Global policy report on the prevention and control of viral hepatitis in WHO Member States

Global policy report on the prevention and control of viral hepatitis IN WHO MEMBER STATES

WHO Library Cataloguing-in-Publication Data Global policy report on the prevention and control of viral hepatitis in WHO Member States. 1. Hepatitis – prevention and control. 2. Hepatitis, Viral, Human – prevention and control. 3. Hepatitis B vaccines. 4. Health policy. 5. National health programs. I. World Health Organization. ISBN 978 92 4 156463 2 (NLM classification: WC 536)

© World Health Organization 2013. All rights reserved. All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Photo credits: Page 10 – WHO / Christopher Black I Page 30 – WHO / Antonio Suarez Weise I Page 66 – WHO / Torgrim Halvari I Page 92 – WHO / Tom Pietrasik I Page 146 – WHO / Andrew Caballero Reynolds I Page 166 – WHO / Jim Holmes Design and layout: Vivian Lee, Design Geneva Technical editing: Bandana Malhotra

Global policy report on the prevention and control of viral hepatitis IN WHO MEMBER STATES

FOREWORD

The five viruses that cause infections of the liver are responsible for a widely prevalent and growing disease burden. No country, rich or poor, is spared. These viruses are important as they cause infectious diseases in their own right. Hepatitis A and E viruses are major foodborne and waterborne infections, which cause millions of cases of acute illness every year, with several months sometimes needed for full recovery. But viral hepatitis also makes a substantial contribution to the burden of chronic diseases and the premature mortality they cause. Worldwide, infections with hepatitis B and C viruses cause an estimated 57% of cases of liver cirrhosis and 78% of cases of primary liver cancer. The availability of a vaccine that confers lifelong protection against infection with the hepatitis B virus gives public health a rare opportunity to prevent a leading cause of cancer, especially in low- and middle-income countries. The significance of these challenges and opportunities was formally acknowledged in 2010, when the World Health Assembly adopted its first resolution on viral hepatitis. That resolution, which called for a comprehensive approach to prevention and control, opened a new era of awareness about the magnitude of disease caused by viral hepatitis and the need for urgent action on several fronts. As attention to viral hepatitis continues to build, so has recognition of the many strategies available for prevention and control in all resource settings. Control measures for viral hepatitis fit well with the current drive to strengthen health systems, especially as many measures touch on the fundamental capacities of a well-functioning health system. These include reaching every child with immunization programmes that include hepatitis B vaccine, protecting against mother-to-child transmission of the virus, and ensuring the safety of blood, transfusion services, organ donation, and injection practices. The broad social and environmental determinants of viral hepatitis further call for improvements in housing, sanitation, and food and water safety. The fact that many infections are silent, causing no symptoms until there is irreversible damage to the liver, points to the urgent need for universal access to immunization, screening, diagnosis, and antiviral therapy. As hepatitis viruses show great diversity in their prevalence and modes of transmission in different parts of the world, policies and strategies for prevention and control need to be tailored to the specific national or sub-national context. The 2010 World Health Assembly resolution urged Member States to generate reliable information as a foundation for building prevention and control measures that match the local epidemiological profile and health system capacities.

This report is a contribution to that objective. It sets out the results of a survey conducted in mid-2012 by the World Health Organization and the World Hepatitis Alliance. The survey aimed to gather country-specific baseline data on hepatitis policies in WHO Member States in all six regions. Survey data also offer insight into conditions in specific countries that may have hindered past efforts to achieve hepatitis policy objectives. Gaps that need to be filled are identified, as are specific areas of policy development where WHO assistance is needed. Such baseline data will serve as a solid benchmark as countries, supported by WHO and its partners, seek to make the “silent” epidemic of viral hepatitis more visible – and more manageable.

Dr Margaret Chan Director-General World Health Organization

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ACKNOWLEDGEMENTS

We would like to sincerely thank the many respondents to this survey from the participating WHO Member States. This document was written by Jeffrey V. Lazarus, Kelly SafreedHarmon and Ida Sperle from the University of Copenhagen in coordination with the World Health Organization’s Global Hepatitis Programme and the World Hepatitis Alliance.a Charles Gore, Hande Harmanci, Jeffrey V. Lazarus, Tim Nguyen, Raquel Peck, Kelly Safreed-Harmon and Stefan Wiktor contributed extensively to the development of this document. The questionnaire was reviewed by members of the WHO Viral Hepatitis Action Group: Diana Chang-Blanc, Jesus Maria GarciaCalleja, Ana Maria Henao-Restrepo, Selma Khamassi, Neelam Dhingra-Kumar, Ana Maria Padilla-Marroquin, Anita Sands, Andreas Ullrich, Annette Verster, Marco Vitoria and Krisantha Weerasuriya. The survey was disseminated to Member States by WHO staff from the regional offices: in AFRO by Frank John Lule, in AMRO/ PAHO by Luis G. Castellanos and Nuria Diez Padrisa, in EMRO by Mamunur Malik, in EURO by Martin Donoghoe and Irina Eramova, in SEARO by Vason Pinyowiwat, in WPRO by Karen Hennessey, Chin-Kei Lee, Ying-Ru Jacqueline Lo, Tamano Matsui and Tomoe Shimada. This project was supported by the Ministry of Health, Labour and Welfare of Japan. The World Hepatitis Alliance provided a research grant to the University of Copenhagen for conducting the survey.

a

The World Hepatitis Alliance is an umbrella nongovernmental organization with 166 patient group members in 67 countries. It was admitted into Official Relations at EB130 and is partnering with WHO in the delivery of materials for World Hepatitis Day.

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ABBREVIATIONS AND ACRONYMS

AFRO AIDS AMRO EMRO EURO GDP HBsAg HCV HIV IDU NGO PAHO PPP int $ SEARO STD STI WHO WPRO

World Health Organization Regional Office for Africa acquired immune deficiency syndrome World Health Organization Regional Office for the Americas World Health Organization Regional Office for the Eastern Mediterranean World Health Organization Regional Office for Europe gross domestic product hepatitis B surface antigen hepatitis C virus human immunodeficiency virus injecting drug user nongovernmental organization Pan American Health Organization purchasing power parity in international dollars World Health Organization Regional Office for South-East Asia sexually transmitted disease sexually transmitted infection World Health Organization World Health Organization Regional Office for the Western Pacific

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TABLE OF CONTENTS

Foreword Acknowledgements Abbreviations and Acronyms Executive summary Chapter 1 Introduction Chapter 2 Global findings Chapter 3 WHO African Region Country summaries Chapter 4 WHO Region of the Americas Country summaries Chapter 5 WHO Eastern Mediterranean Region Country summaries Chapter 6 WHO European Region Country summaries Chapter 7 WHO South-East Asia Region Country summaries Chapter 8 WHO Western Pacific Region Country summaries Annexes

ii iii iv vi 1 3 10 16 30 38 66 73 92 101 146 153 166 173 189

Executive summary

Viral hepatitis is a group of infectious diseases that affects hundreds of millions of people worldwide, causing serious illness and death from acute hepatitis infection, liver cancer and liver cirrhosis. Although there are effective tools and strategies for the prevention and treatment of hepatitis, low awareness of hepatitis has limited their impact. Given the variation in how the five main types of hepatitis (A, B, C, D and E) manifest across and within countries, global prevention and control efforts 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 mid2012, 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 first 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 findings. Chapters three through eight present findings 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 officials 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 specific 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 significant 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 significant 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 specific policy for the prevention of mother-to-child transmission which includes vaccination. This is important as infection transmitted from mothers

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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 efforts 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.

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Chapter 1: Introduction

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Chapter 1:

Introduction

Viral hepatitis is a group of infectious diseases that affects hundreds of millions of people worldwide. Five distinct hepatitis viruses have been identified: A, B, C, D and E. Hepatitis B and C, which can lead to chronic hepatitis, are particularly prevalent; 240 million people are thought to be chronically infected with hepatitis B and 184 million people have antibodies to hepatitis C. 1,2 The five hepatitis viruses have different epidemiological profiles and also vary in terms of their impact and duration. The transmission route depends on the type of virus. Transmission routes that contribute greatly to the spread of hepatitis are exposure to infected blood via blood transfusion or unsafe injection practices, consumption of contaminated food and drinking water, and transmission from mother to child during pregnancy and delivery. Unsafe injection practices, including the use of unsterile needles and syringes, serve as a major pathway for the spread of hepatitis B and C, and reducing transmission of both diseases means changing these practices. Due to its largely asymptomatic nature, viral hepatitis is a silent epidemic; most people are unaware of their infection. Untreated chronic hepatitis B and C infection can result in liver cirrhosis and liver cancer. According to the Global Burden of Disease estimates, hepatitis B and hepatitis C together caused 1.4 million deaths in 2010, including deaths from acute infection, liver cancer and cirrhosis.3 To put these figures in the context of other major infectious diseases, it is estimated that malaria caused 660 000 deaths in 2010,4 and tuberculosis and HIV 1.4 and 1.7 million deaths, respectively, in 2011.5,6 Prevention and control of hepatitis can therefore make a significant contribution to saving lives by preventing cancer and thereby reducing the burden of noncommunicable diseases. The global public health response to viral hepatitis recognizes that surveillance and control are vital to ensure that testing, care and treatment are available to all people who need these services in every country of the world. As there is an effective vaccine for hepatitis B, immunization has been a central strategy for most countries to reduce the burden of hepatitis B. There is no vaccine available to prevent the spread of hepatitis C, but the screening of blood products and the use of sterile needles and syringes have contributed to lowering hepatitis C transmission in many countries.

However, as with other major public health challenges, the mere existence of effective tools and strategies for prevention and treatment is not enough to halt viral hepatitis. A major stumbling block has been the low awareness of viral hepatitis, both in the general population and among key populations. Since knowledge about the various risks and transmission routes is central to preventing the spread of hepatitis, increasing awareness is an important component of the global public health response. Increasing awareness is also key to making hepatitis a larger part of the local, national and regional health agenda. Gaps can be seen between policy and practice, as even in countries with evidence-informed hepatitis policies, there is inadequate implementation of protocols for prevention, treatment and control. This situation indicates a need for improvement in the response to viral hepatitis at all levels.

A global problem with a global response Viral hepatitis is a global health problem from which no country, rich or poor, is spared. This problem takes a multitude of different forms, with factors such as the type of hepatitis, the most common transmission pathways, and the most effective strategies for diagnosis and treatment all varying across and within countries. Thus, global efforts to make hepatitis a public health priority need to be transformed into prevention and control strategies that are tailored to specific conditions at the national and sub-national levels. 1

Prevention and control of viral hepatitis infection: framework for global action. Geneva, WHO, 2012. 2 Mohd Hanafiah K, Groeger J, Flaxman AD, Wiersma ST. Global epidemiology of hepatitis C virus infection: new estimates of age-specific antibody to HCV seroprevalence. Hepatology, 2013, 57(4):1333–1342. 3 Lozano R et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet, 2012, 380(9859):2095–2128. 4 World malaria report 2012. Geneva, WHO, 2012. Available at: http://www.who. int/malaria/publications/world_malaria_report_2012/wmr2012_no_profiles.pdf (accessed on 03 May 2013). 5 Global tuberculosis report 2012. Geneva, WHO, 2012. Available at: http://www. who.int/tb/publications/global_report/gtbr12_main.pdf (accessed on 03 May 2013). 6 UNAIDS Report on the global AIDS epidemic 2012. Geneva, 2012. Available at: http://www.unaids.org/en/resources/publications/2012/name,76121,en.asp (accessed on 03 May 2013).

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Chapter 1: Introduction

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

In 2010, the World Health Assembly adopted resolution WHA 63.18 in recognition of viral hepatitis as a global public health problem.7 The resolution emphasized the need for governments and populations to take action to prevent, diagnose and treat viral hepatitis, and called upon the World Health Organization (WHO) to develop and implement a comprehensive global strategy to support these efforts. WHO has crafted guidance for the World Health Assembly’s 194 Member States within a health systems approach, as described in Prevention and control of viral hepatitis infection: framework for global action.1 The WHO strategy addresses the following axes: 1. Awareness-raising, Partnerships and Resource Mobilization 2. Evidence-based Policy and Data for Action 3. Prevention of Transmission 4. Screening, Care and Treatment. The 2010 resolution adopted by the World Health Assembly furthermore designated 28 July as World Hepatitis Day, envisioning this as an opportunity for Member States to promote awareness about viral hepatitis.7 The first official World Hepatitis Day was in 2011. WHO encourages governments, international organizations and civil society groups around the world to observe World Hepatitis Day with activities that call attention to the disease burden imposed by viral hepatitis, and to the prevention and control measures that need to be implemented.

Monitoring the response: the 2012 survey The periodic evaluation of implementation of the WHO strategy requires an initial baseline survey of how all Member States are responding to viral hepatitis. In mid-2012, WHO and the World Hepatitis Alliance conducted such a survey, asking Member States to provide information relating to the four axes of the WHO strategy. This report presents the survey results. It describes the major dimensions of prevention and control policies and programmes for viral hepatitis in WHO Member States. Furthermore, survey data provide insight into how conditions in specific countries may have hindered previous efforts to achieve hepatitis policy objectives. Findings also highlight gaps that must be addressed in order to improve hepatitis policies and programmes at the national and global levels. The second chapter of this report provides an overview of the global findings. Chapters three through eight present findings from the six WHO regions, including summaries of data from all responding countries. Additional data for selected survey questions appear in Annexes A–C. Annex D describes the study methodology, and Annex E the survey instrument. It is anticipated that follow-up surveys, some utilizing the same questionnaire and others addressing specific issues in greater detail, will be carried out every one to two years to monitor overall progress in implementation of the WHO hepatitis prevention and control strategy. 7

World Health Organization. Sixty-third World Health Assembly. Viral hepatitis: WHA 63.18. Geneva, Switzerland, 21 May 2010.

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Chapter 2: Global findings

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Chapter 2:

Global findings

One hundred and twenty-six Member States submitted the World Health Organization/World Hepatitis Alliance survey (“WHO/Alliance survey”) (Figure 1), a response rate of 64.9%. Respondents and non-respondents are listed by WHO region in Box 1.

Response levels by region are presented in Table 1, along with response levels by income group according to the World Bank classification. 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 80.0% for high-income countries to 47.4% for low-income countries.

Box 1. Responses to the 2012 Global Hepatitis Survey from each WHO region WHO African Region Member States that submitted surveys: Cameroon, Chad, Comoros, Côte d’Ivoire, Mali, Mauritania, Nigeria, Rwanda, Sierra Leone, South Africa, United Republic of Tanzania and Zimbabwe Member States that did not submit surveys: Algeria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cape Verde, Central African Republic, Congo, Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Niger, Sao Tome and Principe, Senegal, Seychelles, Swaziland, Togo, Uganda and Zambia WHO Region of the Americas Member States that submitted surveys: Antigua and Barbuda, Argentina, Bahamas, Barbados, Brazil, Canada, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Suriname, United States of America and Uruguay Member States that did not submit surveys: Belize, Bolivia (Plurinational State of), Chile, Dominica, Haiti, Saint Vincent and the Grenadines, Trinidad and Tobago, and Venezuela (Bolivarian Republic of) WHO Eastern Mediterranean Region Member States that submitted surveys: Afghanistan, Bahrain, Djibouti, Egypt, Iran (Islamic Republic of), Iraq, Jordan, Kuwait, Lebanon, Oman, Pakistan, Qatar, Somalia, South Sudan, Sudan, Syrian Arab Republic and Yemen Member States that did not submit surveys: Libya, Morocco, Saudi Arabia, Tunisia and United Arab Emirates WHO European Region Member States that submitted surveys: Albania, Andorra, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Hungary, Ireland, Israel, Italy, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Malta, Montenegro, Netherlands, Poland, Republic of Moldova, Russian Federation, San Marino, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Tajikistan, The former Yugoslav Republic of Macedonia, Turkey, Ukraine, United Kingdom of Great Britain and Northern Ireland, and Uzbekistan Member States that did not submit surveys: Bosnia and Herzegovina, Greece, Iceland, Kazakhstan, Monaco, Norway, Portugal, Romania and Turkmenistan WHO South-East Asia Region Member States that submitted surveys: Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste Member States that did not submit surveys: no country WHO Western Pacific Region Member States that submitted surveys: Australia, Brunei Darussalam, Cambodia, China, Japan, Kiribati, Lao People’s Democratic Republic, Malaysia, Mongolia, New Zealand, Papua New Guinea, Singapore, Solomon Islands, Tonga and Viet Nam Member States that did not submit surveys: Cook Islands, Fiji, Marshall Islands, Micronesia (Federated States of), Nauru, Niue, Palau, Philippines, Republic of Korea, Samoa, Tuvalu and Vanuatu

Table 1. Responses received by WHO region and income groupa High income (N=50) Africa (N=46) Americas (N=35) Eastern Mediterranean (N=22) Europe (N=53) South-East Asia (N=11) Western Pacific (N=27) Total: Income group a b

Upper–middle income (N=53) 1 (12.5%) 16 (80.0%) 3 (60.0%) 10 (71.4%) 2 (100%) 2 (50.0%) 34 (64.2%)

Lower–middle income (N=50) 3 (27.3%) 6 (85.7%) 8 (88.9%) 5 (100%) 5 (100%) 7 (53.8%) 34 (68.0%)

Low income (N=38) 8 (26.9%) 0 (0%) 2 (100%) 3 (100%) 4 (100%) 1 (25.0%) 18 (47.4%)

Other (N=3)b n/a n/a n/a n/a n/a 0 (0%) 0 (0%)

0 (0%) 5 (83.3%) 4 (66.7%) 26 (83.9%) n/a 5 (83.3%) 40 (80.0%)

Source for income group classifications: World Bank 2012 data (http://data.worldbank.org/about/country-classifications/country-and-lending-groups.) Income group classifications were not available for three Western Pacific countries that did not submit surveys: Cook Islands, Nauru and Niue. n/a = not available

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Chapter 2: Global findings

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Figure 1. Map of global responses

Yes No No data

Figure 2. Responses to the question, “Is there a written national strategy or plan that focuses exclusively or primarily on the

prevention and control of viral hepatitis?”

Yes No

No response No data

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Chapter 2: Global findings

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

National coordination Forty-seven responding Member States (37.3%) reported the existence of a written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis (Figure 2). Eighteen of the 47 Member States with a strategy or plan reported that it focuses exclusively on viral hepatitis, and 20 reported that it addresses other diseases as well. Five countries reported that the strategy or plan addresses only hepatitis B and one reported that it addresses only hepatitis C. Three countries reported that the strategy or plan addresses both hepatitis B and hepatitis C. The 47 Member States that reported the existence of a strategy or plan were asked about its specific components. Forty-six reported the inclusion of a component for vaccination. Fortythree reported the inclusion of a component for prevention of transmission in health-care settings, and the same number for general prevention and surveillance. Thirty-seven reported the inclusion of a component for treatment and care. Thirty-six reported the inclusion of a component for raising awareness. Thirty-five reported the inclusion of a component for the prevention of transmission via injecting drug use. Thirty-six responding Member States (28.6%) reported that they had a governmental unit or department responsible solely for viral hepatitis-related activities. Member States that did so were asked to indicate the number of staff members in the unit or department. Responses (N=30) ranged from 0.1 (New Zealand) to 250 (Brazil) (median, 5). Member States were asked to report the number of people working full-time on hepatitis-related activities in all government agencies or bodies. Among the 47 Member States that provided data for this question, the number ranged from 0 to 213 (median, 2), with Armenia reporting the highest number. Ninety-three responding Member States (73.8%) reported that they had a viral hepatitis prevention and control programme that included activities targeting specific 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). Fortyfour responding Member States (47.3%) reported the inclusion of activities targeting people living with HIV and 36 responding Member States (38.7%) reported the inclusion of activities targeting prisoners. Groups identified less frequently included migrants, indigenous populations, low-income populations, those who are uninsured and those who are homeless.

Sixty responding Member States (47.6%) reported that they collaborated with civil society groups within their countries to develop and implement the governmental viral hepatitis prevention and control programme.

Evidence-based policy and data for action One hundred and four responding Member States (82.5%) reported that they have routine surveillance for viral hepatitis; details are given in Table 2. Table 2. Types of surveillance in Member States reporting the

existence of routine surveillance for viral hepatitis (N=104) No Yes (%) No (%) Do not know response (%) (%) There is a national surveillance system for acute hepatitis infection for the following forms of hepatitis: hepatitis A hepatitis B hepatitis C hepatitis D hepatitis E There is a national surveillance system for chronic hepatitis infection for the following forms of hepatitis: hepatitis B hepatitis C hepatitis D 52.9 49.0 23.1 43.3 46.2 64.4 0 0 0 3.8 4.8 12.5 86.5 96.2 85.6 38.5 45.2 5.8 2.9 9.6 41.3 35.6 0 0 0 1.0 1.0 7.7 1.0 4.8 19.2 18.3

One hundred and seven responding Member States (84.9%) indicated that their countries have standard case definitions for hepatitis infection and 100 (79.4%) indicated that their countries have a central registry for the reporting of deaths, including hepatitis deaths. Fifty-seven Member States reported on the proportion of hepatitis cases and deaths registered as “undifferentiated” or “unclassified” hepatitis. The reported proportion ranged from 0% to 100% (median, 1.0%).a Additional survey findings on surveillance are presented in Table 3. Member States were asked how often hepatitis disease reports were published. Of the responding Member States, 40.5% reported that they publish hepatitis disease reports annually; a

Awareness-raising and partnerships Forty-eight responding Member States (38.1%) reported that they had held events for World Hepatitis Day 2012 (28 July). Since January 2011, 36 responding Member States (28.6%) had funded some type of viral hepatitis public awareness campaign other than World Hepatitis Day (Annex A).

These figures represent data from 55 of the 57 Member States. Data from the Russian Federation and Mali are not included here because those Member States reported the information in a different way. See the Russian Federation and Mali country findings elsewhere in the report for information about undifferentiated/ unclassified hepatitis in those Member States.

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GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Table 3. Data registration and surveillance (N=126) No Yes (%) No (%) Do not know response (%) (%) Liver cancer cases are registered nationally Cases with HIV/hepatitis coinfection are registered nationally Hepatitis outbreaks are reported If YES – Hepatitis outbreaks are further investigated (N=115) 69.8 47.6 91.3 94.8 22.2 45.2 5.6 4.3 5.6 5.6 3.2 0.9 2.4 1.6 0 0

they have established the goal of eliminating or reducing hepatitis B (Figure 3). Member States were asked to report, for a given recent year, the percentage of newborn infants who had received the first dose of hepatitis B vaccine within 24 hours of birth. Among the 86 Member States that provided this information, responses ranged from 0% to 100% (median, 58.0%). Member States were also asked to report, for a given recent year, the percentage of one-year-olds (ages 12–23 months) who had received three doses of hepatitis B vaccine. Among the 101 Member States that provided this information, responses ranged from 0% to 100% (median, 92.0%). Ninety-six responding Member States (76.2%) reported the existence of a national policy that specifically targets mother-tochild transmission of hepatitis B; details are presented in Annex B. Of the Member States with such a policy, 65.6% indicated that one component of the policy calls for screening of all pregnant women for hepatitis B. Eighty-eight responding Member States (69.8%) reported the existence of a specific national strategy and/or policy/ guidelines for preventing hepatitis B and hepatitis C infection in health-care settings. Eighty responding Member States (63.5%) reported that healthcare workers are vaccinated against hepatitis B prior to starting work that might put them at risk of exposure to blood. One hundred and nine responding Member States (86.5%) reported the existence of a national policy on injection safety in health-care settings. These Member States were asked which types of syringes the policy recommends for therapeutic injections. Single-use syringes are recommended in 77.1% of policies, and auto-disable syringes in 30.3% (Figure 4). One hundred and ten responding Member States (87.3%) reported that single-use or auto-disable syringes, needles and cannulas are always available in all health-care facilities. Member States were asked for official estimates of the number and percentage of unnecessary injections administered annually in health-care settings (e.g. injections that are given when an equivalent oral medication is available). One hundred and thirteen Member States reported that the figures are not known and six did not reply. Among the seven responding Member States providing this information, responses ranged from 0% to 68.0% (median, 14.0%), with Denmark and Tonga reporting 0% and Mongolia reporting 68.0%. Additional findings relating to the prevention of hepatitis transmission are presented in Table 4.

21.4%, monthly; and 12.7%, weekly. No hepatitis disease report is published by 23.8% of responding Member States. Thirty-two responding Member States (25.4%) reported the existence of a national public health research agenda for viral hepatitis. Forty-one responding Member States (32.5%) reported that viral hepatitis serosurveys are conducted regularly. Among this subset, 17.1% indicated that serosurveys take place at least once per year and, of the same subset, 43.9% reported that the most recent viral hepatitis serosurvey was carried out in either 2011 or 2012.

Prevention of transmission Fifty-one responding Member States (40.5%) reported that they have a national hepatitis A vaccination policy. Thirty responding Member States (23.8%) reported that Figure 3. Responses to the question, “Has your government

established the goal of eliminating hepatitis B?” (N=12)a Do not know (4.8%) No response 4.0%

Yes (23.8%)

No (67.5%)

Screening, care and treatment a

Four Member States that answered ”yes” to this question (Australia, Latvia, Republic of Moldova and Sweden) added comments indicating that their goals relate to reducing rather than eliminating hepatitis B.

Member States were asked how health professionals in their countries obtain the skills and competencies required to effectively care for people with viral hepatitis. Responding Member States most frequently indicated that these are acquired in schools for health professionals (pre-service education,

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Chapter 2: Global findings

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Figure 4. Proportion of responding Member States with

national policies on injection safety in health-care settings which recommend single-use syringes and auto-disable syringes for therapeutic injections (N=109) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% a

States indicated that there are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral hepatitis. Fifty-nine responding Member States (46.8%) indicated that they have a national policy relating to screening and referral to care for hepatitis B. Forty-eight (38.1%) reported that they have such a policy for hepatitis C. Regarding hepatitis B testing, 116 responding Member States Figure 5. Responses to the question, “Are there national clinical guidelines for the management of viral hepatitis?” (N=126) No response (4.0%) Do not know 7.1%

Single-use syringesa

Auto-disable syringesa

Do not know

Respondents could select both “single-use syringes” and “auto-disable syringes”.

No (38.1%)

Yes (50.8%)

77.0%). Additionally, on-the-job training was identified in 73.0% of responses and postgraduate training in 61.6%. Sixty-four responding Member States (50.8%) reported the existence of national clinical guidelines for the management of viral hepatitis (Figure 5). Thirty-five of these 64 Member States indicated that the guidelines include recommendations for cases with HIV coinfection. Forty-four of 74 responding Member Table 4. Hepatitis prevention: policies, practices and

guidelines (N=126) No Yes (%) No (%) Do not know response (%) (%) There is a national infection control policy for blood banks All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B All donated blood units (including family donations) and blood products nationwide are screened for hepatitis C There is a national policy relating to the prevention of viral hepatitis among people who inject drugs The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety 88.9 5.6 4.0 1.6

94.4

3.2

0

2.4

(92.1%) indicated that people register by name for testing. One hundred and one members of that subset (87.1%) indicated that the names are kept confidential. Fifty-two responding Member States (41.3%) reported that the hepatitis B test is free of charge for all individuals. Among the 70 other Member States that answered the question, 43 (61.4%) reported that the hepatitis B test is free of charge for members of specific groups. Groups identified included blood donors, health-care workers, pregnant women, people living with HIV, patients on haemodialysis, prisoners and people who inject drugs. Sixty-one responding Member States (48.4%) reported that the hepatitis B test is compulsory for members of specific groups. Groups identified included blood donors, health-care workers, pregnant women, people living with HIV, patients on haemodialysis and prisoners. Regarding hepatitis C testing, 109 responding Member States (86.5%) indicated that people register by name for testing. Ninety-five members of that subset (87.2%) indicated that the names are kept confidential. Forty-eight responding Member States (38.1%) reported that the hepatitis C test is free of charge for all individuals. Among the 69 other Member States that answered the question, 39 (56.5%) reported that the hepatitis C test is free of charge for members of specific groups. Groups identified included blood donors, health-care workers, pregnant women, people living with HIV, patients on haemodialysis, prisoners and people who inject drugs. Fifty-seven responding

91.3

3.2

4.0

1.6

34.1

51.6

11.1

3.2

50.0

39.7

7.9

2.4

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Chapter 2: Global findings

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Member States (45.2%) reported that the hepatitis C test is compulsory for members of specific groups. Groups identified included blood donors, health-care workers, pregnant women, people living with HIV, patients on haemodialysis and prisoners. Seventy-nine responding Member States (62.7%) reported that publicly funded treatment is available for hepatitis B. Seventy-five responding Member States (59.5%) reported that publicly funded treatment is available for hepatitis C. Fourteen responding Member States reported the amount spent on publicly funded treatment for hepatitis B and hepatitis C. Details can be found in the summaries of country findings later in this report (see Argentina, Armenia, Bahrain, Croatia, Egypt, Lithuania, Myanmar, New Zealand, Pakistan, Poland, San Marino, Spain, Syrian Arab Republic and Turkey). One hundred and three responding Member States (81.7%) reported that at least one available drug for treating for hepatitis B is on the national essential medicines list or is subsidized by the government (Table 5). The drugs most commonly reported were lamivudine, interferon alpha and pegylated interferon. Eighty-three responding Member States (65.9%) reported that at least one available drug for treating for hepatitis C is on the national essential medicines list or is subsidized by the government. The drugs most commonly reported were ribavirin, pegylated interferon and interferon alpha.

(54.8%) and developing education/training programmes for health professionals (54.0%) (Tables 6 and 7). Responses from individual Member States appear in Annex C.

Table 5. Drugs for treating hepatitis B and C on national

essential medicines lists or subsidized by governments Drugs for treating hepatitis B % of Member States reporting its inclusion (N=126) 66.7 54.0 50.8 48.4 34.9 34.1 23.8 % of Member States reporting its inclusion (N=126) 57.9 54.8 45.2 19.8 18.3

Lamivudine Interferon alpha Pegylated interferon Tenofovir Entecavir Adefovir dipivoxil Telbivudine Drugs for treating hepatitis C

Ribavirin Pegylated interferon Interferon alpha Telaprevir Boceprevir

World Health Organization assistance 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 the national plan for viral hepatitis prevention and control (58.1%), estimating the national burden of viral hepatitis

Table 6. Viral hepatitis control and prevention: areas in which Member States indicated interest in receiving WHO assistance

(N=126) Awareness-raising, partnerships and resource mobilization (first WHO strategic axis) Developing the national plan for viral hepatitis prevention and control Integrating viral hepatitis programmes into other health services Awareness-raising Evidence-based policy and data for action (second WHO strategic axis) Viral hepatitis surveillance Estimating the national burden of viral hepatitis Developing tools to assess the effectiveness of interventions Assessing the economic impact of viral hepatitis Prevention of transmission (third WHO strategic axis) Increasing coverage of the birth dose of the hepatitis B vaccine Screening, care and treatment (fourth WHO strategic axis) Increasing access to treatment Increasing access to diagnostics Improving laboratory quality Developing education/training programmes for health professionals a

58.7% 48.4% 50.8% 52.4% 54.8% 43.7% 49.2% 31.7% 46.0% 49.2% 44.6%a 54.0%

N = 113 (This response option was not included in the survey completed by Belarus, Colombia and countries in the South-East Asia Region.)

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Chapter 2: Global findings

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Table 7. Viral hepatitis control and prevention: areas in which Member States indicated interest in receiving WHO assistance

by income group (N=126) High income (N=50) Upper– middle income (N=53) Lower– middle income (N=50) Low income (N=38)

Awareness-raising, partnerships and resource mobilization (first WHO strategic axis) Developing the national plan for viral hepatitis prevention and control Integrating viral hepatitis programmes into other health services Awareness-raising Evidence-based policy and data for action (second WHO strategic axis) Viral hepatitis surveillance Estimating the national burden of viral hepatitis Developing tools to assess the effectiveness of interventions Assessing the economic impact of viral hepatitis Prevention of transmission (third WHO strategic axis) Increasing coverage of the birth dose of the hepatitis B vaccine Screening, care and treatment (fourth WHO strategic axis) Increasing access to treatment Increasing access to diagnostics Improving laboratory quality Developing education/training programmes for health professionals a

27.5% 20.0% 17.5% 12.5% 25.0% 20.0% 25.0% 5.0% 10.0% 10.0% 5.0% 22.5%

58.8% 58.8% 50.0% 55.9% 61.8% 52.9% 55.9% 29.4% 41.2% 44.1% 43.3%a 55.9%

73.5% 64.7% 73.5% 79.4% 67.6% 58.8% 70.6% 47.1% 76.5% 76.5% 75.9%b 76.5%

100% 61.1% 83.3% 83.3% 83.3% 50.0% 50.0% 66.7% 77.8% 94.4% 92.9%c 83.3%

N = 30 (This response option was not included in the survey completed by Belarus, Colombia, Maldives and Thailand.) N = 29 (This response option was not included in the survey completed by Bhutan, India, Indonesia, Sri Lanka and Timor-Leste.) c N = 14 (This response option was not included in the survey completed by Bangladesh, Democratic People’s Republic of Korea, Myanmar and Nepal.) b

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Chapter 3: WHO African Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Chapter 3:

WHO African Region

Forty-six Member States make up the World Health Organization (WHO) African Region, which has a total population of 857 million.1 The African Region ranks behind the other five WHO regions on key measures of overall population health. It has the lowest life expectancy at birth (54 years in 2009) and the highest infant and under-five mortality rates.2 It has the highest level of unmet need for family planning and one of the lowest immunization coverage levels among one-year-olds.2 The African Region furthermore has severe shortages in its health workforce.3 Like the rest of the world, the African Region has seen noncommunicable diseases become a greater public health challenge in recent years. Deaths from noncommunicable diseases are expected to increase by more than 20% in the Region by 2020.4 Currently, however, it is the only region where mortality from communicable, maternal, perinatal and nutritional conditions still exceeds mortality from noncommunicable diseases.5 All of the African Region’s Member States except for Algeria are in sub-Saharan Africa, which has two thirds of all of the world’s cases of HIV. Researchers who analysed data on HIV and hepatitis from 20 sub-Saharan African countries found a weighted mean prevalence rate of hepatitis B surface antigen (HBsAg) of 15% among people living with HIV, while that of antibodies to hepatitis C virus (HCV) was 7% among people living with HIV.6

Responses to the WHO/Alliance survey were received from 12 of the 46 Member States in the Region (26.1%) (Box 1). Box 1. Responses to the 2012 Global Hepatitis Survey: WHO African Region

Member States that submitted surveys: • Cameroon • Chad • Comoros • Côte d’Ivoire • Mali • Algeria • Angola • Benin • Botswana • Burkina Faso • Burundi • Cape Verde • Central African Republic • Congo • Democratic Republic of the Congo • Equatorial Guinea • Mauritania • Nigeria • Rwanda • Sierra Leone • South Africa • Eritrea • Ethiopia • Gabon • Gambia • Ghana • Guinea • Guinea-Bissau • Kenya • Lesotho • Liberia • Madagascar • Malawi • Mauritius • United Republic of Tanzania • Zimbabwe

Member States that did not submit surveys: • Mozambique • Namibia • Niger • Sao Tome and Principe • Senegal • Seychelles • Swaziland • Togo • Uganda • Zambia

National coordination

Viral hepatitis in the WHO African Region The African Region is estimated to have some of the highest prevalence rates for hepatitis A globally, with ≥90% of children in sub-Saharan Africa exposed to infection by the age of 10 years.a The prevalence of hepatitis E in the Region varies from <2% in several countries to >20% in Central Africa.b The prevalence of hepatitis B is estimated at 8% in West Africa and 5%–7% in central, eastern and southern Africa.c The prevalence of hepatitis C is even higher in some areas, reaching levels of up to 10%.d

Two responding Member States (16.7%) reported the existence of a written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis (Figure 1). Both these Member States (South Africa and Mauritania) reported that it focuses exclusively on viral hepatitis. Member States that reported the existence of a strategy or plan were asked about its specific components. South Africa reported the inclusion of components for vaccination, general prevention, prevention of transmission via injecting drug use,

1 2

a

Jacobsen KH, Wiersma ST. Hepatitis A virus seroprevalence by age and world region, 1990 and 2005. Vaccine, 2010, 28:6653–6657. Aggarwal R. The global prevalence of hepatitis E virus infection and susceptibility: a systematic review. Geneva, World Health Organization, 2010. c Ott JJ, Stevens GA, Groeger J, Wiersma ST. Global epidemiology of hepatitis B virus infection: new estimates of age-specific HBsAg seroprevalence and endemicity. Vaccine, 2012, 30:2212–2219. d Mohd Hanafiah K, Groeger J, Flaxman AD, Wiersma ST. Global epidemiology of hepatitis C virus infection: new estimates of age-specific antibody to HCV seroprevalence. Hepatology, 2013, 57:1333–1342. b

World population prospects: the 2010 revision. New York, United Nations, Department of Economic and Social Affairs, Population Division, 2011. World Health Statistics 2012. Geneva, WHO, 2012. Available at: http://www.who. int/gho/publications/world_health_statistics/2012/en/ (accessed on 03 May 2013). 3 The African Health Monitor, April–June 2010; (12):22–29. Available at: http://ahm. afro.who.int/issue12/pdf/AHM%2012Complete.pdf (accessed on 03 May 2013). 4 Global status report on noncommunicable diseases 2010. Geneva, WHO, 2011. Available at: http://whqlibdoc.who.int/publications/2011/9789240686458_eng. pdf(accessed on 03 May 2013). 5 UNAIDS report on the global AIDS epidemic 2012. Geneva, 2012. Available at: http://www.unaids.org/en/media/unaids/contentassets/documents/epidemio logy/2012/gr2012/20121120_UNAIDS_Global_Report_2012_en.pdf (accessed on 03 May 2013). 6 Barth RE, Huijgen Q, Taljaard J, Hoepelman AI. Hepatitis B/C and HIV in subSaharan Africa: an association between highly prevalent infectious diseases. A systematic review and meta-analysis. International Journal of Infectious Diseases, 2010, 14(12):e1024–e1031.

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Figure 1. Responses to the question, “Is there a written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis?”

Awareness-raising and partnerships Four responding Member States (33.3%) reported that they held events for World Hepatitis Day 2012 (28 July). Since January 2011, one responding Member State (8.3%) had funded some type of viral hepatitis public awareness campaign other than World Hepatitis Day. This Member State (Chad) reported that it addressed the following topics: general information about hepatitis and its transmission, vaccination for hepatitis A and hepatitis B, the importance of knowing one’s hepatitis B and hepatitis C status, and safer sex practices. Six responding Member States (50.0%) reported that they collaborated with civil society groups within their countries to develop and implement the governmental viral hepatitis prevention and control programme. For example, Mali reported collaborating with SOS Hepatitis and Cameroon reported collaborating with Reseau Camerounais contre Hépatites Virales and Société Camerounaise de Gastro-Enterologie. (Further examples can be found in the summaries of country findings later in this chapter.)

Yes No

No response No data

Evidence-based policy and data for action Four responding Member States (33.3%) reported that they have routine surveillance for viral hepatitis; details appear in Table 1. Nine responding Member States (75.0%) indicated that their countries have standard case definitions for hepatitis infection and three (25.0%) indicated that their countries have a central registry for reporting deaths, including hepatitis deaths.

prevention of transmission in health-care settings, treatment and care, and coinfection with HIV. Mauritania reported the inclusion of components for raising awareness, surveillance, vaccination, general prevention, prevention of transmission via injecting drug use, prevention of transmission in health-care settings, treatment and care, and coinfection with HIV. Four responding Member States (33.3%) reported that they have a governmental unit or department responsible solely for viral hepatitis-related activities. Member States that did so were asked to indicate the number of staff members in the unit or department. Responses (N=4) ranged from 2 to 10 (median, 4.5), with Côte d’Ivoire reporting the largest number. Member States were asked to report the number of people working full-time on hepatitis-related activities in all government agencies or bodies. Among the five Member States that provided data for this question, the number ranged from 0 to 7 (median, 3.0), with South Africa reporting the largest number. Seven responding Member States (58.3%) reported that they have a viral hepatitis prevention and control programme that included activities targeting specific populations. The populations most commonly targeted were young children (57.1% of responding Member States within this subset) and health-care workers, including health-care waste handlers (57.1% of responding Member States within this subset). 12

Table 1. Types of surveillance in Member States reporting

the existence of routine surveillance for viral hepatitis (N=4) No Yes (%) No (%) Do not know response (%) (%) There is a national surveillance system for acute hepatitis infection for the following forms of hepatitis: hepatitis A hepatitis B hepatitis C hepatitis D hepatitis E There is a national surveillance system for chronic hepatitis infection for the following forms of hepatitis: hepatitis B hepatitis C hepatitis D 0 25.0 0 75.0 50.0 50.0 0 0 0 25.0 25.0 50.0 75.0 75.0 50.0 0 0 0 0 25.0 50.0 50.0 0 0 0 25.0 25.0 25.0 25.0 25.0 25.0 25.0

Chapter 3: WHO African Region

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Two Member States reported on the proportion of hepatitis cases and deaths registered as “undifferentiated” or “unclassified” hepatitis. One Member State (Mali) reported this to be 15%– 20% for hepatitis B and 4.98% for hepatitis C. The other Member State (Mauritania) reported this to be 10%–20%. Additional survey findings about surveillance are presented in Table 2. Table 2. Data registration and surveillance (N=126) No Yes (%) No (%) Do not know response (%) (%) Liver cancer cases are registered nationally Cases with HIV/hepatitis coinfection are registered nationally Hepatitis outbreaks are reported If YES – Hepatitis outbreaks are further investigated (N=115) 50.0 25.0 66.7 75.0 33.3 50.0 16.7 25.0 16.7 8.3 16.7 0 0 16.7 0 0

Figure 2. Responses to the question, “Has your government established the goal of eliminating hepatitis B?” (N=12)

Do not know (16.7%)

Yes (16.7%)

No (66.7%)

Among the eight Member States that provided this information, responses ranged from 50.0% to 97.0% (median, 83.0%). Three responding Member States (25.0%) reported the existence of a national policy that specifically targets mother-tochild transmission of hepatitis B. One Member State (Cameroon) indicated that the policy calls for health-care providers to follow up with all pregnant women found to have hepatitis B during pregnancy for the purpose of encouraging them to give birth at health-care facilities. The second Member State (Mauritania) indicated that the policy calls for counselling of all pregnant women found to have hepatitis B, and for delivery of the first dose of hepatitis B vaccine to all infants within 24 hours of birth. The third Member State (Comoros) indicated that the policy calls for screening of all pregnant women for hepatitis B. Four responding Member States (33.3%) reported the existence of a specific national strategy and/or policy/guidelines for preventing hepatitis B and hepatitis C infection in health-care settings. One responding Member State (8.3%, South Africa) reported that health-care workers are vaccinated against hepatitis B prior to starting work that might put them at risk of exposure to blood. Twelve responding Member States (100.0%) reported the existence of a national policy on injection safety in healthcare settings. These Member States were asked which types of syringes the policy recommends for therapeutic injections. Single-use syringes are recommended in 66.7% of policies, and auto-disable syringes in 58.3% (Figure 3). Seven responding Member States (58.3%) reported that singleuse or auto-disable syringes, needles and cannulas are always available in all health-care facilities. Member States were asked for official estimates of the number and percentage of unnecessary injections administered annually in health-care settings (e.g. injections that are given

Member States were asked how often hepatitis disease reports were published. Of the responding Member States, 16.7% reported that hepatitis disease reports are published annually, and 8.3% monthly. No hepatitis disease report is published by 41.7% of responding Member States. Two responding Member States (16.7%, Mauritania and Rwanda) reported the existence of a national public health research agenda for viral hepatitis. Two responding Member States (16.7%, Côte d’Ivoire and Rwanda) reported that viral hepatitis serosurveys are conducted regularly. One of the two (Rwanda) indicated that serosurveys take place every two years. Both Member States with regular serosurveys reported that the most recent viral hepatitis serosurvey was carried out in either 2011 or 2012.

Prevention of transmission Three responding Member States (25.0%) reported that they have a national policy for hepatitis A vaccination. Two responding Member States (16.7%, Cameroon and Rwanda) reported that they have established the goal of eliminating hepatitis B (Figure 2). Member States with this goal were asked to specify the timeframe in which they seek to eliminate hepatitis B. Both Member States said that the timeframe was not specified. Member States were asked to report, for a given recent year, the percentage of newborn infants who had received the first dose of hepatitis B vaccine within 24 hours of birth. Among the seven Member States that provided this information, all responses were 0%. Member States were also asked to report, for a given recent year, the percentage of one-year-olds (ages 12–23 months) who had received three doses of hepatitis B vaccine.

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Figure 3. Proportion of responding Member States with

national policies on injection safety in health-care settings which recommend single-use syringes and auto-disable syringes for therapeutic injections (N=12) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Single-use syringes a a

Table 3. Hepatitis prevention: policies, practices and guidelines (N=12) Yes (%) There is a national infection control policy for blood banks All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B All donated blood units (including family donations) and blood products nationwide are screened for hepatitis C There is a national policy relating to the prevention of viral hepatitis among people who inject drugs The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety 100 No (%) 0 Do not know (%) 0

100

0

0

83.3

8.3

8.3

25.0

66.7

8.3

25.0

58.3

16.7

Auto-disable syringes

a

Respondents could select both “single-use syringes” and “auto-disable syringes”.

when an equivalent oral medication is available). Eleven Member States reported that the figures are not known and one did not reply. Additional findings relating to the prevention of hepatitis transmission are presented in Table 3.

