandemic 2019 levels, respectively (1). However, there are disparities across countries. Low-income countries with fragile, weak health systems and those in conflict situation are lagging. The number of children who missed their routine first dose of measles immunization increased from 3 million in 2019 to 3.16 million in 2022 (1). This underperformance, along with the accumulated immunity gap in 2020-2021, exposes us to the risk of preventable deadly outbreaks.

Public health impact of the spread of Anopheles stephensi in the WHO Eastern Mediterranean Region countries in Horn of Africa and Yemen: need for integrated vector surveillance and control.

BACKGROUND: Anopheles stephensi is an efficient vector of both Plasmodium falciparum and Plasmodium vivax in South Asia and the Middle East. The spread of An. stephensi to countries within the Horn of Africa threatens progress in malaria control in this region as well as the rest of sub-Saharan Africa. METHODS: The available malaria data and the timeline for the detection of An. stephensi was reviewed to analyse the role of An. stephensi in malaria transmission in Horn of Africa of the Eastern Mediterranean Region (EMR) in Djibouti, Somalia, Sudan and Yemen. RESULTS: Malaria incidence in Horn of Africa of EMR and Yemen, increased from 41.6 in 2015 to 61.5 cases per 1000 in 2020. The four countries from this region, Djibouti, Somalia, Sudan and Yemen had reported the detection of An. stephensi as of 2021. In Djibouti City, following its detection in 2012, the estimated incidence increased from 2.5 cases per 1000 in 2013 to 97.6 cases per 1000 in 2020. However, its contribution to malaria transmission in other major cities and in other countries, is unclear because of other factors, quality of the urban malaria data, human mobility, uncertainty about the actual arrival time of An. stephensi and poor entomological surveillance. CONCLUSIONS: While An. stephensi may explain a resurgence of malaria in Djibouti, further investigations are needed to understand its interpretation trends in urban malaria across the greater region. More investment for multisectoral approach and integrated surveillance and control should target all vectors particularly malaria and dengue vectors to guide interventions in urban areas.

Accelerating the prevention, control and elimination of communicable diseases through integration and optimization of the support from Gavi and Global Fund: A vision for the Eastern Mediterranean Region.

Over the years, the Eastern Mediterranean Region (EMR) has faced a funding gap with respect to malaria, tuberculosis (TB), HIV, and vaccine-preventable diseases programmes. In the early 2000s, Gavi, the Vaccine Alliance (Gavi) and the Global Fund against AIDS, TB and Malaria (GFATM) became important financial contributors to these programmes. In 2000-2015, funding support from these two global health initiatives allowed progress. However, from 2015, coverage of interventions plateaued, and the region is now behind on the related Sustainable Development Goal (SDG) targets.

Over-Prescription and Overuse of Antimicrobials in the Eastern Mediterranean Region: The Urgent Need for Antimicrobial Stewardship Programs with Access, Watch, and Reserve Adoption.

Excessive antimicrobial use contributes to the development of antimicrobial resistance. In the Eastern Mediterranean region (EMR), there is dearth of information on the prevalence of antimicrobial use in patients hospitalized in acute healthcare settings, clinical indications, types of antimicrobials prescribed, and quality indicators for prescriptions. Between September and December 2019, seven countries in the EMR conducted a standardized point prevalence survey. All patients present in the hospital wards at 8 a.m. on the day of the survey constituted the sample population. We collected data, including patient characteristics, antimicrobials received, therapeutic indication according to predefined lists, and markers of prescribing quality. The survey included data from 139 hospitals in seven countries. Among the 19,611 inpatients surveyed, 11,168 patients received at least one antimicrobial {crude prevalence: 56.9% (95%CI: 56.2-57.6%). The top three classes of antimicrobials prescribed were third-generation cephalosporins (26.7%), beta-lactam penicillins (18.1%), and imidazole derivatives (n = 1655, 9.8%). Carbapenems were most frequently prescribed for the treatment of healthcare-associated infections. Compliance with quality indicators of antimicrobial use was limited where treatment guidelines were available for 41% of antimicrobial prescriptions and targeted antimicrobial treatment represented 21% of therapeutic indications. Overall hospital antimicrobial use was high in countries of the EMR, pointing to the need to design and implement context-specific antimicrobial stewardship programs to optimize antimicrobial use and reduce antimicrobial resistance.