Figure 4. Responses to the question, “Are there national clinical guidelines for the management of viral hepatitis?” (N=12)

Screening, care and treatment Member States were asked how health professionals in their countries obtain the skills and competencies required to effectively care for people with viral hepatitis. Responding Member States most frequently indicated that these are acquired in schools for health professionals (pre-service education, 58.3%). In addition, on-the-job training was identified in 50.0% of responses, and postgraduate training in 50.0%. Four responding Member States (33.3%) reported the existence of national clinical guidelines for the management of viral hepatitis (Figure 4). Two of these four Member States (South Africa and the United Republic of Tanzania) indicated that the guidelines include recommendations for cases with HIV coinfection. Six of nine responding Member States (66.7%) indicated that there are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral hepatitis. Two responding Member States (16.7%, Côte d’Ivoire and Rwanda) indicated that they have national policies relating to screening and referral to care for hepatitis B and hepatitis C. Regarding hepatitis B testing, 12 responding Member States (100.0%) indicated that people register by name for testing. Eleven members of this subset (91.7%) indicated that the names are kept confidential. No responding Member State (0%) reported that the hepatitis B test is free of charge for all individuals. Six responding Member States (50.0%) reported 14

Yes (33.3%) No (66.77%)

that the hepatitis B test is free of charge for members of specific groups. Groups identified included blood donors, people living with HIV and pregnant women. Six responding Member States (50.0%) reported that the hepatitis B test is compulsory for members of specific groups. Groups identified included blood donors, people living with HIV and pregnant women. Regarding hepatitis C testing, eleven responding Member States (91.7%) indicated that people register by name for testing. All members of that subset (100%) indicated that the names are kept confidential. No responding Member State (0%) reported that the hepatitis C test is free of charge for all individuals. Six responding Member States (50.0%) reported that the hepatitis C test is free of charge for members of specific groups. Groups identified included blood donors. Six responding Member

Chapter 3: WHO African Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

States (50.0%) reported that the hepatitis C test is compulsory for members of specific groups. Groups identified included blood donors. Two responding Member States (16.7%) reported that publicly funded treatment is available for hepatitis B and three (25.0%) that it is available for hepatitis C. Information was not provided by any Member State regarding the amount spent on publicly funded treatment for hepatitis B and hepatitis C. Nine responding Member States (75.0%) reported that at least one available drug for treating hepatitis B is on the national essential medicines list or subsidized by the government (Table 4). The drugs most commonly reported were lamivudine, interferon alpha and tenofovir. Five responding Member States (41.7%) reported that at least one available drug for treating hepatitis C is on the national essential medicines list or subsidized by the government. The drugs most commonly reported were ribavirin, pegylated interferon and interferon alpha.

Table 4. Proportion of Member States reporting drugs for

treating hepatitis B and C on national essential medicines lists or subsidized by governments Drugs for treating hepatitis B % of Member States reporting its inclusion (N=12) 33.3 16.7 16.7 8.3 0.0 0.0 0.0 % of Member States reporting its inclusion (N=12) 25.0 25.0 16.7 0.0 0.0

Lamivudine Interferon alpha Tenofovir Pegylated interferon Entecavir Adefovir dipivoxil Telbivudine Drugs for treating hepatitis C

World Health Organization assistance 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: increasing access to treatment (91.7%), developing the national plan for viral hepatitis prevention and control (91.7%), surveillance for viral hepatitis (91.7%) and increasing access to diagnostics (91.7%, Table 5). Responses from individual Member States appear in Annex C.

Ribavirin Pegylated interferon Interferon alpha Telaprevir Boceprevir

Table 5. Viral hepatitis control and prevention: areas in which Member States indicated interest in receiving WHO assistance

(N=12) Awareness-raising, partnerships and resource mobilization (first WHO strategic axis) Developing the national plan for viral hepatitis prevention and control Integrating viral hepatitis programmes into other health services Awareness-raising Evidence-based policy and data for action (second WHO strategic axis) Viral hepatitis surveillance Estimating the national burden of viral hepatitis Developing tools to assess the effectiveness of interventions Assessing the economic impact of viral hepatitis Prevention of transmission (third WHO strategic axis) Increasing coverage of the birth dose of the hepatitis B vaccine Screening, care and treatment (fourth WHO strategic axis) Increasing access to treatment Increasing access to diagnostics Improving laboratory quality Developing education/training programmes for health professionals 91.7% 66.7% 83.3% 91.7% 75.0% 66.7% 58.3% 66.7% 91.7% 91.7% 83.3% 75.0%

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WHO African Region: COUNTRY SUMMARIES

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Chapter 3: WHO African Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Cameroon The Government of Cameroon reports as 20 Population (in millions) (2011) follows. Lower–middle-income Country classification (2012) $2330 Gross national income per capita (PPP int $) (2011) National coordination 5.13% There is no written national strategy or Total health expenditure as % of GDP (2010) $121.55 plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $36.01 Life expectancy at birth (in years) (2009) 51 hepatitis. Human Development Index (2011) 0.482 There is no designated governmental unit/ Median age (in years) (2010) 19 department responsible solely for coordi- Total fertility rate per woman (2010) 4.5 nating and/or carrying out viral hepatitisrelated activities. Information was not provided regarding how many people work Prevention of transmission Screening, care and treatment full-time on hepatitis-related activities in There is a national policy for hepatitis A It is not known how health professionals all government agencies/bodies. vaccination. obtain the skills and competencies required to effectively care for people with The government has a viral hepatitis pre- The government has established the goal viral hepatitis. vention and control programme that in- of eliminating hepatitis B but the timecludes activities targeting the following frame is not specified. There are national clinical guidelines for specific population: newborns. the management of viral hepatitis. InInformation was not provided regarding formation was not provided on whether Awareness-raising and partnerships the percentage of newborn infants nation- these guidelines include recommendaThe government held events for World ally in a given recent year who received tions for cases with HIV coinfection. There Hepatitis Day 2012 but has not funded any the first dose of hepatitis B vaccine within are national clinical guidelines for the other public awareness campaign on viral 24 hours of birth or the percentage of one- management of HIV, which include rechepatitis since January 2011. year-olds nationally (ages 12–23 months) ommendations for coinfection with viral in a given recent year who received three hepatitis. The government collaborates with the fol- doses of hepatitis B vaccine. lowing in-country civil society groups to The government does not have national develop and implement its viral hepatitis There is a national policy that specifically policies relating to screening and referral prevention and control programme: Re- targets mother-to-child transmission of to care for hepatitis B or hepatitis C. seau Camerounais contre Hépatites Virales hepatitis B (Annex B). and Société Camerounaise de Gastro-EnPeople testing for both hepatitis B and There is no specific national strategy and/ hepatitis C register by name; the names terologie. or policy/guidelines for preventing hepa- are kept confidential within the system. Evidence-based policy and data for titis B and hepatitis C infection in health- Hepatitis B and hepatitis C tests are not action care settings. provided free of charge, and are not comThere is no routine surveillance for viral pulsory for members of any specific group. There is a national policy on injection safehepatitis. ty in health-care settings, which recom- Publicly funded treatment is not available There are standard case definitions for mends single-use syringes for therapeutic for hepatitis B but is available for hepatitis hepatitis. Hepatitis deaths are not report- injections. Single-use or auto-disable sy- C. It is not known who is eligible for pubed to a central registry. Information was ringes, needles and cannulas are always licly funded treatment for hepatitis C. Innot provided regarding the percentage of available in all health-care facilities. formation was not provided regarding the hepatitis cases reported as “undifferentiamount spent by the government on such Official government estimates of the ated” or “unknown” hepatitis. treatment for hepatitis C. number and percentage of unnecesLiver cancer cases and cases with HIV/ sary injections administered annually in No drug for treating hepatitis B is on the hepatitis coinfection are not registered health-care settings are not known. national essential medicines list or subsinationally. dized by the government. The following There is a national infection control policy The government publishes hepatitis dis- for blood banks. All donated blood units drugs for treating hepatitis C are on the national essential medicines list or subsiease reports irregularly. (including family donations) and blood dized by the government: pegylated interproducts nationwide are screened for feron and lamivudine. Hepatitis outbreaks are not required to hepatitis B and hepatitis C. be reported to the government. There is adequate laboratory capacity nationally There is no national policy relating to the The Government of Cameroon welcomes to support outbreak investigations and prevention of viral hepatitis among peo- assistance from WHO in one or more areas of viral hepatitis prevention and control other surveillance activities for hepatitis ple who inject drugs. (Annex C). A, hepatitis B and hepatitis C, but not for The government has guidelines that adhepatitis E. dress how hepatitis A and hepatitis E can There is no national public health research be prevented through food and water agenda for viral hepatitis. Viral hepatitis se- safety. rosurveys are not conducted regularly.

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Chapter 3: WHO African Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Chad Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 11.5 Low-income $1360 4.53% $61.67 $15.40 48 0.328 17 6 cannulas are always available in all healthcare facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

The Government of Chad reports as Liver cancer cases and cases with HIV/ follows. hepatitis coinfection are not registered There is no national policy relating to the prevention of viral hepatitis among peonationally. National coordination ple who inject drugs. There is no written national strategy or The government does not publish hepatiThe government does not have guidelines plan that focuses exclusively or prima- tis disease reports. that address how hepatitis A and hepatirily on the prevention and control of viral Hepatitis outbreaks are required to be re- tis E can be prevented through food and hepatitis. ported to the government and are further water safety. There is a designated governmental unit/ investigated. There is adequate laboratory department responsible solely for coordi- capacity nationally to support investiga- Screening, care and treatment nating and/or carrying out viral hepatitis- tion of viral hepatitis outbreaks and other Health professionals obtain the skills and competencies required to effectively care related activities. It has six staff members. surveillance activities. for people with viral hepatitis through There are no people working full-time on hepatitis-related activities in any govern- There is no national public health research schools for health professionals (pre-servagenda for viral hepatitis. Viral hepatitis se- ice education) and postgraduate training. ment agency/body. rosurveys are not conducted regularly. There are no national clinical guidelines The government does not have a viral for the management of viral hepatitis. hepatitis prevention and control pro- Prevention of transmission gramme that includes activities targeting There is no national policy for hepatitis A There are national clinical guidelines for vaccination. the management of HIV, which include specific populations. recommendations for coinfection with viAwareness-raising and partnerships The government has not established the ral hepatitis. goal of eliminating hepatitis B. The government held events for World The government does not have national Hepatitis Day 2012 and has funded other viral hepatitis public awareness cam- It is not known what percentage of new- policies relating to screening and referral born infants nationally in a given recent to care for hepatitis B or hepatitis C. paigns since January 2011 (Annex A). year received the first dose of hepatitis B The government collaborates with the fol- vaccine within 24 hours of birth or what People testing for both hepatitis B and lowing in-country civil society groups to percentage of one-year-olds (ages 12–23 hepatitis C register by name; the names develop and implement its viral hepatitis months) nationally in a given recent year are kept confidential within the system. prevention and control programme: As- received three doses of hepatitis B vaccine. Hepatitis B and hepatitis C tests are not free of charge and are not compulsory for sociation SOS Hepatite Chad and AssociaThere is no national policy that specifically members of any specific group. tion Soleil Levant. targets mother-to-child transmission of Evidence-based policy and data for hepatitis B. Publicly funded treatment is not available action for hepatitis B or hepatitis C. There is no routine surveillance for viral There is no specific national strategy and/ or policy/guidelines for preventing hepa- The following drug for treating hepatitis B hepatitis. titis B and hepatitis C infection in health- is on the national essential medicines list There are standard case definitions for care settings. or subsidized by the government: lamihepatitis. Hepatitis deaths are not reportvudine. No drug for treating hepatitis C is ed to a central registry. The percentage of There is a national policy on injection on the national essential medicines list or safety in health-care settings, which rechepatitis cases reported as “undifferentiatsubsidized by the government. ed” or “unclassified” hepatitis is not known. ommends single-use and auto-disable syringes for therapeutic injections. Single- The Government of Chad welcomes asuse or auto-disable syringes, needles and sistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

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Chapter 3: WHO African Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Comoros The Government of Comoros reports as Population (in millions) (2011) 0.7 follows. Country classification (2012) Low-income Gross national income per capita (PPP int $) (2011) $1110 National coordination 4.51% There is no written national strategy or Total health expenditure as % of GDP (2010) $49.11 plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $33.01 Life expectancy at birth (in years) (2009) 60 hepatitis. Human Development Index (2011) 0.433 There is no designated governmental Median age (in years) (2010) 19 unit/department responsible solely for co- Total fertility rate per woman (2010) 4.9 ordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitis- There is no national public health research The government does not have guidelines related activities in all government agen- agenda for viral hepatitis. Viral hepatitis se- that address how hepatitis A and hepatitis E can be prevented through food and rosurveys are not conducted regularly. cies/bodies. water safety. The government has a viral hepatitis pre- Prevention of transmission vention and control programme that in- There is no national policy for hepatitis A Screening, care and treatment It is not known how health professionals cludes activities targeting the following vaccination. obtain the skills and competencies respecific population: children under the The government has not established the quired to effectively care for people with age of one year. goal of eliminating hepatitis B. viral hepatitis.

Awareness-raising and partnerships

Nationally, no newborn infant in a given recent year received the first dose of hepatitis B vaccine within 24 hours of birth and 86% of one-year-olds (ages 12–23 months) in a given recent year received The government does not collaborate three doses of hepatitis B vaccine. with in-country civil society groups to develop and implement its viral hepatitis There is a national policy that specifically targets mother-to-child transmission of prevention and control programme. hepatitis B (Annex B). The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B and C, but not for any type of chronic hepatitis.

There are no national clinical guidelines for the management of viral hepatitis, or for the management of HIV, which include recommendations for coinfection with viral hepatitis. The government does not have national policies relating to screening and referral to care for hepatitis B or hepatitis C.

People testing for both hepatitis B and Evidence-based policy and data for There is no specific national strategy and/ hepatitis C register by name; the names action

or policy/guidelines for preventing hepa- are kept confidential within the system. titis B and hepatitis C infection in health- Hepatitis B and hepatitis C tests are not care settings. free of charge for all individuals, but they are free of charge for blood donors and There is a national policy on injection people living with HIV. Hepatitis B and safety in health-care settings, which rechepatitis C tests are compulsory for blood There are standard case definitions for ommends single-use and auto-disable donors, people living with HIV and pregsyringes for therapeutic injections. Singlehepatitis. Hepatitis deaths are not reportnant women. use or auto-disable syringes, needles and ed to a central registry. cannulas are always available in all health- Publicly funded treatment is not available It is not known whether liver cancer cases care facilities. for hepatitis B or hepatitis C. are registered nationally. Cases with HIV/ hepatitis coinfection are not registered Official government estimates of the The following drug for treating hepatitis B number and percentage of unneces- is on the national essential medicines list nationally. sary injections administered annually in or subsidized by the government: lamiThe government does not publish hepati- health-care settings are not known. vudine. No drug for treating hepatitis C is tis disease reports. on the national essential medicines list or There is a national infection control policy Hepatitis outbreaks are required to be for blood banks. All donated blood units subsidized by the government. reported to the government but are not (including family donations) and blood The Government of Comoros welcomes further investigated. There is adequate products nationwide are screened for assistance from WHO in one or more areas laboratory capacity nationally to support hepatitis B, but not for hepatitis C. of viral hepatitis prevention and control outbreak investigations and other surveil(Annex C). lance activities for hepatitis A, hepatitis B There is no national policy relating to the prevention of viral hepatitis among peoand hepatitis C, but not for hepatitis E. ple who inject drugs.

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Chapter 3: WHO African Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Côte d’Ivoire Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 20.2 Lower–middle-income $1710 5.30% $97.58 $21.07 50 0.400 19 4.4 number and percentage of unnecessary injections administered annually in health-care settings. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

The Government of Côte d’Ivoire reports The government publishes hepatitis disThe government does not have guidelines as follows. ease reports annually. that address how hepatitis A and hepatiNational coordination Hepatitis outbreaks are not required to be tis E can be prevented through food and There is no written national strategy or reported to the government. There is inad- water safety. plan that focuses exclusively or prima- equate laboratory capacity nationally to rily on the prevention and control of viral support investigation of viral hepatitis out- Screening, care and treatment Health professionals obtain the skills and hepatitis. breaks and other surveillance activities. competencies required to effectively care There is a designated governmental unit/ There is no national public health research for people with viral hepatitis through department responsible solely for coordi- agenda for viral hepatitis. Viral hepatitis training workshops on the management nating and/or carrying out viral hepatitis- serosurveys are conducted regularly; the of viral hepatitis. related activities: Programme National de target populations are children under the Lutte contre les Hépatites Virales. It has age of five years, the general population, There are no national clinical guidelines 10 staff members. There are five full-time firefighters and the military. The last sero- for the management of viral hepatitis. There are national clinical guidelines for equivalent staff members who work on survey was carried out in March 2012. the management of HIV, which include hepatitis-related activities in all governPrevention of transmission recommendations for coinfection with viment agencies/bodies. There is no national policy on hepatitis A ral hepatitis. The government does not have a viral vaccination. The government has national policies rehepatitis prevention and control programme that includes activities targeting The government has not established the lating to screening and referral to care for goal of eliminating hepatitis B. hepatitis B and hepatitis C. specific populations. Information was not provided regarding the percentage of newborn infants nationally in a given recent year who had received the first dose of hepatitis B vaccine within 24 hours of birth. In a given recent year, 62% of one-year-olds (ages The government collaborates with the fol- 12–23 months) had received three doses lowing in-country civil society groups to of hepatitis B vaccine. develop and implement its viral hepatitis prevention and control programme: Ré- There is no national policy that specifically seau Ivoirien de Lutte contre les Hépatites targets mother-to-child transmission of hepatitis B. Virales and Rotaract Côte d’Ivoire.

Awareness-raising and partnerships

The government held events for World Hepatitis Day 2012 but has not funded other viral hepatitis public awareness campaigns since January 2011.

People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are not free of charge and are not compulsory for members of any specific group.

Evidence-based policy and data for action There is no routine surveillance for viral hepatitis. There are standard case definitions for hepatitis. Hepatitis deaths are not reported to a central registry. Information was not provided regarding the percentage of hepatitis cases reported as “undifferentiated” or “unknown” hepatitis. Liver cancer cases and cases with HIV/hepatitis coinfection are registered nationally.

Publicly funded treatment is available for hepatitis B and hepatitis C. The following people are eligible: uninsured patients in Hospital Consultant Abidjan. Information was not provided regarding the amount spent by the government on such treatThere is no specific national strategy and/ ment for hepatitis B and hepatitis C. or policy/guidelines for preventing hepatitis B and hepatitis C infection in health- The following drug for treating hepatitis B care settings. is on the national essential medicines list or subsidized by the government: pegylatThere is a national policy on injection ed interferon. The following drug for treatsafety in health-care settings, which rec- ing hepatitis C is on the national essential ommends auto-disable syringes for thera- medicines list or subsidized by the governpeutic injections. Single-use or auto-disa- ment: pegylated interferon. ble syringes, needles and cannulas are not always available in all health-care facilities. The Government of Côte d’Ivoire welcomes assistance from WHO in one or Information was not provided regard- more areas of viral hepatitis prevention ing official government estimates of the and control (Annex C).

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Chapter 3: WHO African Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Mali The Government of Mali reports as follows.

National coordination There is no written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis.

There is no designated governmental unit/department responsible solely for coordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitisrelated activities in all government agen- Prevention of transmission cies/bodies. There is no national policy on hepatitis A vaccination. The government does not have a viral hepatitis prevention and control pro- It is not known whether the government gramme that includes activities targeting has established the goal of eliminating specific populations. hepatitis B.

Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010)

15.8 Low-income $1040 4.98% $55.58 $25.89 53 0.359 16 6.3

It is not known whether the government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

Screening, care and treatment

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. The government collaborates with the following in-country civil society group to develop and implement its viral hepatitis prevention and control programme: SOS Hepatitis.

Evidence-based policy and data for action There is no routine surveillance for viral hepatitis. There are no standard case definitions for hepatitis. Hepatitis deaths are not reported to a central registry. Of the hepatitis B and hepatitis C cases, 15%–20% and 4.98%, respectively, are reported as “undifferentiated” or “unclassified” hepatitis. Liver cancer cases and cases with HIV/hepatitis coinfection are registered nationally. The government publishes hepatitis disease reports annually. It is not known whether hepatitis outbreaks are required to be reported to the government. There is adequate laboratory capacity nationally to support investigation of viral hepatitis outbreaks and other surveillance activities. It is not known whether there is a national public health research agenda for viral hepatitis, or whether viral hepatitis serosurveys are conducted regularly.

It is not known how health professionals obtain the skills and competencies reIt is not known what percentage of new- quired to effectively care for people with born infants nationally in a given recent viral hepatitis. year received the first dose of hepatitis B vaccine within 24 hours of birth or what There are no national clinical guidelines percentage of one-year-olds (ages 12–23 for the management of viral hepatitis. months) in a given recent year received There are national clinical guidelines for the management of HIV, which include three doses of hepatitis B vaccine. recommendations for coinfection with viThere is no national policy that specifically ral hepatitis. targets mother-to-child transmission of The government does not have national hepatitis B. policies relating to screening and referral There is no specific national strategy and/ to care for hepatitis B or hepatitis C. or policy/guidelines for preventing hepatitis B and hepatitis C infection in health- People testing for both hepatitis B and hepatitis C register by name; the names care settings. are kept confidential within the system. There is a national policy on injection safe- Hepatitis B and hepatitis C tests are not ty in health-care settings, which recom- free of charge for all individuals, but they mends single-use syringes for therapeutic are free of charge for blood donors. Hepainjections. Single-use or auto-disable sy- titis B and hepatitis C tests are compulsory ringes, needles and cannulas are always for blood donors. available in all health-care facilities. Publicly funded treatment is not available Official government estimates of the for hepatitis B or hepatitis C. number and percentage of unnecessary injections administered annually in The following drug for treating hepatitis B is on the national essential medicines list health-care settings are not known. or subsidized by the government: interferThere is a national infection control policy on alpha. The following drugs for treating for blood banks. All donated blood units hepatitis C are on the national essential (including family donations) and blood medicines list or subsidized by the governproducts nationwide are screened for ment: interferon alpha and ribavirin. hepatitis B and hepatitis C. The Government of Mali welcomes assistThere is no national policy relating to the ance from WHO in one or more areas of viral prevention of viral hepatitis among peo- hepatitis prevention and control (Annex C). ple who inject drugs.

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Chapter 3: WHO African Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Mauritania Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Mauritania reports as follows. 3.5 Low-income $2400 4.41% $79.01 $41.96 58 0.453 20 4.5 mends single-use syringes for therapeutic injections. Single-use or auto-disable syringes, needles and cannulas are always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known.

National coordination There is a written national strategy or plan that focuses exclusively on the prevention and control of viral hepatitis. It includes components for raising awareness, surveillance, vaccination, prevention in general, prevention of transmission via injecting drug use, prevention of transmission in health-care settings, treatment and care, and coinfection with HIV. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities: Programme National de Lutte contre les Hépatites. It has three staff members. There are three full-time equivalent staff members who work on hepatitis-related activities in all government agencies/bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), prisoners, people living with HIV and indigenous people.

Awareness-raising and partnerships The government held events for World Hepatitis Day 2012 but has not funded other viral hepatitis public awareness campaigns since January 2011. The government collaborates with the following in-country civil society group to develop and implement its viral hepatitis prevention and control programme: Association Mauritanienne de Lutte contre les Infections Virales.

Evidence-based policy and data for action There is no routine surveillance for viral hepatitis. There are no standard case definitions for hepatitis. It is not known whether deaths,

There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood including from hepatitis, are reported to a products nationwide are screened for central registry. Of all hepatitis cases, 10%– hepatitis B and hepatitis C. 20% are reported as “undifferentiated” or There is a national policy relating to the “unclassified” hepatitis. prevention of viral hepatitis among peoLiver cancer cases and cases with HIV/hep- ple who inject drugs. atitis coinfection are registered nationally. The government does not have guidelines The government publishes hepatitis dis- that address how hepatitis A and hepatiease reports. tis E can be prevented through food and water safety. It is not known whether hepatitis outbreaks are required to be reported to the Screening, care and treatment government. There is inadequate labora- Health professionals obtain the skills and tory capacity nationally to support the in- competencies required to effectively care vestigation of viral hepatitis outbreaks and for people with viral hepatitis through other surveillance activities. schools for health professionals (pre-service education) and postgraduate training. There is a national public health research agenda for viral hepatitis. Viral hepatitis There are no national clinical guidelines serosurveys are not conducted regularly. for the management of viral hepatitis. There are national clinical guidelines for Prevention of transmission the management of HIV, which include There is a national policy for hepatitis A recommendations for coinfection with vivaccination. ral hepatitis. It is not known whether the government Information was not provided on whether has established the goal of eliminating the government has national policies rehepatitis B. lating to screening and referral to care for Nationally, no newborn infant in a given hepatitis B or hepatitis C. recent year received the first dose of hepa- People testing for both hepatitis B and titis B vaccine within 24 hours of birth hepatitis C register by name; the names and 73% of one-year-olds (ages 12–23 are kept confidential within the system. months) in a given recent year received Information was not provided on whether three doses of hepatitis B vaccine. hepatitis B or hepatitis C tests are free of There is a national policy that specifically charge for all individuals or compulsory for targets mother-to-child transmission of members of any specific group. hepatitis B (Annex B). Publicly funded treatment is not available There is a specific national strategy and/or for hepatitis B or hepatitis C. policy/guidelines for preventing hepatitis No drug for treating hepatitis B or hepatitis B and hepatitis C infection in health-care C is on the national essential medicines list settings. Health-care workers are not vac- or subsidized by the government. cinated against hepatitis B prior to starting work that might put them at risk of expo- The Government of Mauritania welcomes sure to blood. assistance from WHO in one or more areas of viral hepatitis prevention and control There is a national policy on injection safe- (Annex C). ty in health-care settings, which recom-

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Chapter 3: WHO African Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Nigeria The Government of Nigeria reports as 162.5 Population (in millions) (2011) follows. Lower–middle-income Country classification (2012) $2290 Gross national income per capita (PPP int $) (2011) National coordination 5.07% There is no written national strategy or Total health expenditure as % of GDP (2010) $121.36 plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $45.98 Life expectancy at birth (in years) (2009) 54 hepatitis. Human Development Index (2011) 0.459 There is no designated governmental Median age (in years) (2010) 18 unit/department responsible solely for co- Total fertility rate per woman (2010) 5.5 ordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitis- Information was not provided on whether It is not known whether there is a national related activities in all government agen- there is a national public health research policy relating to the prevention of viral agenda for viral hepatitis. Viral hepatitis hepatitis among people who inject drugs. cies/bodies. serosurveys are not conducted regularly. It is not known whether the government The government has a viral hepatitis prehas guidelines that address how hepavention and control programme that in- Prevention of transmission cludes activities targeting the following There is no national policy for hepatitis A titis A and hepatitis E can be prevented through food and water safety. specific population: health-care workers vaccination. (including health-care waste handlers). The government has not established the Screening, care and treatment Health professionals obtain the skills and Awareness-raising and partnerships goal of eliminating hepatitis B. competencies required to effectively care Information was not provided on whether the government held events for World Information was not provided regarding for people with viral hepatitis through Hepatitis Day 2012 or funded other viral the percentage of newborn infants na- schools for health professionals (pre-servhepatitis public awareness campaigns tionally in a given recent year who had re- ice education), on-the-job training and ceived the first dose of hepatitis B vaccine postgraduate training. since January 2011. within 24 hours of birth or the percentage Information was not provided on whether of one-year-olds nationally (ages 12–23 There are national clinical guidelines for the government collaborates with in- months) in a given recent year who had the management of viral hepatitis, but country civil society groups to develop received three doses of hepatitis B vaccine. information was not provided on whether these guidelines include recommendaand implement its viral hepatitis prevenThere is no national policy that specifically tions for cases with HIV coinfection. Intion and control programme. targets mother-to-child transmission of formation was not provided on whether Evidence-based policy and data for hepatitis B. there are national clinical guidelines for action the management of HIV, which include There is a specifi c national strategy and/or There is routine surveillance for viral heparecommendations for coinfection with vipolicy/guidelines for preventing hepatitis titis. Information was not provided about ral hepatitis. which specific types of acute and chronic B and hepatitis C infection in health-care settings. It is not known whether healthhepatitis are monitored by surveillance It is not known whether the government care workers are vaccinated against hepa- has national policies relating to screening systems. titis B prior to starting work that might put and referral to care for hepatitis B or hepaThere are standard case definitions for them at risk of exposure to blood. titis C. hepatitis. Deaths, including from hepatitis, There is a national policy on injection are reported to a central registry. InformaPeople testing for both hepatitis B and tion was not provided on the percentage safety in health-care settings, which rec- hepatitis C register by name; the names of hepatitis cases reported as “undifferen- ommends auto-disable syringes for thera- are kept confidential within the system. peutic injections. It is not known whether Hepatitis B and hepatitis C tests are not tiated” or “unknown” hepatitis. single-use or auto-disable syringes, nee- free of charge. Information was not proLiver cancer cases are registered nation- dles and cannulas are always available in vided on whether hepatitis B or hepatitis C ally. Information was not provided on all health-care facilities. tests are compulsory for members of any whether cases with HIV/hepatitis coinfecspecific group. Official government estimates of the tion are registered nationally. number and percentage of unneces- Publicly funded treatment is not available The government publishes hepatitis dis- sary injections administered annually in for hepatitis B or hepatitis C. ease reports monthly. health-care settings are not known. No drug for treating hepatitis B or hepatitis Hepatitis outbreaks are required to be re- There is a national infection control policy C is on the national essential medicines list ported to the government and are further for blood banks. All donated blood units or subsidized by the government. investigated. There is inadequate labora- (including family donations) and blood tory capacity nationally to support inves- products nationwide are screened for The Government of Nigeria welcomes astigation of viral hepatitis outbreaks and hepatitis B. It is not known whether all do- sistance from WHO in one or more areas other surveillance activities. nated blood units (including family dona- of viral hepatitis prevention and control tions) and blood products nationwide are (Annex C). screened for hepatitis C.

23

Chapter 3: WHO African Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Rwanda Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Rwanda reports as follows. 10.9 Low-income $1270 10.48% $121.01 $60.59 59 0.429 19 5.4 Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

National coordination There is no written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities. It has two staff members. There are two full-time equivalent staff members who work on hepatitis-related activities in all government agencies/bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), people living with HIV, children under the age of one year and soldiers.

Awareness-raising and partnerships

There is no national policy relating to the prevention of viral hepatitis among peoThe government does not publish hepati- ple who inject drugs. tis disease reports. The government does not have guidelines Hepatitis outbreaks are required to be re- that address how hepatitis A and hepatiported to the government and are further tis E can be prevented through food and investigated. There is adequate laboratory water safety. capacity nationally to support outbreak investigations and other surveillance ac- Screening, care and treatment tivities for hepatitis B and hepatitis C, but Health professionals obtain the skills and it is not known whether this is the case for competencies required to effectively care for people with viral hepatitis through hepatitis A and hepatitis E. schools for health professionals (preThere is a national public health research service education), on-the-job training, agenda for viral hepatitis. Viral hepatitis postgraduate training and international serosurveys are conducted regularly; the conferences/workshops. target population is pregnant women. The There are no national clinical guidelines last serosurvey was carried out in 2011. for the management of viral hepatitis. Prevention of transmission There are national clinical guidelines for There is no national policy for hepatitis A the management of HIV, which include vaccination. recommendations for coinfection with hepatitis B. The government has established the goal of eliminating hepatitis B but did not pro- The government does not have national vide information about a specific time- policies relating to screening and referral frame for this. to care for hepatitis B or hepatitis C. People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are not free of charge for all individuals, but they are free of charge and compulsory for blood donors. Publicly funded treatment is available for hepatitis B. The following group is eligible: people coinfected with HIV and hepatitis B. Publicly funded treatment is not available for hepatitis C. The amount spent by the government on publicly funded treatment for hepatitis B is not known. The following drugs for treating hepatitis B are on the national essential medicines list or subsidized by the government: lamivudine and tenofovir. No drug for treating hepatitis C is on the national essential medicines list or subsidized by the government. The Government of Rwanda welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

Nationally, no newborn infant in a given recent year received the first dose of hepatitis B vaccine within 24 hours of birth and 97% of one-year-olds (ages 12–23 months) in a given recent year received The government does not collaborate three doses of hepatitis B vaccine. with in-country civil society groups to develop and implement its viral hepatitis There is a national policy that specifically targets mother-to-child transmission of prevention and control programme. hepatitis B (Annex B). The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011.

Evidence-based policy and data for There is a specific national strategy and/or action

There is no routine surveillance for viral policy/guidelines for preventing hepatitis B and hepatitis C infection in health-care hepatitis. settings. Health-care workers are not vacThere are standard case definitions for cinated against hepatitis B prior to starting hepatitis B. It is not known whether deaths, work that might put them at risk of expoincluding from hepatitis, are reported to a sure to blood. central registry. The percentage of hepatitis cases reported as “undifferentiated” or There is a national policy on injection safety in health-care settings, which rec“unclassified” hepatitis is not known. ommends the following types of syringes It is not known whether liver cancer cases for therapeutic injections: single-use and are registered nationally. Cases with HIV/ auto-disable syringes. Single-use or autohepatitis coinfection are not registered disable syringes, needles and cannulas are nationally. always available in all health-care facilities.

24

Chapter 3: WHO African Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Sierra Leone The Government of Sierra Leone reports 6.0 Population (in millions) (2011) as follows. Low-income Country classification (2012) National coordination $840 Gross national income per capita (PPP int $) (2011) There is no written national strategy or Total health expenditure as % of GDP (2010) 13.07% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $107.25 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $12.15 hepatitis. Life expectancy at birth (in years) (2009) 49 Human Development Index (2011) 0.336 There is no designated governmental Median age (in years) (2010) 18 unit/department responsible solely for co- Total fertility rate per woman (2010) 5.0 ordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitis- Prevention of transmission Screening, care and treatment related activities in all government agen- There is no national policy for hepatitis A Health professionals obtain the skills and cies/bodies. vaccination. competencies required to effectively care for people with viral hepatitis through The government has a viral hepatitis pre- The government has not established the schools for health professionals (pre-servvention and control programme that in- goal of eliminating hepatitis B. ice education), on-the-job training and cludes activities targeting the following postgraduate training. specific population: children under the Nationally, 0% of newborn infants in a given recent year received the first dose of There are no national clinical guidelines age of one year. hepatitis B vaccine within 24 hours of birth for the management of viral hepatitis. It Awareness-raising and partnerships and 91% of one-year-olds (ages 12–23 is not known whether there are national The government did not hold events for months) in a given recent year received clinical guidelines for the management of World Hepatitis Day 2012 and has not three doses of hepatitis B vaccine. HIV, which include recommendations for funded other viral hepatitis public awarecoinfection with viral hepatitis. There is no national policy that specifically ness campaigns since January 2011. targets mother-to-child transmission of The government does not have national The government does not collaborate hepatitis B. policies relating to screening and referral with in-country civil society groups to to care for hepatitis B or hepatitis C. There is no specifi c national strategy and/ develop and implement its viral hepatitis or policy/guidelines for preventing hepa- People testing for both hepatitis B and prevention and control programme. titis B and hepatitis C infection in health- hepatitis C register by name; the names Evidence-based policy and data for care settings. are kept confidential within the system. action Hepatitis B and hepatitis C tests are not There is no routine surveillance for viral There is a national policy on injection free of charge for all individuals, but they safety in health-care settings, which rechepatitis. are free of charge for children under the ommends auto-disable syringes for theraThere are standard case definitions for peutic injections. Single-use or auto-disa- age of five years, pregnant women and hepatitis. Hepatitis deaths are not report- ble syringes, needles and cannulas are not breastfeeding mothers. Hepatitis B and ed to a central registry. Information was always available in all health-care facilities. hepatitis C tests are compulsory for blood donors. not provided regarding the percentage of hepatitis cases reported as “undifferenti- Official government estimates of the Publicly funded treatment is not available number and percentage of unnecesated” or “unknown” hepatitis. for hepatitis B or hepatitis C. sary injections administered annually in Liver cancer cases and cases with HIV/ health-care settings are not known. The following drug for treating hepatitis B hepatitis coinfection are not registered is on the national essential medicines list There is a national infection control policy nationally. or subsidized by the government: lamifor blood banks. All donated blood units The government does not publish hepati- (including family donations) and blood vudine. No drug for treating hepatitis C is on the national essential medicines list or tis disease reports. products nationwide are screened for subsidized by the government. hepatitis B and hepatitis C. Hepatitis outbreaks are required to be reported to the government and are further There is no national policy relating to the The Government of Sierra Leone welinvestigated. There is adequate laboratory prevention of viral hepatitis among peo- comes assistance from WHO in one or more areas of viral hepatitis prevention capacity nationally to support investiga- ple who inject drugs. and control (Annex C). tion of viral hepatitis outbreaks and other The government does not have guidelines surveillance activities. that address how hepatitis A and hepatiThere is no national public health research tis E can be prevented through food and agenda for viral hepatitis. Viral hepatitis se- water safety. rosurveys are not conducted regularly.

25

Chapter 3: WHO African Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

South Africa Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 50.5 Upper–middle-income $10 710 8.94% $934.95 $412.34 54 0.619 25 2.5 There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is a national policy relating to the prevention of viral hepatitis among people who inject drugs.

The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water The Government of South Africa reports as It is not known whether the government safety. follows. publishes hepatitis disease reports.

National coordination

There is a written national strategy or plan that focuses exclusively on the prevention and control of viral hepatitis. It includes components for vaccination, prevention in general, prevention of transmission via injecting drug use, prevention of transmission in health-care settings, treatment and It is not known whether there is a national care, and coinfection with HIV. public health research agenda for viral There is no designated governmental hepatitis. Viral hepatitis serosurveys are unit/department responsible solely for not conducted regularly. coordinating and/or carrying out viral hepatitis-related activities. There are seven Prevention of transmission full-time equivalent staff members who There is a national policy for hepatitis A work on hepatitis-related activities in all vaccination. government agencies/bodies. The government has not established the The government has a viral hepatitis pre- goal of eliminating hepatitis B. vention and control programme that inNationally, no newborn infant in a given cludes activities targeting the following recent year received the first dose of hepaspecific population: health-care workers titis B vaccine within 24 hours of birth and (including health-care waste handlers). 50%–80% of one-year-olds (ages 12–23 Awareness-raising and partnerships months) in a given recent year received The government did not hold events for three doses of hepatitis B vaccine. World Hepatitis Day 2012 and has not funded other viral hepatitis public aware- There is no national policy that specifically targets mother-to-child transmission of ness campaigns since January 2011. hepatitis B. The government collaborates with the following in-country civil society group to There is a specific national strategy and/or develop and implement its viral hepatitis policy/guidelines for preventing hepatitis prevention and control programme: the B and hepatitis C infection in health-care settings. Health-care workers are vacciSouth African National Blood Service. nated against hepatitis B prior to starting Evidence-based policy and data for work that might put them at risk of exposure to blood. action There is routine surveillance for viral hepatitis. There is a national surveillance system There is a national policy on injection safefor the following types of acute hepatitis: ty in health-care settings, which recommends single-use syringes for therapeutic A, B and C, and for chronic hepatitis C. injections. It is not known whether singleThere are standard case definitions for use or auto-disable syringes, needles and hepatitis. It is not known whether deaths, cannulas are always available in all healthincluding from hepatitis, are reported to a care facilities. central registry. The percentage of hepatitis cases reported as “undifferentiated” or Official government estimates of the number and percentage of unneces“unclassified” hepatitis is not known. sary injections administered annually in It is not known whether liver cancer cases health-care settings are not known. and cases with HIV/hepatitis coinfection are registered nationally.

Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory capacity nationally to support outbreak investigations and other surveillance activities for hepatitis A, hepatitis B and hepatitis C, but not for hepatitis E.

Screening, care and treatment

Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through schools for health professionals (pre-service education), on-the-job training and postgraduate training. There are national clinical guidelines for the management of viral hepatitis, which include recommendations for cases with HIV coinfection. The government has national policies relating to screening and referral to care for hepatitis B and hepatitis C. People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are not free of charge for all individuals, but they are free of charge at public health-care facilities for people who do not have medical aid. Hepatitis B and hepatitis C tests are compulsory for health-care workers and sources of exposure following incidents of occupational exposure. Publicly funded treatment is not available for hepatitis B, but is available for hepatitis C. Information was not provided on who is eligible for such treatment for hepatitis C. The amount spent by the government on publicly funded treatment for hepatitis C is not known. The following drug for treating hepatitis B is on the national essential medicines list or subsidized by the government: hepatitis B immune globulin. The following drugs for treating hepatitis C are on the national essential medicines list or subsidized by the government: pegylated interferon and ribavirin. The Government of South Africa welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

26

Chapter 3: WHO African Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

United Republic of Tanzania The Government of the United Republic of Population (in millions) (2011) 46.2 Tanzania reports as follows. Country classification (2012) Low-income National coordination Gross national income per capita (PPP int $) (2011) $1500 There is no written national strategy or Total health expenditure as % of GDP (2010) 6.01% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $83.43 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $56.17 hepatitis. Life expectancy at birth (in years) (2009) 55 Human Development Index (2011) 0.466 There is no designated governmental unit/ Median age (in years) (2010) 18 department responsible solely for coordi- Total fertility rate per woman (2010) 5.5 nating and/or carrying out viral hepatitisrelated activities. Information was not provided regarding how many people work It is not known whether there is a national There is a national policy relating to the full-time on hepatitis-related activities in public health research agenda for viral prevention of viral hepatitis among peohepatitis. Viral hepatitis serosurveys are ple who inject drugs. all government agencies/bodies. not conducted regularly. The government does not have guidelines Information was not provided on whether that address how hepatitis A and hepatithe government has a viral hepatitis pre- Prevention of transmission vention and control programme that in- There is no national policy for hepatitis A tis E can be prevented through food and water safety. cludes activities targeting specific popula- vaccination. tions. The government has not established the Screening, care and treatment Health professionals obtain the skills and Awareness-raising and partnerships goal of eliminating hepatitis B. competencies required to effectively care The government did not hold events for World Hepatitis Day 2012 and has not Nationally, no newborn infant in a given for people with viral hepatitis through onfunded other viral hepatitis public aware- recent year received the first dose of hepa- the-job training. titis B vaccine within 24 hours of birth and ness campaigns since January 2011. more than 90% of one-year-olds (ages 12– There are national clinical guidelines for Information was not provided on whether 23 months) in a given recent year received the management of viral hepatitis, which include recommendations for cases with the government collaborates with in- three doses of the hepatitis B vaccine. HIV coinfection. country civil society groups to develop and implement its viral hepatitis preven- There is no national policy that specifically targets mother-to-child transmission of The government does not have national tion and control programme. hepatitis B. policies relating to screening and referral to care for hepatitis B or hepatitis C. Evidence-based policy and data for It is not known whether there is a specific action Information was not provided on whether national strategy and/or policy/guidelines People testing for hepatitis B register by there is routine surveillance for viral hepa- for preventing hepatitis B and hepatitis C name and there is open access to their infection in health-care settings. Health- names. Information was not provided on titis. care workers are not vaccinated against whether people testing for hepatitis C regThere are no standard case definitions for hepatitis B prior to starting work that ister by name. Hepatitis B and hepatitis C hepatitis. Deaths, including from hepatitis, might put them at risk of exposure to tests are not free of charge for all individuare reported to a central registry. Infor- blood. als, but they are free of charge for blood mation was not provided regarding the donors and for people with HIV and other percentage of hepatitis cases reported as There is a national policy on injection safe- chronic illnesses. Hepatitis B and hepatitis “undifferentiated” or “unknown” hepatitis. ty in health-care settings, which recom- C tests are compulsory for blood donors. mends auto-disable syringes for therapeuLiver cancer cases are registered nation- tic injections. Single-use or auto-disable Publicly funded treatment is not available ally. Information was not provided on syringes, needles and cannulas are always for hepatitis B or hepatitis C. whether cases with HIV/hepatitis coinfec- available in all health-care facilities. The following drug for treating hepatitis B tion are registered nationally. Official government estimates of the is on the national essential medicines list The government publishes hepatitis dis- number and percentage of unneces- or subsidized by the government: tenoease reports. sary injections administered annually in fovir. No drug for treating hepatitis C is health-care settings are not known. on the national essential medicines list or Hepatitis outbreaks are required to be resubsidized by the government. ported to the government but are not fur- There is a national infection control policy ther investigated. for blood banks. All donated blood units The Government of the United Republic of (including family donations) and blood Tanzania welcomes assistance from WHO There is inadequate laboratory capacity products nationwide are screened for in one or more areas of viral hepatitis prenationally to support investigation of viral hepatitis B and hepatitis C. vention and control (Annex C). hepatitis outbreaks and other surveillance activities.

27

Chapter 3: WHO African Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Zimbabwe Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 12.8 Low-income ----49 0.376 19 3.3 There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water The Government of Zimbabwe reports as The government does not publish hepati- safety. follows. tis disease reports.

National coordination

Hepatitis outbreaks are required to be reThere is no written national strategy or ported to the government and are further plan that focuses exclusively or prima- investigated. There is inadequate laborarily on the prevention and control of viral tory capacity nationally to support inveshepatitis. tigation of viral hepatitis outbreaks and other surveillance activities. There is no designated governmental unit/department responsible solely for co- There is no national public health research ordinating and/or carrying out viral hepa- agenda for viral hepatitis. Viral hepatitis setitis-related activities. It is not known how rosurveys are not conducted regularly. many people work full-time on hepatitisrelated activities in all government agen- Prevention of transmission There is no national policy for hepatitis A cies/bodies. vaccination. The government does not have a viral hepatitis prevention and control pro- The government has not established the gramme that includes activities targeting goal of eliminating hepatitis B. specific populations. Nationally, no newborn infant in a given Awareness-raising and partnerships recent year received the first dose of hepaThe government did not hold events for titis B vaccine within 24 hours of birth and World Hepatitis Day 2012 and has not more than 80% of one-year-olds (ages 12– funded other viral hepatitis public aware- 23 months) in a given recent year received three doses of hepatitis B vaccine. ness campaigns since January 2011. The government does not collaborate There is no national policy that specifically with in-country civil society groups to targets mother-to-child transmission of develop and implement its viral hepatitis hepatitis B. prevention and control programme. There is no specific national strategy and/ Evidence-based policy and data for or policy/guidelines for preventing hepatitis B and hepatitis C infection in healthaction There is routine surveillance for viral hepa- care settings. Health-care workers are not titis. There is a national surveillance system vaccinated against hepatitis B prior to for the following types of acute hepatitis: starting work that might put them at risk A and B, but not for any type of chronic of exposure to blood. hepatitis. There is a national policy on injection safeThere are standard case definitions for ty in health-care settings, which recomhepatitis. Deaths, including from hepatitis, mends single-use syringes for therapeuare reported to a central registry. The per- tic injections. Single-use or auto-disable centage of hepatitis cases reported as “un- syringes, needles and cannulas are not differentiated” or “unclassified” hepatitis is always available in all health-care facilities. not known. Official government estimates of the Liver cancer cases are registered nation- number and percentage of unnecesally, but cases with HIV/hepatitis coinfec- sary injections administered annually in health-care settings are not known. tion are not.

Screening, care and treatment

Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through schools for health professionals (pre-service education) and on-the-job training. There are no national clinical guidelines for the management of viral hepatitis. There are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral hepatitis. The government does not have national policies relating to screening and referral to care for hepatitis B or hepatitis C. People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are not free of charge or compulsory for members of any specific group. Publicly funded treatment is not available for hepatitis B or hepatitis C. The following drug for treating hepatitis B is on the national essential medicines list or subsidized by the government: interferon alpha. The following drug for treating hepatitis C is on the national essential medicines list or subsidized by the government: interferon alpha. The Government of Zimbabwe welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

28

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

29

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

30

Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Chapter 4:

WHO Region of the Americas

Thirty-five Member States make up the World Health Organization (WHO) Region of the Americas, which has a total population of 939 million.1 Most of the Region’s countries are low- and middle-income countries, but it also encompasses the high-income countries of Canada and the United States of America.2 The average life expectancy in the Region of the Americas in 2010 was 76.2 years, which represented a fouryear increase from 2005.3 By 2020, the Region will be home to almost 200 million people above the age of 60 years.3 Longer life expectancy and lifestyle changes have driven increases in noncommunicable diseases, and these diseases now cause more than three fourths of the deaths in the Region annually.4 The Region of the Americas and the WHO European Region have the highest incidence rates of all types of cancer.5 Other notable public health issues in the Region of the Americas include road traffic accidents and violence. One quarter of the world’s 600 000 annual homicides occur there.3 The Region of the Americas stands out for its progress against vaccine-preventable diseases, and the high level of childhood vaccination coverage.3 Although communicable diseases cause only about 13% of deaths in the Region of the Americas, they impose a high burden of disease in some populations.3 A 2008 literature review focusing on neglected tropical diseases in Latin America and the Caribbean concluded that the subregion may have a higher burden of disease from neglected tropical diseases such as hookworm infestation and Chagas disease than from malaria, tuberculosis or HIV.6 The Region of the Americas saw a decline in the rate of new HIV infections between 2001 and 2009.3 1

Viral hepatitis in the WHO Region of the Americas Most countries in Latin America and the Caribbean (LAC) show intermediate endemicity for hepatitis A. However, the prevalence varies from region to region. For instance, the seroprevalence of anti-hepatitis A in persons between the ages of 15 and 19 years in the Caribbean and Andean regions (Peru, Ecuador, Bolivia) is 57% and 96%, respectively.a A low prevalence and outbreaks of hepatitis E have been reported in some LAC countries. Although higher prevalence has been reported elsewhere, little is known about the epidemiology of this infection in the Region. For instance, studies in the Brazilian population show prevalence rates of around 3% in adults, while in Bolivia, the rates ranged from 1.7% to 16.2%.b Recent data indicate that from 1990 to 2005, the prevalence of hepatitis B infection fell on average to below 2% in the central and tropical Latin American regions, while it remained between 2% and 4% in the Caribbean, Andean and southern Latin American regions.c In Andean, central, southern and tropical Latin American countries, approximately seven million adults are estimated to be anti-hepatitis C positive, meaning that they have been exposed to hepatitis C and could contract chronic infection.d With respect to hepatitis D, a high prevalence of coinfection among hepatitis B cases has been observed in the Amazonian region.e For example, a study from Colombia showed that among hepatitis B-positive inhabitants, 5.2% were hepatitis D-positive and all except one were from the Amazonian region.f a

World population prospects: the 2010 revision. New York, United Nations, Department of Economic and Social Affairs, Population Division, 2011. 2 Country and lending groups [web site]. The World Bank. Available at: http:// data.worldbank.org/about/country-classifications/country-and-lendinggroups#Low_income (accessed on 26 February 2013). 3 Health in the Americas: 2012 edition. Regional outlook and country profiles. Washington, DC, WHO Regional Office for the Americas, 2012. Available at: http:// www.paho.org/saludenlasamericas/docs/hia-2012-summary.pdf (accessed on 05 May 2013). 4 Non-communicable diseases in the Americas: building a healthier future. Washington, DC, WHO Regional Office for the Americas, 2011. Available at: http://new.paho.org/hq/index.php?option=com_docman&task=doc_view &gid=14832&Itemid= (accessed on 05 May 2013). 5 Global status report on noncommunicable diseases 2010. Geneva, WHO, 2011. Available at: http://whqlibdoc.who.int/publications/2011/9789240686458_eng. pdf= (accessed on 05 May 2013). 6 Hotez PJ et al. The neglected tropical diseases of Latin America and the Caribbean: a review of disease burden and distribution and a roadmap for control and elimination. PLoS Neglected Tropical Diseases, 2008, 2(9):e300. doi: 10.1371/journal.pntd.0000300.

Jacobsen KH, Wiersma ST. Hepatitis A virus seroprevalence by age and world region, 1990 and 2005. Vaccine, 2010, 28:6653–6657. b Aggarwal R. The global prevalence of hepatitis E virus infection and susceptibility: a systematic review. Geneva, World Health Organization, 2010. c Ott JJ, Stevens GA, Groeger J, Wiersma ST. Global epidemiology of hepatitis B virus infection: new estimates of age-specific HBsAg seroprevalence and endemicity. Vaccine, 2012, 30:2212–2219. d Mohd Hanafiah K, Groeger J, Flaxman AD, Wiersma ST. Global epidemiology of hepatitis C virus infection: new estimates of age-specific antibody to HCV seroprevalence. Hepatology, 2013, 57:1333–1342. e Pascarella S, Negro F. Hepatitis D virus: an update. Liver International, 2011, 31:7–21. f Alvarado-Mora MV et al. Hepatitis B (HBV), hepatitis C (HCV) and hepatitis delta (HDV) viruses in the Colombian population – how is the epidemiological situation? PLoS One, 2011, 6 (4):e18888.

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Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Responses to the WHO/Alliance survey were received from 27 of the 35 Member States in the Region (77.1%). Box 1. Responses to the 2012 Global Hepatitis Survey: WHO Region of the Americas

Figure 1. Responses to the question, “Is there a written

national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis?”

Member States that submitted surveys: • Antigua and Barbuda • Argentina • Bahamas • Barbados • Brazil • Canada • Colombia • Costa Rica • Cuba • Belize • Bolivia (Plurinational state of) • Chile • Dominican Republic • Ecuador • El Salvador • Grenada • Guatemala • Guyana • Honduras • Jamaica • Mexico • Nicaragua • Panama • Paraguay • Peru • Saint Kitts and Nevis • Saint Lucia • Suriname • United States of America • Uruguay

Member States that did not submit surveys: • Dominica • Trinidad and Tobago • Haiti • Venezuela (Bolivar• Saint Vincent and ian Republic of) the Grenadines

Yes No

No response No data

National coordination Nine responding Member States (33.3%) reported the existence of a written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis (Figure 1). Two of the nine Member States with a strategy or plan (Argentina and the United States of America) reported that it focuses exclusively on viral hepatitis, and five (Brazil, Canada, Cuba, Peru and Suriname) reported that it addresses other diseases as well. Two countries (Ecuador and El Salvador) reported that the strategy or plan only addresses hepatitis B. The nine Member States that reported the existence of a strategy or plan were asked about its specific components. All nine reported the inclusion of a component for vaccination. Eight reported the inclusion of components for surveillance and prevention of transmission in health-care settings. Seven reported the inclusion of components for general prevention, treatment and care, and coinfection with HIV. Six reported the inclusion of a component for raising awareness. Four reported the inclusion of a component for the prevention of transmission via injecting drug use. Seven responding Member States (25.9%) reported that they have a governmental unit or department responsible solely for viral hepatitis-related activities. Member States that did so were asked to indicate the number of staff members in the unit or department. Responses (N=4) ranged from 1 (Cuba) to 250 (Brazil) (median, 54). Member States were asked to report the number of people working full-time on hepatitis-related activities in all government agencies or bodies. Among the 13 Member States that provided data for this question, the numbers ranged from 0 to 150 (median, 0), with the United States of America reporting the largest number. 32

Twenty responding Member States (74.1%) reported that they have a viral hepatitis prevention and control programme that includes activities targeting specific populations. The populations most commonly targeted were health-care workers, including health-care waste handlers (100% of responding Member States within this subset) and people living with HIV (60.0% of responding Member States within this subset). Six responding Member States reported the inclusion of activities targeting prisoners, and five, the inclusion of activities targeting people who inject drugs. Groups identified less frequently included migrants, indigenous populations, lowincome populations, those who are uninsured and those who are homeless.

Awareness-raising and partnerships Twelve responding Member States (44.4%) reported that they had held events for World Hepatitis Day 2012 (28 July). Since January 2011, six responding Member States (22.2%) had funded some type of viral hepatitis public awareness campaign other than World Hepatitis Day (Table 1).

Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Table 1. Topics of public awareness campaigns on viral hepatitis held in Member States since January 2011 (N=6) Argentina Brazil General information about hepatitis and its transmission Vaccination for hepatitis A and hepatitis B Importance of knowing one’s hepatitis B and hepatitis C status Safe water and good sanitation Safer sex practices Harm reduction for people who inject drugs Safe workplace practices Other a a

Table 2. Types of surveillance in Member States that reported the existence of routine surveillance for viral hepatitis (N=24) No Yes (%) No (%) Do not know response (%) (%) There is a national surveillance system for acute hepatitis infection for the following forms of hepatitis: hepatitis A hepatitis B hepatitis C hepatitis D hepatitis E There is a national surveillance system for chronic hepatitis infection for the following forms of hepatitis: hepatitis B hepatitis C hepatitis D 45.8 37.5 16.7 50.0 54.2 70.8 0 0 0 4.2 8.3 12.5 70.8 100 79.2 37.5 29.2 20.8 0 12.5 45.8 54.2 0 0 0 0 0 8.3 0 8.3 16.7 16.7

Cuba

Guate- Suri- United mala name States of America X X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X X X

X X X X

X

X

Details can be found in the summaries of country findings later in this chapter.

Table 3. Data registration and surveillance (N=27) No Yes (%) No (%) Do not know response (%) (%) Liver cancer cases are registered nationally Cases with HIV/hepatitis coinfection are registered nationally Hepatitis outbreaks are reported If YES – Hepatitis outbreaks are further investigated (N=115) 63.0 40.7 92.6 88.0 18.5 51.9 3.7 8.0 7.4 7.4 3.7 0 11.1 0 0 4.0

Eight responding Member States (29.6%) reported that they collaborated with civil society groups within their countries to develop and implement the governmental viral hepatitis prevention and control programme. For example, Canada reported collaborating with the Canadian Society for International Health, Canadian AIDS Treatment Information Exchange and University of British Columbia. Peru reported that it collaborated with Asociación Ciudadana de Lucha contra la Hepatitis. (Further examples can be found in the summaries of country findings later in this chapter.)

Evidence-based policy and data for action Twenty-four responding Member States (88.9%) reported that they have routine surveillance for viral hepatitis; details appear in Table 2. Twenty-one responding Member States (77.8%) indicated that their countries have standard case definitions for hepatitis infection and 25 (92.6%) indicated that their countries have a central registry for the reporting of deaths, including hepatitis deaths. Eight Member States reported on the proportion of hepatitis cases and deaths registered as “undifferentiated” or “unclassified” hepatitis. The reported proportion ranged from 0% to 60.0% (median, 27.5%). Additional survey findings about surveillance are presented in Table 3.

Member States were asked how often hepatitis disease reports are published. Of the responding Member States, 48.1% reported that hepatitis disease reports are published annually; 11.1%, monthly; and 7.4%, weekly. No hepatitis disease report is published by 25.9% of responding Member States. Five responding Member States (18.5%) (Argentina, Canada, Cuba, Guyana and Peru) reported the existence of a national public health research agenda for viral hepatitis. Seven responding Member States (25.9%) reported that viral hepatitis serosurveys are conducted regularly. Among this subset, two (Canada and the United States of America) indicated that serosurveys take place every two years and one (Argentina) indicated that serosurveys take place twice annually. Of the

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same subset, 57.1% reported that the most recent viral hepatitis serosurvey was carried out in either 2011 or 2012.

Table 4. Activities called for in national policy targeting mother-to-child transmission of hepatitis B (N=19) All infants receive the first dose of hepatitis B vaccine within 24 hours of birth X X X X X X X X X X X X X X X X X X X X X X X X X X 13 X X X 14 X 12 X X X X 15 X X X 17 All pregnant women found to have hepatitis B are counselled Health-care providers follow up with all pregnant women found to have hepatitis B during pregnancy for the purpose of encouraging them to give birth at health-care facilities X X X X X X X Upon delivery, all infants born to women with hepatitis B receive hepatitis B immunoglobulin X X X X X X X X X X X X X X X X X X X X X

Prevention of transmission All pregnant women are screened for hepatitis B Antigua and Barbuda Argentina Bahamas Brazil Canada Colombia Costa Rica Cuba Ecuador Grenada Guatemala Guyana X X X Honduras Jamaica Panama Peru Suriname United States of America Uruguay TOTAL

Nine responding Member States (33.3%) reported that they have a national policy on hepatitis A vaccination. Five responding Member States (18.5%) reported that they have established the goal of eliminating hepatitis B (Figure 2). Member States with this goal were asked to specify the timeframe in which they seek to eliminate hepatitis B. Of the three Member States that answered this question, two (Costa Rica and Suriname) said that the timeframe was not specified while the third (Cuba) said 2013 for the paediatric population and 2015 for the rest of the population. Figure 2. Responses to the question, “Has your government

X X X

established the goal of eliminating hepatitis B?” (N=27) Do not know (3.7%) No response 7.4%

Yes (18.5%)

No (70.4%)

Member States were asked to report, for a given recent year, the percentage of newborn infants who had received the first dose of hepatitis B vaccine within 24 hours of birth. Among the 18 Member States that provided this information, responses ranged from 0% to 100% (median, 33.5%). Member States were also asked to report, for a given recent year, the percentage of one-year-olds (ages 12–23 months) who had received three doses of hepatitis B vaccine. Among the 18 Member States that provided this information, responses ranged from 79.7% to 100% (median, 94.0%). Nineteen responding Member States (70.4%) reported the existence of a national policy that specifically targets motherto-child transmission of hepatitis B; details are presented in Table 4. More than two thirds of Member States with such a policy indicated that one component of the policy calls for screening of all pregnant women for hepatitis B. Twenty responding Member States (74.1%) reported the existence of a specific national strategy and/or policy/guidelines for preventing hepatitis B and hepatitis C infection in healthcare settings. 34

Nineteen responding Member States (70.4%) reported that health-care workers are vaccinated against hepatitis B prior to starting work that might put them at risk of exposure to blood. Twenty-three responding Member States (85.2%) reported the existence of a national policy on injection safety in healthcare settings. These Member States were asked which types of syringes the policy recommends for therapeutic injections. Single-use syringes are recommended in 56.5% of policies, and auto-disable syringes in 47.8% (Figure 3). Twenty-six responding Member States (96.3%) reported that single-use or auto-disable syringes, needles and cannulas are always available in all health-care facilities.

Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Figure 3. Proportion of responding Member States with

Screening, care and treatment Member States were asked how health professionals in their countries obtain the skills and competencies required to effectively care for people with viral hepatitis. Responding Member States most frequently indicated that these are acquired in schools for health professionals (pre-service education, 74.1%). Additionally, on-the-job training was identified in 70.4% of responses, and postgraduate training in 46.2%.a Nine responding Member States (33.3%) reported the existence of national clinical guidelines for the management of viral hepatitis (Figure 4). Eight of these nine Member States indicated that the guidelines include recommendations for cases with HIV coinfection. Eight of 13 responding Member States (61.5%) indicated that there are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral hepatitis. Fourteen responding Member States (51.9%) indicated that they have a national policy relating to screening and referral to care for hepatitis B. Ten (37.0%) reported having such a policy for hepatitis C. Regarding hepatitis B testing, 25 responding Member States (92.6%) indicated that people register by name for testing. Twenty-one members of that subset (84.0%) indicated that the names are kept confidential. Fourteen responding Member States (51.9%) reported that the hepatitis B test is free of charge for all individuals. Among the nine other Member States that answered the question, eight (88.9%) reported that the hepatitis B test is free of charge for members of specific groups. Groups identified included blood donors, pregnant women and people living with HIV. Nine responding Member States (33.3%) reported that the hepatitis B test is compulsory for members of specific groups. Groups identified included blood donors and pregnant women. Figure 4. Responses to the question, “Are there national clinical guidelines for the management of viral hepatitis?” (N=27)

national policies on injection safety in health-care settings which recommend single-use syringes and auto-disable syringes for therapeutic injections (N=23) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Single-use syringesa a

Auto-disable syringesa

Respondents could select both “single-use syringes” and “auto-disable syringes”.

Table 5. Hepatitis prevention: policies, practices and

guidelines (N=27) No Yes (%) No (%) Do not know response (%) (%) There is a national infection control policy for blood banks All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B All donated blood units (including family donations) and blood products nationwide are screened for hepatitis C There is a national policy relating to the prevention of viral hepatitis among people who inject drugs The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety 77.8 7.4 11.1 3.7

96.3

0

0

3.7

88.9

0

7.4

3.7

14.8

63.0

14.8

7.4

59.3

25.9

7.4

7.4

Do not know 7.1% No response (4.0%)

Yes (33.3%)

Member States were asked for official estimates of the number and percentage of unnecessary injections administered annually in health-care settings (e.g. injections that are given when an equivalent oral medication is available). Twenty-one Member States reported that the figures are not known and four did not reply. Cuba reported that less than 5.0% of the total injections that are administered annually in health-care settings are unnecessary and Guyana reported that less than 14.0% are unnecessary.

No (66.77%)

a

N=26 (This response option was not included in the survey completed by Colombia.)

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Regarding hepatitis C testing, 22 responding Member States (81.5%) indicated that people register by name for testing. Eighteen members of that subset (81.8%) indicated that names are kept confidential. Twelve responding Member States (44.4%) reported that the hepatitis C test is free of charge for all individuals. Among the nine other Member States that answered the question, five (55.6%) reported that the hepatitis C test is free of charge for members of specific groups. Groups identified included blood donors, pregnant women and people living with HIV. Seven responding Member States (25.9%) reported that the hepatitis C test is compulsory for members of specific groups. Groups identified included blood donors and pregnant women. Sixteen responding Member States (59.3%) reported that publicly funded treatment is available for hepatitis B and 13 (48.1%) that it is available for hepatitis C. One responding Member State reported the amount spent on publicly funded treatment for hepatitis B and hepatitis C. Details can be found in the summaries of country findings later in this chapter (see Argentina). Twenty-two responding Member States (81.5%) reported that at least one available drug for treating hepatitis B is on the national essential medicines list or subsidized by the government (Table 6). The drugs most commonly reported were tenofovir, lamivudine and interferon alpha. Table 6. Proportion of Member States reporting drugs for

Twelve responding Member States (44.4%) reported that at least one available drug for treating hepatitis C is on the national essential medicines list or subsidized by the government. The drugs most commonly reported were interferon alpha, pegylated interferon and ribavirin.

World Health Organization assistance 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: surveillance for viral hepatitis (74.1%) and estimating the national burden of viral hepatitis (70.4%) (Table 7). Responses from individual Member States appear in Annex C.

treating hepatitis B and C on national essential medicines lists or subsidized by governments Drugs for treating hepatitis B % of Member States reporting its inclusion (N=12) 59.3 59.3 40.7 33.3 22.2 18.5 11.1 % of Member States reporting its inclusion (N=12) 37.0 37.0 25.9 11.1 7.4

Lamivudine Interferon alpha Tenofovir Pegylated interferon Entecavir Adefovir dipivoxil Telbivudine Drugs for treating hepatitis C

Ribavirin Pegylated interferon Interferon alpha Telaprevir Boceprevir

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Table 7. Viral hepatitis control and prevention: areas in which Member States indicated interest in receiving WHO assistance

(N=27) Awareness-raising, partnerships and resource mobilization (first WHO strategic axis) Developing the national plan for viral hepatitis prevention and control Integrating viral hepatitis programmes into other health services Awareness-raising Evidence-based policy and data for action (second WHO strategic axis) Viral hepatitis surveillance Estimating the national burden of viral hepatitis Developing tools to assess the effectiveness of interventions Assessing the economic impact of viral hepatitis Prevention of transmission (third WHO strategic axis) Increasing coverage of the birth dose of the hepatitis B vaccine Screening, care and treatment (fourth WHO strategic axis) Increasing access to treatment Increasing access to diagnostics Improving laboratory quality Developing education/training programmes for health professionals a

63.0% 59.3% 59.3% 74.1% 70.4% 51.9% 55.6% 33.3% 37.0% 55.6% 46.2%a 63.0%

N=26 (This response option was not included in the survey completed by Colombia.)

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GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

WHO Region of the Americas: COUNTRY SUMMARIES

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Antigua and Barbuda The Government of Antigua and Barbuda 0.09 Population (in millions) (2011) reports as follows. Upper–middle-income Country classification (2012) $17 900 Gross national income per capita (PPP int $) (2011) National coordination 6.03% There is no written national strategy or Total health expenditure as % of GDP (2010) $990.55 plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $702.97 Life expectancy at birth (in years) (2009) 74 hepatitis. Human Development Index (2011) 0.764 There is no designated governmental Median age (in years) (2010) -unit/department responsible solely for co- Total fertility rate per woman (2010) 2.1 ordinating and/or carrying out viral hepatitis-related activities. There are no people working full-time on hepatitis-related ac- Prevention of transmission be prevented through food and water tivities in any government agency/body. There is no national policy on hepatitis A safety. vaccination. The government does not have a viral Screening, care and treatment hepatitis prevention and control pro- The government has not established the Health professionals obtain the skills and gramme that includes activities targeting goal of eliminating hepatitis B. competencies required to effectively care specific populations. for people with viral hepatitis through Nationally, 8% of newborn infants in a schools for health professionals (pre-servAwareness-raising and partnerships given recent year received the first dose ice education), on-the-job training and The government did not hold events for of hepatitis B vaccine within 24 hours of postgraduate training. World Hepatitis Day 2012 and has not birth. It is not known what percentage funded other viral hepatitis public aware- of one-year-olds (ages 12–23 months) There are national clinical guidelines for ness campaigns since January 2011. nationally in a given recent year received the management of viral hepatitis and for the management of HIV, which include three doses of hepatitis B vaccine. The government does not collaborate recommendations for coinfection with viwith in-country civil society groups to There is a national policy that specifically ral hepatitis. develop and implement its viral hepatitis targets mother-to-child transmission of prevention and control programme. The government has national policies rehepatitis B (Annex B). lating to screening and referral to care for Evidence-based policy and data for There is no specific national strategy and/ hepatitis B, but not for hepatitis C. action or policy/guidelines for preventing hepaThere is routine surveillance for viral hepa- titis B and hepatitis C infection in health- People testing for both hepatitis B and titis. There is a national surveillance system care settings. Health-care workers are vac- hepatitis C register by name; the names for the following types of acute hepatitis: cinated against hepatitis B prior to starting are kept confidential within the system. A, B and C, but not for any type of chronic work that might put them at risk of expo- Hepatitis B and hepatitis C tests are not hepatitis. free of charge for all individuals, but they sure to blood. are free of charge for blood donors. InforThere are standard case definitions for There is no national policy on injection mation was not provided on whether hephepatitis. Deaths, including from hepatitis, safety in health-care settings. Single-use atitis B or hepatitis C tests are compulsory are reported to a central registry. The per- or auto-disable syringes, needles and can- for members of any specific group. centage of hepatitis cases reported as “un- nulas are always available in all health-care differentiated” or “unclassified” hepatitis is facilities. Publicly funded treatment for hepatitis not known. B and hepatitis C is available to all public Official government estimates of the hospital patients who contribute to the Liver cancer cases and cases with HIV/hep- number and percentage of unneces- medical benefits scheme. The amount atitis coinfection are registered nationally. sary injections administered annually in spent by the government on publicly health-care settings are not known. funded treatment for hepatitis B and hepThe government does not publish hepatiatitis C is not known. tis disease reports. There is no national infection control policy for blood banks. All donated blood The following drug for treating hepatitis Hepatitis outbreaks are required to be re- units (including family donations) and ported to the government and are further blood products nationwide are screened B is on the national essential medicines list or is subsidized by the government: investigated. There is adequate laboratory for hepatitis B and hepatitis C. tenofovir. No drug for treating hepatitis C capacity nationally to support outbreak investigations and other surveillance activi- There is no national policy relating to the is on the national essential medicines list ties for hepatitis B and hepatitis C, but not prevention of viral hepatitis among peo- or subsidized by the government. for hepatitis A and hepatitis E. ple who inject drugs. The Government of Antigua and Barbuda There is no national public health research The government has guidelines that ad- did not indicate a need for assistance from agenda for viral hepatitis. Viral hepatitis se- dress how hepatitis A and hepatitis E can WHO in relation to viral hepatitis prevention and control. rosurveys are not conducted regularly.

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Argentina Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Argentina reports as follows. 40.8 Upper–middle-income $17 130 8.10% $1286.68 $702.56 75 0.797 30 2.2 Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

National coordination There is a written national strategy or plan that focuses exclusively on the prevention and control of viral hepatitis. It includes components for raising awareness, surveillance, vaccination, prevention in general, prevention of transmission in health-care settings, treatment and care, and coinfection with HIV. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities. This programme is part of the AIDS and STD Directorate. Information was not provided regarding how many staff members this office has. There are eight full-time equivalent staff members who work on hepatitis-related activities in all government agencies/bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), people living with HIV and the uninsured.

Awareness-raising and partnerships The government held events for World Hepatitis Day 2012 and has funded other viral hepatitis public awareness campaigns since January 2011 (Annex A). The government collaborates with the following in-country civil society group to develop and implement its viral hepatitis prevention and control programme: Fundación HCV Sin Fronteras.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C, D and E, and for the following types of chronic hepatitis: B, C and D. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Information was not provided regarding the

There is no national policy relating to the prevention of viral hepatitis among peopercentage of hepatitis cases reported as ple who inject drugs. “undifferentiated” or “unknown” hepatitis. The government has guidelines that adLiver cancer cases and cases with HIV/hep- dress how hepatitis A and hepatitis E can atitis coinfection are registered nationally. be prevented through food and water safety. The government publishes hepatitis disease reports annually. Screening, care and treatment Health professionals obtain the skills and Hepatitis outbreaks are required to be re- competencies required to effectively care ported to the government and are further for people with viral hepatitis through oninvestigated. There is adequate laboratory the-job training and postgraduate traincapacity nationally to support investiga- ing. tion of viral hepatitis outbreaks and other surveillance activities. There are national clinical guidelines for the management of viral hepatitis, which There is a national public health research include recommendations for cases with agenda for viral hepatitis. Viral hepatitis HIV coinfection. There are national cliniserosurveys are conducted regularly; the cal guidelines for the management of HIV, target population is children. Information which include recommendations for coinwas not provided regarding when the last fection with viral hepatitis. serosurvey was carried out. The government has national policies rePrevention of transmission lating to screening and referral to care for There is a national policy on hepatitis A hepatitis B and hepatitis C. vaccination. People testing for both hepatitis B and The government has not established the hepatitis C register by name; the names goal of eliminating hepatitis B. are kept confidential within the system. Nationally, 94.4% of newborn infants in a Hepatitis B and hepatitis C tests are free of given recent year received the first dose of charge for all individuals and are not comhepatitis B vaccine within 24 hours of birth pulsory for members of any specific group. and 92.5% of one-year-olds (ages 12–23 Publicly funded treatment is available for months) in a given recent year received hepatitis B and hepatitis C. The following three doses of hepatitis B vaccine. groups are eligible: all people without soThere is a national policy that specifically cial coverage. The government spends 40 targets mother-to-child transmission of million pesos (US$ 8.8 million) annually on publicly funded treatment for hepatitis B hepatitis B (Annex B). and hepatitis C. There is a specific national strategy and/or policy/guidelines for preventing hepatitis The following drugs for treating hepatitis B B and hepatitis C infection in health-care are on the national essential medicines list settings. Health-care workers are vacci- or subsidized by the government: pegylatnated against hepatitis B prior to starting ed interferon, lamivudine, entecavir and work that might put them at risk of expo- tenofovir. The following drugs for treating hepatitis C are included on the national sure to blood. essential medicines list or subsidized by There is a national policy on injection safe- the government: pegylated interferon and ty in health-care settings, which recom- ribavirin. mends single-use syringes for therapeutic injections. Single-use or auto-disable sy- The Government of Argentina welcomes ringes, needles and cannulas are always assistance from WHO in one or more areas of viral hepatitis prevention and control available in all health-care facilities. (Annex C).

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Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Bahamas The Government of the Bahamas reports Population (in millions) (2011) 0.3 as follows. Country classification (2012) High-income National coordination Gross national income per capita (PPP int $) (2011) -There is no written national strategy or Total health expenditure as % of GDP (2010) 7.98% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $1988.45 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $906.66 hepatitis. Life expectancy at birth (in years) (2009) 76 Human Development Index (2011) 0.771 There is no designated governmental Median age (in years) (2010) 31 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.6 ordinating and/or carrying out viral hepatitis-related activities. There are no people working full-time on hepatitis-related ac- Prevention of transmission schools for health professionals (pre-servtivities in any government agency/body. There is no national policy on hepatitis A ice education), on-the-job training and vaccination. postgraduate training. The government does not have a viral hepatitis prevention and control pro- The government has not established the There are no national clinical guidelines gramme that includes activities targeting goal of eliminating hepatitis B. for the management of viral hepatitis. specific populations. There are national clinical guidelines for Nationally, less than 1% of newborn in- the management of HIV, which include Awareness-raising and partnerships fants in a given recent year received the recommendations for coinfection with The government did not hold events for first dose of hepatitis B vaccine within 24 viral hepatitis. World Hepatitis Day 2012 and has not hours of birth and 97% of one-year-olds funded other viral hepatitis public aware- (ages 12–23 months) in a given recent year The government does not have national ness campaigns since January 2011. received three doses of hepatitis B vaccine. policies relating to screening and referral to care for hepatitis B or hepatitis C. The government does not collaborate There is a national policy that specifically with in-country civil society groups to targets mother-to-child transmission of People testing for both hepatitis B and develop and implement its viral hepatitis hepatitis B (Annex B). hepatitis C register by name; the names prevention and control programme. are kept confidential within the system. There is no specific national strategy and/ Hepatitis B and hepatitis C tests are not Evidence-based policy and data for or policy/guidelines for preventing hepa- free of charge for all individuals, but they action titis B and hepatitis C infection in health- are free of charge for children, indigent There is routine surveillance for viral hepa- care settings. people, senior citizens and civil servants. titis. There is a national surveillance system Hepatitis B and hepatitis C tests are not for the following types of acute hepatitis: There is a national policy on injection safecompulsory for members of any specific A, B and C, and for the following types of ty in health-care settings, which recomgroup. mends auto-disable syringes for therapeuchronic hepatitis: B and C. tic injections. Single-use or auto-disable Publicly funded treatment for hepatitis B It is not known whether there are stand- syringes, needles and cannulas are always and hepatitis C is available to all residents. ard case definitions for hepatitis. Deaths, available in all health-care facilities. The amount spent by the government on including from hepatitis, are reported to a publicly funded treatment for hepatitis B central registry. The percentage of hepati- Official government estimates of the and hepatitis C is not known. tis cases reported as “undifferentiated” or number and percentage of unnecessary injections administered annually in “unclassified” hepatitis is not known. The following drugs for treating hepatitis B health-care settings are not known. are on the national essential medicines list Information was not provided on whether or subsidized by the government: interliver cancer cases are registered nationally. There is a national infection control policy feron alpha, lamivudine, entecavir, telbivuCases with HIV/hepatitis coinfection are for blood banks. All donated blood units (including family donations) and blood dine and tenofovir. The following drugs for not registered nationally. products nationwide are screened for treating hepatitis C are on the national essential medicines list or subsidized by the The government does not publish hepati- hepatitis B and hepatitis C. government: interferon alpha, ribavirin tis disease reports. There is no national policy relating to the and telaprevir. Hepatitis outbreaks are required to be re- prevention of viral hepatitis among peoThe Government of the Bahamas welported to the government and are further ple who inject drugs. comes assistance from WHO in one or investigated. There is adequate laboratory capacity nationally to support outbreak in- The government has guidelines that ad- more areas of viral hepatitis prevention vestigations and other surveillance activi- dress how hepatitis A and hepatitis E can and control (Annex C). ties for hepatitis A, hepatitis B and hepati- be prevented through food and water tis C, but it is not known if this is the case safety. for hepatitis D and hepatitis E.

Screening, care and treatment

There is no national public health research Health professionals obtain the skills and agenda for viral hepatitis. Viral hepatitis se- competencies required to effectively care for people with viral hepatitis through rosurveys are not conducted regularly.

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Barbados Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 0.3 High-income -7.97% $1523.45 $990.36 76 0.793 37 1.6 It is not known whether there is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

The government does not have guidelines that address how hepatitis A and hepatiThe Government of Barbados reports as hepatitis coinfection are not registered tis E can be prevented through food and follows. nationally. water safety.

National coordination

The government publishes hepatitis disThere is no written national strategy or ease reports monthly. plan that focuses exclusively or primarily on the prevention and control of viral Hepatitis outbreaks are not required to be reported to the government. There is hepatitis. adequate laboratory capacity nationally There is no designated governmental to support outbreak investigations and unit/department responsible solely for co- other surveillance activities for hepatitis B ordinating and/or carrying out viral hepa- and hepatitis C, but this is not the case for titis-related activities. There are no people hepatitis A and hepatitis E. working full-time on hepatitis-related acThere is no national public health research tivities in any government agency/body. agenda for viral hepatitis. Viral hepatitis seThe government has a viral hepatitis pre- rosurveys are not conducted regularly. vention and control programme that includes activities targeting the following Prevention of transmission specific populations: health-care workers There is no national policy on hepatitis A (including health-care waste handlers), vaccination. soldiers, police officers, sanitary workers, The government has not established the infants and adolescents. goal of eliminating hepatitis B.

Screening, care and treatment It is not known how health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis. There are no national clinical guidelines for the management of viral hepatitis or for HIV, which include recommendations for coinfection with viral hepatitis. The government does not have national policies relating to screening and referral to care for hepatitis B or hepatitis C. People testing for both hepatitis B and hepatitis C register by name; there is open access to their names. Hepatitis B and hepatitis C tests are free of charge for all individuals and are not compulsory for members of any specific group. Publicly funded treatment is available for hepatitis B and hepatitis C. The following groups are eligible for such treatment for hepatitis B: nationals and residents; and for hepatitis C: nationals. The amount spent by the government on publicly funded treatment for hepatitis B and hepatitis C is not known. The following drugs for treating hepatitis

Awareness-raising and partnerships

Nationally, no newborn infant in a given recent year received the first dose of hepatitis B vaccine within 24 hours of birth and 95% of one-year-olds (ages 12–23 months) in a given recent year received The government does not collaborate three doses of hepatitis B vaccine. with in-country civil society groups to develop and implement its viral hepatitis There is a national policy that specifically targets mother-to-child transmission of prevention and control programme. hepatitis B (Annex B). The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: B and C, but not for any type of chronic hepatitis.

Evidence-based policy and data for There is no specific national strategy and/ B are on the national essential medicines action or policy/guidelines for preventing hepa- list or subsidized by the government: in-

There are no standard case definitions for hepatitis. It is not known whether deaths, including from hepatitis, are reported to a central registry. The percentage of hepatitis cases reported as “undifferentiated” or “unclassified” hepatitis is not known. It is not known whether liver cancer cases are registered nationally. Cases with HIV/

titis B and hepatitis C infection in health- terferon alpha, pegylated interferon, lamivudine and tenofovir. The following drugs care settings. for treating hepatitis C are on the national There is no national policy on injection essential medicines list or subsidized by safety in health-care settings. Single-use the government: interferon alpha and or auto-disable syringes, needles and can- pegylated interferon. nulas are always available in all health-care The Government of Barbados welcomes facilities. assistance from WHO in one or more areas Official government estimates of the of viral hepatitis prevention and control number and percentage of unneces- (Annex C). sary injections administered annually in health-care settings are not known.

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GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Brazil The Government of Brazil reports as 196.7 Population (in millions) (2011) follows. Upper–middle-income Country classification (2012) $11 420 Gross national income per capita (PPP int $) (2011) National coordination 9.01% There is a written national strategy or plan Total health expenditure as % of GDP (2010) $1028.29 that focuses primarily on the prevention Per capita total health expenditure (PPP int $) (2010) and control of viral hepatitis, and also in- Per capita government health expenditure (PPP int $) (2010) $483.49 73 tegrates other diseases. It includes compo- Life expectancy at birth (in years) (2009) 0.718 nents for raising awareness, surveillance, Human Development Index (2011) 29 vaccination, prevention in general, preven- Median age (in years) (2010) 1.8 tion of transmission via injecting drug use, Total fertility rate per woman (2010) prevention of transmission in health-care settings, treatment and care, and coinfecHepatitis outbreaks are required to be re- products nationwide are screened for heption with HIV. ported to the government and are further atitis B and hepatitis C. There is a designated governmental unit/ investigated. There is adequate laboratory department responsible solely for coordi- capacity nationally to support investiga- There is a national policy relating to the nating and/or carrying out viral hepatitis- tion of viral hepatitis outbreaks and other prevention of viral hepatitis among people who inject drugs. related activities: National Department of surveillance activities. STD, AIDS and Viral Hepatitis. It has 250 The government has guidelines that adstaff members. It is not known how many There is no national public health research dress how hepatitis A and hepatitis E can agenda for viral hepatitis. Viral hepatitis sepeople work full-time on hepatitis-related be prevented through food and water activities in all government agencies/bod- rosurveys are conducted regularly; target safety. populations include the general populaies. tion, adolescents, health professionals, Screening, care and treatment The government has a viral hepatitis pre- pregnant women and tattooists. The last Health professionals obtain the skills and vention and control programme that in- serosurvey was carried out in July 2012. competencies required to effectively care cludes activities targeting the following for people with viral hepatitis through onPrevention of transmission specific populations: health-care workers the-job training, postgraduate training and (including health-care waste handlers), There is a national policy on hepatitis A training for multidisciplinary teams. vaccination. people who inject drugs, prisoners, sex workers, people living with HIV, the unin- The government has not established the There are national clinical guidelines for sured, indigenous people, pregnant wom- goal of eliminating hepatitis B. the management of viral hepatitis, which en and men who have sex with men. include recommendations for cases with It is not known what percentage of new- HIV coinfection. Awareness-raising and partnerships born infants nationally in a given recent The government held events for World year received the first dose of hepatitis B The government has national policies reHepatitis Day 2012 and has funded other vaccine within 24 hours of birth or what lating to screening and referral to care for viral hepatitis public awareness campaigns percentage of one-year-olds (ages 12–23 hepatitis B and hepatitis C. since January 2011 (Annex A). months) nationally in a given recent year People testing for both hepatitis B and The government collaborates with in- received three doses of hepatitis B vaccine. hepatitis C register by name; the names country civil society groups to develop and There is a national policy that specifically are kept confidential within the system. implement its viral hepatitis prevention targets mother-to-child transmission of Hepatitis B and hepatitis C tests are free of and control programme. charge for all individuals and are not comhepatitis B (Annex B). Evidence-based policy and data for There is a specific national strategy and/or pulsory for members of any specific group. action Publicly funded treatment for hepatitis B There is routine surveillance for viral hepa- policy/guidelines for preventing hepatitis and hepatitis C is available to the entire B and hepatitis C infection in health-care titis. There is a national surveillance system population. Information was not provided for the following types of acute hepatitis: A, settings. Health-care workers are vaccinat- regarding the amount spent by the goved against hepatitis B prior to starting work B, C, D and E, and for the following types of that might put them at risk of exposure to ernment on such treatment for hepatitis B chronic hepatitis: B, C and D. and hepatitis C. blood. There are standard case definitions for The following drugs for treating hepatitis hepatitis. Deaths, including from hepatitis, There is a national policy on injection safe- B are on the national essential medicines ty in health-care settings, which recomare reported to a central registry. Informalist or subsidized by the government: intion was not provided on the percentage mends single-use syringes for therapeutic terferon alpha, pegylated interferon, lamiinjections. Single-use or auto-disable syof hepatitis cases reported as “undifferentiringes, needles and cannulas are always vudine, adefovir dipivoxil, entecavir and ated” or “unknown” hepatitis. tenofovir. The following drugs for treating available in all health-care facilities. hepatitis C are on the national essential Liver cancer cases are not registered nationally, but cases with HIV/hepatitis coin- Official government estimates of the medicines list or subsidized by the governnumber and percentage of unnecessary ment: interferon alpha, pegylated interferfection are. injections administered annually in health- on and ribavirin. The government publishes hepatitis dis- care settings are not known. The Government of Brazil welcomes asease reports annually and in the case of sistance from WHO in one or more areas There is a national infection control policy outbreaks. for blood banks. All donated blood units of viral hepatitis prevention and control (including family donations) and blood (Annex C). 43

Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Canada Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 34.3 High-income $39 660 11.29% $4403.62 $3104.41 81 0.908 40 1.7 single-use syringes for therapeutic injections. Single-use or auto-disable syringes, needles and cannulas are always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known.

There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products The Government of Canada reports as ported to a central registry. Of hepatitis cases, nationwide are screened for hepatitis B and 0%–10.0% is reported as “undifferentiated” or hepatitis C. follows. “unclassified” hepatitis. National coordination There is a national policy relating to the preThere is a written national strategy or plan Liver cancer cases are registered nationally, vention of viral hepatitis among people who that focuses primarily on the prevention and but cases with HIV/hepatitis coinfection are inject drugs. control of viral hepatitis, and also integrates not. The government has guidelines that address other diseases. It includes components for raising awareness, surveillance, vaccination, The government publishes hepatitis disease how hepatitis A and hepatitis E can be prevented through food and water safety. prevention in general, prevention of trans- reports annually. mission via injecting drug use, prevention Hepatitis outbreaks are reported to local Screening, care and treatment of transmission in health-care settings, treatpublic health authorities and are further in- Health professionals obtain the skills and ment and care, and coinfection with HIV. vestigated only at the local level. There is ad- competencies required to effectively care for There is a designated governmental unit/ equate laboratory capacity nationally to sup- people with viral hepatitis through schools department responsible solely for coordinat- port investigation of viral hepatitis outbreaks for health professionals (pre-service education), on-the-job training and postgraduate ing and/or carrying out viral hepatitis-related and other surveillance activities. training. activities. The name of this office was not proThere is a national public health research vided. It is not known how many people work agenda for viral hepatitis. Viral hepatitis se- There are national clinical guidelines for the full-time on hepatitis-related activities in all rosurveys are conducted regularly; the target management of viral hepatitis, which include government agencies/bodies. population is the general population. The recommendations for cases with HIV coinfecThe government has a viral hepatitis preven- last serosurvey was carried out from 2009 to tion. tion and control programme that includes 2011. The government has national policies relatactivities targeting the following specific Prevention of transmission ing to screening and referral to care for hepapopulations: health-care workers (including There is a national policy on hepatitis A vac- titis B and hepatitis C. health-care waste handlers), people who incination. ject drugs, migrants, prisoners, the homeless, People testing for both hepatitis B and hepapeople living with HIV, low-income popula- The government has established the goal of titis C register by name; the names are kept tions, indigenous people, ethnocultural pop- eliminating hepatitis B but information was confidential within the system. Hepatitis B ulations and youth. not provided about a specific timeframe for and hepatitis C tests are free of charge for all individuals, and are compulsory for blood Awareness-raising and partnerships this goal. The government held events for World Hepa- Information was not provided on the per- donors and for some health-care workers in titis Day 2012 but has not funded other viral centage of newborn infants nationally in a certain jurisdictions. hepatitis public awareness campaigns since given recent year who received the first dose Publicly funded treatment is available for January 2011. of hepatitis B vaccine within 24 hours of birth hepatitis B and hepatitis C. All Canadian resior the percentage of one-year-olds nationally dents are eligible for this. The amount spent The government collaborates with the follow(ages 12–23 months) in a given recent year by the government on such treatment for ing in-country civil society groups to develop who received three doses of hepatitis B vac- hepatitis B and hepatitis C is not known. and implement its viral hepatitis prevention cine. and control programme: Canadian Society The following drugs for treating hepatitis B for International Health, Canadian AIDS Treat- There is a national policy that specifically tar- are on the national essential medicines list ment Information Exchange and University of gets mother-to-child transmission of hepati- or subsidized by the government: interferon British Columbia Hepatitis Services. tis B (Annex B). alpha, pegylated interferon, lamivudine, adeEvidence-based policy and data for There is a specific national strategy and/or fovir dipivoxil, entecavir and telbivudine. The following drugs for treating hepatitis C are on action policy/guidelines for preventing hepatitis B There is a national surveillance system for the and hepatitis C infection in health-care set- the national essential medicines list or subfollowing types of acute hepatitis: A, B and C, tings. Health-care workers are vaccinated sidized by the government: pegylated interand for the following types of chronic hepa- against hepatitis B prior to starting work that feron, ribavirin, boceprevir and telaprevir. titis: B and C. might put them at risk of exposure to blood. The Government of Canada welcomes assistThere are standard case definitions for hepa- There is a national policy on injection safety ance from WHO in one or more areas of viral titis. Deaths, including from hepatitis, are re- in health-care settings, which recommends hepatitis prevention and control (Annex C).