Review of the neglected tropical diseases programme implementation during 2012-2019 in the WHO-Eastern Mediterranean Region.

INTRODUCTION: The 2012-2020 WHO NTD roadmap set targets for control, elimination, and eradication of neglected tropical diseases (NTDs). It recommends 5 strategies, out of which preventive chemotherapy (PC) and intensified disease management were key to achieve targets. WHO estimated that globally, between 2012 and 2019, the number of persons affected by NTDs decreased from nearly 2.1 to 1.7 billion people. We analysed the situation of NTDs in the WHO Eastern Mediterranean Region (EMR) in 2020 to assess the progress with the 2012-2020 roadmap and to identify gaps. METHODS: We reviewed data repositories of national data sources for 2012 to 2019 including the Global Indicator Data Platform for Sustainable Development Goals, the Global Health Observatory data repository, the WHO PC databank, and the EMR data repository. We allocated countries a Red-Amber-Green (RAG) rating based on standardized criteria, on progress and current situation of each of 11 priority NTDs. RESULTS: All 22 countries in EMR were affected by 1 or more autochthonous or imported NTDs. In 2019, WHO estimated that in EMR, 78 million people required interventions for NTDs, a 38% decline compared with 2012. Twelve of 22 countries needed priority public health action (i.e., red) for 1 or more NTD. Of these, Sudan needed priority public health action for 6 NTDs and Yemen for 5. Eleven countries also needed priority public health action for cutaneous leishmaniasis, and 5 countries for rabies and trachoma. Visceral leishmaniasis is on the increase in Afghanistan, Libya, Syria, and Yemen. CONCLUSION: Since the first roadmap of NTDs in 2012, the EMR has made a substantial progress. Nevertheless, many challenges remain in the prevention and control of NTDs. EMR needs a regional approach to control NTDs in countries most affected and a coordinated strategy to stop the continuing increase of cutaneous leishmaniasis and a possible resurgence of visceral leishmaniasis.

Progress towards elimination of viral hepatitis by 2030 in the WHO Eastern Mediterranean Region, 2019.

The WHO Global Health Sector Strategy and hepatitis regional action plan for the WHO Eastern Mediterranean Region (EMR) proposed strategic directions for countries to progress towards the elimination of viral hepatitis by 2030. In 2019, we reviewed progress to gain a picture of current pressures and identify priority actions for member states to reach this goal. We collected data from country, regional, and global reports published in 2015-19, questionnaires completed by countries, and convened a regional consultation with programme managers and partners. We analysed these data along three thematic areas: governance and finance, strategic information, and service delivery. 15 of the 22 EMR countries completed the review. Of these, 10 (67%) had a national strategy and six (40%) allocated funds to it. 11 (73%) countries had testing and treatment guidelines in line with WHO recommendations. Ten (67%) countries had burden and coverage estimates, four (27%) reported on the cascade of care for hepatitis C virus (HCV), three (20%) reported on the cascade of care for hepatitis B (HBV), and three (20%) had mortality estimates. By 2019, the regional hepatitis B vaccination coverage among infants was 82% for the third dose and 33% for the timely birth dose. For harm reduction, 27 syringes were distributed per injecting drug user per year. Between 2015 and 2019, HCV diagnosis increased from 18% to 33% and treatment for hepatitis C increased from 12% to 26%. Within the same time period, diagnosis of HBV diagnosis increased from 2% to 14% and treatment initiation increased from less than 1% to 2%. EMR countries made progress in governance, policy development, coverage of the third dose of the hepatitis B vaccine, and testing and treatment for HCV infection. However, birth dose vaccination, injection safety, harm reduction, and testing and treatment are limited by insufficient financing. Core interventions need to be included within national universal health coverage packages as an initial move towards elimination.