44

Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Colombia The Government of Colombia reports as 46.9 Population (in millions) (2011) follows. Upper–middle-income Country classification (2012) National coordination $9560 Gross national income per capita (PPP int $) (2011) There is no written national strategy or plan Total health expenditure as % of GDP (2010) 7.59% that focuses exclusively or primarily on the Per capita total health expenditure (PPP int $) (2010) $712.59 prevention and control of viral hepatitis. Per capita government health expenditure (PPP int $) (2010) $518.04 Life expectancy at birth (in years) (2009) 76 There is no designated governmental unit/ Human Development Index (2011) 0.710 department responsible solely for coordi- Median age (in years) (2010) 27 nating and/or carrying out viral hepatitis- Total fertility rate per woman (2010) 2.4 related activities. There are three full-time equivalent staff members who work on hepatitis-related activities in all govern- There is no national public health research The government has guidelines that adagenda for viral hepatitis. Viral hepatitis se- dress how hepatitis A and hepatitis E can ment agencies/bodies. be prevented through food and water rosurveys are not conducted regularly. The government has a viral hepatitis presafety. vention and control programme that in- Prevention of transmission cludes activities targeting the following There is a national policy on hepatitis A Screening, care and treatment Health professionals obtain the skills and specific populations: health-care workers vaccination. competencies required to effectively care (including health-care waste handlers), people living with HIV and indigenous The government has not established the for people with viral hepatitis through goal of eliminating hepatitis B. schools for health professionals (pre-servpeople. ice education) and on-the-job training. Nationally, 82.7% of newborn infants in a Awareness-raising and partnerships given recent year received the fi rst dose of There are national clinical guidelines for The government did not hold events for World Hepatitis Day 2012 and has not hepatitis B vaccine within 24 hours of birth the management of viral hepatitis. funded other viral hepatitis public aware- and 85.4% of one-year-olds (ages 12–23 months) in a given recent year received The government has national policies reness campaigns since January 2011. lating to screening and referral to care for three doses of hepatitis B vaccine. hepatitis B and hepatitis C. The government does not collaborate with in-country civil society groups to develop There is a national policy that specifically and implement its viral hepatitis preven- targets mother-to-child transmission of People testing for both hepatitis B and hepatitis C register by name; the names hepatitis B (Annex B). tion and control programme. are kept confidential within the system. Evidence-based policy and data for There is a specific national strategy and/ Information was not provided on whether or policy for preventing hepatitis B and hepatitis B or hepatitis C tests are free of action There is routine surveillance for viral hepa- hepatitis C infection in health-care settings. charge for all individuals or compulsory for titis. There is a national surveillance system Health-care workers are vaccinated against members of any specific group. for the following types of acute hepatitis: hepatitis B prior to starting work that might Publicly funded treatment is available for A and B, but not for any type of chronic put them at risk of exposure to blood. hepatitis B and hepatitis C. Information hepatitis. There is a national policy on injection safe- was not provided regarding who is eligible There are standard case definitions for ty in health-care settings, which recom- for this or the amount spent by the governhepatitis. Deaths, including from hepatitis, mends single-use syringes for therapeutic ment on such treatment. are reported to a central registry. Sixty per injections. Single-use or auto-disable sycent of hepatitis cases are reported as “un- ringes, needles and cannulas are always The following drugs for treating hepatitis B are on the national essential medicines available in all health-care facilities. differentiated” or “unclassified” hepatitis. list or subsidized by the government: interLiver cancer cases and cases with HIV/hep- Official government estimates of the feron alpha, pegylated interferon, lamivuatitis coinfection are registered nationally. number and percentage of unnecessary dine and tenofovir. The following drugs for injections administered annually in health- treating hepatitis C are on the national esThe government publishes hepatitis dis- care settings are not known. sential medicines list or subsidized by the ease reports weekly and monthly. government: interferon alpha, pegylated There is a national infection control policy Hepatitis outbreaks are required to be re- for blood banks. All donated blood units interferon and ribavirin. ported to the government and are further (including family donations) and blood The Government of Colombia welcomes investigated. There is adequate laboratory products nationwide are screened for hep- assistance from WHO in one or more areas capacity nationally to support investiga- atitis B and hepatitis C. of viral hepatitis prevention and control tion of viral hepatitis outbreaks and other (Annex C). There is no national policy relating to the surveillance activities. prevention of viral hepatitis among people who inject drugs.

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Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Costa Rica Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Costa Rica reports as follows. 4.7 Upper–middle-income $11 860 10.94% $1241.53 $845.50 79 0.744 28 1.8 There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

National coordination There is no written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis. There is no designated governmental unit/department responsible solely for coordinating and/or carrying out viral hepatitis-related activities. There are no people working full-time on hepatitis-related activities in any government agency/body. The government does not have a viral hepatitis prevention and control programme that includes activities targeting specific populations.

The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water Hepatitis outbreaks are required to be re- safety. ported to the government and are further investigated. There is adequate laboratory Screening, care and treatment capacity nationally to support investiga- Health professionals obtain the skills and tion of viral hepatitis outbreaks and other competencies required to effectively care surveillance activities for hepatitis A, hepa- for people with viral hepatitis through titis B and hepatitis C. Information was not schools for health professionals (pre-servprovided on whether this is the case for ice education), on-the-job training and postgraduate training. hepatitis E.

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011.

The government does not collaborate with in-country civil society groups to develop and implement its viral hepatitis There is a national policy that specifically Publicly funded treatment is available for prevention and control programme. targets mother-to-child transmission of hepatitis B and hepatitis C. All people dihepatitis B (Annex B). agnosed with hepatitis B and hepatitis Evidence-based policy and data for C in the health services are eligible. The action There is a specific national strategy and/or amount spent by the government on pubThere is routine surveillance for viral hepa- policy/guidelines for preventing hepatitis licly funded treatment for hepatitis B and titis. There is a national surveillance system B and hepatitis C infection in health-care hepatitis C is not known. for the following types of acute hepatitis: settings. Health-care workers are vacciA, B, C, D and E but not for any type of nated against hepatitis B prior to starting The following drugs for treating hepatitis chronic hepatitis. work that might put them at risk of expo- B are on the national essential medicines sure to blood. list or subsidized by the government: There are no standard case definitions for interferon alpha, pegylated interferon, hepatitis. Deaths, including from hepatitis, There is a national policy on injection lamivudine and tenofovir. The following are reported to a central registry. Of hepa- safety in health-care settings. The policy drugs for treating hepatitis C are included titis cases, 51% are reported as “undiffer- recommends auto-disable syringes for on the national essential medicines list or entiated” or “unclassified” hepatitis. therapeutic injections. Single-use or auto- subsidized by the government: pegylated disable syringes, needles and cannulas are Liver cancer cases are registered nation- always available in all health-care facilities. interferon and ribavirin. ally, but cases with HIV/hepatitis coinfecThe Government of Costa Rica welcomes tion are not. Official government estimates of the assistance from WHO in one or more areas number and percentage of unnecesThe government publishes hepatitis dis- sary injections administered annually in of viral hepatitis prevention and control (Annex C). ease reports annually. health-care settings are not known.

There is no national public health research There are no national clinical guidelines agenda for viral hepatitis. Viral hepatitis se- for the management of viral hepatitis or for the management of HIV, which include rosurveys are not conducted regularly. recommendations for coinfection with Prevention of transmission viral hepatitis. There is no national policy on hepatitis A The government has national policies revaccination. lating to screening and referral to care for The government has established the goal hepatitis B and hepatitis C. of eliminating hepatitis B but has not dePeople testing for both hepatitis B and fined a timeframe for this goal. hepatitis C register by name; the names Nationally, 91% of newborn infants in a are kept confidential within the system. given recent year received the first dose of Hepatitis B and hepatitis C tests are free of hepatitis B vaccine within 24 hours of birth charge for all individuals. Information was and 84% of one-year-olds (ages 12–23 not provided on whether hepatitis B or months) in a given recent year received hepatitis C tests are compulsory for memthree doses of hepatitis B vaccine. bers of any specific group.

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Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Cuba The Government of Cuba reports as Population (in millions) (2011) 11.3 follows. Country classification (2012) Upper–middle-income Gross national income per capita (PPP int $) (2011) -National coordination 10.63% There is a written national strategy or plan Total health expenditure as % of GDP (2010) $431.23 that focuses primarily on the prevention Per capita total health expenditure (PPP int $) (2010) and control of viral hepatitis, and also in- Per capita government health expenditure (PPP int $) (2010) $394.46 78 tegrates other diseases. It includes compo- Life expectancy at birth (in years) (2009) 0.776 nents for raising awareness, surveillance, Human Development Index (2011) 38 vaccination, prevention in general, preven- Median age (in years) (2010) 1.5 tion of transmission via injecting drug use, Total fertility rate per woman (2010) prevention of transmission in health-care settings, treatment and care, and coinfeccapacity nationally to support investiga- prevention of viral hepatitis among people tion with HIV. tion of viral hepatitis outbreaks and other who inject drugs. There is a designated governmental unit/ surveillance activities. The government has guidelines that addepartment responsible solely for coordinating and/or carrying out viral hepatitis- There is a national public health research dress how hepatitis A and hepatitis E can related activities. It has one staff member. agenda for viral hepatitis. Viral hepatitis se- be prevented through food and water safety. The name of this office was not provided. rosurveys are not conducted regularly. There are 22 full-time equivalent staff Prevention of transmission Screening, care and treatment members who work on hepatitis-related There is no national policy on hepatitis A Health professionals obtain the skills and activities in all government agencies/bod- vaccination. competencies required to effectively care ies. for people with viral hepatitis through The government has established the goal The government has a viral hepatitis pre- of eliminating hepatitis B by 2013 for the schools for health professionals (pre-servvention and control programme that in- paediatric population and by 2015 for the ice education), on-the-job training and postgraduate training. cludes activities targeting the following rest of the population. specific populations: health-care workers There are national clinical guidelines for (including health-care waste handlers), Nationally, 100% of newborn infants in a the management of viral hepatitis, which people who inject drugs, migrants, prison- given recent year received the first dose of include recommendations for cases with ers, people living with HIV and chronically hepatitis B vaccine within 24 hours of birth HIV coinfection. ill patients. and 100% of one-year-olds (ages 12–23 months) in a given recent year received The government has national policies reAwareness-raising and partnerships three doses of hepatitis B vaccine. lating to screening and referral to care for The government held events for World hepatitis B and hepatitis C. Hepatitis Day 2012 and has funded other There is a national policy that specifically viral hepatitis public awareness campaigns targets mother-to-child transmission of People testing for both hepatitis B and since January 2011 (Annex A). hepatitis B (Annex B). hepatitis C register by name; the names are kept confidential within the system. The government does not collaborate with There is a specific national strategy and/or Hepatitis B and hepatitis C tests are free of in-country civil society groups to develop policy/guidelines for preventing hepatitis charge for all individuals. Hepatitis B tests and implement its viral hepatitis preven- B and hepatitis C infection in health-care are compulsory for pregnant women and tion and control programme. settings. Health-care workers are vaccinat- organ and tissue donors, and hepatitis C against hepatitis B prior to starting work tests for organ and tissue donors. Evidence-based policy and data for ed that might put them at risk of exposure to action blood. Publicly funded treatment is available for There is routine surveillance for viral hepahepatitis B and hepatitis C. All people with titis. There is a national surveillance system There is a national policy on injection medical prescriptions are eligible. Inforfor the following types of acute hepatitis: A, safety in health-care settings, which recmation was not provided regarding the B, C, D and E and for the following types of ommends single-use and auto-disable amount spent by the government on pubchronic hepatitis: B, C and D. syringes for therapeutic injections. Single- licly funded treatment for hepatitis B and use or auto-disable syringes, needles and hepatitis C. There are standard case definitions for cannulas are always available in all healthhepatitis. Deaths, including from hepatitis, care facilities. The following drugs for treating hepatitis are reported to a central registry. No hepaB are on the national essential medicines titis case is reported as “undifferentiated” or Less than 5% of injections administered list or subsidized by the government: inter“unclassified” hepatitis. annually in health-care settings are unnec- feron alpha, pegylated interferon, lamivuessary, according to official government dine, adefovir dipivoxil and tenofovir. The Liver cancer cases and cases with HIV/hepestimates. following drugs for treating hepatitis C are atitis coinfection are registered nationally. on the national essential medicines list or There is a national infection control policy subsidized by the government: interferon The government publishes hepatitis disfor blood banks. All donated blood units alpha, pegylated interferon and ribavirin. ease reports annually, bi-annually and (including family donations) and blood quarterly. products nationwide are screened for hep- The Government of Cuba welcomes assistance from WHO in one or more areas Hepatitis outbreaks are required to be re- atitis B and hepatitis C. of viral hepatitis prevention and control ported to the government and are further There is a national policy relating to the (Annex C). investigated. There is adequate laboratory

47

Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Dominican Republic (the) Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 10.1 Upper–middle-income $9420 6.22% $577.57 $250.39 71 0.689 25 2.6 syringes, needles and cannulas are always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

The Government of the Dominican Information was not provided on whether Republic reports as follows. the government publishes hepatitis dis- It is not known whether there is a national policy relating to the prevention of viral ease reports. National coordination hepatitis among people who inject drugs. There is no written national strategy or Hepatitis outbreaks are required to be replan that focuses exclusively or prima- ported to the government. Information The government does not have guidelines rily on the prevention and control of viral was not provided on whether they are that address how hepatitis A and hepatihepatitis. further investigated. There is adequate tis E can be prevented through food and laboratory capacity nationally to support water safety. There is no designated governmental investigation of viral hepatitis outbreaks unit/department responsible solely for co- and other surveillance activities for hepa- Screening, care and treatment ordinating and/or carrying out viral hepa- titis A, hepatitis B and hepatitis C. Informa- Health professionals obtain the skills and titis-related activities. It is not known how tion was not provided on whether this is competencies required to effectively care for people with viral hepatitis through many people work full-time on hepatitis- the case for hepatitis E. schools for health professionals (pre-servrelated activities in all government agencies/bodies. There is no national public health research ice education). agenda for viral hepatitis. Viral hepatitis seInformation was not provided on whether The government has a viral hepatitis pre- rosurveys are not conducted regularly. there are national clinical guidelines for vention and control programme that inthe management of viral hepatitis. cludes activities targeting the following Prevention of transmission specific populations: health-care workers There is no national policy on hepatitis A Information was not provided on whether (including health-care waste handlers) vaccination. the government has national policies reand newborns. The government has not established the lating to screening and referral to care for hepatitis B or hepatitis C. Awareness-raising and partnerships goal of eliminating hepatitis B. The government did not hold events for World Hepatitis Day 2012 and has not Nationally, 82.1% of newborn infants in a Information was not provided on whether funded other viral hepatitis public aware- given recent year received the first dose of people testing for hepatitis B or hepatitis C hepatitis B vaccine within 24 hours of birth register by name, or whether the tests are ness campaigns since January 2011. and 79.7% of one-year-olds (ages 12–23 free of charge for all individuals or compulThe government does not collaborate months) in a given recent year received sory for members of any specific group. with in-country civil society groups to three doses of hepatitis B vaccine. Publicly funded treatment is available for develop and implement its viral hepatitis There is no national policy that specifically hepatitis B and hepatitis C. Information prevention and control programme. targets mother-to-child transmission of was not provided regarding who is eligible for this, or on the amount spent by the Evidence-based policy and data for hepatitis B. action government on such treatment for hepatiThere is no routine surveillance for viral There is a specific national strategy and/or tis B and hepatitis C. policy/guidelines for preventing hepatitis hepatitis. B and hepatitis C infection in health-care The following drug for treating hepatitis B There are standard case definitions for settings. Health-care workers are not vac- is on the national essential medicines list hepatitis. Deaths, including from hepatitis, cinated against hepatitis B prior to starting or subsidized by the government: interare reported to a central registry. The per- work that might put them at risk of expo- feron alpha. The following drug for treatcentage of hepatitis cases reported as “un- sure to blood. ing hepatitis C is on the national essential differentiated” or “unclassified” hepatitis is medicines list or subsidized by the governThere is a national policy on injection safe- ment: interferon alpha. not known. ty in health-care settings, which recomLiver cancer cases and cases with HIV/ mends auto-disable syringes for therapeu- The Government of the Dominican Rehepatitis coinfection are not registered tic injections. Single-use or auto-disable public welcomes assistance from WHO in nationally. one or more areas of viral hepatitis prevention and control (Annex C).

48

Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Ecuador The Government of Ecuador reports as Population (in millions) (2011) 14.7 follows. Country classification (2012) Upper–middle-income National coordination Gross national income per capita (PPP int $) (2011) $8510 There is a written national strategy or plan Total health expenditure as % of GDP (2010) 8.06% that focuses exclusively on the prevention Per capita total health expenditure (PPP int $) (2010) $653.17 and control of hepatitis B. It includes com- Per capita government health expenditure (PPP int $) (2010) $243.08 ponents for vaccination and treatment and Life expectancy at birth (in years) (2009) 75 care. Human Development Index (2011) 0.720 Median age (in years) (2010) 26 There is no designated governmental unit/ Total fertility rate per woman (2010) 2.5 department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities. It is not known how many B. Information was not provided regarding There is no national policy relating to the people work full-time on hepatitis-related whether this is the case for hepatitis C and prevention of viral hepatitis among people who inject drugs. activities in all government agencies/bod- hepatitis E. ies. There is no national public health research It is not known whether the government The government has a viral hepatitis pre- agenda for viral hepatitis. Viral hepatitis se- has guidelines that address how hepatitis A and hepatitis E can be prevented vention and control programme that in- rosurveys are not conducted regularly. through food and water safety. cludes activities targeting the following specific populations: health-care workers Prevention of transmission (including health-care waste handlers) and There is no national policy on hepatitis A Screening, care and treatment Health professionals obtain the skills and vaccination. sex workers. competencies required to effectively care Awareness-raising and partnerships The government has not established the for people with viral hepatitis through schools for health professionals (pre-servInformation was not provided on whether goal of eliminating hepatitis B. the government held events for World Nationally, 16.3% of newborn infants in a ice education). Hepatitis Day 2012. It has not funded other given recent year received the first dose of viral hepatitis public awareness campaigns hepatitis B vaccine within 24 hours of birth It is not known whether there are national clinical guidelines for the management of since January 2011. and 100% of one-year-olds (ages 12–23 viral hepatitis. The government does not collaborate with months) in a given recent year received The government does not have national in-country civil society groups to develop three doses of hepatitis B vaccine. and implement its viral hepatitis preven- There is a national policy that specifically policies relating to screening and referral to care for hepatitis B or hepatitis C. tion and control programme. targets mother-to-child transmission of People testing for both hepatitis B and Evidence-based policy and data for hepatitis B (Annex B). hepatitis C register by name; the names are action There is routine surveillance for viral hepa- There is a specific national strategy and/or kept confidential within the system. Hepatitis. There is a national surveillance system policy/guidelines for preventing hepatitis titis B tests are free of charge for all indifor the following types of acute hepatitis: B and hepatitis C infection in health-care viduals, but not hepatitis C tests. Hepatitis A, B and C, but not for any type of chronic settings. Health-care workers are vaccinat- B and hepatitis C tests are not compulsory ed against hepatitis B prior to starting work for members of any specific group. hepatitis. that might put them at risk of exposure to Publicly funded treatment for hepatitis B is There are standard case definitions for blood. available to some segments of the populahepatitis. Deaths, including from hepatitis, are reported to a central registry. Informa- There is a national policy on injection safe- tion, but information was not provided on tion was not provided on the percentage ty in health-care settings, which recom- who is eligible and the amount spent by of hepatitis cases reported as “undifferenti- mends auto-disable syringes for therapeu- the government on such treatment. Pubtic injections. Single-use or auto-disable licly funded treatment is not available for ated” or “unknown” hepatitis. syringes, needles and cannulas are always hepatitis C. Liver cancer cases are registered nationally. available in all health-care facilities. The following drug for treating hepatitis B It is not known whether cases with HIV/ hepatitis coinfection are registered nation- Official government estimates of the is on the national essential medicines list number and percentage of unnecessary or subsidized by the government: lamivually. injections administered annually in health- dine. No drug for treating hepatitis C is on The government does not publish hepati- care settings are not known. the national essential medicines list or subtis disease reports. sidized by the government. It is not known whether there is a national Hepatitis outbreaks are required to be infection control policy for blood banks. All The Government of Ecuador welcomes reported to the government but are not donated blood units and blood products assistance from WHO in one or more arfurther investigated. There is adequate nationwide are screened for hepatitis B. It eas of viral hepatitis prevention and conlaboratory capacity nationally to support is not known whether all donated blood trol (Annex C). outbreak investigations and other surveil- units (including family donations) and lance activities for hepatitis A and hepatitis blood products nationwide are screened for hepatitis C.

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Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

El Salvador Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 6.2 Lower–middle-income $6630 6.91% $450.25 $277.82 72 0.674 23 2.3 not provided regarding the type of syringes the policy recommends for therapeutic injections. Single-use or auto-disable syringes, needles and cannulas are always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known.

There is a national infection control policy for blood banks. All donated blood units The Government of El Salvador reports as Liver cancer cases are registered nation- (including family donations) and blood follows. ally. It is not known whether cases with products nationwide are screened for hepHIV/hepatitis coinfection are registered atitis B, but it is not known whether these National coordination nationally. are screened for hepatitis C. There is a written national strategy or plan that focuses exclusively on the preven- The government does not publish hepati- It is not known whether there is a national tion and control of hepatitis B. It includes tis disease reports. policy relating to the prevention of viral components for surveillance, vaccination, hepatitis among people who inject drugs. prevention in general and prevention of It is not known whether hepatitis outbreaks are required to be reported to the It is not known whether the government transmission in health-care settings. government, or whether there is adequate has guidelines that address how hepaThere is no designated governmental laboratory capacity nationally to support titis A and hepatitis E can be prevented unit/department responsible solely for co- investigation of viral hepatitis outbreaks through food and water safety. ordinating and/or carrying out viral hepa- and other surveillance activities. Screening, care and treatment titis-related activities. It is not known how many people work full-time on hepatitis- There is no national public health research Health professionals obtain the skills and related activities in all government agen- agenda for viral hepatitis. Viral hepatitis se- competencies required to effectively care rosurveys are not conducted regularly. for people with viral hepatitis through cies/bodies. schools for health professionals (pre-servPrevention of transmission The government has a viral hepatitis preice education). vention and control programme that in- There is no national policy on hepatitis A It is not known whether there are national cludes activities targeting the following vaccination. clinical guidelines for the management of specific population: health-care workers It is not known whether the government viral hepatitis or for HIV, which include rec(including health-care waste handlers). has established the goal of eliminating ommendations for coinfection with viral Awareness-raising and partnerships hepatitis B. hepatitis. The government held events for World Nationally, 5% of newborn infants in a The government does not have national Hepatitis Day 2012 but has not funded other viral hepatitis public awareness given recent year received the first dose of policies relating to screening and referral hepatitis B vaccine within 24 hours of birth to care for hepatitis B or hepatitis C. campaigns since January 2011. and 95% of one-year-olds (ages 12–23 The government does not collaborate months) in a given recent year received People testing for both hepatitis B and hepatitis C register by name; the names with in-country civil society groups to three doses of hepatitis B vaccine. are kept confidential within the system. develop and implement its viral hepatitis There is no national policy that specifically Hepatitis B and hepatitis C tests are free of prevention and control programme. targets mother-to-child transmission of charge for all individuals and are not comEvidence-based policy and data for hepatitis B. pulsory for members of any specific group. action It is not known whether there is a specifi c There is a national surveillance system for It is not known whether publicly funded the following types of acute hepatitis: A, national strategy and/or policy/guidelines treatment is available for hepatitis B or B and C, but not for any type of chronic for preventing hepatitis B and hepatitis C hepatitis C. infection in health-care settings. Informahepatitis. tion was not provided on whether health- No drug for treating hepatitis B or hepatitis There are standard case definitions for care workers are vaccinated against hepa- C is on the national essential medicines list hepatitis. Deaths, including from hepatitis, titis B prior to starting work that might put or subsidized by the government. are reported to a central registry. Fifty per them at risk of exposure to blood. The Government of El Salvador welcomes cent of hepatitis cases are reported as “unThere is a national policy on injection safe- assistance from WHO in one or more areas differentiated” or “unclassified” hepatitis. ty in health-care settings. Information was of viral hepatitis prevention and control (Annex C).

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Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Grenada The Government of Grenada reports as 0.1 Population (in millions) (2011) follows. Upper–middle-income Country classification (2012) $10 350 Gross national income per capita (PPP int $) (2011) National coordination 5.86% There is no written national strategy or plan Total health expenditure as % of GDP (2010) $594.09 that focuses exclusively or primarily on the Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) $267.16 prevention and control of viral hepatitis. 73 Life expectancy at birth (in years) (2009) There is no designated governmental unit/ Human Development Index (2011) 0.748 department responsible solely for coordi- Median age (in years) (2010) 25 nating and/or carrying out viral hepatitis- Total fertility rate per woman (2010) 2.2 related activities. It is not known how many people work full-time on hepatitis-related activities in all government agencies/bod- Prevention of transmission Screening, care and treatment ies. There is no national policy on hepatitis A Health professionals obtain the skills and vaccination. competencies required to effectively care The government has a viral hepatitis prefor people with viral hepatitis through onvention and control programme that in- The government has not established the the-job training. cludes activities targeting the following goal of eliminating hepatitis B. specific populations: health-care workers There are no national clinical guidelines (including health-care waste handlers), Nationally, 100% of newborn infants in a for the management of viral hepatitis. Inpeople living with HIV and pregnant wom- given recent year received the first dose of formation was not provided on whether hepatitis B vaccine within 24 hours of birth there are national clinical guidelines for en. and 95% of one-year-olds (ages 12–23 the management of HIV and whether they Awareness-raising and partnerships months) in a given recent year received include recommendations for coinfection The government did not hold events for three doses of hepatitis B vaccine. with viral hepatitis. World Hepatitis Day 2012 and has not funded other viral hepatitis public aware- There is a national policy that specifically The government has national policies retargets mother-to-child transmission of lating to screening and referral to care for ness campaigns since January 2011. hepatitis B (Annex B). hepatitis B, but not for hepatitis C. The government does not collaborate with There is a specifi c national strategy and/or in-country civil society groups to develop People testing for both hepatitis B and and implement its viral hepatitis preven- policy/guidelines for preventing hepatitis hepatitis C register by name; there is open B and hepatitis C infection in health-care access to the names. Hepatitis B tests are tion and control programme. settings. Information was not provided on not free of charge for all individuals, but Evidence-based policy and data for whether health-care workers are vaccinat- they are free of charge for antenatal womaction ed against hepatitis B prior to starting work en, health-care workers and people living There is routine surveillance for viral hepa- that might put them at risk of exposure to with HIV. Information was not provided on titis. There is a national surveillance system blood. whether hepatitis C tests are free of charge for the following types of acute hepatitis: B for all individuals. Hepatitis B and hepatitis and C, and for the following types of chron- There is a national policy on injection safe- C tests are not compulsory for members of ty in health-care settings, which recomic hepatitis: B and C. any specific group. mends single-use syringes for therapeutic There are standard case definitions for injections. Single-use or auto-disable sy- Publicly funded treatment is available for hepatitis. Deaths, including from hepatitis, ringes, needles and cannulas are always hepatitis B. The following groups are eligiare reported to a central registry. Informa- available in all health-care facilities. ble: pregnant women, health-care workers tion was not provided regarding the perand people living with HIV. The amount centage of hepatitis cases reported as “un- Official government estimates of the spent by the government on such treatnumber and percentage of unnecessary differentiated” or “unknown” hepatitis. ment for hepatitis B is not known. Publicly injections administered annually in healthfunded treatment is not available for hepaLiver cancer cases are registered nationally, care settings are not known. titis C. but cases with HIV/hepatitis coinfection There is a national infection control policy are not. The following drugs for treating hepatitis for blood banks. All donated blood units The government publishes hepatitis dis- (including family donations) and blood B are on the national essential medicines list or subsidized by the government: lamiease reports annually. products nationwide are screened for hepvudine and tenofovir. No drug for treatatitis B and hepatitis C. ing hepatitis C is on the national essential Hepatitis outbreaks are required to be reported to the government but are not There is no national policy relating to the medicines list or subsidized by the governfurther investigated. There is adequate prevention of viral hepatitis among people ment. laboratory capacity nationally to support who inject drugs. The Government of Grenada welcomes outbreak investigations and other surveillance activities for hepatitis B and hepatitis The government has guidelines that ad- assistance from WHO in one or more areas dress how hepatitis A and hepatitis E can of viral hepatitis prevention and control C, but not for hepatitis A and hepatitis E. be prevented through food and water (Annex C). There is no national public health research safety. agenda for viral hepatitis. Viral hepatitis serosurveys are not conducted regularly.

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Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Guatemala Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 14.8 -$4760 6.85% $324.92 $116.39 69 0.574 19 4 sary injections administered annually in health-care settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

The Government of Guatemala reports as The government does not publish hepati- The government has guidelines that address how hepatitis A and hepatitis E can follows. tis disease reports. be prevented through food and water National coordination Hepatitis outbreaks are required to be re- safety. There is no written national strategy or ported to the government and are further plan that focuses exclusively or prima- investigated. There is adequate laboratory Screening, care and treatment rily on the prevention and control of viral capacity nationally to support outbreak in- Health professionals obtain the skills and hepatitis. vestigations and other surveillance activi- competencies required to effectively care ties for hepatitis A, hepatitis B and hepa- for people with viral hepatitis through There is no designated governmental titis C. Information was not provided on schools for health professionals (pre-servunit/department responsible solely for co- whether this is the case for hepatitis E. ice education), on-the-job training and ordinating and/or carrying out viral heppostgraduate training. atitis-related activities. Information was There is no national public health research not provided on how many people work agenda for viral hepatitis. Viral hepatitis se- There are national clinical guidelines for the management of viral hepatitis, which full-time on hepatitis-related activities in rosurveys are not conducted regularly. include recommendations for cases with all government agencies/bodies. Prevention of transmission HIV coinfection. There are national cliniThe government has a viral hepatitis pre- There is no national policy on hepatitis A cal guidelines for the management of HIV, vention and control programme that in- vaccination. which include recommendations for coincludes activities targeting the following fection with viral hepatitis. specific populations: health-care workers The government has not established the The government has national policies re(including health-care waste handlers) goal of eliminating hepatitis B. lating to screening and referral to care for and newborns. Nationally, 31% of newborn infants in a hepatitis B and hepatitis C. Awareness-raising and partnerships given recent year received the first dose of The government held events for World hepatitis B vaccine within 24 hours of birth People testing for both hepatitis B and Hepatitis Day 2012 and has funded other and 87% of one-year-olds (ages 12–23 hepatitis C register by name, but informaviral hepatitis public awareness cam- months) in a given recent year received tion was not provided on whether their three doses of hepatitis B vaccine. names are kept confidential within the paigns since January 2011 (Annex A). system or whether there is open access The government collaborates with the fol- There is a national policy that specifically to their names. Hepatitis B and hepatitis C lowing in-country civil society group to targets mother-to-child transmission of tests are free of charge for all individuals. develop and implement its viral hepatitis hepatitis B (Annex B). Information was not provided on whether prevention and control programme: Asohepatitis B or hepatitis C tests are compulThere is a specifi c national strategy and/or ciacion Guatemaltecadel Higado. policy/guidelines for preventing hepatitis sory for members of any specific group. Evidence-based policy and data for B and hepatitis C infection in health-care Publicly funded treatment is not available settings. Health-care workers are vacci- for hepatitis B or hepatitis C. action There is routine surveillance for viral hepa- nated against hepatitis B prior to starting titis. There is a national surveillance system work that might put them at risk of expo- No drug for treating hepatitis B or hepatitis for the following types of acute hepatitis: sure to blood. C is on the national essential medicines list A, B and C, but not for any type of chronic or subsidized by the government. There is a national policy on injection safehepatitis. ty in health-care settings, which recom- The Government of Guatemala welcomes There are standard case definitions for mends single-use syringes for therapeutic assistance from WHO in one or more areas hepatitis. Deaths, including from hepatitis, injections. Single-use or auto-disable sy- of viral hepatitis prevention and control ringes, needles and cannulas are always (Annex C). are reported to a central registry. available in all health-care facilities. Liver cancer cases are registered nationally, but cases with HIV/hepatitis coinfec- Official government estimates of the number and percentage of unnecestion are not.

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Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Guyana The Government of Guyana reports as Population (in millions) (2011) 0.8 follows. Country classification (2012) Lower–middle-income National coordination Gross national income per capita (PPP int $) (2011) $3460 There is no written national strategy or plan Total health expenditure as % of GDP (2010) 5.38% that focuses exclusively or primarily on the Per capita total health expenditure (PPP int $) (2010) $166.69 prevention and control of viral hepatitis. Per capita government health expenditure (PPP int $) (2010) $142.35 Life expectancy at birth (in years) (2009) 67 There is no designated governmental unit/ Human Development Index (2011) 0.633 department responsible solely for coordi- Median age (in years) (2010) 24 nating and/or carrying out viral hepatitis- Total fertility rate per woman (2010) related activities. Information was not provided on how many people work full-time on hepatitis-related activities in all govern- Prevention of transmission Screening, care and treatment ment agencies/bodies. There is no national policy on hepatitis A Health professionals obtain the skills and vaccination. competencies required to effectively care The government has a viral hepatitis prefor people with viral hepatitis through vention and control programme that in- The government has not established the schools for health professionals (pre-servcludes activities targeting the following goal of eliminating hepatitis B. ice education) and on-the-job training. specific populations: health-care workers (including health-care waste handlers) and Nationally, no newborn infant in a given There are national clinical guidelines for recent year received the first dose of hepa- the management of viral hepatitis. Inforpeople living with HIV. titis B vaccine within 24 hours of birth. In mation was not provided on whether they Awareness-raising and partnerships a given recent year, 92% of one-year-olds include recommendations for cases with The government did not hold events for (ages 12–23 months) received three doses HIV coinfection. There are national cliniWorld Hepatitis Day 2012 and has not of hepatitis B vaccine. cal guidelines for the management of HIV, funded other viral hepatitis public awarewhich include recommendations for coinThere is a national policy that specifically ness campaigns since January 2011. fection with viral hepatitis. targets mother-to-child transmission of The government collaborates with the hepatitis B (Annex B). The government has national policies refollowing in-country civil society groups lating to screening and referral to care for There is a specifi c national strategy and/or to develop and implement its viral hepahepatitis B but not for hepatitis C. titis prevention and control programme: policy/guidelines for preventing hepatitis B and hepatitis C infection in health-care groups for health-care workers and people People testing for hepatitis B register by settings. Health-care workers are vaccinat- name; the names are kept confidential living with HIV. ed against hepatitis B prior to starting work within the system. Hepatitis B tests are free Evidence-based policy and data for that might put them at risk of exposure to of charge for all individuals and are comaction blood. pulsory for certain groups but information There is routine surveillance for viral hepawas not provided regarding which groups. titis. There is a national surveillance system There is a national policy on injection safety in health-care settings, which recom- Information was not provided on whether for acute as well as chronic hepatitis B. mends single-use syringes for therapeutic people testing for hepatitis C register by There are standard case definitions for injections. Single-use or auto-disable sy- name, whether the tests are free of charge hepatitis. Deaths, including from hepati- ringes, needles and cannulas are always for all individuals or compulsory for memtis, are reported to a central registry. The available in all health-care facilities. bers of any specific group. percentage of hepatitis cases reported as “undifferentiated” or “unclassified” hepati- Less than 14% of injections administered Publicly funded treatment for hepatitis B is annually in health-care settings are unnec- available to the entire population, but not tis was not known. essary, according to official government for hepatitis C. The amount spent by the Liver cancer cases and cases with HIV/hep- estimates. government on such treatment for hepatiatitis coinfection are registered nationally. tis B is not known. There is a national infection control policy The government publishes hepatitis dis- for blood banks. All donated blood units The following drugs for treating hepatitis B ease reports monthly. (including family donations) and blood are on the national essential medicines list products nationwide are screened for hep- or subsidized by the government: interferHepatitis outbreaks are required to be re- atitis B and hepatitis C. on alpha, adefovir dipivoxil and tenofovir. It ported to the government and are further investigated. There is adequate laboratory There is no national policy relating to the is not known which drugs for treating hepcapacity nationally to support outbreak in- prevention of viral hepatitis among people atitis C are on the national essential medicines list or subsidized by the government. vestigations and other surveillance activi- who inject drugs. ties for hepatitis A, hepatitis B and hepatitis The Government of Guyana welcomes asThe government has guidelines that adC, but not for hepatitis E. sistance from WHO in one or more areas dress how hepatitis A and hepatitis E can There is a national public health research be prevented through food and water of viral hepatitis prevention and control (Annex C). agenda for viral hepatitis. Viral hepatitis se- safety. rosurveys are not conducted regularly.

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GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Honduras Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Honduras reports as follows. 7.8 Lower–middle-income $3820 6.75% $262.79 $171.36 69 0.625 21 3.1 mends auto-disable syringes for therapeutic injections. Single-use or auto-disable syringes, needles and cannulas are always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known.

National coordination There is no written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out hepatitis Brelated activities. The name of this office was not provided. Information was not provided on how many staff members this office has. There are no people working full-time on hepatitis-related activities in any government agency/body. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers) and prisoners.

There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood It is not known whether liver cancer cases products nationwide are screened for are registered nationally. Cases with HIV/ hepatitis B and hepatitis C. hepatitis coinfection are not registered There is no national policy relating to the nationally. prevention of viral hepatitis among peoThe government publishes hepatitis dis- ple who inject drugs. ease reports annually. The government does not have guidelines Hepatitis outbreaks are required to be re- that address how hepatitis A and hepatiported to the government and are further tis E can be prevented through food and investigated. There is adequate laboratory water safety. capacity nationally to support investigation of viral hepatitis outbreaks and other Screening, care and treatment Health professionals obtain the skills and surveillance activities. competencies required to effectively care There is no national public health research for people with viral hepatitis through onagenda for viral hepatitis. Viral hepatitis the-job training. serosurveys are conducted regularly; the target population is blood donors. Infor- It is not known whether there are national mation was not provided regarding when clinical guidelines for the management of viral hepatitis. Information was not providthe last serosurvey was carried out. ed on whether there are national clinical Prevention of transmission guidelines for the management of HIV and There is no national policy on hepatitis A whether they include recommendations vaccination. for coinfection with viral hepatitis. The government has national policies relating to screening and referral to care for hepatitis B and hepatitis C. People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are free of charge for all individuals, and are not compulsory for members of any specific group. It is not known whether publicly funded treatment is available for hepatitis B or hepatitis C. No drug for treating hepatitis B or hepatitis C is on the national essential medicines list or subsidized by the government. The Government of Honduras welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

The government has not established the The government did not hold events for goal of eliminating hepatitis B. World Hepatitis Day 2012 and has not funded other viral hepatitis public aware- Nationally, 98% of newborn infants in a given recent year received the first dose of ness campaigns since January 2011. hepatitis B vaccine within 24 hours of birth The government does not collaborate and 100% of one-year-olds (ages 12–23 with in-country civil society groups to months) in a given recent year received develop and implement its viral hepatitis three doses of hepatitis B vaccine. prevention and control programme. There is a national policy that specifically Evidence-based policy and data for targets mother-to-child transmission of hepatitis B (Annex B). action There is routine surveillance for viral hepatitis. There is a national surveillance system There is a specific national strategy and/or for acute hepatitis B but not for any type of policy/guidelines for preventing hepatitis B and hepatitis C infection in health-care chronic hepatitis. settings. Health-care workers are vacciThere are standard case definitions for nated against hepatitis B prior to starting hepatitis. Deaths, including from hepatitis, work that might put them at risk of expoare reported to a central registry. The per- sure to blood. centage of hepatitis cases reported as “undifferentiated” or “unclassified” hepatitis is There is a national policy on injection safety in health-care settings, which recomnot known.

Awareness-raising and partnerships

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Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Jamaica The Government of Jamaica reports as Population (in millions) (2011) 2.8 follows. Country classification (2012) Upper–middle-income Gross national income per capita (PPP int $) (2011) -National coordination 4.81% There is no written national strategy or plan Total health expenditure as % of GDP (2010) $371.64 that focuses exclusively or primarily on the Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) $198.85 prevention and control of viral hepatitis. Life expectancy at birth (in years) (2009) 71 There is no designated governmental unit/ Human Development Index (2011) 0.727 department responsible solely for coordi- Median age (in years) (2010) 27 nating and/or carrying out viral hepatitis- Total fertility rate per woman (2010) 2.3 related activities. There are no people working full-time on hepatitis-related activities in any government agency/body. Prevention of transmission Screening, care and treatment There is no national policy on hepatitis A Health professionals obtain the skills and The government does not have a viral hep- vaccination. competencies required to effectively care atitis prevention and control programme for people with viral hepatitis through that includes activities targeting specific The government has not established the schools for health professionals (pre-servpopulations. goal of eliminating hepatitis B. ice education), on-the-job training and Awareness-raising and partnerships Nationally, no newborn infant in a given postgraduate training. The government held events for World recent year received the first dose of hepa- It is not known whether there are national Hepatitis Day 2012 but has not funded titis B vaccine within 24 hours of birth and clinical guidelines for the management of other viral hepatitis public awareness cam- 92% of one-year-olds (ages 12–23 months) viral hepatitis or for the management of paigns since January 2011. in a given recent year received three doses HIV, and whether the latter include recof hepatitis B vaccine. ommendations for coinfection with viral The government does not collaborate with in-country civil society groups to develop There is a national policy that specifically hepatitis. and implement its viral hepatitis preven- targets mother-to-child transmission of The government does not have national tion and control programme. hepatitis B (Annex B). policies relating to screening and referral Evidence-based policy and data for There is a specific national strategy and/or to care for hepatitis B or hepatitis C. action policy/guidelines for preventing hepatitis People testing for both hepatitis B and There is routine surveillance for viral hepa- B and hepatitis C infection in health-care hepatitis C register by name; the names titis. There is a national surveillance system settings. Health-care workers are vaccinat- are kept confidential within the system. for the following types of acute hepatitis: A, ed against hepatitis B prior to starting work Hepatitis B and hepatitis C tests are free B, C, D and E, and for the following types of that might put them at risk of exposure to of charge for all individuals and are comchronic hepatitis: B, C and D. blood. pulsory for blood donors and patients on There are standard case definitions for There is a national policy on injection safe- dialysis. hepatitis. Deaths, including from hepatitis, ty in health-care settings, which recom- Publicly funded treatment is available for are reported to a central registry. The per- mends single-use syringes for therapeutic hepatitis B and hepatitis C. People who centage of hepatitis cases reported as “un- injections. Single-use or auto-disable sy- seek care in the public health-care system differentiated” or “unclassified” hepatitis is ringes, needles and cannulas are always are eligible for publicly funded treatment not known. available in all health-care facilities. for hepatitis B but information on this for Liver cancer cases and cases with HIV/ Official government estimates of the hepatitis C was not provided. The amount hepatitis coinfection are not registered na- number and percentage of unnecessary spent by the government on publicly funded treatment for hepatitis B and hepatitis C tionally. injections administered annually in healthis not known. care settings are not known. The government publishes hepatitis disThe following drug for treating hepatitis B ease reports annually. There is a national infection control policy is on the national essential medicines list for blood banks. All donated blood units Hepatitis outbreaks are required to be re- (including family donations) and blood or subsidized by the government: lamivuported to the government and are further products nationwide are screened for hep- dine. No drug for treating hepatitis C is on the national essential medicines list or subinvestigated. There is inadequate laborato- atitis B and hepatitis C. sidized by the government. ry capacity nationally to support investigation of viral hepatitis outbreaks and other There is no national policy relating to the The Government of Jamaica welcomes assurveillance activities. prevention of viral hepatitis among people sistance from WHO in one or more areas who inject drugs. of viral hepatitis prevention and control There is no national public health research agenda for viral hepatitis. Viral hepatitis se- The government has guidelines that ad- (Annex C). rosurveys are not conducted regularly. dress how hepatitis A and hepatitis E can be prevented through food and water safety.

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GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Mexico Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) Information was not provided on whether there is a national infection control policy for blood banks and whether all donated blood units (including family donations) The Government of Mexico reports as Cases with HIV/hepatitis coinfection are and blood products nationwide are follows. not registered nationally. screened for hepatitis B and hepatitis C. 114.8 Upper–middle-income $15 390 6.32% $959.32 $469.19 76 0.770 27 2.3 dles and cannulas are always available in all health-care facilities. Information was not provided on official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings.

National coordination

The government publishes hepatitis disInformation was not provided on whether ease reports annually. there is a written national strategy or plan that focuses exclusively or primarily on the Hepatitis outbreaks are required to be reported to the government and are furprevention and control of viral hepatitis. ther investigated. Information was not Information was not provided on whether provided on whether there is adequate there is a designated governmental unit/ laboratory capacity nationally to support department responsible solely for coordi- investigation of viral hepatitis outbreaks nating and/or carrying out viral hepatitis- and other surveillance activities. related activities, or how many people work full-time on hepatitis-related activi- There is no national public health research agenda for viral hepatitis. Viral hepatitis seties in all government agencies/bodies. rosurveys are not conducted regularly. Information was not provided on whether the government has a viral hepatitis pre- Prevention of transmission vention and control programme that in- Information was not provided on whether cludes activities targeting specific popula- there is a national policy on hepatitis A vaccination or whether the government tions. has established the goal of eliminating Awareness-raising and partnerships hepatitis B. Information was not provided on whether the government held events for World Information was not provided on the perHepatitis Day 2012 or funded other viral centage of newborn infants nationally hepatitis public awareness campaigns in a given recent year who received the first dose of hepatitis B vaccine within 24 since January 2011. hours of birth or the percentage of oneInformation was not provided on whether year-olds nationally (ages 12–23 months) the government collaborates with in- in a given recent year who received three country civil society groups to develop doses of hepatitis B vaccine. and implement its viral hepatitis prevenInformation was not provided on whether tion and control programme. there is a national policy that specifically Evidence-based policy and data for targets mother-to-child transmission of action hepatitis B. There is routine surveillance for viral hepatitis. There is a national surveillance system Information was not provided on whether for the following types of acute hepatitis: there is a specific national strategy and/or A, B, C and D, but not for any type of chron- policy/guidelines for preventing hepatitis B and hepatitis C infection in health-care ic hepatitis. settings, or whether health-care workers There are standard case definitions for are vaccinated against hepatitis B prior to hepatitis. Deaths, including from hepatitis, starting work that might put them at risk are reported to a central registry. Of the of exposure to blood. hepatitis cases, 10.2% are reported as “unInformation was not provided on whethdifferentiated” or “unclassified” hepatitis. er there is a national policy on injection Information was not provided on whether safety in health-care settings, or whether liver cancer cases are registered nationally. single-use or auto-disable syringes, nee-

Information was not provided on whether there is a national policy relating to the prevention of viral hepatitis among people who inject drugs. Information was not provided on whether the government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

Screening, care and treatment Information was not provided on how health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis. Information was not provided on whether there are national clinical guidelines for the management of viral hepatitis and for the management of HIV, and whether the latter include recommendations for coinfection with viral hepatitis. Information was not provided on whether the government has national policies relating to screening and referral to care for hepatitis B or hepatitis C. Information was not provided on whether people testing for hepatitis B or hepatitis C register by name, and whether hepatitis B or hepatitis C tests are free of charge for all individuals or compulsory for members of any specific group. Information was not provided on whether publicly funded treatment is available for hepatitis B or hepatitis C and, if so, who is eligible for this. Information was not provided on whether any drug for treating hepatitis B and hepatitis C is on the national essential medicines list or subsidized by the government. The Government of Mexico did not indicate a need for assistance from WHO in relation to viral hepatitis prevention and control.

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Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Nicaragua The Government of Nicaragua reports as Population (in millions) (2011) 5.9 follows. Country classification (2012) Lower–middle-income National coordination Gross national income per capita (PPP int $) (2011) $3730 There is no written national strategy or plan Total health expenditure as % of GDP (2010) 9.14% that focuses exclusively or primarily on the Per capita total health expenditure (PPP int $) (2010) $252.73 prevention and control of viral hepatitis. Per capita government health expenditure (PPP int $) (2010) $134.65 Life expectancy at birth (in years) (2009) 74 There is no designated governmental unit/ Human Development Index (2011) 0.589 department responsible solely for coordi- Median age (in years) (2010) 22 nating and/or carrying out viral hepatitis- Total fertility rate per woman (2010) 2.6 related activities. It is not known how many people work full-time on hepatitis-related activities in all government agencies/bod- whether viral hepatitis serosurveys are Information was not provided on whether there is a national policy relating to the conducted regularly. ies. prevention of viral hepatitis among people The government has a viral hepatitis pre- Prevention of transmission who inject drugs. vention and control programme that in- There is a national policy on hepatitis A Information was not provided on whether cludes activities targeting the following vaccination. the government has guidelines that adspecific populations: health-care workers (including health-care waste handlers) and The government has not established the dress how hepatitis A and hepatitis E can goal of eliminating hepatitis B. be prevented through food and water people living with HIV. Information was not provided on the per- safety.

Awareness-raising and partnerships

centage of newborn infants nationally in a given recent year who received the first dose of hepatitis B vaccine within 24 hours of birth or the percentage of one-year-olds nationally (ages 12–23 months) in a given recent year who received three doses of The government collaborates with in- hepatitis B vaccine. country civil society groups to develop and implement its viral hepatitis prevention There is no national policy that specifically and control programme, but the identity targets mother-to-child transmission of hepatitis B. of these partners was not provided. The government held events for World Hepatitis Day 2012. It is not known whether the government has funded other viral hepatitis public awareness campaigns since January 2011.

Screening, care and treatment Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through schools for health professionals (pre-service education) and on-the-job training.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B and C, but not for any type of chronic hepatitis. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Liver cancer cases and cases with HIV/hepatitis coinfection are registered nationally.

The government publishes hepatitis disease reports as warranted. Information was not provided regarding official government estimates of the Hepatitis outbreaks are required to be re- number and percentage of unnecessary ported to the government and are further injections administered annually in healthinvestigated. There is adequate laboratory care settings. capacity nationally to support outbreak investigations and other surveillance activi- There is a national infection control policy ties for hepatitis A, hepatitis B and hepatitis for blood banks. All donated blood units C. Information was not provided on wheth- (including family donations) and blood er this is the case for hepatitis E. products nationwide are screened for hepatitis B and hepatitis C. There is no national public health research agenda for viral hepatitis. It is not known

Information was not provided on whether there are national clinical guidelines for the management of viral hepatitis or for the management of HIV, and whether the latter include recommendations for coinfecIt is not known whether there is a specific tion with viral hepatitis. national strategy and/or policy/guidelines for preventing hepatitis B and hepatitis C The government does not have national infection in health-care settings. Health- policies relating to screening and referral care workers are not vaccinated against to care for hepatitis B or hepatitis C. hepatitis B prior to starting work that might People testing for both hepatitis B and put them at risk of exposure to blood. hepatitis C register by name; the names There is a national policy on injection are kept confidential within the system. safety in health-care settings, which rec- Hepatitis B and hepatitis C tests are free of ommends single-use and auto-disable charge for all individuals and are compulsyringes for therapeutic injections. Single- sory for donors. use or auto-disable syringes, needles and cannulas are always available in all health- Publicly funded treatment is not available for hepatitis B or hepatitis C. care facilities. The following drug for treating hepatitis B is on the national essential medicines list or subsidized by the government: interferon alpha. No drug for treating hepatitis C is on the national essential medicines list or subsidized by the government. The Government of Nicaragua welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

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GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Panama Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 3.6 Upper–middle-income $14 510 8.10 $1123.43 $843.72 77 0.768 27 2.5 syringes, needles and cannulas are always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. It is not known whether there is a national policy relating to the prevention of viral hepatitis among people who inject drugs. The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

The Government of Panama reports as Information was not provided on whether follows. liver cancer cases are registered nationally. Cases with HIV/hepatitis coinfection are National coordination not registered nationally. There is no written national strategy or plan that focuses exclusively or prima- The government publishes hepatitis disrily on the prevention and control of viral ease reports annually. hepatitis. Hepatitis outbreaks are required to be There is no designated governmental reported to the government and are furunit/department responsible solely for co- ther investigated. Information was not ordinating and/or carrying out viral hep- provided on whether there is adequate atitis-related activities. Information was laboratory capacity nationally to support not provided on how many people work investigation of viral hepatitis outbreaks full-time on hepatitis-related activities in and other surveillance activities. all government agencies/bodies. Information was not provided on whether The government does not have a viral there is a national public health research hepatitis prevention and control pro- agenda for viral hepatitis. Viral hepatitis gramme that includes activities targeting serosurveys are not conducted regularly. specific populations.

Screening, care and treatment Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through schools for health professionals (pre-service education) and on-the-job training.

Information was not provided on whether there are national clinical guidelines for the management of viral hepatitis. There are no national clinical guidelines for the Prevention of transmission management of HIV, which include recAwareness-raising and partnerships There is a national policy on hepatitis A ommendations for coinfection with viral It is not known whether the government vaccination. hepatitis. held events for World Hepatitis Day 2012 or funded other viral hepatitis public The government has not established the Information was not provided on whether the government has national policies reawareness campaigns since January 2011. goal of eliminating hepatitis B. lating to screening and referral to care for Information was not provided on whether Nationally, 89% of newborn infants in a hepatitis B or hepatitis C. the government collaborates with in- given recent year received the first dose of country civil society groups to develop hepatitis B vaccine within 24 hours of birth People testing for both hepatitis B and and implement its viral hepatitis preven- and 94% of one-year-olds (ages 12–23 hepatitis C register by name; the names months) in a given recent year received are kept confidential within the system. tion and control programme. three doses of hepatitis B vaccine. Information was not provided on whether Evidence-based policy and data for hepatitis B or hepatitis C tests are free of There is a national policy that specifically charge for all individuals, but they are action There is routine surveillance for viral hepa- targets mother-to-child transmission of compulsory for blood donors. titis. There is a national surveillance system hepatitis B (Annex B). for the following types of acute hepatitis: Information was not provided on whether A, B, C, D and E. Information was not pro- There is a specific national strategy and/or publicly funded treatment is available for vided on whether there is a national sur- policy/guidelines for preventing hepatitis hepatitis B or C. veillance system for any type of chronic B and hepatitis C infection in health-care settings. Health-care workers are vacci- No drug for treating hepatitis B or hepatitis hepatitis. nated against hepatitis B prior to starting C is on the national essential medicines list There are standard case definitions for work that might put them at risk of expo- or subsidized by the government. hepatitis. Deaths, including from hepatitis, sure to blood. The Government of Panama welcomes asare reported to a central registry. Information was not provided on the percentage There is a national policy on injection safe- sistance from WHO in one or more areas of hepatitis cases reported as “undifferen- ty in health-care settings, which recom- of viral hepatitis prevention and control mends auto-disable syringes for therapeu- (Annex C). tiated” or “unknown” hepatitis. tic injections. Single-use or auto-disable

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GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Paraguay The Government of Paraguay reports as Population (in millions) (2011) 6.6 follows. Country classification (2012) Lower–middle-income National coordination Gross national income per capita (PPP int $) (2011) $5390 There is no written national strategy or plan Total health expenditure as % of GDP (2010) 5.87% that focuses exclusively or primarily on the Per capita total health expenditure (PPP int $) (2010) $302.35 prevention and control of viral hepatitis. Per capita government health expenditure (PPP int $) (2010) $110.07 Life expectancy at birth (in years) (2009) 74 There is no designated governmental unit/ Human Development Index (2011) 0.665 department responsible solely for coordi- Median age (in years) (2010) 23 nating and/or carrying out viral hepatitis- Total fertility rate per woman (2010) 3.0 related activities. Information was not provided on how many people work full-time on hepatitis-related activities in all govern- target populations are people who inject There is no national policy relating to the drugs, sex workers and men who have sex prevention of viral hepatitis among people ment agencies/bodies. with men. Information was not provided who inject drugs. The government has a viral hepatitis pre- on when the last serosurvey was carried The government has guidelines that advention and control programme that in- out. dress how hepatitis A and hepatitis E can cludes activities targeting the following be prevented through food and water specific populations: health-care workers Prevention of transmission (including health-care waste handlers), There is a national policy on hepatitis A safety. people living with HIV and patients on vaccination. Screening, care and treatment haemodialysis. The government has not established the Health professionals obtain the skills and competencies required to effectively care Awareness-raising and partnerships goal of eliminating hepatitis B. for people with viral hepatitis through The government did not hold events for World Hepatitis Day 2012 and has not Information was not provided regarding schools for health professionals (pre-servfunded other viral hepatitis public aware- the percentage of newborn infants nation- ice education) and on-the-job training. ally in a given recent year who received the ness campaigns since January 2011. first dose of hepatitis B vaccine within 24 There are no national clinical guidelines for The government does not collaborate with hours of birth or the percentage of one- the management of viral hepatitis. There in-country civil society groups to develop year-olds nationally (ages 12–23 months) are national clinical guidelines for the manand implement its viral hepatitis preven- in a given recent year who received three agement of HIV, which include recommendations for coinfection with viral hepatitis. doses of hepatitis B vaccine. tion and control programme.

Evidence-based policy and data for There is no national policy that specifically The government does not have national action targets mother-to-child transmission of policies relating to screening and referral There is no routine surveillance for viral hepatitis B. hepatitis. There is a specific national strategy and/or There are no standard case definitions for policy/guidelines for preventing hepatitis hepatitis. Deaths, including from hepatitis, B and hepatitis C infection in health-care are reported to a central registry. Informa- settings. Health-care workers are vaccinattion was not provided on the percentage ed against hepatitis B prior to starting work of hepatitis cases reported as “undifferenti- that might put them at risk of exposure to ated” or “unknown” hepatitis. blood. Liver cancer cases and cases with HIV/hep- There is a national policy on injection safeatitis coinfection are registered nationally. ty in health-care settings, which recommends auto-disable syringes for therapeuThe government does not publish hepati- tic injections. Single-use or auto-disable tis disease reports. syringes, needles and cannulas are always Hepatitis outbreaks are required to be re- available in all health-care facilities. ported to the government and are further investigated. There is adequate laboratory capacity nationally to support outbreak investigations and other surveillance activities for hepatitis A, hepatitis B and hepatitis C, but not for hepatitis E. There is no national public health research agenda for viral hepatitis. Viral hepatitis serosurveys are conducted regularly; the to care for hepatitis B or hepatitis C. People testing for both hepatitis B and hepatitis C register by name, and there is open access to their names. Hepatitis B and hepatitis C tests are free of charge for all individuals and are not compulsory for members of any specific group. Publicly funded treatment is not available for hepatitis B or hepatitis C.

The following drugs for treating hepatitis B are on the national essential medicines list or subsidized by the government: lamivudine and tenofovir. No drug for treating hepatitis C is on the national essential Information was not provided on official medicines list or subsidized by the governgovernment estimates of the number and ment. percentage of unnecessary injections administered annually in health-care settings. The Government of Paraguay welcomes assistance from WHO in one or more areas There is a national infection control policy of viral hepatitis prevention and control for blood banks. All donated blood units (Annex C). (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

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Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Peru Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Peru reports as follows.

National coordination There is a written national strategy or plan that focuses primarily on the prevention and control of viral hepatitis, and also integrates other diseases. It includes components for raising awareness, surveillance, vaccination, prevention in general, prevention of transmission in health-care settings, treatment and care, and coinfection with HIV. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitis-related activities: Estrategia Sanitaria Nacional de Prevención y Control de ITS, VIH/SIDA y Hepatitis B. It has eight staff members. There are eight full-time equivalent staff members who work on hepatitis-related activities in all government agencies/bodies.

The government does not have guidelines that address how hepatitis A and hepatitis E can be prevented through food and water The government publishes hepatitis disease safety. reports as warranted.

29.4 Upper–middle-income $9440 5.08% $481.03 $259.87 76 0.725 26 2.5

There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

Screening, care and treatment

Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory capacity nationally to support outbreak investigations and other surveillance activities for hepatitis A, hepatitis B and hepatitis C. Information was not provided regarding whether this is the case for hepatitis E.

Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through schools for health professionals (pre-service education). There are national clinical guidelines for the management of viral hepatitis, which include recommendations for cases with HIV coinfection. Information was not provided on whether there are national clinical guidelines for the management of HIV and whether they include recommendations for coinfection with viral hepatitis.

There is a national public health research agenda for viral hepatitis. Viral hepatitis serosurveys are conducted regularly; the target populations are the general population, the Amazonian indigenous population and men who have sex with men. The last serosurvey The government has national policies relating to screening and referral to care for hepawas carried out in 2011. titis B, but information was not provided on Prevention of transmission whether this is the case for hepatitis C. There is no national policy on hepatitis A vacPeople testing for hepatitis B register by The government has a viral hepatitis preven- cination. name; the names are kept confidential within tion and control programme that includes activities targeting the following specific The government has not established the goal the system. Hepatitis B tests are not free of charge for all individuals, but they are free of populations: health-care workers (including of eliminating hepatitis B. charge for indigenous populations. Hepatitis health-care waste handlers) and indigenous Nationally, 36% of newborn infants in a given B tests are not compulsory for members of people. recent year received the first dose of hepatitis any specific group. Information was not proAwareness-raising and partnerships B vaccine within 24 hours of birth and 90% of vided on whether people testing for hepatitis The government held events for World Hepa- one-year-olds (ages 12–23 months) in a given C register by name, whether the tests are free titis Day 2012 but has not funded other viral recent year received three doses of hepatitis of charge for all individuals, or are compulsohepatitis public awareness campaigns since B vaccine. ry for members of any specific group. January 2011. There is a national policy that specifically tar- Publicly funded treatment is available for The government collaborates with the fol- gets mother-to-child transmission of hepati- hepatitis B but not for hepatitis C. Informalowing in-country civil society group to de- tis B (Annex B). tion was not provided on the amount spent velop and implement its viral hepatitis preThere is a specific national strategy and/or by the government on publicly funded treatvention and control programme: Asociación policy/guidelines for preventing hepatitis B ment for hepatitis B. Ciudadana de Lucha contra la Hepatitis. and hepatitis C infection in health-care set- The following drugs for treating hepatitis B Evidence-based policy and data for tings. Health-care workers are vaccinated are on the national essential medicines list against hepatitis B prior to starting work that or subsidized by the government: interferon action There is routine surveillance for viral hepati- might put them at risk of exposure to blood. alpha, entecavir and tenofovir. The following tis. There is a national surveillance system for There is a national policy on injection safety drugs for treating hepatitis C are on the naacute and chronic hepatitis B. in health-care settings, which recommends tional essential medicines list or subsidized by the government: pegylated interferon and There are standard case definitions for hepa- auto-disable syringes for therapeutic injecribavirin. titis. Hepatitis deaths are not reported to a tions. Single-use or auto-disable syringes, central registry. The percentage of hepatitis needles and cannulas are always available in The Government of Peru welcomes assistcases reported as “undifferentiated” or “un- all health-care facilities. ance from WHO in one or more areas of viral classified” hepatitis is not known. Official government estimates of the number hepatitis prevention and control (Annex C). Liver cancer cases and cases with HIV/hepatitis coinfection are registered nationally. and percentage of unnecessary injections administered annually in health-care settings are not known.

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Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Saint Kitts and Nevis The Government of Saint Kitts and Nevis Population (in millions) (2011) 0.05 reports as follows. Country classification (2012) High-income National coordination Gross national income per capita (PPP int $) (2011) $16 470 There is no written national strategy or plan Total health expenditure as % of GDP (2010) 6.66% that focuses exclusively or primarily on the Per capita total health expenditure (PPP int $) (2010) $867.54 prevention and control of viral hepatitis. Per capita government health expenditure (PPP int $) (2010) $525.48 Life expectancy at birth (in years) (2009) 74 There is no designated governmental unit/ Human Development Index (2011) 0.735 department responsible solely for coordi- Median age (in years) (2010) -nating and/or carrying out viral hepatitis- Total fertility rate per woman (2010) 1.8 related activities and there are no people working full-time on hepatitis-related activities in any government agency/body. Prevention of transmission The government has guidelines that adThere is no national policy on hepatitis A dress how hepatitis A and hepatitis E can The government has a viral hepatitis pre- vaccination. be prevented through food and water vention and control programme that insafety. cludes activities relating to hepatitis B vac- The government has not established the cination for health-care workers. Screening, care and treatment goal of eliminating hepatitis B. Health professionals obtain the skills and Awareness-raising and partnerships Information was not provided on the per- competencies required to effectively care The government did not hold events for centage of newborn infants nationally in for people with viral hepatitis through World Hepatitis Day 2012 and has not a given recent year who received the first schools for health professionals (pre-servfunded other viral hepatitis public aware- dose of hepatitis B vaccine within 24 hours ice education). ness campaigns since January 2011. of birth or the percentage of one-year-olds nationally (ages 12–23 months) in a given It is not known whether there are national The government does not collaborate with recent year who received three doses of clinical guidelines for the management of in-country civil society groups to develop hepatitis B vaccine. viral hepatitis. and implement its viral hepatitis prevention and control programme. There is no national policy that specifically The government does not have national targets mother-to-child transmission of policies relating to screening and referral Evidence-based policy and data for hepatitis B. to care for hepatitis B or hepatitis C.

action

There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute and chronic hepatitis: B and C.

There is a specific national strategy and/or policy/guidelines for preventing hepatitis B and hepatitis C infection in health-care settings. Health-care workers are vaccinated against hepatitis B prior to starting work There are standard case definitions for that might put them at risk of exposure to hepatitis. Deaths, including from hepatitis, blood. are reported to a central registry. The percentage of hepatitis cases reported as “un- There is a national policy on injection safedifferentiated” or “unclassified” hepatitis is ty in health-care settings, which recomnot known. mends single-use syringes for therapeutic injections. Single-use or auto-disable syLiver cancer cases and cases with HIV/ ringes, needles and cannulas are always hepatitis coinfection are not registered na- available in all health-care facilities. tionally. Official government estimates of the The government publishes hepatitis dis- number and percentage of unnecessary ease reports annually. injections administered annually in healthHepatitis outbreaks are required to be re- care settings are not known. ported to the government and are further It is not known whether there is a national investigated. There is adequate laboratory infection control policy for blood banks. All capacity nationally to support outbreak in- donated blood units (including family dovestigations and other surveillance activi- nations) and blood products nationwide ties for hepatitis A, hepatitis B and hepatitis are screened for hepatitis B and hepatitis C. C, but not for hepatitis E. There is no national policy relating to the There is no national public health research prevention of viral hepatitis among people agenda for viral hepatitis. Viral hepatitis se- who inject drugs. rosurveys are not conducted regularly.

People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are not free of charge for all individuals, but hepatitis B tests are free of charge for antenatal women in the public system and blood donors. Hepatitis B and hepatitis C tests are not compulsory for members of any specific group. Publicly funded treatment is not available for hepatitis B or hepatitis C. The following drugs for treating hepatitis B drugs are on the national essential medicines list or subsidized by the government: lamivudine and tenofovir. No drug for treating hepatitis C is on the national essential medicines list or subsidized by the government. The Government of Saint Kitts and Nevis welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

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Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Saint Lucia Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 0.2 Upper–middle-income $11 220 8.70% $803.94 $486.37 74 0.723 27 2.0 There is no national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

The government does not have guidelines that address how hepatitis A and hepatitis E can be prevented through food and The Government of Saint Lucia reports as The government does not publish hepati- water safety. follows. tis disease reports.

National coordination

Screening, care and treatment

Hepatitis A outbreaks are required to be There is no written national strategy or reported to the government and are furplan that focuses exclusively or prima- ther investigated. There is inadequate rily on the prevention and control of viral laboratory capacity nationally to support hepatitis. investigation of viral hepatitis outbreaks and other surveillance activities. There is no designated governmental unit/department responsible solely for co- There is no national public health research ordinating and/or carrying out viral hepa- agenda for viral hepatitis. Viral hepatitis setitis-related activities. It is not known how rosurveys are not conducted regularly. many people work full-time on hepatitisrelated activities in all government agen- Prevention of transmission There is no national policy on hepatitis A cies/bodies. vaccination. The government does not have a viral hepatitis prevention and control pro- The government has not established the gramme that includes activities targeting goal of eliminating hepatitis B. specific populations. It is not known what percentage of newAwareness-raising and partnerships born infants nationally in a given recent The government did not hold events for year received the first dose of hepatitis B World Hepatitis Day 2012 and has not vaccine within 24 hours of birth or what funded other viral hepatitis public aware- percentage of one-year-olds (ages 12–23 months) in a given recent year received ness campaigns since January 2011. three doses of hepatitis B vaccine. The government does not collaborate with in-country civil society groups to There is no national policy that specifically develop and implement its viral hepatitis targets mother-to-child transmission of hepatitis B. prevention and control programme.

It is not known how health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis. There are no national clinical guidelines for the management of viral hepatitis. It is not known whether there are national clinical guidelines for the management of HIV and whether they include recommendations for coinfection with viral hepatitis. The government does not have national policies relating to screening and referral to care for hepatitis B or hepatitis C. People testing for hepatitis B register by name; the names are kept confidential within the system. Hepatitis B tests are not free of charge for all individuals, but they are free of charge for blood donors and pregnant women. Hepatitis B tests are compulsory for pregnant women. Information was not provided on whether people testing for hepatitis C register by name, whether the test is free of charge for all individuals or whether it is compulsory for members of any specific group. Publicly funded treatment is not available

Evidence-based policy and data for There is no specific national strategy and/ for hepatitis B or hepatitis C. or policy/guidelines for preventing hepaaction

There is no routine surveillance for viral titis B and hepatitis C infection in health- The following drugs for treating hepatitis care settings. hepatitis. B are on the national essential medicines list or subsidized by the government: lamiThere are no standard case definitions for There is no national policy on injection vudine and tenofovir. No drug for treatsafety in health-care settings. Single-use hepatitis. Deaths, including from hepatitis, ing hepatitis C is on the national essential are reported to a central registry. Informa- or auto-disable syringes, needles and canmedicines list or subsidized by the governtion was not provided on the percentage nulas are always available in all health-care ment. of hepatitis cases reported as “undifferen- facilities. tiated” or “unknown” hepatitis. Official government estimates of the The Government of Saint Lucia welcomes assistance from WHO in one or more areas Liver cancer cases and cases with HIV/ number and percentage of unnecesof viral hepatitis prevention and control hepatitis coinfection are not registered sary injections administered annually in (Annex C). health-care settings are not known. nationally.

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Chapter 4: WHO Region of the Americas

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Suriname The Government of Suriname reports as Population (in millions) (2011) follows. Country classification (2012) National coordination Gross national income per capita (PPP int $) (2011) There is a written national strategy or plan Total health expenditure as % of GDP (2010) that focuses primarily on the prevention Per capita total health expenditure (PPP int $) (2010) and control of viral hepatitis, and also in- Per capita government health expenditure (PPP int $) (2010) tegrates other diseases. It includes compo- Life expectancy at birth (in years) (2009) nents for surveillance, vaccination, preven- Human Development Index (2011) tion of transmission in health-care settings Median age (in years) (2010) and coinfection with HIV. Total fertility rate per woman (2010) There is no designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities. There are no people working full-time on hepatitis-related activities in any government agency/body. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), people living with HIV and pregnant women. 0.5 Upper–middle-income $7710 7.02% $523.36 $250.17 72 0.680 28 2.3

There is no national public health research The government does not have guidelines agenda for viral hepatitis. Viral hepatitis se- that address how hepatitis A and hepatitis E can be prevented through food and warosurveys are not conducted regularly. ter safety.

Prevention of transmission

There is no national policy on hepatitis A Screening, care and treatment Health professionals obtain the skills and vaccination. competencies required to effectively care The government has established the goal for people with viral hepatitis through of eliminating hepatitis B but information schools for health professionals (pre-servwas not provided about a specific time- ice education), on-the-job training and frame for this goal. postgraduate training. There are national clinical guidelines for the management of viral hepatitis and for the management of HIV, which include recommendations for coinfection with viral hepatitis. The government has national policies relating to screening and referral to care for hepatitis B and hepatitis C for pregnant women. People testing for both hepatitis B and

It is not known what percentage of newborn infants nationally in a given recent The government held events for World year received the first dose of hepatitis B Hepatitis Day 2012 and has funded other vaccine within 24 hours of birth. In a given viral hepatitis public awareness campaigns recent year, 86% of one-year-olds (ages 12–23 months) received three doses of since January 2011 (Annex A). hepatitis B vaccine. The government does not collaborate with in-country civil society groups to develop There is a national policy that specifically and implement its viral hepatitis preven- targets mother-to-child transmission of hepatitis B (Annex B). tion and control programme.

Awareness-raising and partnerships

Evidence-based policy and data for There is a specific national strategy and/or hepatitis C register by name; the names are policy/guidelines for preventing hepatitis kept confidential within the system. Hepaaction There is routine hospital-based surveillance for viral hepatitis. The surveillance system registers all patients who have a diagnosis of hepatitis (either acute or chronic). It is not known whether there are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Information was not provided regarding the percentage of hepatitis cases reported as “undifferentiated” or “unknown” hepatitis. B and hepatitis C infection in health-care settings. Health-care workers are vaccinated against hepatitis B prior to starting work that might put them at risk of exposure to blood. titis B and hepatitis C tests are not free of charge for all individuals, but they are free of charge and compulsory for blood donors. Publicly funded treatment is available for hepatitis B and hepatitis C, but information was not provided on who is eligible for this. The amount spent by the government on such treatment for hepatitis B and hepatitis C is not known. The following drug for treating hepatitis B is on the national essential medicines list or subsidized by the government: tenofovir. No drug for treating hepatitis C is on the national essential medicines list or subsidized by the government. The Government of Suriname welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

There is a national policy on injection safety in health-care settings, which recommends single-use syringes for therapeutic injections. Single-use or auto-disable syringes, needles and cannulas are always available in all health-care facilities.

Liver cancer cases and cases with HIV/hep- Official government estimates of the atitis coinfection are registered nationally. number and percentage of unnecessary injections administered annually in healthThe government publishes hepatitis dis- care settings are not known. ease reports regularly. There is a national infection control policy Hepatitis outbreaks are required to be re- for blood banks. All donated blood units ported to the government and are further (including family donations) and blood investigated. There is adequate laboratory products nationwide are screened for hepcapacity nationally to support outbreak in- atitis B and hepatitis C. vestigations and other surveillance activities for hepatitis A, hepatitis B and hepatitis It is not known whether there is a national policy relating to the prevention of viral C, but not for hepatitis E. hepatitis among people who inject drugs.

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United States of America Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 313.1 High-income $48 820 17.89% $8361.73 $4436.61 79 0.910 37 2.1 single-use syringes for therapeutic injections. Single-use or auto-disable syringes, needles and cannulas are always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known.

There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products The Government of the United States of the following types of acute hepatitis: A, B, C nationwide are screened for hepatitis B and and D and for the following types of chronic hepatitis C. America reports as follows. hepatitis: B and C. National coordination There is a national policy relating to the preThere is a written national strategy or plan There are standard case definitions for hepa- vention of viral hepatitis among people who that focuses exclusively on the prevention titis. Deaths, including from hepatitis, are re- inject drugs. and control of viral hepatitis. It includes com- ported to a central registry. No hepatitis case ponents for raising awareness, surveillance, is reported as “undifferentiated” or “unclassi- The government has guidelines that address how hepatitis A and hepatitis E can be prevaccination, prevention in general, preven- fied” hepatitis. vented through food and water safety. tion of transmission via injecting drug use, prevention of transmission in health-care Liver cancer cases are registered nationally, settings, treatment and care, and coinfection but cases with HIV/hepatitis coinfection are Screening, care and treatment Health professionals obtain the skills and not. with HIV. competencies required to effectively care for There is a designated governmental unit/ Hepatitis outbreaks are required to be re- people with viral hepatitis through schools department responsible solely for coordinat- ported to the government and are further for health professionals (pre-service educaing and/or carrying out viral hepatitis-related investigated. There is adequate laboratory tion), on-the-job training, postgraduate trainactivities: the Division of Viral Hepatitis within capacity nationally to support investigation ing and continuing medical education. the National Center for HIV/AIDS, Viral Hepati- of viral hepatitis outbreaks and other surveilThere are national clinical guidelines for the tis, STD, and TB Prevention (US Centers for Dis- lance activities. management of viral hepatitis, which inease Control and Prevention). It has 100 staff There is no national public health research clude recommendations for cases with HIV members. There are 150 full-time equivalent agenda for viral hepatitis. Viral hepatitis coinfection. staff members who work on hepatitis-related serosurveys are conducted regularly; the taractivities in all government agencies/bodies. get populations are children over the age of The government has national policies relatThe government has a viral hepatitis preven- six years and the general population. The last ing to screening and referral to care for hepatitis B and hepatitis C. tion and control programme that includes serosurvey was carried out in 2011. activities targeting the following specific People testing for both hepatitis B and hepaPrevention of transmission populations: health-care workers (including There is a national policy on hepatitis A titis C register by name; the names are kept health-care waste handlers), people who inconfidential within the system. Hepatitis B vaccination. ject drugs, migrants, prisoners, the homeless, and hepatitis C tests are not free of charge people living with HIV, low-income popula- The government has established the goal of and are not compulsory for members of any tions, the uninsured, immigrants and refu- eliminating hepatitis B but information was specific group. gees, people born between 1945 and 1965, not provided about a specific timeframe for Asian–Americans, military veterans, and peo- this goal. Publicly funded treatment is not available for ple who have chronic hepatitis C and live in hepatitis B or hepatitis C. Nationally, 58% of newborn infants in a given areas underserved by treatment specialists. recent year received the first dose of hepatitis The following drugs for treating hepatitis B Awareness-raising and partnerships B vaccine within 24 hours of birth and 90% of are on the national essential medicines list The government held events for World Hepa- one-year-olds (ages 12–23 months) in a given or subsidized by the government: interferon titis Day 2012 and has funded other viral recent year received three doses of hepatitis alpha, pegylated interferon, lamivudine, hepatitis public awareness campaigns since B vaccine. adefovir dipivoxil, entecavir, telbivudine and January 2011 (Annex A). tenofovir. The following drugs for treating There is a national policy that specifically tar- hepatitis C are on the national essential mediThe government collaborates with the follow- gets mother-to-child transmission of hepaticines list or subsidized by the government: ing in-country civil society groups to develop tis B (Annex B). interferon alpha, pegylated interferon, ribaviand implement its viral hepatitis prevention rin, boceprevir and telaprevir. and control programme: Viral Hepatitis Ac- There is a specific national strategy and/or tion Coalition, National Viral Hepatitis Round- policy/guidelines for preventing hepatitis B The Government of the United States of table, and Asia and Pacific Alliance to Elimi- and hepatitis C infection in health-care set- America did not indicate a need for assistnate Viral Hepatitis. tings. Health-care workers are vaccinated ance from WHO in relation to viral hepatitis against hepatitis B prior to starting work that Evidence-based policy and data for might put them at risk of exposure to blood. prevention and control.

action

There is routine surveillance for viral hepatitis. There is a national surveillance system for

There is a national policy on injection safety in health-care settings, which recommends

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Uruguay The Government of Uruguay reports as 3.4 Population (in millions) (2011) follows. Upper–middle-income Country classification (2012) National coordination $14 640 Gross national income per capita (PPP int $) (2011) There is no written national strategy or plan Total health expenditure as % of GDP (2010) 8.35% that focuses exclusively or primarily on the Per capita total health expenditure (PPP int $) (2010) $1188.09 prevention and control of viral hepatitis. Per capita government health expenditure (PPP int $) (2010) $796.71 76 Life expectancy at birth (in years) (2009) There is no designated governmental unit/ Human Development Index (2011) 0.783 department responsible solely for coordi- Median age (in years) (2010) 34 nating and/or carrying out viral hepatitis- Total fertility rate per woman (2010) 2.1 related activities. Information was not provided regarding how many people work full-time on hepatitis-related activities in all Prevention of transmission Screening, care and treatment government agencies/bodies. There is a national policy on hepatitis A Health professionals obtain the skills and vaccination. competencies required to effectively care The government has a viral hepatitis prefor people with viral hepatitis through vention and control programme that in- The government has not established the schools for health professionals (pre-servcludes activities targeting the following goal of eliminating hepatitis B. ice education), on-the-job training and specific populations: health-care workers postgraduate training. (including health-care waste handlers), Information was not provided on the perpeople who inject drugs, prisoners and centage of newborn infants nationally in There are national clinical guidelines for a given recent year who received the first the management of viral hepatitis, which people living with HIV. dose of hepatitis B vaccine within 24 hours include recommendations for cases with Awareness-raising and partnerships of birth or the percentage of one-year-olds HIV coinfection. There are national cliniThe government held events for World nationally (ages 12–23 months) in a given cal guidelines for the management of HIV, Hepatitis Day 2012 but has not funded recent year who received three doses of which include recommendations for coinother viral hepatitis public awareness cam- hepatitis B vaccine. fection with viral hepatitis. paigns since January 2011. There is a national policy that specifically The government does not have national The government does not collaborate with targets mother-to-child transmission of policies relating to screening and referral in-country civil society groups to develop hepatitis B (Annex B). to care for hepatitis B or hepatitis C. and implement its viral hepatitis prevenThere is a specifi c national strategy and/or tion and control programme. People testing for both hepatitis B and policy/guidelines for preventing hepatitis B hepatitis C register by name; the names are Evidence-based policy and data for and hepatitis C infection in health-care set- kept confidential within the system. Hepaaction tings. Health-care workers are vaccinated titis B and hepatitis C tests are not free of There is routine surveillance for viral hepa- against hepatitis B prior to starting work charge for all individuals, but they are free titis. There is a national surveillance system that might put them at risk of exposure to of charge for donors, people who have for the following types of acute hepatitis: A, blood. been in accidents and pregnant women. B, C, D and E but not for any type of chronic Hepatitis B and hepatitis C tests are comThere is a national policy on injection safehepatitis. pulsory for patients with kidney disease, ty in health-care settings, which recomThere are standard case definitions for mends auto-disable syringes for therapeu- donors and pregnant women. hepatitis. Deaths, including from hepatitis, tic injections. Single-use or auto-disable Publicly funded treatment is not available are reported to a central registry. Of hepati- syringes, needles and cannulas are always for hepatitis B, but is available for hepatitis tis cases, 0.03% are reported as “undifferen- available in all health-care facilities. C. Eligibility for publicly funded treatment tiated” or “unclassified” hepatitis. for hepatitis C is extended to everyone Official government estimates of the Liver cancer cases and cases with HIV/hep- number and percentage of unnecessary through the national resources fund. Inforatitis coinfection are registered nationally. injections administered annually in health- mation was not provided on the amount spent by the government on such treatcare settings are not known. ment for hepatitis C. The government publishes hepatitis disease reports annually. There is a national infection control policy The following drugs for treating hepatitis for blood banks. All donated blood units Hepatitis outbreaks are required to be re- (including family donations) and blood B are on the national essential medicines ported to the government and are further products nationwide are screened for hep- list or subsidized by the government: pegylated interferon and lamivudine. The investigated. There is adequate laboratory atitis B and hepatitis C. following drugs for treating hepatitis C are capacity nationally to support outbreak investigations and other surveillance activi- There is no national policy relating to the on the national essential medicines list or ties for hepatitis A, hepatitis B and hepatitis prevention of viral hepatitis among people subsidized by the government: pegylated interferon and ribavirin. C. Information was not provided on wheth- who inject drugs. er this is the case for hepatitis E. The government has guidelines that ad- The Government of Uruguay welcomes There is no national public health research dress how hepatitis A and hepatitis E can assistance from WHO in one or more areas agenda for viral hepatitis. Viral hepatitis se- be prevented through food and water of viral hepatitis prevention and control (Annex C). rosurveys are not conducted regularly. safety.

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Chapter 5: WHO Eastern Mediterranean Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Chapter 5:

WHO Eastern Mediterranean Region Twenty-two Member States make up the World Health Organization (WHO) Eastern Mediterranean Region, which has a total population of 605 million.1 More than two thirds of the Region’s age-standardized mortality in 2008 was attributable to noncommunicable diseases,2 and deaths from noncommunicable diseases are expected to increase by more than 20% by 2020.3 Although the overall HIV prevalence in the Region is only an estimated 0.2%, the estimated annual number of new HIV infections increased from 2001 to 2010, and almost 90 000 children and adults were newly infected in 2010.4,5 Almost half of the population of the Eastern Mediterranean Region lives in malaria risk areas; health system capacity for responding to malaria is limited.5 Tuberculosis caused 17% of all deaths from infectious and parasitic diseases in 2008.6 Five of the Region’s countries are among the ten countries in the world that host the largest proportions of internally displaced persons per population, which places an additional strain on their health systems.7 Responses to the WHO/Alliance survey were received from 17 of the 22 Member States in the region (77.3%). Box 1. Responses to the 2012 Global Hepatitis Survey: WHO Eastern Mediterranean Region

Member States that submitted surveys:

Viral hepatitis in the WHO Eastern Mediterranean Region The prevalence of hepatitis A in the Region has decreased in recent decades; where studies from the 1980s reported 100% exposure rate by the age of 10 years, more recent studies indicate a modest decrease to 50% of children exposed by the age of 15 years.a The prevalence of hepatitis E infection is high (>15%) in Sudan, South Sudan, Pakistan and Somalia; however, the burden is highly uncertain.b It is estimated that approximately 4.3 million people are infected with hepatitis B and 800 000 people are infected with hepatitis C annually in the Region.c In North Africa and the Middle Eastern region, low–intermediate (2%– 4%) prevalence of hepatitis B was reported across all age groups in 2005.d The prevalence of hepatitis C is estimated to be 1%–4.6%, with levels as high as 15% and higher than 20% in parts of Egypt and Pakistan, respectively. Overall, an estimated 17 million people in the Region suffer from chronic hepatitis C infection.c a

• Afghanistan • Bahrain • Djibouti • Egypt • Iran (Islamic Republic of) • Iraq • Libya • Morocco • Saudi Arabia

• Jordan • Kuwait • Lebanon • Oman • Pakistan • Qatar

• Somalia • South Sudan • Sudan • Syrian Arab Republic • Yemen

Member States that did not submit surveys: • Tunisia • United Arab Emirates

1

Jacobsen KH, Wiersma ST. Hepatitis A virus seroprevalence by age and world region, 1990 and 2005. Vaccine, 2010, 28:6653–6657. Rein DB et al. The global burden of hepatitis E virus genotypes 1 and 2 in 2005. Hepatology, 2012, 55:988–997. c WHO Regional Office for the Eastern Mediterranean. The growing threats of hepatitis B and hepatitis C in the Eastern Mediterranean Region: a call for action. Presented at the Fifty-sixth session of the WHO Regional Committee for the Eastern Mediterranean. Fez, Morocco, 5–8 October 2009 [Document no: EM/ RC/56/3]. Available at: http://applications.emro. who.int/docs/EM_RC56_3_en.pdf (accessed on 07 June 2013). d Ott JJ, Stevens GA, Groeger J, Wiersma ST. Global epidemiology of hepatitis B virus infection: new estimates of age-specific HBsAg seroprevalence and endemicity. Vaccine, 2012, 30:2212–2219. b

World population prospects: the 2010 revision. New York, United Nations, Department of Economic and Social Affairs, Population Division, 2011. 2 World health statistics 2012. Geneva, WHO, 2012. Available at: http://apps.who. int/iris/bitstream/10665/44844/1/9789241564441_eng.pdf (accessed on 11 May 2013). 3 Global status report on noncommunicable diseases 2010. Geneva, WHO, 2011. Available at: http://whqlibdoc.who.int/publications/2011/9789240686458_eng. pdf (accessed on 11 May 2013). 4 UNAIDS report on the global AIDS epidemic 2012. Geneva, UNAIDS, 2012. Available at: http://www.unaids.org/en/media/unaids/contentassets/documents/ epidem iology/2012/gr2012/20121120_UNAIDS_Global_Report_2012_en.pdf (accessed on 11 May 2013). 5 The work of WHO in the Eastern Mediterranean Region: annual report of the Regional Director, 1 January–31 December 2011. Cairo, WHO Regional Office for the Eastern Mediterranean, 2012. Available at: http://applications.emro.who.int/docs/RD_ Annual_Report_2012_en_14587.pdf (accessed on 11 May 2013). 6 Causes of death 2008 summary tables. Geneva, Health Statistics and Informatics Department, World Health Organization, May 2011. Available at: http://www. who.int/entity/gho/mortality_burden_disease/global_burden_disease_ DTH6_2008.xls (accessed on 11 May 2013). 7 Global overview 2011: people internally displaced by conflict and violence. Geneva, Internal Displacement Monitoring Centre, April 2012. Available at: http://www. internal-displacement.org/publications/global-overview-2011.pdf (accessed on 11 May 2013).

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National coordination Nine responding Member States (52.9%) reported the existence of a written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis (Figure 1). Six of the nine Member States with a strategy or plan (Bahrain, Egypt, Iraq, Jordan, Kuwait and Lebanon) reported that it focuses exclusively on viral hepatitis, and two (Oman and Sudan) reported that it addresses other diseases as well. One country (Iran) reported that the strategy or plan addresses only hepatitis B and hepatitis C. Figure 1. Responses to the question, “Is there a written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis?”