Worldwide prevalence of hepatitis B virus and hepatitis C virus among patients with cirrhosis at country, region, and global levels: a systematic review.

BACKGROUND: Empirical, updated country-level estimates on the proportion of cirrhosis attributable to viral hepatitis are required. We estimated the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in patients with cirrhosis at country, regional, and global levels as an approximation for the fractions of cirrhosis attributable to viral hepatitis. METHODS: In this systematic review, we searched MEDLINE, Embase, Web of Science, and Scielo between Jan 1, 1993, and Aug 1, 2021. Studies were eligible if they reported on the prevalence of both HBV and HCV infection in representative studies of at least 20 patients with cirrhosis. Studies were excluded if they used first-generation HCV assays or were from a selected population of patients with cirrhosis (eg, patients selected based on specific causes, veterans, injecting drug users). Two authors (CJA and CdM) selected and extracted aggregated data from the selected publications. Data were extracted for study recruitment period, age, sex, and cause of cirrhosis, among others. Data about heavy alcohol consumption and non-alcoholic fatty liver disease (NAFLD) were also extracted when available. Aggregated data from studies from key publications were requested from the authors of the original study if selection of patients was unclear or information on causes was missing. We estimated the country-specific prevalence of causes of cirrhosis by pooling study-level data from the same country using a random-effects model. Subsequently, we estimated the regional (WHO region and UN subregion) and global prevalence by weighting the country-specific prevalence by the number of new liver cancer cases that occurred in 2020, as estimated in GLOBOCAN. The study was registered with PROSPERO, CRD42020149323. FINDINGS: Our database searches identified 21 338 records, and a further nine records were identified by scanning references of key publications. After excluding duplicates and assessing full-text articles for eligibility, 520 publications from 86 countries or territories (and reporting on 1 376 503 patients with cirrhosis) were included in the systematic review. The prevalence of HBV infection was lower among patients with cirrhosis in Europe, the Americas, and Oceania (UN subregional prevalence ranges 3-14%) than in Africa and Asia (8-61%). HCV infection prevalence was heterogenous, even within regions (12-83%). The combined prevalence of HBV and HCV infection exceeded 50% in most Asian and African regions. Globally, among patients with cirrhosis, 42% had HBV infection and 21% had HCV infection. The contribution of heavy alcohol use was highest in Europe (country range 16-78%), the Americas (17-52%), and Oceania (15-37%) and lowest in Asia (0-41%). Data on NAFLD were limited. INTERPRETATION: HBV and HCV could account for almost two thirds of the global burden of cirrhosis. With the availability of effective interventions for the prevention or treatment of HBV and HCV, the data presented in this study will help to effectively allocate resources towards viral hepatitis elimination and to design interventions at the country level. FUNDING: International Agency for Research on Cancer, World Health Organization.

Increasing Antimicrobial Resistance in World Health Organization Eastern Mediterranean Region, 2017-2019.

To better guide the regional response to antimicrobial resistance (AMR), we report the burden of AMR over time in countries in the World Health Organization Eastern Mediterranean Region. To assess the capacities of national infection prevention and control and antimicrobial stewardship programs, we analyzed data on bloodstream infections reported to the Global Antimicrobial Resistance Surveillance System during 2017-2019, data from 7 countries on nationally representative surveys of antimicrobial prescriptions, and data from 2 regional surveys. The median proportion of bloodstream infections was highest for carbapenem-resistant Acinetobacter spp. (70.3%) and lowest for carbapenem-resistant Escherichia coli (4.6%). Results of the regional assessments indicate that few countries have capacities for infection prevention and control and antimicrobial stewardship programs to prevent emergence and spread of AMR. Overall, the magnitude of the problem and the limited capacity to respond emphasize the need for regional political leadership in addressing AMR.