Member States were asked to report the number of people working full-time on hepatitis-related activities in all government agencies or bodies. Among the six Member States that provided data for this question, the number ranged from 0 to 47 (median, 3), with Iran reporting the largest number. Ten responding Member States (58.8%) reported that they have a viral hepatitis prevention and control programme that includes activities targeting specific populations. The populations most commonly targeted are health-care workers, including healthcare waste handlers (100% of responding Member States within this subset) and prisoners (80.0% of responding Member States within this subset). Six responding Member States reported the inclusion of activities targeting people who inject drugs and five reported the inclusion of activities targeting people living with HIV. Groups identified less frequently included migrants, indigenous populations, low-income populations, those who are uninsured and those who are homeless.

Awareness-raising and partnerships Eight responding Member States (47.1%) reported that they had held events for World Hepatitis Day 2012 (28 July). Since January 2011, seven responding Member States (41.2%) had funded some type of viral hepatitis public awareness campaign other than World Hepatitis Day (Table 1).

Table 1. Topics of public awareness campaigns on viral

hepatitis held in Member States since January 2011 (N=7) Egypt General information about hepatitis and its transmission Vaccination for hepatitis A and hepatitis B Importance of knowing one’s hepatitis B and hepatitis C status Safe water and good sanitation Safer sex practices Harm reduction for people who inject drugs Safe workplace practices Other a a

Iran

Iraq

Jordan Oman

Pakistan Qatar X X

X

X

X

X

Yes No

No response No data

X

X

X

X

X

The nine Member States that reported the existence of a strategy or plan were asked about its specific components. All nine reported the inclusion of components for surveillance and general prevention. Eight reported the inclusion of components for vaccination, prevention of transmission in health-care settings and prevention of transmission via injecting drug use. Seven reported the inclusion of a component for raising awareness, six reported the inclusion of a component for treatment and care, and three reported the inclusion of a component for coinfection with HIV. Ten responding Member States (58.8%) reported that they have a governmental unit or department responsible solely for viral hepatitis-related activities. Member States that did so were asked to indicate the number of staff members in the unit or department. Responses (N=9) ranged from 2 to 44 (median, 4), with Iraq reporting the largest number.

X

X

X

X

X

X X X

X

X

X

X X

X

X X

Details can be found in the summaries of country findings later in this chapter.

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Five responding Member States (29.4%) reported that they collaborated with civil society groups within their countries to develop and implement the governmental viral hepatitis prevention and control programme. For example, Lebanon reported collaborating with the Lebanese Red Cross and Lebanese Scouts, while Qatar reported collaborating with the Qatar Red Crescent Society. (Further examples can be found in the summaries of country findings later in this chapter.)

Table 3. Data registration and surveillance (N=17) No Yes (%) No (%) Do not know response (%) (%) Liver cancer cases are registered nationally Cases with HIV/hepatitis coinfection are registered nationally Hepatitis outbreaks are reported If YES – Hepatitis outbreaks are further investigated (N=115) 70.6 47.1 100 94.1 23.5 47.1 0 5.9 5.9 5.9 0 0 0 0 0 0

Evidence-based policy and data for action Fifteen responding Member States (88.2%) reported that they have routine surveillance for viral hepatitis; details appear in Table 2. Table 2. Types of surveillance in Member States that reported the existence of routine surveillance for viral hepatitis (N=15) No Yes (%) No (%) Do not know response (%) (%) There is a national surveillance system for acute hepatitis infection for the following forms of hepatitis: hepatitis A hepatitis B hepatitis C hepatitis D hepatitis E There is a national surveillance system for chronic hepatitis infection for the following forms of hepatitis: hepatitis B hepatitis C hepatitis D 46.7 46.7 26.7 53.3 53.3 60.0 0 0 0 0 0 13.3 86.7 86.3 86.3 40.0 53.3 0 13.3 13.7 33.3 26.7 0 0 0 0 0 13.3 0 0 26.7 20.0

Nine responding Member States (52.9%) reported the existence of a national public health research agenda for viral hepatitis. Four responding Member States (23.5%) reported that viral hepatitis serosurveys are conducted regularly. Among this subset of responding Member States, one (Kuwait) indicated that serosurveys take place every year. The same Member State reported that the most recent viral hepatitis serosurvey was carried out in 2011.

Prevention of transmission Four responding Member States (23.5%) reported that they have a national policy on hepatitis A vaccination. Five responding Member States (29.4%) reported that they have established the goal of eliminating hepatitis B (Figure 2). Member States with this goal were asked to specify the timeframe in which they seek to eliminate hepatitis B. Of the two Member States that answered this question, one (Bahrain) said 2015 and one (Lebanon) said 2020. Figure 2. Responses to the question, “Has your government established the goal of eliminating hepatitis B?” (N=17) No response 11.8%

Sixteen responding Member States (94.1%) indicated that their countries have standard case definitions for hepatitis infection and 11 (64.7%) indicated that their countries have a central registry for the reporting of deaths, including hepatitis deaths. Nine Member States reported on the proportion of hepatitis cases and deaths registered as “undifferentiated” or “unclassified” hepatitis. The reported proportions ranged from 0% to 100% (median, 7.0%). Additional survey findings about surveillance are presented in Table 3. Member States were asked how often hepatitis disease reports are published. Of the responding Member States, 35.3% reported that they publish hepatitis disease reports annually; 17.6%, monthly; and 23.5%, weekly. No hepatitis disease report is published by 17.6% of responding Member States.

Yes (29.4%)

No (58.8%)

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Eleven responding Member States (64.7%) reported the existence of a national policy that specifically targets mother-tochild transmission of hepatitis B; details are presented in Table 4. Slightly less than half of the Member States with such a policy indicated that one component of the policy calls for screening of all pregnant women for hepatitis B. Eleven responding Member States (64.7%) reported the existence of a specific national strategy and/or policy/guidelines for preventing hepatitis B and hepatitis C infection in healthcare settings. Nine responding Member States (52.9%) reported that healthcare workers are vaccinated against hepatitis B prior to starting work that might put them at risk of exposure to blood. Thirteen responding Member States (76.5%) reported the existence of a national policy on injection safety in healthcare settings. These Member States were asked which types of syringes the policy recommends for therapeutic injections. Single-use syringes are recommended in 84.6% of policies, and auto-disable syringes in 23.1% (Figure 3). Fourteen responding Member States (82.4%) reported that single-use or auto-disable syringes, needles and cannulas are always available in all health-care facilities. Member States were asked for official estimates of the number and percentage of unnecessary injections administered annually in health-care settings (e.g. injections that are given when an equivalent oral medication is available). Sixteen Member States reported that the figures are not known and one (Pakistan) reported that 20.0% of the total injections administered annually in health-care settings are unnecessary. Additional findings relating to the prevention of hepatitis transmission are presented in Table 5.

Bahrain Djibouti Egypt Iran Iraq Jordan Kuwait Lebanon Oman Pakistan Qatar TOTAL

X

X X

X

X X

X X X

X X X

X X X X

X X 5 X 5 X 5 X 6

Figure 3. Proportion of responding Member States with national policies on injection safety in health-care settings which recommend single-use syringes and auto-disable syringes for therapeutic injections (N=13) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% a

Screening, care and treatment Member States were asked how health professionals in their countries obtain the skills and competencies required to effectively care for people with viral hepatitis. Responding Member States most frequently indicated that these are obtained in schools for health professionals (pre-service education, 82.4%). Additionally, on-the-job training was identified in 70.6% of responses, and postgraduate training in 52.9%.

Single-use syringesa

Auto-disable syringesa

Do not know

Respondents could select both “single-use syringes” and “auto-disable syringes”.

70

All infants receive the first dose of hepatitis B vaccine within 24 hours of birth X X X X X X X X X X 10

All pregnant women found to have hepatitis B are counselled

Health-care providers follow up with all pregnant women found to have hepatitis B during pregnancy for the purpose of encouraging them to give birth at health-care facilities

Upon delivery, all infants born to women with hepatitis B receive hepatitis B immunoglobulin

All pregnant women are screened for hepatitis B

Member States were asked to report, for a given recent year, the percentage of newborn infants who had received the first dose of hepatitis B vaccine within 24 hours of birth. Among the 13 Member States that provided this information, responses ranged from 0% to 100% (median, 90.0%). Member States were also asked to report, for a given recent year, the percentage of one-year-olds (ages 12–23 months) who had received three doses of hepatitis B vaccine. Among the 14 Member States that provided this information, responses ranged from 0% to 100% (median, 91.0%).

Table 4. Activities called for in national policy targeting mother-to-child transmission of hepatitis B (N=11)

Chapter 5: WHO Eastern Mediterranean Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Table 5. Hepatitis prevention: policies, practices and

guidelines (N=17) No Yes (%) No (%) Do not know response (%) (%) There is a national infection control policy for blood banks All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B All donated blood units (including family donations) and blood products nationwide are screened for hepatitis C There is a national policy relating to the prevention of viral hepatitis among people who inject drugs The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety 76.5 17.6 5.9 0

Figure 4. Responses to the question, “Are there national clinical guidelines for the management of viral hepatitis?” (N=17) Do not know 5.9%

82.4

11.8

0

5.9

100

0

0

0

No (41.2%)

Yes (52.9%)

23.5

76.5

0

0

41.2

58.8

0

0

Nine responding Member States (52.9%) reported the existence of national clinical guidelines for the management of viral hepatitis (Figure 4). Five of these nine Member States indicated that the guidelines include recommendations for cases with HIV coinfection. Six of 12 responding Member States (50.0%) indicated that there are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral hepatitis. Eight responding Member States (47.1%) indicated that they have a national policy relating to screening and referral to care for hepatitis B. Eight (47.1%) reported having such a policy for hepatitis C. Regarding hepatitis B testing, 16 responding Member States (94.1%) indicated that people register by name for testing. Twelve members of that subset (75.0%) indicated that the names are kept confidential. Seven responding Member States (41.2%) reported that the hepatitis B test is free of charge for all individuals. Among the ten other Member States, five (50.0%) reported that the test is free of charge for members of specific groups. Groups identified included blood donors, healthcare workers and patients on haemodialysis. Nine responding Member States (52.9%) reported that the hepatitis B test is compulsory for members of specific groups. Groups identified included blood donors, health-care workers, patients on haemodialysis and prisoners. Regarding hepatitis C testing, 16 responding Member States (94.1%) indicated that people register by name for testing. Twelve members of that subset (75.0%) indicated that the names are kept confidential. Seven responding Member States (41.2%) reported that the hepatitis C test is free of charge for all

individuals. Among the ten other Member States, five (50.0%) reported that the test is free of charge for members of specific groups. Groups identified included blood donors, healthcare workers and patients on haemodialysis. Nine responding Member States (52.9%) reported that the hepatitis C test is compulsory for members of specific groups. Groups identified included blood donors, health-care workers, patients on haemodialysis and prisoners. Table 6. Proportion of Member States reporting drugs for

treating hepatitis B and C on national essential medicines lists or subsidized by governments Drugs for treating hepatitis B % of Member States reporting its inclusion (N=12) 64.7 64.7 52.9 41.2 35.3 23.5 17.6 % of Member States reporting its inclusion (N=12) 64.7 64.7 47.1 11.8 11.8

Lamivudine Interferon alpha Tenofovir Pegylated interferon Entecavir Adefovir dipivoxil Telbivudine Drugs for treating hepatitis C

Ribavirin Pegylated interferon Interferon alpha Telaprevir Boceprevir

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Eleven responding Member States (64.7%) reported that publicly funded treatment is available for hepatitis B and 11 (64.7%) that publicly funded treatment is available for hepatitis C. Four responding Member States reported the amount spent on publicly funded treatment for hepatitis B and hepatitis C. Details can be found in the summaries of country findings later in this chapter (see Bahrain, Egypt, Pakistan and Syrian Arab Republic). Thirteen responding Member States (76.5%) reported that at least one available drug for treating hepatitis B is on the national essential medicines list or subsidized by the government (Table 6). The drugs most commonly reported were interferon alpha, pegylated interferon and lamivudine. Twelve responding Member States (70.6%) reported that at least one available drug for treating hepatitis C is on the national essential medicines list or subsidized by the government. The drugs most commonly reported were ribavirin, pegylated interferon and interferon alpha.

World Health Organization assistance 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 the national plan for viral hepatitis prevention and control (82.4%), developing tools to assess the effectiveness of interventions (82.4%) and assessing the economic impact of viral hepatitis (82.4%) (Table 7). Responses from individual Member States appear in Annex C.

Table 7. Viral hepatitis control and prevention: areas in which Member States indicated interest in receiving WHO assistance

(N=17) Awareness-raising, partnerships and resource mobilization (first WHO strategic axis) Developing the national plan for viral hepatitis prevention and control Integrating viral hepatitis programmes into other health services Awareness-raising Evidence-based policy and data for action (second WHO strategic axis) Viral hepatitis surveillance Estimating the national burden of viral hepatitis Developing tools to assess the effectiveness of interventions Assessing the economic impact of viral hepatitis Prevention of transmission (third WHO strategic axis) Increasing coverage of the birth dose of the hepatitis B vaccine Screening, care and treatment (fourth WHO strategic axis) Increasing access to treatment Increasing access to diagnostics Improving laboratory quality Developing education/training programmes for health professionals 82.4% 64.7% 76.5% 64.7% 76.5% 82.4% 82.4% 41.2% 76.5% 70.6% 70.6% 76.5%

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WHO Eastern Mediterranean Region: COUNTRY SUMMARIES

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Afghanistan Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 32.4 Low-income $1140 7.58% $44.47 $5.18 48 0.398 17 6.3 There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is a national HIV policy that includes a policy relating to the prevention of viral hepatitis among people who inject drugs.

The government does not have guidelines that address how hepatitis A and hepatitis E can be prevented through food and waThe Government of Afghanistan reports as The government does not publish hepati- ter safety. follows. tis disease reports.

National coordination

Screening, care and treatment

Hepatitis outbreaks are required to be reThere is no written national strategy or plan ported to the government and are further that focuses exclusively or primarily on the investigated. There is inadequate laboratoprevention and control of viral hepatitis. ry capacity nationally to support investigation of viral hepatitis outbreaks and other There is no designated governmental unit/ surveillance activities. department responsible solely for coordinating and/or carrying out viral hepatitis- There is no national public health research related activities. Information was not pro- agenda for viral hepatitis. Viral hepatitis sevided on how many people work full-time rosurveys are not conducted regularly. on hepatitis-related activities in all governPrevention of transmission ment agencies/bodies. There is no national policy on hepatitis A The government does not have a viral hep- vaccination. atitis prevention and control programme that includes activities targeting specific The government has not established the goal of eliminating hepatitis B. populations. Nationally, no newborn infant in a given The government did not hold events for recent year received the first dose of hepaWorld Hepatitis Day 2012 and has not titis B vaccine within 24 hours of birth and funded other viral hepatitis public aware- 82% of one-year-olds (ages 12–23 months) in a given recent year received three doses ness campaigns since January 2011. of hepatitis B vaccine. The government does not collaborate with in-country civil society groups to develop There is no national policy that specifically and implement its viral hepatitis preven- targets mother-to-child transmission of hepatitis B. tion and control programme.

Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through schools for health professionals (pre-service education), on-the-job training and postgraduate training. There are no national clinical guidelines for the management of viral hepatitis or for the management of HIV, which include recommendations for coinfection with viral hepatitis. The government does not have national policies relating to screening and referral to care for hepatitis B or hepatitis C. Information was not provided on whether people testing for hepatitis B register by name. People testing for hepatitis C do not register by name. Hepatitis B and hepatitis C tests are not free of charge for all individuals, but they are free of charge for blood donors and injecting drug users. Hepatitis B and hepatitis C tests are not compulsory for members of any specific group. Publicly funded treatment is not available for hepatitis B or hepatitis C. The following drugs for treating hepatitis B are on the national essential medicines list or subsidized by the government: interferon alpha and pegylated interferon. The following drugs for treating hepatitis C are on the national essential medicines list or subsidized by the government: interferon alpha and pegylated interferon. The Government of Afghanistan welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

Awareness-raising and partnerships

Evidence-based policy and data for There is no specific national strategy and/ or policy/guidelines for preventing hepatiaction There is routine surveillance for viral hepa- tis B and hepatitis C infection in health-care titis. There is a national surveillance system settings. for the following types of acute hepatitis: A, B, C and D, but not for any type of chronic There is a national policy on injection safety in health-care settings, but information hepatitis. was not provided on the type of syringes There are standard case definitions for it recommends for therapeutic injections. hepatitis. Deaths, including from hepatitis, It is not known whether single-use or autoare reported to a central registry. All hepa- disable syringes, needles and cannulas are titis cases (100%) are reported as “undiffer- always available in all health-care facilities. entiated” or “unclassified” hepatitis. Official government estimates of the Liver cancer cases and cases with HIV/ number and percentage of unnecessary hepatitis coinfection are not registered na- injections administered annually in healthcare settings are not known. tionally.

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Bahrain The Government of Bahrain reports as Population (in millions) (2011) follows. Country classification (2012) Gross national income per capita (PPP int $) (2011) National coordination There is a written national strategy or plan Total health expenditure as % of GDP (2010) that focuses exclusively on the prevention Per capita total health expenditure (PPP int $) (2010) and control of viral hepatitis. It includes Per capita government health expenditure (PPP int $) (2010) components for surveillance, vaccination, Life expectancy at birth (in years) (2009) prevention in general, prevention of trans- Human Development Index (2011) mission via injecting drug use, prevention Median age (in years) (2010) of transmission in health-care settings, Total fertility rate per woman (2010) and treatment and care. There is no designated governmental unit/department responsible solely for coordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitisrelated activities in all government agencies/bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), people who inject drugs, prisoners and people living with HIV. 1.3 High-income -4.97% $1083.06 $794.15 74 0.806 30 2.5

There is a national public health research The government has guidelines that adagenda for viral hepatitis. Viral hepatitis dress how hepatitis A and hepatitis E can be prevented through food and water serosurveys are not conducted regularly. safety.

Prevention of transmission

Awareness-raising and partnerships It is not known whether the government held events for World Hepatitis Day 2012 or funded other viral hepatitis public awareness campaigns since January 2011. The government does not collaborate with in-country civil society groups to develop and implement its viral hepatitis prevention and control programme.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C, D and E, and for the following types of chronic hepatitis: B, C and D.

There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. No hepa- Official government estimates of the titis case is reported as “undifferentiated” number and percentage of unnecesor “unclassified” hepatitis. sary injections administered annually in Liver cancer cases and cases with HIV/hep- health-care settings are not known. atitis coinfection are registered nationally. There is a national infection control policy The government publishes hepatitis disease reports every three months. Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory capacity nationally to support investigation of viral hepatitis outbreaks and other surveillance activities.

There is a national policy on hepatitis A Screening, care and treatment Health professionals obtain the skills and vaccination. competencies required to effectively care The government has established the goal for people with viral hepatitis through of eliminating hepatitis B by2015. schools for health professionals (pre-service education), on-the-job training and Nationally in 2011, all newborn children of postgraduate training. hepatitis B-infected mothers and mothers of unknown status received the first dose There are national clinical guidelines for of hepatitis B vaccine within 24 hours of the management of viral hepatitis, but birth, and 99.8% of one-year-olds (ages these do not include recommendations 12–23 months) received three doses of for cases with HIV coinfection. hepatitis B vaccine. The government has national policies reThere is a national policy that specifically lating to screening and referral to care for targets mother-to-child transmission of hepatitis B and hepatitis C. hepatitis B (Annex B). People testing for both hepatitis B and There is a specific national strategy and/or hepatitis C register by name; the names policy/guidelines for preventing hepatitis are kept confidential within the system. B and hepatitis C infection in health-care Hepatitis B and hepatitis C tests are free of settings. Health-care workers are vacci- charge for all individuals and are not comnated against hepatitis B prior to starting pulsory for members of any specific group. work that might put them at risk of expoPublicly funded treatment for hepatitis sure to blood. B and hepatitis C is available to all BahThere is a national policy on injection safe- raini citizens. The government spends ty in health-care settings, which recom- BD 273 377 (US$ 725 332) annually on mends single-use syringes for therapeutic hepatitis B and hepatitis C drugs. Other injections. Single-use or auto-disable sy- treatment costs are publicly funded as ringes, needles and cannulas are always well, but the total amount spent on hepaavailable in all health-care facilities. titis is not known. The following drugs for treating hepatitis B are on the national essential medicines list or subsidized by the government: pegylated interferon, lamivudine, entecavir and tenofovir. The following drugs for treating hepatitis C are on the national essential for blood banks. All donated blood units medicines list or subsidized by the govern(including family donations) and blood ment: pegylated interferon and ribavirin. products nationwide are screened for hepatitis B and hepatitis C. The Government of Bahrain welcomes assistance from WHO in one or more areas There is a national policy relating to the of viral hepatitis prevention and control prevention of viral hepatitis among peo(Annex C). ple who inject drugs.

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Djibouti Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 0.9 Lower–middle-income $2450 7.24% $170.01 $110.99 60 0.430 21 3.8 injections administered annually in healthcare settings are not known. There is no national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis C, but not for hepatitis B. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

The Government of Djibouti reports as The government publishes hepatitis dis- The government does not have guidelines that address how hepatitis A and hepatitis follows. ease reports annually. E can be prevented through food and waNational coordination Hepatitis outbreaks are required to be re- ter safety. There is no written national strategy or plan ported to the government and are further that focuses exclusively or primarily on the investigated. There is adequate laboratory Screening, care and treatment prevention and control of viral hepatitis. capacity nationally to support investiga- Health professionals obtain the skills and tion of viral hepatitis outbreaks and other competencies required to effectively care There is no designated governmental unit/ surveillance activities. for people with viral hepatitis through department responsible solely for coordischools for health professionals (pre-servnating and/or carrying out viral hepatitis- There is a national public health research ice education). related activities. There are three full-time agenda for viral hepatitis. Viral hepatitis seThere are no national clinical guidelines for equivalent staff members who work on rosurveys are not conducted regularly. the management of viral hepatitis. There hepatitis-related activities in all governPrevention of transmission are national clinical guidelines for the manment agencies/bodies. There is no national policy on hepatitis A agement of HIV, which include recommenThe government does not have a viral hep- vaccination. dations for coinfection with viral hepatitis. atitis prevention and control programme that includes activities targeting specific Information was not provided on whether The government does not have national the government has established the goal policies relating to screening and referral populations. of eliminating hepatitis B. to care for hepatitis B or hepatitis C.

Awareness-raising and partnerships

Nationally, 90% of newborn infants in a given recent year received the first dose of hepatitis B vaccine within 24 hours of birth and 75% of one-year-olds (ages 12–23 months) in a given recent year received The government does not collaborate with three doses of hepatitis B vaccine. in-country civil society groups to develop and implement its viral hepatitis preven- There is a national policy that specifically targets mother-to-child transmission of tion and control programme. hepatitis B (Annex B). The government held events for World Hepatitis Day 2012 but has not funded other viral hepatitis public awareness campaigns since January 2011.

People testing for both hepatitis B and hepatitis C register by name, and there is open access to their names. Hepatitis B and hepatitis C tests are not free of charge for all individuals but are free for certain groups; information was not provided regarding which groups. Hepatitis B and hepatitis C tests are not compulsory for members of any specific group.

Evidence-based policy and data for Publicly funded treatment is not available There is no specific national strategy and/ for hepatitis B or hepatitis C. action There is no routine surveillance for viral or policy/guidelines for preventing hepatitis B and hepatitis C infection in health-care hepatitis. settings. There are standard case definitions for hepatitis. Deaths, including from hepatitis, There is no national policy on injection are reported to a central registry. Of hepa- safety in health-care settings. Single-use titis cases, 7% are reported as “undifferenti- or auto-disable syringes, needles and cannulas are always available in all health-care ated” or “unclassified” hepatitis. facilities. Liver cancer cases and cases with HIV/hepatitis coinfection are registered nationally. Official government estimates of the number and percentage of unnecessary No drug for treating hepatitis B or hepatitis C is on the national essential medicines list or subsidized by the government. The Government of Djibouti welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

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Egypt The Government of Egypt reports as Population (in millions) (2011) 82.5 follows. Country classification (2012) Lower–middle-income Gross national income per capita (PPP int $) (2011) National coordination $6120 There is a written national strategy or plan Total health expenditure as % of GDP (2010) 4.66% that focuses exclusively on the prevention Per capita total health expenditure (PPP int $) (2010) $288.57 and control of viral hepatitis. It includes Per capita government health expenditure (PPP int $) (2010) $107.94 components for raising awareness, surveil- Life expectancy at birth (in years) (2009) 71 lance, vaccination, prevention in general, Human Development Index (2011) 0.644 prevention of transmission via injecting Median age (in years) (2010) 24 drug use, prevention of transmission in Total fertility rate per woman (2010) 2.7 health-care settings, and treatment and care. ties for hepatitis A, hepatitis B and hepati- The government has guidelines that address how hepatitis A and hepatitis E can There is a designated governmental unit/ tis C, but not for hepatitis E. be prevented through food and water department responsible solely for coordinating and/or carrying out viral hepatitis- There is no national public health research safety. related activities: Hepatitis Unit, Preven- agenda for viral hepatitis. Viral hepatitis tive Sector, Ministry of Health. It has three serosurveys are conducted regularly; the Screening, care and treatment staff members. There are three full-time target population is people aged 15–59 Health professionals obtain the skills and equivalent staff members who work on years. The last serosurvey was carried out competencies required to effectively care for people with viral hepatitis through onhepatitis-related activities in all govern- in 2008. the-job training and postgraduate trainment agencies/bodies. Prevention of transmission ing. The government has a viral hepatitis pre- There is no national policy on hepatitis A There are national clinical guidelines for vention and control programme that in- vaccination. cludes activities targeting the following The government has established the goal the management of viral hepatitis but it is specific populations: health-care workers of eliminating hepatitis B in children under not known whether they include recom(including health-care waste handlers) five years of age, but did not provide infor- mendations for cases with HIV coinfection. and patients on dialysis. mation about a specific timeframe for this. The government does not have national Awareness-raising and partnerships Nationally, no newborn infant in a given policies relating to screening and referral The government did not hold events for recent year received the first dose of hepa- to care for hepatitis B or hepatitis C. World Hepatitis Day 2012, but has fund- titis B vaccine within 24 hours of birth People testing for both hepatitis B and ed other viral hepatitis public awareness and 95% of one-year-olds (ages 12–23 hepatitis C register by name; the names campaigns since January 2011 (Annex A). months) in a given recent year received are kept confidential within the system. Hepatitis B and hepatitis C tests are free of The government collaborates with the fol- three doses of hepatitis B vaccine. lowing in-country civil society groups to There is a national policy that specifically charge for all individuals and are compuldevelop and implement its viral hepatitis targets mother-to-child transmission of sory for patients on dialysis, visa applicants and blood donors. prevention and control programme: Ter- hepatitis B (Annex B). ros, Misr-elkheir and the Sawiris FoundaPublicly funded treatment for hepatitis B tion. There is a specific national strategy and/or and hepatitis C is available to all people policy/guidelines for preventing hepatitis Evidence-based policy and data for B and hepatitis C infection in health-care with health insurance and for those supported by the governmental treatment action settings. Health-care workers are vaccinat- programme. There is routine surveillance for viral hepa- ed against hepatitis B. titis. There is a national surveillance system The government spends about LE 800 milfor the following types of acute hepatitis: There is a national policy on injection safe- lion (US$ 131.8 million) annually on pubA, B and C, but not for any type of chronic ty in health-care settings, which recom- licly funded treatment for hepatitis B and hepatitis. mends single-use syringes for therapeutic hepatitis C. injections. Single-use or auto-disable syThere are standard case definitions for ringes, needles and cannulas are always The following drugs for treating hepatitis hepatitis. Deaths, including from hepatitis, available in all health-care facilities. B are on the national essential medicines are reported to a central registry. Of hepalist or subsidized by the government: titis cases, 69% are reported as “undiffer- Official government estimates of the pegylated interferon and lamivudine. The entiated” or “unclassified” hepatitis. number and percentage of unneces- following drugs for treating hepatitis C are sary injections administered annually in on the national essential medicines list or Liver cancer cases are registered nation- health-care settings are not known. subsidized by the government: pegylated ally, but cases with HIV/hepatitis coinfecinterferon and ribavirin. tion are not. There is a national infection control policy for blood banks. All donated blood units The government publishes hepatitis dis- (including family donations) and blood The Government of Egypt welcomes assistance from WHO in one or more areas ease reports annually. products nationwide are screened for of viral hepatitis prevention and control (Annex C). Hepatitis outbreaks are required to be re- hepatitis B and hepatitis C. ported to the government and are further There is no national policy relating to the investigated. There is adequate laboratory prevention of viral hepatitis among peocapacity nationally to support outbreak in- ple who inject drugs. vestigations and other surveillance activi77

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Iran (Islamic Republic of) There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepThe Government of Iran reports as follows. Liver cancer cases and cases with HIV/hep- atitis B and hepatitis C. atitis coinfection are registered nationally. National coordination There is a national policy relating to the There is a written national strategy or plan The government publishes hepatitis dis- prevention of viral hepatitis among people that focuses exclusively on the prevention ease reports monthly. who inject drugs. and control of hepatitis B and hepatitis C. It includes components for raising aware- Hepatitis outbreaks are required to be re- The government does not have guidelines ness, surveillance, vaccination, prevention ported to the government and are further that address how hepatitis A and hepatitis in general, prevention of transmission via investigated. There is adequate laboratory E can be prevented through food and wainjecting drug use, prevention of transmis- capacity nationally to support outbreak in- ter safety. sion in health-care settings, and treatment vestigations and other surveillance activities for hepatitis A, hepatitis B and hepatitis Screening, care and treatment and care. C. Information was not provided on wheth- Health professionals obtain the skills and competencies required to effectively care There is a designated governmental unit/ er this is the case for hepatitis E. for people with viral hepatitis through department responsible solely for coordinating and/or carrying out viral hepatitis- There is a national public health research schools for health professionals (pre-servrelated activities: the Viral Hepatitis Unit. agenda for viral hepatitis. Viral hepatitis ice education) and on-the-job training. It has five staff members. There are 47 full- serosurveys are conducted regularly; the time equivalent staff members who work target populations include the general There are national clinical guidelines for on hepatitis-related activities in all govern- population and people who inject drugs. the management of viral hepatitis but they Information was not provided on when the do not include recommendations for cases ment agencies/bodies. with HIV coinfection. There are national last serosurvey was carried out. clinical guidelines for the management of The government has a viral hepatitis preHIV, which include recommendations for vention and control programme that in- Prevention of transmission cludes activities targeting the following There is no national policy on hepatitis A coinfection with viral hepatitis. specific populations: health-care workers vaccination. The government has national policies re(including health-care waste handlers), The government has established the goal lating to screening and referral to care for people who inject drugs, prisoners and of eliminating hepatitis B but did not pro- hepatitis B and hepatitis C. people living with HIV. vide information about a specific timePeople testing for both hepatitis B and Awareness-raising and partnerships frame for this. hepatitis C register by name; the names are The government held events for World Hepatitis Day 2012 and has funded other Nationally, 98% of newborn infants in a kept confidential within the system. Hepaviral hepatitis public awareness campaigns given recent year received the first dose of titis B and hepatitis C tests are not free of hepatitis B vaccine within 24 hours of birth. charge and are not compulsory for memsince January 2011 (Annex A). Information was not provided on the per- bers of any specific group. Information was not provided on whether centage of one-year-olds nationally (ages the government collaborates with in- 12–23 months) in a given recent year who Publicly funded treatment for hepatitis B country civil society groups to develop and received three doses of hepatitis B vaccine. and hepatitis C is available to insurance companies. implement its viral hepatitis prevention There is a national policy that specifi cally and control programme. targets mother-to-child transmission of Information was not provided on the amount spent by the government on pubEvidence-based policy and data for hepatitis B (Annex B). licly funded treatment for hepatitis B and action There is routine surveillance for viral hepa- There is a specific national strategy and/or hepatitis C. titis. There is a national surveillance system policy/guidelines for preventing hepatitis Information was not provided on whether for the following types of acute hepatitis: B B and hepatitis C infection in health-care any drug for treating hepatitis B or hepatiand C, and for the following types of chron- settings. Health-care workers are vaccinattis C is on the national essential medicines ed against hepatitis B prior to starting work ic hepatitis: B, C and D. that might put them at risk of exposure to list or subsidized by the government. There are standard case definitions for blood. Information was not provided on whether hepatitis. Deaths, including from hepatitis, the Government of Iran has a need for asThere is a national policy on injection are reported to a central registry. The persistance from WHO in relation to viral hepasafety in health-care settings, which reccentage of hepatitis cases reported as “untitis prevention and control. differentiated” or “unclassified” hepatitis is ommends single-use and auto-disable syringes for therapeutic injections. Singlenot known. Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 74.8 Upper–middle-income $11 420 5.60% $836.28 $335.61 73 0.707 27 1.7 use or auto-disable syringes, needles and cannulas are always available in all healthcare facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known.

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Iraq The Government of Iraq reports as follows.

National coordination There is a written national strategy or plan that focuses exclusively on the prevention and control of viral hepatitis. It includes components for raising awareness, surveillance, vaccination, prevention in general, prevention of transmission via injecting drug use, and prevention of transmission in health-care settings. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities: Viral Hepatitis Section, Communicable Disease Control Center, Ministry of Health. It has 44 staff members. There are 44 full-time equivalent staff members who work on hepatitis-related activities in all government agencies/ bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), migrants, prisoners, low-income populations, indigenous people, pregnant women, patients on haemodialysis and those with thalassaemia, and preoperative patients.

Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory capacity nationally to support outbreak investigations and other surveillance activities for hepatitis B and hepatitis C, but not for hepatitis A and hepatitis E. There is a national public health research agenda for viral hepatitis. Viral hepatitis serosurveys are conducted regularly; the target population is the general population. The last serosurvey was carried out in 2005–2006.

32.7 Lower–middle-income $3750 8.42% $340.13 $118.35 66 0.573 18 4.7

(including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs. The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

Screening, care and treatment

Health professionals obtain the skills and competencies required to effectively care There is a national policy on hepatitis A for people with viral hepatitis through schools for health professionals (pre-servvaccination. ice education), on-the-job training and The government has not established the postgraduate training. goal of eliminating hepatitis B. It is not known whether there are national Awareness-raising and partnerships Nationally, 88% of newborn infants in a clinical guidelines for the management of The government held events for World given recent year received the first dose of viral hepatitis. Hepatitis Day 2012 and has funded other hepatitis B vaccine within 24 hours of birth viral hepatitis public awareness cam- and 89% of one-year-olds (ages 12–23 The government has national policies repaigns since January 2011 (Annex A). months) in a given recent year received lating to screening and referral to care for hepatitis B and hepatitis C. The government does not collaborate three doses of the hepatitis B vaccine. with in-country civil society groups to There is a national policy that specifically People testing for both hepatitis B and develop and implement its viral hepatitis targets mother-to-child transmission of hepatitis C register by name, and there is prevention and control programme. open access to their names. Hepatitis B hepatitis B (Annex B). and hepatitis C tests are free of charge for Evidence-based policy and data for There is a specific national strategy and/or all individuals and compulsory for blood action policy/guidelines for preventing hepatitis donors. There is routine surveillance for viral hepa- B and hepatitis C infection in health-care titis. There is a national surveillance system settings. Health-care workers are vacci- Publicly funded treatment for hepatitis B for the following types of acute hepatitis: nated against hepatitis B prior to starting and hepatitis C is available to all patients A, B, C, D and E, and for the following types work that might put them at risk of expo- who need it. The amount spent by the of chronic hepatitis: B, C and D. government on such treatment for hepasure to blood. titis B and hepatitis C is not known. There are standard case definitions for There is a national policy on injection hepatitis. Hepatitis deaths are not report- safety in health-care settings, which rec- The following drugs for treating hepatitis ed to a central registry. Information was ommends single-use and auto-disable B are on the national essential medicines not provided on the percentage of hepa- syringes for therapeutic injections. Single- list or subsidized by the government: titis cases reported as “undifferentiated” or use or auto-disable syringes, needles and interferon alpha, pegylated interferon, “unknown” hepatitis. cannulas are always available in all health- lamivudine and adefovir dipivoxil. The following drugs for treating hepatitis C are It is not known whether liver cancer cases care facilities. on the national essential medicines list or are registered nationally. Cases with HIV/ Official government estimates of the subsidized by the government: interferon hepatitis coinfection are not registered number and percentage of unneces- alpha, pegylated interferon and ribavirin. nationally. sary injections administered annually in The Government of Iraq welcomes asThe government publishes hepatitis health-care settings are not known. sistance from WHO in one or more ardisease reports weekly, monthly and There is a national infection control policy eas of viral hepatitis prevention and conannually. for blood banks. All donated blood units trol (Annex C).

Prevention of transmission

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Jordan Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Jordan reports as follows. 6.3 Upper–middle-income $5930 8.04% $448.45 $303.41 71 0.698 21 3.1 There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

National coordination There is a written national strategy or plan that focuses exclusively on the prevention and control of viral hepatitis. It includes components for raising awareness, surveillance, vaccination, prevention in general, prevention of transmission via injecting drug use, prevention of transmission in health-care settings, treatment and care, and coinfection with HIV.

There is no designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities. It is not known how many Prevention of transmission people work full-time on hepatitis-related There is no national policy on hepatitis A activities in all government agencies/bodvaccination. ies. The government has not established the The government has a viral hepatitis pregoal of eliminating hepatitis B. vention and control programme that includes activities targeting the following Nationally, no newborn infant in a given specific populations: health-care workers recent year received the first dose of hepa(including health-care waste handlers), titis B vaccine within 24 hours of birth and prisoners, people living with HIV and close 97% of one-year-olds (ages 12–23 months) contacts of people who are positive for in a given recent year received three doses hepatitis B or hepatitis C. of hepatitis B vaccine.

The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water Liver cancer cases are registered nationally, safety. but it is not known whether cases with HIV/ Screening, care and treatment hepatitis coinfection are. Health professionals obtain the skills and The government publishes hepatitis dis- competencies required to effectively care ease reports annually. for people with viral hepatitis through schools for health professionals (pre-servHepatitis outbreaks are required to be re- ice education), on-the-job training and ported to the government and are further postgraduate training. investigated. There is adequate laboratory capacity nationally to support investiga- There are national clinical guidelines for tion of viral hepatitis outbreaks and other the management of viral hepatitis, which surveillance activities. include recommendations for cases with HIV coinfection. There is no national public health research agenda for viral hepatitis. Viral hepatitis se- The government has national policies rerosurveys are not conducted regularly. lating to screening and referral to care for hepatitis B and hepatitis C. People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are not free of charge for all individuals, but they are free of charge for health-care workers and close contacts of people who are positive for hepatitis B or hepatitis C. Hepatitis B and hepatitis C tests are compulsory for healthcare workers.

Publicly funded treatment for hepatitis B There is a national policy that specifically and hepatitis C is available to Jordanians The government held events for World targets mother-to-child transmission of who seek treatment but have no insurance. Information was not provided on the Hepatitis Day 2012 and has funded other hepatitis B (Annex B). amount spent by the government on pubviral hepatitis public awareness campaigns since January 2011 (Annex A). There is a specific national strategy and/or licly funded treatment for hepatitis B and policy/guidelines for preventing hepatitis hepatitis C. The government collaborates with in- B and hepatitis C infection in health-care country civil society groups to develop and settings. Health-care workers are vaccinat- The following drugs for treating hepatitis implement its viral hepatitis prevention ed against hepatitis B prior to starting work B are on the national essential medicines and control programme, but information that might put them at risk of exposure to list or subsidized by the government: interferon alpha, pegylated interferon, lamivuwas not provided on the identity of these. blood. dine, adefovir dipivoxil and entecavir. The Evidence-based policy and data for There is a national policy on injection safe- following drugs for treating hepatitis C are action ty in health-care settings, which recom- on the national essential medicines list or There is routine surveillance for viral hepa- mends single-use syringes for therapeutic subsidized by the government: interferon titis. There is a national surveillance system injections. Single-use or auto-disable sy- alpha, pegylated interferon and ribavirin. for the following types of acute hepatitis: ringes, needles and cannulas are always A, B and C, and for the following types of available in all health-care facilities. The Government of Jordan welcomes aschronic hepatitis: B and C. sistance from WHO in one or more areas Official government estimates of the of viral hepatitis prevention and control There are standard case definitions for number and percentage of unnecessary (Annex C). hepatitis. Deaths, including from hepatitis, injections administered annually in healthare reported to a central registry. No hepa- care settings are not known. titis case is reported as “undifferentiated” or “unclassified” hepatitis.

Awareness-raising and partnerships

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Kuwait The Government of Kuwait reports as Population (in millions) (2011) 2.8 follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination $53 720 There is a written national strategy or plan Total health expenditure as % of GDP (2010) 2.63% that focuses exclusively on the prevention Per capita total health expenditure (PPP int $) (2010) $1132.54 and control of viral hepatitis. It includes Per capita government health expenditure (PPP int $) (2010) $910.20 components for raising awareness, surveil- Life expectancy at birth (in years) (2009) 78 lance, vaccination, prevention in general, Human Development Index (2011) 0.760 prevention of transmission via injecting Median age (in years) (2010) 28 drug use, prevention of transmission in Total fertility rate per woman (2010) 2.3 health-care settings, treatment and care, and coinfection with HIV. investigated. There is adequate laboratory There is a national policy relating to the There is a designated governmental unit/ capacity nationally to support investiga- prevention of viral hepatitis among peodepartment responsible solely for coordi- tion of viral hepatitis outbreaks and other ple who inject drugs. nating and/or carrying out viral hepatitis- surveillance activities. The government does not have guidelines related activities: Fighting Epidemics Unit, Preventive Medicine Department. It has There is a national public health research that address how hepatitis A and hepatieight staff members. It is not known how agenda for viral hepatitis. Viral hepatitis tis E can be prevented through food and many people work full-time on hepatitis- serosurveys are conducted regularly; the water safety. related activities in all government agen- target populations are children, the gen- Screening, care and treatment eral population and people who inject cies/bodies. drugs. The last serosurvey was carried out Health professionals obtain the skills and competencies required to effectively care The government has a viral hepatitis pre- in 2011. for people with viral hepatitis through vention and control programme that inschools for health professionals (pre-servcludes activities targeting the following Prevention of transmission There is a national policy on hepatitis A ice education), on-the-job training and specific populations: health-care workers postgraduate training. (including health-care waste handlers), vaccination. people who inject drugs, migrants, prisoners, people living with HIV, indigenous people, new army and police recruits, pregnant women and new employees. The government has established the goal of eliminating hepatitis B but did not provide information about a specific timeframe for this. Nationally, 95% of newborn infants in a given recent year received the first dose of hepatitis B vaccine within 24 hours of birth and 95% of one-year-olds (ages 12–23 months) in a given recent year received three doses of hepatitis B vaccine. There are national clinical guidelines for the management of viral hepatitis, which include recommendations for cases with HIV coinfection. The government has national policies relating to screening and referral to care for hepatitis B and hepatitis C. People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are free of charge for all individuals, and are compulsory for health-care workers, immigrants, pregnant women, prisoners, new recruits in the army and police, and new employees. Publicly funded treatment for hepatitis B and hepatitis C is available to the entire population. The amount spent by the government on such treatment for hepatitis B and hepatitis C is not known. The following drugs for treating hepatitis B are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon, lamivudine, entecavir and telbivudine. The following drugs for treating hepatitis C are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon, ribavirin, boceprevir and telaprevir. The Government of Kuwait welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C). 81

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012. Information was not provided on whether the government has funded other viral hepatitis public awareness campaigns since January 2011.

The government does not collaborate There is a national policy that specifically with in-country civil society groups to targets mother-to-child transmission of develop and implement its viral hepatitis hepatitis B (Annex B). prevention and control programme. There is a specific national strategy and/or Evidence-based policy and data for policy/guidelines for preventing hepatitis action B and hepatitis C infection in health-care There is routine surveillance for viral hepa- settings. Health-care workers are vaccititis. There is a national surveillance system nated against hepatitis B prior to starting for the following types of acute hepatitis: work that might put them at risk of expoA, B, C, D and E, but not for chronic hepa- sure to blood. titis B or hepatitis C. Information was not provided on whether there is a national There is a national policy on injection safesurveillance system for chronic hepatitis D. ty in health-care settings, which recommends single-use syringes for therapeutic There are standard case definitions for injections. Single-use or auto-disable syhepatitis. It is not known whether deaths, ringes, needles and cannulas are always including from hepatitis, are reported to a available in all health-care facilities. central registry. No hepatitis case is reported as “undifferentiated” or “unclassified” Official government estimates of the hepatitis. number and percentage of unnecessary injections administered annually in Liver cancer cases and cases with HIV/hep- health-care settings are not known. atitis coinfection are registered nationally. There is a national infection control policy The government publishes hepatitis dis- for blood banks. All donated blood units ease reports monthly. (including family donations) and blood Hepatitis outbreaks are required to be re- products nationwide are screened for ported to the government and are further hepatitis B and hepatitis C.

Chapter 5: WHO Eastern Mediterranean Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Lebanon Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 4.3 Upper–middle-income $14 470 7.03% $980.43 $383.95 74 0.739 29 1.8 injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

The Government of Lebanon reports differentiated” or “unclassified” hepatitis is The government has guidelines that address how hepatitis A and hepatitis E can as follows. not known. be prevented through food and water National coordination Liver cancer cases and cases with HIV/hep- safety. There is a written national strategy or plan atitis coinfection are registered nationally. Screening, care and treatment that focuses exclusively on the prevention and control of viral hepatitis. It includes The government publishes hepatitis dis- It is not known how health professionals obtain the skills and competencies recomponents for raising awareness, surveil- ease reports annually. quired to effectively care for people with lance, vaccination, prevention in general, prevention of transmission via injecting Hepatitis outbreaks are required to be re- viral hepatitis. drug use, prevention of transmission in ported to the government and are further health-care settings, treatment and care, investigated. There is adequate laboratory There are national clinical guidelines for capacity nationally to support outbreak in- the management of viral hepatitis, which and coinfection with HIV. vestigations and other surveillance activi- include recommendations for cases with There is a designated governmental unit/ ties for hepatitis A, hepatitis B and hepatitis HIV coinfection. There are national clinical guidelines for the management of HIV, department responsible solely for coordi- C, but not for hepatitis E. which include recommendations for coinnating and/or carrying out viral hepatitisrelated activities: the National Program for There is a national public health research fection with viral hepatitis. Prevention of Viral Hepatitis. It has three agenda for viral hepatitis. Viral hepatitis seThe government has national policies restaff members. There are three full-time rosurveys are not conducted regularly. lating to screening and referral to care for equivalent staff members who work on Prevention of transmission hepatitis-related activities in all govern- There is no national policy on hepatitis A hepatitis B and hepatitis C. ment agencies/bodies. vaccination. People testing for both hepatitis B and The government has a viral hepatitis pre- The government has established the goal hepatitis C register by name; the names are kept confidential within the system. Hepavention and control programme that in- of eliminating hepatitis B by 2020. titis B and hepatitis C tests are not free of cludes activities targeting the following specific populations: health-care workers Nationally, 90% of newborn infants in a charge and not compulsory for members (including health-care waste handlers), given recent year received the first dose of of any specific group. hepatitis B vaccine within 24 hours of birth Publicly funded treatment is available for people who inject drugs and prisoners. and 80% of one-year-olds (ages 12–23 Awareness-raising and partnerships months) in a given recent year received hepatitis B and hepatitis C. The following people are eligible for publicly funded The government did not hold events for three doses of hepatitis B vaccine. treatment for hepatitis B: patients with no World Hepatitis Day 2012 and has not funded other viral hepatitis public aware- There is a national policy that specifically social security coverage. Information was ness campaigns since January 2011. targets mother-to-child transmission of not provided on who is eligible for such treatment for hepatitis C. Information was hepatitis B (Annex B). not provided on the amount spent by the The government collaborates with the following in-country civil society groups to There is a specific national strategy and/or government on publicly funded treatment develop and implement its viral hepatitis policy/guidelines for preventing hepatitis for hepatitis B and hepatitis C. prevention and control programme: the B and hepatitis C infection in health-care Lebanese Red Cross, SIDC, Hep B and Leba- settings. Health-care workers are vaccinat- The following drugs for treating hepatitis B nese Scouts. ed against hepatitis B prior to starting work are on the national essential medicines list that might put them at risk of exposure to or subsidized by the government: pegylated interferon, lamivudine, entecavir and Evidence-based policy and data for blood. action tenofovir. The following drugs for treating There is routine surveillance for viral hepa- There is a national policy on injection safe- hepatitis C are on the national essential titis. There is a national surveillance system ty in health-care settings. It is not known medicines list or subsidized by the governfor the following types of acute hepatitis: what types of syringes the policy recom- ment: pegylated interferon and ribavirin. A, B and C, and for the following types of mends for therapeutic injections. Singlechronic hepatitis: B and C. use or auto-disable syringes, needles and The Government of Lebanon welcomes cannulas are always available in all health- assistance from WHO in one or more areas There are standard case definitions for care facilities. of viral hepatitis prevention and control hepatitis. Deaths, including from hepatitis, (Annex C). are reported to a central registry. The per- Official government estimates of the centage of hepatitis cases reported as “un- number and percentage of unnecessary

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Oman The Government of Oman reports as Population (in millions) (2011) follows. Country classification (2012) Gross national income per capita (PPP int $) (2011) National coordination There is a written national strategy or plan Total health expenditure as % of GDP (2010) that focuses primarily on the prevention Per capita total health expenditure (PPP int $) (2010) and control of viral hepatitis, but also inte- Per capita government health expenditure (PPP int $) (2010) grates other diseases. It includes compo- Life expectancy at birth (in years) (2009) nents for surveillance, vaccination, preven- Human Development Index (2011) tion in general, prevention of transmission Median age (in years) (2010) via injecting drug use, and prevention of Total fertility rate per woman (2010) transmission in health-care settings. There is no designated governmental unit/department responsible solely for coordinating and/or carrying out viral hepatitis-related activities. There are no people working full-time on hepatitis-related activities in any government agency/body. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific population: health-care workers (including health-care waste handlers). 2.8 High-income $25 720 2.77% $597.59 $478.87 74 0.705 25 2.3

There is no national public health research The government does not have guidelines agenda for viral hepatitis. Viral hepatitis se- that address how hepatitis A and hepatitis E can be prevented through food and rosurveys are not conducted regularly. water safety.

Prevention of transmission

Awareness-raising and partnerships

The government did not hold events for World Hepatitis Day 2012, but has funded other viral hepatitis public awareness campaigns since January 2011 (Annex A). There is a national policy that specifically The government does not collaborate targets mother-to-child transmission of with in-country civil society groups to hepatitis B (Annex B). develop and implement its viral hepatitis There is a specific national strategy and/or prevention and control programme. policy/guidelines for preventing hepatitis Evidence-based policy and data for B and hepatitis C infection in health-care settings. Health-care workers are vacciaction There is routine surveillance for viral hepa- nated against hepatitis B prior to starting titis. There is a national surveillance system work that might put them at risk of expofor the following types of acute hepatitis: sure to blood. A, B, C, D and E, but not for any type of There is a national policy on injection safechronic hepatitis. ty in health-care settings, which recomThere are standard case definitions for hepatitis. Hepatitis deaths are not reported to a central registry. Of hepatitis cases, 21.1% are reported as “undifferentiated” or “unclassified” hepatitis. Liver cancer cases are registered nationally, but cases with HIV/hepatitis coinfection are not. The government publishes hepatitis disease reports weekly.

There is no national policy on hepatitis A Screening, care and treatment Health professionals obtain the skills and vaccination. competencies required to effectively care The government has not established the for people with viral hepatitis through goal of eliminating hepatitis B. schools for health professionals (pre-service education). Nationally, 98% of newborn infants in a given recent year received the first dose of There are no national clinical guidelines hepatitis B vaccine within 24 hours of birth for the management of viral hepatitis or and 99% of one-year-olds (ages 12–23 for the management of HIV, which include months) in a given recent year received recommendations for coinfection with vithree doses of hepatitis B vaccine. ral hepatitis. The government has national policies relating to screening and referral to care for hepatitis B and hepatitis C. People testing for both hepatitis B and hepatitis C register by name, and there is open access to their names. Hepatitis B and hepatitis C tests are free of charge for all individuals and are compulsory for donors, patients on dialysis, prisoners, expatriate workers and health-care workers. Publicly funded treatment is not available for hepatitis B or hepatitis C.

Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory capacity nationally to support investiga- There is no national policy relating to the tion of viral hepatitis outbreaks and other prevention of viral hepatitis among people who inject drugs. surveillance activities.

mends single-use syringes for therapeutic injections. Single-use or auto-disable sy- The following drugs for treating hepatitis ringes, needles and cannulas are always B are on the national essential medicines list or subsidized by the government: inavailable in all health-care facilities. terferon alpha, pegylated interferon and Official government estimates of the lamivudine. The following drugs for treatnumber and percentage of unneces- ing hepatitis C are on the national essensary injections administered annually in tial medicines list or subsidized by the health-care settings are not known. government: interferon alpha, pegylated interferon and ribavirin. There is a national infection control policy for blood banks. All donated blood units The Government of Oman welcomes as(including family donations) and blood sistance from WHO in one or more areas products nationwide are screened for of viral hepatitis prevention and control hepatitis B and hepatitis C. (Annex C).

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Pakistan Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Pakistan reports as follows. 176.7 Lower–middle-income $2870 2.20% $58.72 $22.59 63 0.504 22 3.4 There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis C, but not for hepatitis B. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

National coordination There is no written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities: Provincial Hepatitis Control Programs. It is not known how many staff members this office has, or how many people work full-time on hepatitis-related activities in all government agencies/bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), people who inject drugs, prisoners and people living with HIV.

Awareness-raising and partnerships The government held events for World Hepatitis Day 2012 and has funded other viral hepatitis public awareness campaigns since January 2011 (Annex A). The government does not collaborate with in-country civil society groups to develop and implement its viral hepatitis prevention and control programme.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for acute hepatitis A, but not for any type of chronic hepatitis. There are standard case definitions for hepatitis. Hepatitis deaths are not reported to a central registry. Information was not provided regarding the percentage of hepatitis cases reported as “undifferentiated” or “unknown” hepatitis. Liver cancer cases are not registered nationally, but cases with HIV/hepatitis coinfection are.

The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water The government has published one hepa- safety. titis disease report that described a national hepatitis prevalence study conducted in Screening, care and treatment Health professionals obtain the skills and 2008. competencies required to effectively care Hepatitis outbreaks are required to be re- for people with viral hepatitis through ported to the government and are further schools for health professionals (pre-servinvestigated. There is adequate laboratory ice education), on-the-job training and capacity nationally to support investiga- postgraduate training. tion of viral hepatitis outbreaks and other There are national clinical guidelines for surveillance activities. the management of viral hepatitis, which There is no national public health research include recommendations for cases with agenda for viral hepatitis. Viral hepatitis se- HIV coinfection. There are national clinirosurveys are not conducted regularly. cal guidelines for the management of HIV, which include recommendations for coinPrevention of transmission fection with viral hepatitis. There is no national policy on hepatitis A vaccination. The government does not have national policies relating to screening and referral The government has not established the to care for hepatitis B or hepatitis C. goal of eliminating hepatitis B. People testing for both hepatitis B and Nationally, no newborn infant in a given hepatitis C register by name, and there recent year received the first dose of hepa- is open access to their names. Hepatitis B titis B vaccine within 24 hours of birth and and hepatitis C tests are not free of charge 56% of one-year-olds (ages 12–23 months) and not compulsory for members of any in a given recent year received three doses specific group. of hepatitis B vaccine. Publicly funded treatment for hepatitis B There is a national policy that specifically and hepatitis C is available to patients who targets mother-to-child transmission of cannot pay for treatment. The government hepatitis B (Annex B). spends PRs 200–300 million (US$ 2.1–3.2 There is a specific national strategy and/or million) per province annually on publicly policy/guidelines for preventing hepatitis funded treatment for hepatitis B and hepaB and hepatitis C infection in health-care titis C. settings. Health-care workers are vaccinat- The following drugs for treating hepatitis ed against hepatitis B prior to starting work B are on the national essential medicines that might put them at risk of exposure to list or subsidized by the government: interblood. feron alpha, pegylated interferon, lamivuThere is no national policy on injection dine and entecavir. The following drugs for safety in health-care settings. Single-use treating hepatitis C are on the national esor auto-disable syringes, needles and can- sential medicines list or subsidized by the nulas are not always available in all health- government: interferon alpha, pegylated interferon and ribavirin. care facilities. Twenty per cent of injections administered The Government of Pakistan welcomes annually in health-care settings are unnec- assistance from WHO in one or more aressary, according to official government eas of viral hepatitis prevention and control (Annex C). estimates.

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Qatar The Government of Qatar reports as Population (in millions) (2011) 1.9 follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination $86 440 There is no written national strategy or Total health expenditure as % of GDP (2010) 1.81% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $1622.47 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $1256.65 Life expectancy at birth (in years) (2009) hepatitis. 78 Human Development Index (2011) 0.831 There is a designated governmental unit/ Median age (in years) (2010) 32 department responsible solely for coordi- Total fertility rate per woman (2010) 2.3 nating and/or carrying out viral hepatitisrelated activities, but its name was not provided. It has three staff members. There There is a national public health research tis E can be prevented through food and are 15 full-time equivalent staff members agenda for viral hepatitis. Viral hepatitis water safety. who work on hepatitis-related activities in serosurveys are not conducted regularly. Screening, care and treatment all government agencies/bodies. Prevention of transmission Health professionals obtain the skills and The government has a viral hepatitis pre- There is a national policy on hepatitis A competencies required to effectively care for people with viral hepatitis through vention and control programme that in- vaccination. schools for health professionals (pre-servcludes activities targeting the following specific populations: health-care workers The government has not established the ice education), on-the-job training and postgraduate training. (including health-care waste handlers), goal of eliminating hepatitis B. people who inject drugs, migrants, prison- Nationally, 100% of newborn infants in a There are national clinical guidelines for ers and expatriates. given recent year received the first dose of the management of viral hepatitis, which Awareness-raising and partnerships hepatitis B vaccine within 24 hours of birth include recommendations for cases with The government held events for World and 95% of one-year-olds (ages 12–23 HIV coinfection. Hepatitis Day 2012 and has funded other months) in a given recent year received The government has national policies reviral hepatitis public awareness cam- three doses of hepatitis B vaccine. lating to screening and referral to care for paigns since January 2011 (Annex A). There is a national policy that specifically hepatitis B and hepatitis C. The government collaborates with the fol- targets mother-to-child transmission of People testing for both hepatitis B and lowing in-country civil society group to hepatitis B (Annex B). develop and implement its viral hepatitis There is a specific national strategy and/or hepatitis C register by name; the names prevention and control programme: the policy/guidelines for preventing hepatitis are kept confidential within the system. Hepatitis B and hepatitis C tests are free of Qatar Red Crescent Society. B and hepatitis C infection in health-care charge for all individuals and compulsory Evidence-based policy and data for settings. Health-care workers are vacci- for pregnant women, couples planning to nated against hepatitis B prior to starting marry, prisoners and expatriates. Hepatitis action There is routine surveillance for viral hepa- work that might put them at risk of expo- C tests are compulsory for certain groups but information was not provided regardtitis. There is a national surveillance system sure to blood. for the following types of acute hepatitis: There is a national policy on injection safe- ing which groups. A, B, C and E, and for the following types ty in health-care settings, which recomof chronic hepatitis: B and C. Information mends single-use syringes for therapeutic Publicly funded treatment for hepatitis B was not provided on whether there is a injections. Single-use or auto-disable sy- and hepatitis C is available to the entire national surveillance system for chronic ringes, needles and cannulas are always population. The amount spent by the government on such treatment for hepatitis B hepatitis D. available in all health-care facilities. and hepatitis C is not known. There are standard case definitions for Official government estimates of the hepatitis. Deaths, including from hepatitis, number and percentage of unneces- The following drugs for treating hepatitis B are reported to a central registry. Of hepa- sary injections administered annually in are on the national essential medicines list or subsidized by the government: intertitis cases, 0.38% is reported as “undiffer- health-care settings are not known. feron alpha, pegylated interferon, lamivuentiated” or “unclassified” hepatitis. dine, adefovir, entecavir, telbivudine and There is a national infection control policy Liver cancer cases and cases with HIV/hep- for blood banks. All donated blood units tenofovir. The following drugs for treating atitis coinfection are registered nationally. (including family donations) and blood hepatitis C are on the national essential medicines list or subsidized by the governThe government publishes hepatitis dis- products nationwide are screened for ment: interferon alpha, pegylated interferhepatitis B and hepatitis C. ease reports annually and also internally on, ribavirin, boceprevir and telaprevir. every six months. There is no national policy relating to the The Government of Qatar welcomes asHepatitis outbreaks are required to be re- prevention of viral hepatitis among peo- sistance from WHO in one or more areas ported to the government and are further ple who inject drugs. of viral hepatitis prevention and control investigated. There is adequate laboratory The government does not have guidelines (Annex C). capacity nationally to support investiga- that address how hepatitis A and hepatition of viral hepatitis outbreaks and other surveillance activities.

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Somalia There is no national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepThe Government of Somalia reports as Liver cancer cases are registered nationally, atitis B, but information was not provided follows. but cases with HIV/hepatitis coinfection on whether this is the case for hepatitis C. are not. National coordination There is no national policy relating to the There is no written national strategy or plan The government does not publish hepati- prevention of viral hepatitis among people that focuses exclusively or primarily on the tis disease reports. who inject drugs. prevention and control of viral hepatitis. Hepatitis outbreaks are required to be The government does not have guidelines There is no designated governmental unit/ reported to the government but are not that address how hepatitis A and hepatitis department responsible solely for coordi- further investigated. There is adequate E can be prevented through food and wanating and/or carrying out viral hepatitis- laboratory capacity nationally to support ter safety. related activities. It is not known how many investigation of viral hepatitis outbreaks Screening, care and treatment people work full-time on hepatitis-related and other surveillance activities. It was not known how health professionactivities in all government agencies/bodThere is no national public health research als obtain the skills and competencies reies. agenda for viral hepatitis. Viral hepatitis se- quired to effectively care for people with The government does not have a viral hep- rosurveys are not conducted regularly. viral hepatitis. atitis prevention and control programme There are no national clinical guidelines that includes activities targeting specific Prevention of transmission There is no national policy on hepatitis A for the management of viral hepatitis, populations. vaccination. but there are for the management of HIV, Awareness-raising and partnerships which include recommendations for coinThe government held events for World The government has not established the fection with viral hepatitis. Hepatitis Day 2012, but has not funded goal of eliminating hepatitis B. People testing for both hepatitis B and other viral hepatitis public awareness camNationally, no newborn infant in a given hepatitis C register by name; the names are paigns since January 2011. recent year received the first dose of hepa- kept confidential within the system. HepaThe government does not collaborate with titis B vaccine within 24 hours of birth and titis B and hepatitis C tests are not free of in-country civil society groups to develop no one-year-old (ages 12–23 months) in a charge and not compulsory for members and implement its viral hepatitis preven- given recent year received three doses of of any specific group. hepatitis B vaccine. tion and control programme. Publicly funded treatment is not available Evidence-based policy and data for There is no national policy that specifically for hepatitis B or hepatitis C. targets mother-to-child transmission of action There is no routine surveillance for viral hepatitis B. No drug for treating hepatitis B or hepatitis hepatitis. C is on the national essential medicines list There is no specific national strategy and/ or subsidized by the government. There are standard case definitions for or policy/guidelines for preventing hepatihepatitis. Deaths, including from hepatitis, tis B and hepatitis C infection in health-care The Government of Somalia welcomes asare reported to a central registry. The per- settings. sistance from WHO in one or more areas centage of hepatitis cases reported as “unof viral hepatitis prevention and control differentiated” or “unclassified” hepatitis is There is no national policy on injection (Annex C). safety in health-care settings. Single-use not known. Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 9.6 Low-income ----51 -18 6.3 or auto-disable syringes, needles and cannulas are always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known.

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South Sudan The Government of South Sudan reports Population (in millions) (2011) -as follows. Country classification (2012) Lower–middle-income Gross national income per capita (PPP int $) (2011) National coordination -There is no written national strategy or Total health expenditure as % of GDP (2010) -plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) -rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) -Life expectancy at birth (in years) (2009) hepatitis. -Human Development Index (2011) -There is a designated governmental unit/ Median age (in years) (2010) -department responsible solely for coordi- Total fertility rate per woman (2010) -nating and/or carrying out viral hepatitisrelated activities: Emergency Preparedness and Response Department. It has five There is no national public health research The government does not have guidelines staff members. It is not known how many agenda for viral hepatitis. Viral hepatitis se- that address how hepatitis A and hepatitis E can be prevented through food and people work full-time on hepatitis-related rosurveys are not conducted regularly. water safety. activities in all government agencies/bodPrevention of transmission ies. There is no national policy on hepatitis A Screening, care and treatment Health professionals obtain the skills and The government does not have a viral vaccination. competencies required to effectively care hepatitis prevention and control programme that includes activities targeting The government has not established the for people with viral hepatitis through goal of eliminating hepatitis B. schools for health professionals (pre-servspecific populations. ice education) and on-the-job training. Awareness-raising and partnerships It is not known what percentage of newborn infants nationally in a given recent There are no national clinical guidelines The government did not hold events for World Hepatitis Day 2012 and has not year received the first dose of hepatitis B for the management of viral hepatitis, funded other viral hepatitis public aware- vaccine within 24 hours of birth or what but there are for the management of HIV, percentage of one-year-olds (ages 12–23 which include recommendations for coinness campaigns since January 2011. months) in a given recent year received fection with viral hepatitis. The government does not collaborate three doses of hepatitis B vaccine. The government does not have national with in-country civil society groups to develop and implement its viral hepatitis There is no national policy that specifically policies relating to screening and referral targets mother-to-child transmission of to care for hepatitis B or hepatitis C. prevention and control programme. hepatitis B. People testing for both hepatitis B and Evidence-based policy and data for There is no specific national strategy and/ hepatitis C register by name; the names action There is routine surveillance for viral hepa- or policy/guidelines for preventing hepa- are kept confidential within the system. titis. There is a national surveillance system titis B and hepatitis C infection in health- Hepatitis B and hepatitis C tests are not free of charge for all individuals, but they for the following types of acute hepatitis: care settings. B, C and E, but not for any type of chronic There is no national policy on injection are free of charge and compulsory for blood donors. hepatitis. safety in health-care settings. Single-use or auto-disable syringes, needles and canPublicly funded treatment for hepatitis B There are no standard case definitions for hepatitis. Deaths, including from hepatitis, nulas are always available in all health-care and hepatitis C is available to the entire population. The amount spent by the govare reported to a central registry. The per- facilities. centage of hepatitis cases reported as “un- Official government estimates of the ernment on such treatment for hepatitis B differentiated” or “unclassified” hepatitis is number and percentage of unneces- and hepatitis C is not known. not known. sary injections administered annually in The following drugs for treating hepatitis B are on the national essential medicines Liver cancer cases are registered nation- health-care settings are not known. ally, but cases with HIV/hepatitis coinfec- There is no national infection control list or subsidized by the government: lamivudine and tenofovir. No drug for treattion are not. policy for blood banks. All donated blood ing hepatitis C is on the national essential units (including family donations) and The government does not publish hepatimedicines list or subsidized by the governblood products nationwide are screened tis disease reports. ment. for hepatitis B and hepatitis C. Hepatitis outbreaks are required to be reThe Government of South Sudan welported to the government and are further There is no national policy relating to the comes assistance from WHO in one or investigated. There is inadequate labora- prevention of viral hepatitis among peo- more areas of viral hepatitis prevention tory capacity nationally to support inves- ple who inject drugs. and control (Annex C). tigation of viral hepatitis outbreaks and other surveillance activities.

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Sudan Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 44.6 Lower–middle-income $2120 6.32% $141.39 $42.16 59 0.408 20 4.4 Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

There is no national policy relating to the prevention of viral hepatitis among people The Government of Sudan reports as Liver cancer cases and cases with HIV/ who inject drugs. follows. hepatitis coinfection are not registered naThe government does not have guidelines tionally. National coordination that address how hepatitis A and hepatitis There is a written national strategy or plan The government publishes hepatitis dis- E can be prevented through food and wathat focuses primarily on the prevention ease reports weekly. ter safety. and control of viral hepatitis, and also integrates other diseases. It includes com- Hepatitis outbreaks are required to be re- Screening, care and treatment ponents for raising awareness, surveillance ported to the government and are further Health professionals obtain the skills and investigated. There is inadequate laborato- competencies required to effectively care and prevention in general. ry capacity nationally to support investiga- for people with viral hepatitis through There is no designated governmental unit/ tion of viral hepatitis outbreaks and other schools for health professionals (pre-servdepartment responsible solely for coordi- surveillance activities. ice education) and on-the-job training. nating and/or carrying out viral hepatitisrelated activities. Information was not pro- There is a national public health research There are no national clinical guidelines vided regarding how many people work agenda for viral hepatitis. Viral hepatitis se- for the management of viral hepatitis, or for the management of HIV, which include full-time on hepatitis-related activities in all rosurveys are not conducted regularly. recommendations for coinfection with vigovernment agencies/bodies. Prevention of transmission ral hepatitis. There is no national policy on hepatitis A The government does not have a viral hepThe government does not have national atitis prevention and control programme vaccination. policies relating to screening and referral that includes activities targeting specific The government has not established the to care for hepatitis B or hepatitis C. populations. goal of eliminating hepatitis B. People testing for both hepatitis B and Awareness-raising and partnerships The government held events for World Nationally, no newborn infant in a given hepatitis C register by name; the names Hepatitis Day 2012, but has not funded recent year received the first dose of hepa- are kept confidential within the system. other viral hepatitis public awareness cam- titis B vaccine within 24 hours of birth and Hepatitis B and hepatitis C tests are free of 93% of one-year-olds (ages 12–23 months) charge for all individuals and compulsory paigns since January 2011. in a given recent year received three doses for blood donors. The government does not collaborate with of hepatitis B vaccine. Publicly funded treatment is not available in-country civil society groups to develop and implement its viral hepatitis preven- There is no national policy that specifically for hepatitis B or hepatitis C. targets mother-to-child transmission of tion and control programme. hepatitis B. The following drug for treating hepatitis B is on the national essential medicines list or Evidence-based policy and data for There is no specific national strategy and/ subsidized by the government: ribavirin. action There is routine surveillance for viral hepa- or policy/guidelines for preventing hepatititis. There is a national surveillance system tis B and hepatitis C infection in health-care The Government of Sudan welcomes assistance from WHO in one or more areas for acute hepatitis A, but not for any type of settings. of viral hepatitis prevention and control chronic hepatitis. There is a national policy on injection safe- (Annex C). There are standard case definitions for ty in health-care settings, which recomhepatitis. Deaths, including from hepatitis, mends single-use syringes for therapeuare reported to a central registry. Of hepati- tic injections. Single-use or auto-disable tis cases, 90% are reported as “undifferenti- syringes, needles and cannulas are always available in all health-care facilities. ated” or “unclassified” hepatitis.

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Syrian Arab Republic The Government of the Syrian Arab Population (in millions) (2011) 20.8 Republic reports as follows. Country classification (2012) Lower–middle-income Gross national income per capita (PPP int $) (2011) National coordination $5080 There is no written national strategy or Total health expenditure as % of GDP (2010) 3.41% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $174.20 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $80.13 Life expectancy at birth (in years) (2009) hepatitis. 74 Human Development Index (2011) 0.632 There is a designated governmental unit/ Median age (in years) (2010) 21 department responsible solely for coordi- Total fertility rate per woman (2010) 2.9 nating and/or carrying out viral hepatitisrelated activities: the Viral Hepatitis Control Unit. It has four staff members. It is not not provided on whether viral hepatitis Screening, care and treatment Health professionals obtain the skills and known how many people work full-time serosurveys are conducted regularly. competencies required to effectively care on hepatitis-related activities in all governPrevention of transmission for people with viral hepatitis through ment agencies/bodies. Information was not provided on whether schools for health professionals (pre-servInformation was not provided on wheth- there is a national policy for hepatitis A ice education), on-the-job training and er the government has a viral hepati- vaccination or whether the government postgraduate training. tis prevention and control programme has established the goal of eliminating There are national clinical guidelines for that includes activities targeting specific hepatitis B. the management of viral hepatitis, but populations. Information was not provided on the per- they do not include recommendations for Awareness-raising and partnerships centage of newborn infants nationally cases with HIV coinfection. Information was not provided on whether in a given recent year who received the the government held events for World first dose of hepatitis B vaccine within 24 The government has national policies reHepatitis Day 2012 or has funded other vi- hours of birth or the percentage of one- lating to screening and referral to care for ral hepatitis public awareness campaigns year-olds nationally (ages 12–23 months) hepatitis B and hepatitis C. since January 2011. in a given recent year who received three People testing for both hepatitis B and doses of hepatitis B vaccine. The government collaborates with the hepatitis C register by name; the names following in-country civil society groups Information was not provided on whether are kept confidential within the system. to develop and implement its viral hepa- there is a national policy that specifically Hepatitis B and hepatitis C tests are not titis prevention and control programme: targets mother-to-child transmission of free of charge for all individuals, but they Syrian Red Crescent Society and Syrian hepatitis B. are free of charge for blood donors. HepaFamily Planning Association. titis B and hepatitis C tests are compulInformation was not provided on whether sory for blood donors, couples planning Evidence-based policy and data for there is a specific national strategy and/or to marry, patients on haemodialysis and action policy/guidelines for preventing hepatitis those who undergo frequent haemotransThere is routine surveillance for viral hepa- B and hepatitis C infection in health-care fusion. titis. There is a national surveillance system settings. for the following types of acute hepatitis: Publicly funded treatment for hepatitis A, B, C, D and E, and for the following types There is a national policy on injection safe- B and hepatitis C is available to Syrian ty in health-care settings, which recom- citizens and refugees. The government of chronic hepatitis: B, C and D. mends single-use syringes for therapeutic spends LS 700 000 (US$ 11 112) per paThere are standard case definitions for injections. Single-use or auto-disable sy- tient annually on publicly funded treathepatitis. Hepatitis deaths are not report- ringes, needles and cannulas are always ment for hepatitis B and hepatitis C. ed to a central registry. Information was available in all health-care facilities. not provided on the percentage of hepaThe following drugs for treating hepatitis B titis cases reported as “undifferentiated” or Official government estimates of the are on the national essential medicines list number and percentage of unneces- or subsidized by the government: inter“unknown” hepatitis. sary injections administered annually in feron alpha, pegylated interferon, lamivuLiver cancer cases and cases with HIV/hep- health-care settings are not known. dine, adefovir dipivoxil, entecavir, telbivuatitis coinfection are registered nationally. There is a national infection control policy dine and tenofovir. The following drugs for The government publishes hepatitis dis- for blood banks. All donated blood units treating hepatitis C are on the national esease reports quarterly. (including family donations) and blood sential medicines list or subsidized by the products nationwide are screened for government: interferon alpha, pegylated interferon and ribavirin. Hepatitis outbreaks are required to be hepatitis B and hepatitis C. reported to the government and are further investigated. Information was not There is no national policy relating to the The Government of the Syrian Arab Reprovided on whether there is adequate prevention of viral hepatitis among peo- public welcomes assistance from WHO in one or more areas of viral hepatitis prevenlaboratory capacity nationally to support ple who inject drugs. tion and control (Annex C). investigation of viral hepatitis outbreaks The government has guidelines that adand other surveillance activities. dress how hepatitis A and hepatitis E can There is a national public health research be prevented through food and water agenda for viral hepatitis. Information was safety.

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Yemen Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Yemen reports as follows. It is not known whether there is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide Liver cancer cases and cases with HIV/ are screened for hepatitis B and hepatitis C. hepatitis coinfection are not registered naThere is no national policy relating to the tionally. prevention of viral hepatitis among people The government publishes hepatitis dis- who inject drugs. ease reports weekly. The government does not have guidelines Hepatitis outbreaks are required to be re- that address how hepatitis A and hepatitis ported to the government and are further E can be prevented through food and wainvestigated. There is adequate laboratory ter safety. capacity nationally to support investigation of viral hepatitis outbreaks and other Screening, care and treatment Health professionals obtain the skills and surveillance activities. competencies required to effectively care It is not known whether there is a national for people with viral hepatitis through public health research agenda for viral schools for health professionals (pre-servhepatitis. Viral hepatitis serosurveys are not ice education). conducted regularly. There are no national clinical guidelines for Prevention of transmission the management of viral hepatitis. InforThere is no national policy on hepatitis A mation was not provided on whether there vaccination. are national clinical guidelines for the management of HIV, which include recommenThe government has not established the dations for coinfection with viral hepatitis. goal of eliminating hepatitis B. The government does not have national Nationally, no newborn infant in a given policies relating to screening and referral recent year received the first dose of hepa- to care for hepatitis B or hepatitis C. titis B vaccine within 24 hours of birth and 81% of one-year-olds (ages 12–23 months) People testing for both hepatitis B and in a given recent year received three doses hepatitis C register by name; the names are of hepatitis B vaccine. kept confidential within the system. Hepatitis B and hepatitis C tests are not free of There is no national policy that specifically charge or compulsory for members of any targets mother-to-child transmission of specific group. hepatitis B. Publicly funded treatment is not available There is a specific national strategy and/or for hepatitis B or hepatitis C. policy/guidelines for preventing hepatitis B and hepatitis C infection in health-care No drug for treating hepatitis B or hepatitis settings. Health-care workers are not vac- C is on the national essential medicines list cinated against hepatitis B prior to starting or subsidized by the government. work that might put them at risk of expoThe Government of Yemen welcomes assure to blood. sistance from WHO in one or more areas There is a national policy on injection of viral hepatitis prevention and control safety in health-care settings, which rec- (Annex C). ommends single-use and auto-disable syringes for therapeutic injections. Single24.8 Lower–middle-income $2170 5.18% $122.18 $29.52 65 0.462 4 5.2 use or auto-disable syringes, needles and cannulas are not always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known.

National coordination There is no written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities: Disease Control and Surveillance, General Directorate. It has two staff members. It is not known how many people work full-time on hepatitis-related activities in all government agencies/ bodies. The government does not have a viral hepatitis prevention and control programme that includes activities targeting specific populations.

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. The government does not collaborate with in-country civil society groups to develop and implement its viral hepatitis prevention and control programme.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B and C. Information was not provided on whether there is a national surveillance system for acute hepatitis D or hepatitis E. There is no national surveillance system for any type of chronic hepatitis. There are standard case definitions for hepatitis. Hepatitis deaths are not reported to a central registry. The percentage of hepatitis cases reported as “undifferentiated” or “unclassified” hepatitis is not known.

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Chapter 6:

WHO European Region

The 53 Member States of the World Health Organization (WHO) European Region together have a population of 899 million, with the Russian Federation accounting for approximately one six of this total.1 The European Region, which includes 45 highincome and upper–middle-income countries,2 is characterized by increasing life expectancy and a health profile shaped more by noncommunicable than by communicable diseases. At the same time, the widely varying social, political and economic circumstances of different countries translate into markedly different health needs and health outcomes at the national and subnational levels. While the European Region’s under-five mortality rate of 7.9 per 1000 live births is the lowest in the world, some countries in the Region have considerably higher and lower rates.3 Average life expectancy for the Region reached 76 years in 2010, with a 13-year difference between the lowest and highest national averages (69 and 82 years, respectively).3 By 2050, more than one fourth of the Region’s population will be aged 65 years or older.3 This trend is one factor driving the increase in noncommunicable disease rates in the European Region, but lifestyle factors are also thought to play a major role in shaping the health of the population. The European Region has the highest prevalence of tobacco use among all WHO regions, as well as the highest alcohol consumption. 3 Noncommunicable diseases account for some 80% of deaths in the European Region, with circulatory diseases causing almost half of all mortality.3 In 28 countries of the European Region, cancer is the leading cause of premature death. Among men, the forms of cancer resulting in the highest mortality are lung, colon, stomach and prostate cancer; among women, they are breast, lung, stomach, colon, cervical and ovarian cancer3. Communicable diseases that contribute notably to the disease burden include viral hepatitis, tuberculosis, HIV infection and sexually transmitted infections.3 Tuberculosis causes more than 40% of all deaths from communicable diseases,3 and some countries in central and eastern Europe have an especially high burden of multidrug-resistant tuberculosis.4 Although new HIV infections are decreasing globally, the eastern part of the European Region has the fastest-growing HIV epidemic in the world,4 a trend driven largely by injecting drug use.5

Viral hepatitis in the WHO European Region The seroprevalence and incidence of hepatitis A vary geographically, increasing from west (<50% exposed by the age of 30 years) to east (≥50% exposed by the age of 30 years).a Although the total number of cases is decreasing, hepatitis A infection is still an important public health threat in the Region, with a potential for outbreaks.b Hepatitis E is responsible for fewer than 5% of cases of acute hepatitis in western Europe and, in most studies, antibodies against hepatitis E have been found in a small proportion (0%–10%) of healthy persons; for other parts of Europe, the prevalence is higher, reaching up to 27.8%.c In the WHO European Region, over 13 million adults are living with hepatitis B and 15 million with hepatitis C.d This data suggest that almost one in fifty adults is infected with hepatitis B and a similar proportion of people have chronic hepatitis C. Most of those infected in the WHO European Region live in eastern European and central Asian countries: 66% of those with hepatitis B and 64% of those with hepatitis C.d People who inject drugs are the most affected (15% for hepatitis B and 44% for hepatitis C), but infection is also common in other vulnerable population groups such as men who have sex with men (8.7% and 4.2%, respectively), and sex workers (3.3% and 11%, respectively).d By comparison, rates in the general population of countries in the European Region outside the European Union and European Free Trade Association are 3.8% for hepatitis B and 2.3 % for hepatitis C.d

1

World population prospects: the 2010 revision. New York, United Nations, Department of Economic and Social Affairs, Population Division, 2011. 2 The World Bank. Country and lending groups [web site]. Available at: http:// data.worldbank.org/about/country-classifications/country-and-lendinggroups#Europe_and_Central_Asia (accessed on 11 May 2013). 3 The European health report 2012: charting the way to well-being. Geneva, World Health Organization Regional Office for Europe, 2013. 4 Global tuberculosis report 2012. Geneva, World Health Organization, 2012. Available at: http://www.who.int/tb/publications/global_report/gtbr12_main. pdf (accessed on 11 May 2013). 5 UNAIDS. Regional fact sheet 2012: eastern Europe and central Asia. Available at: http://www.unaids.org/en/media/unaids/contentassets/documents/epidemio logy/2012/gr2012/2012_FS_regional_ecca_en.pdf (accessed on 11 May 2013).

a

Jacobsen K. The global prevalence of hepatitis A virus infection and susceptibility: a systematic review. Geneva, Department of Immunization, Vaccines and Biologicals, World Health Organization, 2010 [WHO/IVB 10.01]. b Payne L. Hepatitis A in the European Union: responding to challenges related to new epidemiological patterns. Eurosurveillance, 2009, 14:3. c Aggarwal R. The global prevalence of hepatitis E virus infection and susceptibility: a systematic review. Geneva, World Health Organization, 2010. d Hope VD, Eramova I, Capurro D, Donoghoe MC. Prevalence and estimation of hepatitis B and C infections in the WHO EuropeanRegion: a review of data focusing on the countries outside the European Union and the European Free Trade Association. Epidemiology and Infection, 2013, 29:1-17.

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Responses to the WHO/Alliance survey were received from 44 of the 53 Member States in the European Region (83.0%). Box 1. Responses to the 2012 Global Hepatitis Survey: WHO European Region

Member States that submitted surveys: • Albania • Andorra • Armenia • Austria • Azerbaijan • Belarus • Belgium • Bulgaria • Croatia • Cyprus • Czech Republic • Denmark • Estonia • Finland • France • Georgia • Germany • Hungary • Ireland • Israel • Italy • Kyrgyzstan • Latvia • Lithuania • Luxembourg • Malta • Montenegro • Netherlands • Poland • Republic of Moldova • Russian Federation • San Marino • Serbia • Slovakia • Slovenia • Spain • Sweden • Switzerland • Tajikistan • The former Yugoslav • Republic of Macedonia • Turkey • Ukraine • United Kingdom of Great Britain and Northern Ireland • Uzbekistan

National coordination Thirteen responding Member States (29.5%) reported the existence of a written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis (Figure 1). Four of the 13 Member States with a strategy or plan (the Czech Republic, France, Kyrgyzstan and the Republic of Moldova) reported that it focuses exclusively on viral hepatitis, and seven (Armenia, Austria, Denmark, Israel, Russian Federation, Slovenia and Uzbekistan) reported that it addresses other diseases as well. One country (Turkey) reported that the strategy or plan addresses only hepatitis B, and one (the United Kingdom of Great Britain and Northern Ireland) reported that it addresses only hepatitis C. The 13 Member States that reported the existence of a strategy or plan were asked about its specific components. All 13 reported the inclusion of a component for prevention of transmission in health-care settings. Twelve reported the inclusion of components for surveillance, vaccination and prevention of transmission via injecting drug use. Eleven reported the inclusion of components for general prevention, and treatment and care. Eight reported the inclusion of components for raising awareness and coinfection with HIV. Seven responding Member States (15.9%) reported that they have a governmental unit or department responsible solely for viral hepatitis-related activities.a Member States that did so were a

Member States that did not submit surveys: • Bosnia and Herzegovina • Greece • Iceland • Kazakhstan • Monaco • Norway • Portugal • Romania • Turkmenistan

One Member State responded that there is no governmental unit but a special national multidisciplinary expert team responsible for hepatitis-related activities.

Figure 1. Responses to the question, “Is there a written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis?”

Yes No

No response No data

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asked to indicate the number of staff members in the unit or department. Responses (N=5) ranged from 2 to 7 (median, 3), with the Republic of Moldova reporting the largest number. Member States were asked to report the number of people working full-time on hepatitis-related activities in all government agencies or bodies. Among the 13 Member States that provided data for this question, the number ranged from 0 to 213 (median, 1.5), with Armenia reporting the largest number. Thirty-four responding Member States (77.3%) reported that they have a viral hepatitis prevention and control programme that includes activities targeting specific populations. The populations most commonly targeted are people who inject drugs (91.2% of responding Member States within this subset) and health-care workers, including health-care waste handlers (94.1% of responding Member States within this subset). Twenty-one responding Member States reported the inclusion of activities targeting people living with HIV, and 17 reported the inclusion of activities targeting prisoners. Groups identified less frequently included migrants, indigenous populations, lowincome populations, those who are uninsured and those who are homeless. Table 1. Topics of public awareness campaigns on viral hepatitis held in Member States since January 2011 (N=10)

Awareness-raising and partnerships Seventeen responding Member States (38.6%) reported that they had held events for World Hepatitis Day 2012 (28 July). Since January 2011, ten responding Member States (22.7%) had funded some type of viral hepatitis public awareness campaign other than World Hepatitis Day (Table 1). Twenty-nine responding Member States (65.9%) reported that they collaborated with civil society groups within their countries to develop and implement the governmental viral hepatitis prevention and control programme. For example, Armenia reported collaborating with the Armenian Hepatitis Forum and the Netherlands reported collaborating with the National Hepatitis Centrum. (Further examples can be found in the summaries of country findings later in this chapter.)

Evidence-based policy and data for action Forty-three responding Member States (97.7%) reported that they have routine surveillance for viral hepatitis; details appear in Table 2. Forty-two responding Member States (95.5%) indicated that their countries have standard case definitions for hepatitis infection and 42 (95.5%) indicated that their countries have a central registry for the reporting of deaths, including hepatitis deaths. Table 2. Types of surveillance in Member States that reported the existence of routine surveillance for viral hepatitis (N=43) No Yes (%) No (%) Do not know response (%) (%) There is a national surveillance system for acute hepatitis infection for the following forms of hepatitis: hepatitis A hepatitis B hepatitis C hepatitis D hepatitis E 100 100 95.3 46.5 55.8 0 0 4.7 41.9 30.2 0 0 0 0 0 0 0 0 11.6 14.0

United Kingdom of Great Britain and Northern Ireland X

General information about hepatitis and its transmission Vaccination for hepatitis A and hepatitis B Importance of knowing one’s hepatitis B and hepatitis C status Safe water and good sanitation Safer sex practices Harm reduction for people who inject drugs Safe workplace practices

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Russian Federation X X X X

Netherlands

Republic of Moldova

Armenia

Slovenia

Sweden

Belarus

Croatia

Turkey

X

X

X

X

X

X

X

X X X X X

X X X X X

There is a national surveillance system for chronic hepatitis infection for the following forms of hepatitis: hepatitis B hepatitis C hepatitis D 65.1 62.8 30.2 32.6 34.9 62.8 0 0 0 2.3 2.3 7.0

X

X X

X X

X X

X X

X X

X

X

X X

X

X X

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Twenty-nine Member States reported on the proportion of hepatitis cases and deaths registered as “undifferentiated” or “unclassified” hepatitis. The reported proportions ranged from 0% to 21.0% (median, 1.0%).a Additional survey findings about surveillance are presented in Table 3. Table 3. Data registration and surveillance (N=44) No Yes (%) No (%) Do not know response (%) (%) Liver cancer cases are registered nationally Cases with HIV/hepatitis coinfection are registered nationally Hepatitis outbreaks are reported If YES – Hepatitis outbreaks are further investigated (N=115) 79.5 65.9 95.5 100 18.2 34.1 4.5 0 2.3 0 0 0 0 0 0 0

Prevention of transmission Thirty responding Member States (68.2%) reported that they have a national policy on hepatitis A vaccination. Seven responding Member States (15.9%) reported that they have established the goal of eliminating or reducing hepatitis B (Figure 2). Member States with this goal were asked to specify the timeframe in which they seek to eliminate or reduce hepatitis B. Among the three Member States that answered this question, Latvia reported a target of reducing the proportion of acute hepatitis B cases among children by 2011–2012, and the Republic of Moldova and Sweden reported targets of reducing hepatitis B by 2016. Figure 2. Responses to the question, “Has your government established the goal of eliminating hepatitis B?” (N=44) No response 2.3% Do not know 4.5% Yes a (15.9%)

Member States were asked how often hepatitis disease reports are published. Of the responding Member States, 47.7% reported that they publish hepatitis disease reports annually; 36.4%, monthly; and 13.6%, weekly. No hepatitis disease report is published by 11.4% of responding Member States. Eight responding Member States (18.2%) reported the existence of a national public health research agenda for viral hepatitis. Twenty responding Member States (45.5%) reported that besides routine surveillance of viral hepatitis, serosurveys are conducted regularly. The majority of the surveys targeted the general population, pregnant women, men who have sex with men, and people who inject drugs. Among this subset of responding Member States, 20.0% indicated that serosurveys take place at least once per year and, of the same subset, 40.0% reported that the most recent viral hepatitis serosurvey was carried out in either 2011 or 2012. a

No (77.3%)

a

Three Member States (Latvia, Republic of Moldova and Sweden) that answered ”yes” to this question added comments indicating that their goals relate to reducing rather than eliminating hepatitis B.