United for dignity: four strategic shifts to get to zero leprosy by 2030.

Leprosy, or Hansen's disease, is a curable infectious disease caused by the bacillus M. leprae. In 1991, the World Health Assembly WHA44.9 set the goal for "elimination of leprosy as a public health problem" as less than one case on treatment per 10 000 population by 2000. Since then, global leprosy strategies have focused on reducing the prevalence of the disease at country level and reducing transmission. Early detection and prompt treatment with multidrug therapy, the keystone for leprosy control, led to the achievement of this goal at global level by 2000, and in almost all countries, at least at the national level, by 2015.

HIV epidemiology in the WHO Eastern Mediterranean region: a multicountry programme review.

BACKGROUND: Worldwide, HIV incidence, and mortality has decreased since 2010; however, in the WHO Eastern Mediterranean region, trends continue to increase. We reviewed the regional progress to understand determinants of this situation and inform strategies to accelerate the response. METHODS: We conducted a multicountry programme review of 22 countries in the WHO Eastern Mediterranean region from Jan 1, 2010 to Dec 31, 2020. We extracted data from WHO's global AIDS monitoring system, UNAIDS estimates, and country reports regarding incident cases, policy uptake, and antiretrovirals used. We analysed data to describe incidence, testing practices, treatment coverage, and mortality to identify bottlenecks leading to persisting incidence and mortality. FINDINGS: Due to COVID-19 disruptions, the volume of HIV testing in 2020 halved to 3·0 million tests compared with 2019 with 8017 people living with HIV identified (0·27% positivity yield). In comparison with a 0·18% positivity yield from the 6·5 million tests in 2019. HIV tests were done in migrants (59·6%), groups at low risk (38·9%), and key populations (1·5%). Diagnoses with advanced disease increased from 27·3% in 2017 to 37·0% in 2019. In 2019, among 52 318 people on treatment, only 2888 (6%) received optimised regimens as per WHO recommendations. The number of people on treatment increased from 19 000 in 2010 with a coverage of 8% to 110 000 in 2020 with a coverage of 25%. Late diagnoses and suboptimal regimens could explain the increase in mortality from 9600 in 2010 to 17 000 in 2020. INTERPRETATION: In the Eastern Mediterranean region, inefficient testing and suboptimal treatment lead to underdiagnosis, persisting transmission, late treatment, and rising mortality. The HIV epidemic is growing faster than the response. A change in thinking is needed to test groups at high risk, transition to optimised treatment, and deliver patient-centred services that maximise retention. FUNDING: World Health Organization.

The global hepatitis delta virus (HDV) epidemic: what gaps to address in order to mount a public health response?

BACKGROUND: Co-infection between hepatitis B virus (HBV) and hepatitis delta virus (HDV) causes the severest chronic hepatitis and is associated with a high risk of cirrhosis and hepatocellular carcinoma (HCC). The Global Health Sector Strategy on Viral Hepatitis called for the elimination of hepatitis (- 65% mortality and - 90% incidence) by 2030. Our aims were to summarize key points of knowledge and to identify the gaps that need to be addressed to mount a public health response to HDV. METHODS: We performed a current literature review in terms of epidemiology by WHO regions, genotypes distribution and their pathogenicity, factors associated with HDV infection, mortality due to HDV infection, testing strategies and treatment. RESULTS: Prevalence of infection and genotypes are heterogeneous distributed, with highest prevalence in foci around the Mediterranean, in the Middle East, and in Central, Northern Asia and Eastern Asia. Persons who inject drugs (PWID) and migrants from highly endemic areas are highly affected. While antibody detection tests are available, HDV RNA tests of current infection are not standardized nor widely available. The few therapeutic options, including lofartinib, are not widely available; however several new and promising agents have entered clinical trials. CONCLUSION: HDV infection is an poorly known cause of chronic liver disease. To mount a public health response, we need a better description of the HDV epidemic, standardized testing strategies and better treatment options.