These figures represent data from 29 of the 30 Member States. Data from the Russian Federation are not included here because they were reported in a different way. See the Russian Federation country findings later in this chapter for information about undifferentiated/unclassified hepatitis in that Member State.

Member States were asked to report, for a given recent year, the percentage of newborn infants who had received the first dose of hepatitis B vaccine within 24 hours of birth. Among the 28 Member States that provided this information, responses ranged from 0% to 100% (median, 93.5%). Member States were also asked to report, for a given recent year, the percentage of one-year-olds (ages 12–23 months) who had received three

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Table 4. Activities called for in national policy targeting mother-to-child transmission of hepatitis B (N=41) Health-care providers follow up with all pregnant women found to have hepatitis B during pregnancy for the purpose of encouraging them to give birth at health-care facilities X X X X X X Upon delivery, all infants born to women with hepatitis B receive hepatitis B immunoglobulin X X X

All pregnant women are screened for hepatitis B Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Belarus Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Hungary Ireland Israel Italy Kyrgyzstan Latvia Lithuania Luxembourg Malta Montenegro Netherlands Poland Republic of Moldova Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden The former Yugoslav Republic of Macedonia Turkey Ukraine United Kingdom of Great Britain and Northern Ireland TOTAL

All pregnant women found to have hepatitis B are counselled X X X X X X

All infants receive the first dose of hepatitis B vaccine within 24 hours of birth X X X X X X X X X X X X X X X X X X X X X X X X X X X X

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 32

X

X X X X X X X X X X X X X X X X X X X X X X X X X X X X 32

X X X X

X X X X X X X X X X X X

X X

X X X X

X X X X

X X X X X X X X X X X X 26

X X X X X X X X X 26

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doses of hepatitis B vaccine. Among the 38 Member States that provided this information, responses ranged from 30.0% to 99.3% (median, 95.0%). Forty-one responding Member States (93.2%) reported the existence of a national policy that specifically targets mother-tochild transmission of hepatitis B; details are presented in Table 4. Three fourths of Member States with such a policy indicated that one component of the policy calls for screening of all pregnant women for hepatitis B. Thirty-seven responding Member States (84.1%) reported the existence of a specific national strategy and/or policy/ guidelines for preventing hepatitis B and hepatitis C infection in health-care settings. Thirty-seven responding Member States (84.1%) reported that health-care workers are vaccinated against hepatitis B prior to starting work that might put them at risk of exposure to blood. Thirty-nine responding Member States (88.6%) reported the existence of a national policy on injection safety in healthcare settings. These Member States were asked which types of syringes the policy recommends for therapeutic injections. Single-use syringes are recommended in 79.5% of policies, and auto-disable syringes in 12.8% (Figure 3). Figure 3. Proportion of responding Member States with

Member States were asked for official estimates of the number and percentage of unnecessary injections administered annually in health-care settings (e.g. injections that are given when an equivalent oral medication is available). Forty-three Member States reported that the figures are not known and one (Denmark) reported that no unnecessary injection is administered annually in health-care settings. Additional findings relating to the prevention of hepatitis transmission are presented in Table 5. Table 5. Hepatitis prevention: policies, practices and guidelines (N=44) No Yes (%) No (%) Do not know response (%) (%) There is a national infection control policy for blood banks All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B All donated blood units (including family donations) and blood products nationwide are screened for hepatitis C There is a national policy relating to the prevention of viral hepatitis among people who inject drugs The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety 95.5 2.3 0 2.3

95.5

2.3

0

2.3

97.7

0

0

2.3

national policies on injection safety in health-care settings which recommend single-use syringes and auto-disable syringes for therapeutic injections (N=39) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% a

56.8

27.3

11.4

4.5

56.8

31.8

9.1

2.3

Screening, care and treatment Member States were asked how health professionals in their countries obtain the skills and competencies required to effectively care for people with viral hepatitis. Responding Member States most frequently indicated that these are obtained in schools for health professionals (pre-service education, 81.8%). Additionally, on-the-job training was identified in 79.5% of responses, and postgraduate training in 75.0%. Single-use syringesa Auto-disable syringesa Do not know

Respondents could select both “single-use syringes” and “auto-disable syringes”.

Forty-one responding Member States (93.2%) reported that single-use or auto-disable syringes, needles and cannulas are always available in all health-care facilities.

Twenty-nine responding Member States (65.9%) reported the existence of national clinical guidelines for the management of viral hepatitis (Figure 4). Sixteen of these 29 Member States indicated that the guidelines include recommendations for cases with HIV coinfection. Nineteen of 29 responding Member States (65.5%) indicated that there are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral hepatitis.

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Figure 4. Responses to the question, “Are there national

clinical guidelines for the management of viral hepatitis?” (N=44) No response 2.3% Do not know 4.5%

inject drugs and people living with HIV. Twenty-two responding Member States (50.0%) reported that the hepatitis C test is compulsory for members of specific groups. Groups identified included blood donors, health-care workers, pregnant women and patients on haemodialysis. Thirty-six responding Member States (81.8%) reported that publicly funded treatment is available for hepatitis B and 34 (77.3%) that it is available for hepatitis C. Eight responding Member States reported the amount spent on publicly funded treatment for hepatitis B and hepatitis C. Details can be found in the summaries of country findings later in this chapter (see Armenia, Croatia, Germany, Lithuania, Poland, San Marino, Spain and Turkey). Thirty-eight responding Member States (86.4%) reported that at least one available drug for treating hepatitis B is on the national essential medicines list or subsidized by the government. The drugs most commonly reported were lamivudine, interferon alpha, tenofovir and pegylated interferon (Table 6). Table 6. Proportion of Member States reporting drugs for

No (27.3%) Yes (65.9%)

Twenty-two responding Member States (50.0%) indicated that they have a national policy relating to screening and referral to care for hepatitis B. Twenty-one (47.7%) reported that they have such a policy for hepatitis C. Regarding hepatitis B testing, 40 responding Member States (90.9%) indicated that people register by name for testing. Thirty-six members of that subset (90.0%) indicated that the names are kept confidential. Nineteen responding Member States (43.2%) reported that the hepatitis B test is free of charge for all individuals. Among the 25 other Member States, 19 (76.0%) reported that the hepatitis B test is free of charge for members of specific groups. Groups identified included blood donors, health-care workers, prisoners, pregnant women, people who inject drugs and people living with HIV. Twentyfour responding Member States (54.5%) reported that the hepatitis B test is compulsory for members of specific groups. Groups identified included blood donors, health-care workers, pregnant women and patients on haemodialysis. Regarding hepatitis C testing, 40 responding Member States (90.9%) indicated that people register by name for testing. Thirty-six members of that subset (90.0%) indicated that the names are kept confidential. Twenty responding Member States (45.5%) reported that the hepatitis C test is free of charge for all individuals. Among the 24 other Member States, 18 (75.0%) reported that the hepatitis C test is free of charge for members of specific groups. Groups identified included blood donors, health-care workers, prisoners, pregnant women, people who

treating hepatitis B and C on national essential medicines lists or subsidized by governments Drugs for treating hepatitis B % of Member States reporting its inclusion (N=12) 84.1 77.3 75.0 61.4 54.5 50.0 38.6 % of Member States reporting its inclusion (N=12) 86.4 79.5 68.2 38.6 38.6

Lamivudine Interferon alpha Tenofovir Pegylated interferon Entecavir Adefovir dipivoxil Telbivudine Drugs for treating hepatitis C

Ribavirin Pegylated interferon Interferon alpha Telaprevir Boceprevir

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Thirty-nine responding Member States (88.6%) reported that at least one available drug for treating hepatitis C is on the national essential medicines list or subsidized by the government. The drugs most commonly reported were interferon alpha, pegylated interferon and ribavirin.

World Health Organization assistance 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 the national plan for viral hepatitis prevention and control (39.5%), and assessing the economic impact of viral hepatitis (39.5%) (Table 7). Responses from individual Member States appear in Annex C. Table 7. Viral hepatitis control and prevention: areas in which governments indicated interest in receiving WHO assistance

(N=44) Awareness-raising, partnerships and resource mobilization (first WHO strategic axis) Developing the national plan for viral hepatitis prevention and control Integrating viral hepatitis programmes into other health services Awareness-raising Evidence-based policy and data for action (second WHO strategic axis) Viral hepatitis surveillance Estimating the national burden of viral hepatitis Developing tools to assess the effectiveness of interventions Assessing the economic impact of viral hepatitis Prevention of transmission (third WHO strategic axis) Increasing coverage of the birth dose of the hepatitis B vaccine Screening, care and treatment (fourth WHO strategic axis) Increasing access to treatment Increasing access to diagnostics Improving laboratory quality Developing education/training programmes for health professionals a

38.6% 29.5% 27.3% 22.7% 34.1% 22.7% 38.6% 9.1% 25.0% 22.7% 20.9%a 34.1%

N=43 (This response option was not included in the survey completed by Belarus.)

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WHO European Region: COUNTRY SUMMARIES

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Albania Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 3.2 Lower–middle-income $8820 5.66% $577.28 $225.38 73 0.739 30 1.5 syringes, needles and cannulas are always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

The Government of Albania reports as Liver cancer cases are not registered nafollows. tionally, but cases with HIV/hepatitis coin- It is not known whether there is a national policy relating to the prevention of viral fection are. National coordination hepatitis among people who inject drugs. There is no written national strategy or plan The government publishes hepatitis disThe government does not have guidelines that focuses exclusively or primarily on the ease reports monthly. that address how hepatitis A and hepatitis prevention and control of viral hepatitis. Hepatitis outbreaks are required to be re- E can be prevented through food and waThere is a designated governmental unit/ ported to the government and are further ter safety. department responsible solely for coordi- investigated. There is adequate laboratory nating and/or carrying out viral hepatitis- capacity nationally to support investiga- Screening, care and treatment related activities: Department of Infection tion of viral hepatitis outbreaks and other Health professionals obtain the skills and competencies required to effectively care and Disease Control. It has five staff mem- surveillance activities. for people with viral hepatitis through bers. There are two full-time equivalent staff members who work on hepatitis-re- There is a national public health research schools for health professionals (pre-servlated activities in all government agencies/ agenda for viral hepatitis. Viral hepatitis ice education), on-the-job training and serosurveys are conducted regularly; the postgraduate training. bodies. target populations are the general popuThe government has a viral hepatitis pre- lation, men who have sex with men, preg- It is not known whether there are national vention and control programme that in- nant women and health-care workers. The clinical guidelines for the management of viral hepatitis. cludes activities targeting the following last serosurvey was carried out in 2003. specific populations: health-care workers The government does not have national (including health-care waste handlers), Prevention of transmission policies relating to screening and referral There is no national policy on hepatitis A people living with HIV, students and pregto care for hepatitis B or hepatitis C. vaccination. nant women. Awareness-raising and partnerships The government has not established the People testing for both hepatitis B and hepatitis C register by name; the names The government held events for World goal of eliminating hepatitis B. are kept confidential within the system. Hepatitis Day 2012 but has not funded other viral hepatitis public awareness cam- Nationally, 97.4% of newborn infants in a Hepatitis B and hepatitis C tests are free of given recent year received the first dose of charge for all individuals. Information was paigns since January 2011. hepatitis B vaccine within 24 hours of birth not provided on whether hepatitis B or The government does not collaborate with and 99.1% of one-year-olds (ages 12–23 hepatitis C tests are compulsory for memin-country civil society groups to develop months) in a given recent year received bers of any specific group. and implement its viral hepatitis preven- three doses of hepatitis B vaccine. It is not known whether publicly funded tion and control programme. There is a national policy that specifically treatment is available for hepatitis B or Evidence-based policy and data for targets mother-to-child transmission of hepatitis C and, if so, the amount spent by hepatitis B (Annex B). action the government on such treatment. There is routine surveillance for viral hepatitis. There is a national surveillance system There is a specific national strategy and/or The following drug for treating hepatitis B for the following types of acute hepatitis: policy/guidelines for preventing hepatitis is on the national essential medicines list or A, B and C, but not for any type of chronic B and hepatitis C infection in health-care subsidized by the government: interferon settings. Health-care workers are vaccinat- alpha. The following drug for treating hephepatitis. ed against hepatitis B prior to starting work atitis C is on the national essential mediThere are standard case definitions for that might put them at risk of exposure to cines list or subsidized by the government: hepatitis. Deaths, including from hepatitis, blood. interferon alpha. are reported to a central registry. Of hepatitis cases, 21% are reported as “undifferenti- There is a national policy on injection safe- The Government of Albania welcomes asty in health-care settings, which recom- sistance from WHO in one or more areas ated” or “unclassified” hepatitis. mends single-use syringes for therapeu- of viral hepatitis prevention and control tic injections. Single-use or auto-disable (Annex C).

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Andorra The Government of Andorra reports as Population (in millions) (2011) 0.8 follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination -There is no written national strategy or Total health expenditure as % of GDP (2010) 7.52% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $3254.52 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $2281.10 Life expectancy at birth (in years) (2009) hepatitis. 82 Human Development Index (2011) 0.836 There is no designated governmental Median age (in years) (2010) -unit/department responsible solely for co- Total fertility rate per woman (2010) 1.3 ordinating and/or carrying out viral hepatitis-related activities. There are no people working full-time on hepatitis-related ac- The government has not established the The government has guidelines that address how hepatitis A and hepatitis E can goal of eliminating hepatitis B. tivities in any government agency/body. be prevented through food and water Information was not provided on whether Nationally, 93% of newborn infants in a safety. the government has a viral hepatitis pre- given recent year received the first dose of vention and control programme that in- hepatitis B vaccine within 24 hours of birth Screening, care and treatment cludes activities targeting specific popula- and 99% of one-year-olds (ages 12–23 Health professionals obtain the skills and months) in a given recent year received competencies required to effectively care tions. for people with viral hepatitis through three doses of hepatitis B vaccine. Awareness-raising and partnerships schools for health professionals (pre-servThe government did not hold events for There is a national policy that specifically ice education). World Hepatitis Day 2012 and has not targets mother-to-child transmission of Information was not provided on whether funded other viral hepatitis public aware- hepatitis B (Annex B). there are national clinical guidelines for ness campaigns since January 2011. There is a specific national strategy and/or the management of viral hepatitis. There The government does not collaborate policy/guidelines for preventing hepatitis are no national clinical guidelines for the with in-country civil society groups to B and hepatitis C infection in health-care management of HIV, which include recdevelop and implement its viral hepatitis settings. Health-care workers are vacci- ommendations for coinfection with viral nated against hepatitis B prior to starting hepatitis. prevention and control programme. work that might put them at risk of expoEvidence-based policy and data for sure to blood. The government does not have national action policies relating to screening and referral There is routine surveillance for viral hepa- There is a national policy on injection to care for hepatitis B or hepatitis C. titis. There is a national surveillance system safety in health-care settings, which recfor the following types of acute hepatitis: ommends single-use and auto-disable People testing for both hepatitis B and A, B and C, but not for any type of chronic syringes for therapeutic injections. Single- hepatitis C register by name; the names hepatitis. use or auto-disable syringes, needles and are kept confidential within the system. cannulas are always available in all health- Hepatitis B and hepatitis C tests are not There are standard case definitions for care facilities. free of charge and are not compulsory for hepatitis. Deaths, including from hepatitis, members of any specific group. are reported to a central registry. No hepa- Official government estimates of the titis case is reported as “undifferentiated” number and percentage of unneces- Publicly funded treatment for hepatitis B or “unclassified” hepatitis. sary injections administered annually in and hepatitis C is available to the entire population. The amount spent by the govhealth-care settings are not known. Liver cancer cases and cases with HIV/hepernment on such treatment is not known. atitis coinfection are registered nationally. In response to questions about screening of blood, the respondent stated, “In An- The following drugs for treating hepatitis B The government publishes hepatitis dis- dorra there are no blood banks. We work are on the national essential medicines list ease reports annually. in collaboration with Spain and France, or subsidized by the government: interferon alpha, pegylated interferon, lamivuHepatitis outbreaks are required to be re- following their rules.” No further informadine, adefovir dipivoxil, entecavir, telbivuported to the government and are further tion was provided on whether there is a dine and tenofovir. The following drugs for national infection control policy for blood investigated. There is adequate laboratory treating hepatitis C are on the national esbanks, or whether all donated blood units capacity nationally to support investigasential medicines list or subsidized by the tion of viral hepatitis outbreaks and other (including family donations) and blood government: interferon alpha, pegylated products nationwide are screened for surveillance activities. interferon, ribavirin, boceprevir and telhepatitis B and hepatitis C. aprevir. There is no national public health research agenda for viral hepatitis. Viral hepatitis se- Information was not provided on whether there is a national policy relating to the The Government of Andorra did not inrosurveys are not conducted regularly. prevention of viral hepatitis among peo- dicate a need for assistance from WHO in relation to viral hepatitis prevention and ple who inject drugs. Prevention of transmission control. There is no national policy on hepatitis A vaccination.

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Armenia Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Armenia reports as follows.

3.1 Lower–middle-income $6100 4.40% $238.52 $96.92 70 0.806 32 1.7

There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is a national policy relating to the prevention of viral hepatitis among people who inject drugs. The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

The government publishes hepatitis disease Screening, care and treatment reports monthly. Health professionals obtain the skills and National coordination Hepatitis outbreaks are required to be re- competencies required to effectively care for There is a written national strategy or plan ported to the government and are further people with viral hepatitis through schools that focuses primarily on the prevention and investigated. There is adequate laboratory for health professionals (pre-service educacontrol of viral hepatitis, and also integrates capacity nationally to support investigation tion), on-the-job training, postgraduate trainother diseases. It includes components for of viral hepatitis outbreaks and other surveil- ing and thematic workshops. raising awareness, surveillance, vaccination, lance activities. There are no national clinical guidelines for prevention in general, prevention of transmission via injecting drug use, prevention There is a national public health research the management of viral hepatitis, but there of transmission in health-care settings, treat- agenda for viral hepatitis. Viral hepatitis sero- are for the management of HIV, which include surveys are conducted regularly. The target recommendations for coinfection with viral ment and care, and coinfection with HIV. populations are health-care workers at risk hepatitis. There is no designated governmental unit/ of parenterally transmitted hepatitis, donors department responsible solely for coordinat- and pregnant women. Information was not The government has national policies relating and/or carrying out viral hepatitis-related provided on when the last serosurvey was ing to screening and referral to care for hepatitis B and hepatitis C. activities. There are 213 full-time equivalent carried out. staff members who work on hepatitis-related People testing for both hepatitis B and hepaactivities in all government agencies/bodies. Prevention of transmission There is a national policy on hepatitis A vac- titis C register by name; the names are kept confidential within the system. Hepatitis B The government has a viral hepatitis preven- cination. and hepatitis C tests are not free of charge for tion and control programme that includes activities targeting the following specific The government has not established the goal all individuals, but they are free of charge for patients with acute hepatitis, blood donors populations: health-care workers (including of eliminating hepatitis B. and pregnant women in the city of Yerevan. health-care waste handlers), people who inNationally, 96% of newborn infants in a given Hepatitis B and hepatitis C tests are compulject drugs and people living with HIV. recent year received the first dose of hepatitis sory for patients with hepatitis, people livAwareness-raising and partnerships B vaccine within 24 hours of birth and 95% of ing with HIV, health-care workers at risk of The government held events for World Hepa- one-year-olds (ages 12–23 months) in a given parenterally transmitted hepatitis and pregtitis Day 2012 and has funded other viral recent year received three doses of hepatitis nant women in Yerevan. hepatitis public awareness campaigns since B vaccine. Publicly funded treatment is available for January 2011 (Annex A). There is a national policy that specifically tar- acute hepatitis B and hepatitis C. The government collaborates with the follow- gets mother-to-child transmission of hepatiThe government spends dram 120 000– ing in-country civil society group to develop tis B (Annex B). 150 000 (US$ 298–373) per patient in sum on and implement its viral hepatitis prevention There is a specific national strategy and/or publicly funded treatment for hepatitis B and and control programme: the Armenian Hepapolicy/guidelines for preventing hepatitis B hepatitis C. titis Forum. and hepatitis C infection in health-care setEvidence-based policy and data for tings. Health-care workers are vaccinated The following drugs for treating hepatitis B against hepatitis B prior to starting work that are on the national essential medicines list action There is routine surveillance for viral hepatitis. might put them at risk of exposure to blood. or subsidized by the government: interferon There is a national surveillance system for the alpha, pegylated interferon and lamivudine. following types of acute hepatitis: A, B, C, D There is a national policy on injection safety The following drugs for treating hepatitis C and E, but not for any type of chronic hepa- in health-care settings, which recommends are on the national essential medicines list or single-use and auto-disable syringes for ther- subsidized by the government: interferon altitis. apeutic injections. Single-use or auto-disable pha, pegylated interferon and ribavirin. There are standard case definitions for hepa- syringes, needles and cannulas are always titis. Deaths, including from hepatitis, are re- available in all health-care facilities. The Government of Armenia welcomes assistported to a central registry. Of hepatitis cases, ance from WHO in one or more areas of viral 2.8% are reported as “undifferentiated” or “un- Official government estimates of the number hepatitis prevention and control (Annex C). and percentage of unnecessary injections classified” hepatitis. administered annually in health-care settings Liver cancer cases and cases with HIV/hepati- are not known. tis coinfection are registered nationally.

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Austria The Government of Austria reports as Population (in millions) (2011) 8.4 follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination $42 050 There is a written national strategy or plan Total health expenditure as % of GDP (2010) 10.97% that focuses primarily on the prevention Per capita total health expenditure (PPP int $) (2010) $4387.92 and control of viral hepatitis, and also in- Per capita government health expenditure (PPP int $) (2010) $3401.20 tegrates other diseases. It includes com- Life expectancy at birth (in years) (2009) 80 ponents for raising awareness, surveil- Human Development Index (2011) 0.908 lance, vaccination, prevention in general, Median age (in years) (2010) 42 prevention of transmission via injecting Total fertility rate per woman (2010) 1.4 drug use, prevention of transmission in health-care settings, treatment and care, capacity nationally to support investiga- Information was not provided on whether and coinfection with HIV. tion of viral hepatitis outbreaks and other the government has guidelines that address how hepatitis A and hepatitis E can There is no designated governmental surveillance activities. be prevented through food and water unit/department responsible solely for coordinating and/or carrying out viral hepa- There is no national public health research safety. titis-related activities. It is not known how agenda for viral hepatitis. Viral hepatitis seScreening, care and treatment many people work full-time on hepatitis- rosurveys are not conducted regularly. Health professionals obtain the skills and related activities in all government agen- Prevention of transmission competencies required to effectively care cies/bodies. There is a national policy on hepatitis A for people with viral hepatitis through schools for health professionals (pre-servThe government has a viral hepatitis pre- vaccination. vention and control programme that in- The government has not established the ice education). cludes activities targeting the following goal of eliminating hepatitis B. There are national clinical guidelines for specific populations: health-care workers (including health-care waste handlers), Nationally, less than 1% of newborn in- the management of viral hepatitis, but people who inject drugs and people living fants in a given recent year received the they do not include recommendations for cases with HIV coinfection. There are nawith HIV. first dose of hepatitis B vaccine within 24 tional clinical guidelines for the managehours of birth and 95% of one-year-olds Awareness-raising and partnerships (ages 12–23 months) in a given recent year ment of HIV, which include recommendaThe government did not hold events for received three doses of hepatitis B vaccine. tions for coinfection with viral hepatitis. World Hepatitis Day 2012 and has not funded other viral hepatitis public aware- There is a national policy that specifically The government does not have national policies relating to screening and referral ness campaigns since January 2011. targets mother-to-child transmission of to care for hepatitis B or hepatitis C. hepatitis B (Annex B). The government collaborates with incountry civil society groups to develop There is a specific national strategy and/or People testing for both hepatitis B and and implement its viral hepatitis preven- policy/guidelines for preventing hepatitis hepatitis C register by name; the names tion and control programme. Information B and hepatitis C infection in health-care are kept confidential within the system. was not provided about the identity of settings. Health-care workers are vacci- Hepatitis B and hepatitis C tests are free of charge for all individuals and are not comcivil society partners. nated against hepatitis B prior to starting pulsory for members of any specific group. work that might put them at risk of expoEvidence-based policy and data for sure to blood. Publicly funded treatment is available for action There is routine surveillance for viral hepa- There is a national policy on injection hepatitis B and hepatitis C. Information titis. There is a national surveillance system safety in health-care settings, which rec- was not provided on who is eligible for for the following types of acute hepatitis: ommends single-use and auto-disable this. The amount spent by the government A, B, C, D and E, and for the following types syringes for therapeutic injections. Single- on publicly funded treatment for hepatitis B and hepatitis C is not known. of chronic hepatitis: B, C and D. use or auto-disable syringes, needles and cannulas are always available in all health- The following drugs for treating hepatitis B There are standard case definitions for care facilities. are on the national essential medicines list hepatitis. Deaths, including from hepatitis, are reported to a central registry. The per- Official government estimates of the or subsidized by the government: intercentage of hepatitis cases reported as “un- number and percentage of unneces- feron alpha, lamivudine and tenofovir. The differentiated” or “unclassified” hepatitis is sary injections administered annually in following drugs for treating hepatitis C are on the national essential medicines list or not known. health-care settings are not known. subsidized by the government: interferon Liver cancer cases and cases with HIV/hep- There is a national infection control policy alpha and ribavirin. atitis coinfection are registered nationally. for blood banks. All donated blood units The Government of Austria did not indi(including family donations) and blood The government publishes hepatitis dis- products nationwide are screened for cate a need for assistance from WHO in relation to viral hepatitis prevention and ease reports monthly. hepatitis B and hepatitis C. control. Hepatitis outbreaks are required to be re- There is a national policy relating to the ported to the government and are further prevention of viral hepatitis among peoinvestigated. There is adequate laboratory ple who inject drugs.

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Azerbaijan Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Azerbaijan reports as follows. 9.3 Upper–middle-income $8960 5.88% $579.07 $117.49 68 0.733 30 2.2 Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

National coordination There is no written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities: Republican Centre of Hygiene and Epidemiology, Department of Intestinal Infections. It has three staff members. There is one full-time equivalent staff member who works on hepatitis-related activities in all government agencies/ bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific population: pregnant women.

Awareness-raising and partnerships The government held events for World Hepatitis Day 2012 but has not funded other viral hepatitis public awareness campaigns since January 2011.

The government collaborates with the following in-country civil society group to develop and implement its viral hepatitis prevention and control programme: Vish- There is a national policy that specifically Publicly funded treatment is not available targets mother-to-child transmission of for hepatitis B or hepatitis C. nevskaya-Rostropovich Foundation. hepatitis B (Annex B). The following drugs for treating hepatitis B Evidence-based policy and data for There is no specific national strategy and/ are on the national essential medicines list action There is routine surveillance for viral hepa- or policy/guidelines for preventing hepati- or subsidized by the government: lamivutitis. There is a national surveillance system tis B and hepatitis C infection in health-care dine and tenofovir. The following drug for for the following types of acute hepatitis: settings. Health-care workers are not vacci- treating hepatitis C is on the national esA, B and C, but not for any type of chronic nated against hepatitis B prior to starting sential medicines list or subsidized by the work that might put them at risk of expo- government: ribavirin. hepatitis. sure to blood. There are standard case definitions for The Government of Azerbaijan welcomes hepatitis. Deaths, including from hepatitis, There is a national policy on injection safe- assistance from WHO in one or more areas are reported to a central registry. No hepa- ty in health-care settings, which recom- of viral hepatitis prevention and control titis case is reported as “undifferentiated” or mends auto-disable syringes for therapeu- (Annex C). tic injections. Single-use or auto-disable “unclassified” hepatitis. syringes, needles and cannulas are always Liver cancer cases and cases with HIV/hep- available in all health-care facilities. atitis coinfection are registered nationally.

There is no national policy relating to the prevention of viral hepatitis among people The government publishes hepatitis dis- who inject drugs. ease reports monthly. The government has guidelines that adHepatitis outbreaks are required to be re- dress how hepatitis A and hepatitis E can ported to the government and are further be prevented through food and water investigated. There is adequate laboratory safety. capacity nationally to support outbreak investigations and other surveillance activi- Screening, care and treatment ties for hepatitis A, hepatitis B and hepatitis Health professionals obtain the skills and competencies required to effectively care C, but not for hepatitis E. for people with viral hepatitis through There is no national public health research schools for health professionals (pre-servagenda for viral hepatitis. Viral hepatitis ice education) and postgraduate training. serosurveys are conducted regularly; the target populations are pregnant women, There are no national clinical guidelines for blood donors and medical staff. Informa- the management of viral hepatitis. Infortion was not provided on when the last mation was not provided on whether there are national clinical guidelines for the manserosurvey was carried out. agement of HIV, which include recommenPrevention of transmission dations for coinfection with viral hepatitis. There is no national policy on hepatitis A The government does not have national vaccination. policies relating to screening and referral The government has not established the to care for hepatitis B or hepatitis C. goal of eliminating hepatitis B. People testing for both hepatitis B and Nationally, 99% of newborn infants in a hepatitis C register by name; the names given recent year received the first dose of are kept confidential within the system. hepatitis B vaccine within 24 hours of birth Hepatitis B and hepatitis C tests are free of and 96% of one-year-olds (ages 12–23 charge for all individuals, and are compulmonths) in a given recent year received sory for pregnant women, blood donors three doses of hepatitis B vaccine. and medical staff.

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Belarus The Government of Belarus reports as Population (in millions) (2011) 9.6 follows. Country classification (2012) Upper–middle-income Gross national income per capita (PPP int $) (2011) National coordination $14 460 There is no written national strategy or Total health expenditure as % of GDP (2010) 5.61% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $786.12 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $610.70 Life expectancy at birth (in years) (2009) hepatitis. 70 Human Development Index (2011) 0.785 There is no designated governmental Median age (in years) (2010) 38 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.4 ordinating and/or carrying out viral hepatitis-related activities. There are 20–25 fulltime equivalent staff members who work target populations are people who in- The government has guidelines that adon hepatitis-related activities in all govern- ject drugs, men who have sex with men, dress how hepatitis A and hepatitis E can pregnant women, people living with HIV, be prevented through food and water ment agencies/bodies. health-care workers, members of the mili- safety. The government has a viral hepatitis pre- tary and prisoners. Information was not vention and control programme that in- provided on when the last serosurvey was Screening, care and treatment Health professionals obtain the skills and cludes activities targeting the following carried out. competencies required to effectively care specific populations: people who inject for people with viral hepatitis through drugs, prisoners, people living with HIV, Prevention of transmission sex workers and men who have sex with There is a national policy on hepatitis A schools for health professionals (pre-servvaccination. ice education), on-the-job training and men. postgraduate training. Awareness-raising and partnerships The government has not established the There are national clinical guidelines for The government held events for World goal of eliminating hepatitis B. the management of viral hepatitis, which Hepatitis Day 2012 and has funded other viral hepatitis public awareness cam- Nationally, 100% of newborn infants in a include recommendations for cases with given recent year received the first dose of HIV coinfection. paigns since January 2011 (Annex A). hepatitis B vaccine within 24 hours of birth The government collaborates with the fol- and 98%–100% of one-year-olds (ages 12– The government has national policies relowing in-country civil society groups to 23 months) in a given recent year received lating to screening and referral to care for hepatitis B and hepatitis C. develop and implement its viral hepatitis three doses of hepatitis B vaccine. prevention and control programme: NGO “Positive Movement” and Belarusian Red There is a national policy that specifically People testing for both hepatitis B and targets mother-to-child transmission of hepatitis C register by name; the names Cross. are kept confidential within the system. hepatitis B (Annex B). Hepatitis B and hepatitis C tests are free of Evidence-based policy and data for There is a specific national strategy and/ charge for all individuals and are compulaction There is routine surveillance for viral hepa- or policy for preventing hepatitis B and sory for members of some specific groups titis. There is a national surveillance system hepatitis C infection in health-care set- but these groups were not identified. for the following types of acute hepatitis: tings. Health-care workers are vaccinated A, B, C, D and E, and for the following types against hepatitis B prior to starting work Publicly funded treatment is available for that might put them at risk of exposure to hepatitis B and C. Information was not of chronic hepatitis: B, C and D. provided on who is eligible for publicly blood. funded treatment for hepatitis B. Publicly There are standard case definitions for hepatitis. Deaths, including from hepatitis, There is a national policy on injection safe- funded treatment for hepatitis C is availare reported to a central registry. Infor- ty in health-care settings, which recom- able only to people with acute infection mation was not provided regarding the mends single-use syringes for therapeutic (not those with chronic infection). Inforpercentage of hepatitis cases reported as injections. Single-use or auto-disable sy- mation was not provided on the amount “undifferentiated” or “unknown” hepatitis. ringes, needles and cannulas are always spent by the government on such treatavailable in all health-care facilities. ment for hepatitis B and hepatitis C. Liver cancer cases and cases with HIV/hepatitis coinfection are registered nationally. Official government estimates of the The following drugs for treating hepatitis number and percentage of unneces- B are on the national essential medicines The government publishes hepatitis dis- sary injections administered annually in list: interferon alpha, pegylated interferon, health-care settings are not known. ease reports monthly and annually. lamivudine and tenofovir. The following drugs for treating hepatitis C are on the Hepatitis outbreaks are reported to the There is a national infection control policy national essential medicines list: interferon for blood banks. All donated blood units government and are further investigated. alpha, pegylated interferon and ribavirin. There is adequate laboratory capacity na- (including family donations) and blood tionally to support investigation of out- products nationwide are screened for The Government of Belarus welcomes ashepatitis B and hepatitis C. breaks and other surveillance activities. sistance from WHO in one or more areas of viral hepatitis prevention and control Information was not provided on whether There is a national policy relating to the (Annex C). there is a national public health research prevention of viral hepatitis among peoagenda for viral hepatitis. Viral hepatitis ple who inject drugs. serosurveys are conducted regularly; the

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Belgium Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Belgium reports as follows. 10.8 High-income $39 190 10.71% $4025.11 $3008.52 80 0.886 41 1.8 Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

National coordination There is no written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis. There is no designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities. It is not known how many people work full-time on hepatitis-related activities in all government agencies/bodies.

The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers Prevention of transmission (including health-care waste handlers), There is a national policy on hepatitis A The government does not have national policies relating to screening and referral newborns and unvaccinated adolescents. vaccination. to care for hepatitis B or hepatitis C. Awareness-raising and partnerships The government has not established the People testing for both hepatitis B and The government did not hold events for goal of eliminating hepatitis B. hepatitis C register by name; the names World Hepatitis Day 2012 and has not funded other viral hepatitis public aware- Information was not provided on the per- are kept confidential within the system. centage of newborn infants nationally in Hepatitis B and hepatitis C tests are free of ness campaigns since January 2011. a given recent year who received the first charge for all individuals and are not comThe government collaborates with the fol- dose of hepatitis B vaccine within 24 hours pulsory for members of any specific group. lowing in-country civil society groups to of birth. In a given recent year, 91% of onedevelop and implement the vaccination year-olds (ages 12–23 months) received Publicly funded treatment for hepatitis B and hepatitis C is available to the entire component of its viral hepatitis prevention three doses of hepatitis B vaccine. population. Information was not provided and control programme: well baby clinics, school health services, and organizations There is a national policy that specifically on the amount spent by the government for health-care providers who are involved targets mother-to-child transmission of on such treatment. in vaccination, such as paediatricians and hepatitis B (Annex B). The following drugs for treating hepatitis B other physicians. There is a specific national strategy and/or are on the national essential medicines list policy/guidelines for preventing hepatitis or subsidized by the government: interferEvidence-based policy and data for B and hepatitis C infection in health-care on alpha, pegylated interferon, lamivudine, action There is routine surveillance for viral hepa- settings. Health-care workers are vaccinat- adefovir dipivoxil, entecavir and tenofovir. titis. There is a national surveillance system ed against hepatitis B prior to starting work The following drugs for treating hepatitis for the following types of acute hepatitis: that might put them at risk of exposure to C are on the national essential medicines A, B and C, but not for any type of chronic blood. list or subsidized by the government: interhepatitis. There is a national policy on injection safe- feron alpha, pegylated interferon, ribavirin, boceprevir and telaprevir. There are standard case definitions for ty in health-care settings, which recommends single-use syringes for therapeutic hepatitis. Deaths, including from hepatitis, The Government of Belgium welcomes asare reported to a central registry. The per- injections. Single-use or auto-disable sy- sistance from WHO in one or more areas centage of hepatitis cases reported as “un- ringes, needles and cannulas are always of viral hepatitis prevention and control differentiated” or “unclassified” hepatitis is available in all health-care facilities. (Annex C). not known.

There is a national policy relating to the prevention of viral hepatitis among people Liver cancer cases and cases with HIV/hep- who inject drugs. atitis coinfection are registered nationally. It is not known whether the government The government publishes hepatitis dis- has guidelines that address how hepaease reports annually. titis A and hepatitis E can be prevented through food and water safety. Hepatitis outbreaks are required to be reported to the government and are further Screening, care and treatment investigated. There is adequate laboratory Health professionals obtain the skills and capacity nationally to support investiga- competencies required to effectively care tion of viral hepatitis outbreaks and other for people with viral hepatitis through surveillance activities. schools for health professionals (pre-service education), on-the-job training and There is no national public health research postgraduate training. agenda for viral hepatitis. Viral hepatitis serosurveys are conducted regularly; the tar- There are national clinical guidelines for get population is the general population. the management of viral hepatitis, which The last serosurvey was carried out in 2006. include recommendations for cases with HIV coinfection.

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Bulgaria The Government of Bulgaria reports as Population (in millions) (2011) 7.4 follows. Country classification (2012) Upper–middle-income Gross national income per capita (PPP int $) (2011) National coordination $14 160 There is no written national strategy or Total health expenditure as % of GDP (2010) 6.87% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $434.89 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $236.97 Life expectancy at birth (in years) (2009) hepatitis. 74 Human Development Index (2011) 0.771 There is no designated governmental Median age (in years) (2010) 42 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.5 ordinating and/or carrying out viral hepatitis-related activities. Information was not provided on how many people work target population is the general popula- be prevented through food and water full-time on hepatitis-related activities in tion. The last serosurvey was carried out safety. in 2011. all government agencies/bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific population: health-care workers (including health-care waste handlers).

Prevention of transmission

Screening, care and treatment

Awareness-raising and partnerships The government held events for World Hepatitis Day 2012 but has not funded other viral hepatitis public awareness campaigns since January 2011. The government collaborates with the following in-country civil society groups to develop and implement its viral hepatitis prevention and control programme: Hepasist National Association to Fight Hepatitis and Hepactive Association to Fight Hepatitis.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C, D and E, but not for any type of chronic hepatitis. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Less than 5% of hepatitis cases are reported as “undifferentiated” or “unclassified” hepatitis. Liver cancer cases and cases with HIV/hepatitis coinfection are registered nationally. The government publishes hepatitis disease reports weekly. Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory capacity nationally to support outbreak investigations and other surveillance activities for hepatitis A, hepatitis B, and hepatitis C, but not for hepatitis E. There is no national public health research agenda for viral hepatitis. Viral hepatitis serosurveys are conducted regularly; the

Health professionals obtain the skills and There is a national policy on hepatitis A competencies required to effectively care vaccination. for people with viral hepatitis through onthe-job training and postgraduate trainThe government has established the goal ing. of eliminating hepatitis B but does not have a specific timeframe for this. There are national clinical guidelines for the management of viral hepatitis, but Nationally, 98.6% of newborn infants in a they do not include recommendations for given recent year received the first dose of cases with HIV coinfection. There are nahepatitis B vaccine within 24 hours of birth tional clinical guidelines for the manageand 96.0% of one-year-olds (ages 12–23 ment of HIV, which include recommendamonths) in a given recent year received tions for coinfection with viral hepatitis. three doses of hepatitis B vaccine. The government does not have national There is a national policy that specifically policies relating to screening and referral targets mother-to-child transmission of to care for hepatitis B or hepatitis C. hepatitis B (Annex B). People testing for both hepatitis B and There is a specific national strategy and/or hepatitis C register by name; the names policy/guidelines for preventing hepatitis are kept confidential within the system. B and hepatitis C infection in health-care Hepatitis B and hepatitis C tests are not settings. Health-care workers are vacci- free of charge for all individuals, but are nated against hepatitis B prior to starting free of charge for injecting drug users, work that might put them at risk of expo- men who have sex with men, prisoners sure to blood. and sex workers. Hepatitis B and hepatitis C tests are not compulsory for members of There is a national policy on injection safeany specific group. ty in health-care settings, which recommends single-use syringes for therapeutic Publicly funded treatment for hepatitis B injections. Single-use or auto-disable sy- and hepatitis C is available to all people ringes, needles and cannulas are always with health insurance. Information was available in all health-care facilities. not provided on the amount spent by the government on such treatment. Official government estimates of the number and percentage of unneces- The following drugs for treating hepatitis sary injections administered annually in B are on the national essential medicines health-care settings are not known. list or subsidized by the government: interferon alpha, pegylated interferon, There is a national infection control policy lamivudine, adefovir dipivoxil, entecavir for blood banks. All donated blood units and telbivudine. The following drugs for (including family donations) and blood treating hepatitis C are on the national esproducts nationwide are screened for sential medicines list or subsidized by the hepatitis B and hepatitis C. government: interferon alpha, pegylated There is a national policy relating to the interferon and ribavirin. prevention of viral hepatitis among peoThe Government of Bulgaria welcomes asple who inject drugs. sistance from WHO in one or more areas The government has guidelines that ad- of viral hepatitis prevention and control dress how hepatitis A and hepatitis E can (Annex C).

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Croatia Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 4.3 High-income $18 760 7.76% $1066.72 $1284.54 76 0.834 42 1.5 injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is a national policy relating to the prevention of viral hepatitis among people who inject drugs.

The Government of Croatia reports as Liver cancer cases and cases with HIV/ The government has guidelines that follows. hepatitis coinfection are registered address how hepatitis A and hepatitis E can be prevented through food and water nationally. National coordination safety. There is no written national strategy or plan The government publishes hepatitis Screening, care and treatment that focuses exclusively or primarily on the disease reports monthly and annually. Health professionals obtain the skills and prevention and control of viral hepatitis. Hepatitis outbreaks are required to be competencies required to effectively care There is no designated governmental reported to the government and are for people with viral hepatitis through unit/department responsible solely for further investigated. There is adequate schools for health professionals (precoordinating and/or carrying out viral laboratory capacity nationally to support service education), on-the-job training and hepatitis-related activities. Information was investigation of viral hepatitis outbreaks postgraduate training. not provided on how many people work and other surveillance activities. There are national clinical guidelines for full-time on hepatitis-related activities in all There is no national public health research the management of viral hepatitis, which government agencies/bodies. agenda for viral hepatitis. Viral hepatitis include recommendations for cases with The government has a viral hepatitis serosurveys are not conducted regularly. HIV coinfection. prevention and control programme that The government has national policies includes activities targeting the following Prevention of transmission specific populations: health-care workers There is a national policy on hepatitis A relating to screening and referral to care for hepatitis B and hepatitis C. (including health-care waste handlers), vaccination. people who inject drugs, prisoners and The government has not established the Whether or not people who test for people living with HIV. goal of eliminating hepatitis B. hepatitis B or hepatitis C register by name depends on the setting. If they do register Awareness-raising and partnerships Nationally, 96% of newborn infants in a by name, these are kept confidential within The government held events for World Hepatitis Day 2012 and has funded other given recent year received the first dose of the system. Hepatitis B and hepatitis C tests viral hepatitis public awareness campaigns hepatitis B vaccine within 24 hours of birth are free of charge for all individuals and and 96% of one-year-olds (ages 12–23 compulsory for blood and organ donors. since January 2011 (Annex A). months) in a given recent year received Publicly funded treatment for hepatitis B The government collaborates with the three doses of hepatitis B vaccine. is available to the entire population, while following in-country civil society groups to There is a national policy that specifi cally for hepatitis C it is available to all people develop and implement its viral hepatitis prevention and control programme: targets mother-to-child transmission of who have public health insurance. The hepatitis B (Annex B). government spends approximately HRK 20 HULOH Hepatos, HUHIV. million (US$ 3.4 million) annually on such There is a specifi c national strategy and/ Evidence-based policy and data for or policy/guidelines for preventing treatment for hepatitis B and hepatitis C. action There is routine surveillance for viral hepatitis B and hepatitis C infection in The following drugs for treating hepatitis hepatitis. There is a national surveillance health-care settings. Health-care workers B are on the national essential medicines system for the following types of acute are vaccinated against hepatitis B prior to list or subsidized by the government: hepatitis: A, B, C, D and E, and for the starting work that might put them at risk of pegylated interferon, lamivudine, following types of chronic hepatitis: B, C exposure to blood. telbivudine and tenofovir. The following and D. There is a national policy on injection drugs for treating hepatitis C are on the national essential medicines list or There are standard case definitions safety in health-care settings, which subsidized by the government: pegylated for hepatitis. Deaths, including from recommends single-use syringes for interferon and ribavirin. hepatitis, are reported to a central registry. therapeutic injections. Single-use or autoOf hepatitis cases, 1%–5% is reported disable syringes, needles and cannulas are The Government of Croatia welcomes as “undifferentiated” or “unclassified” always available in all health-care facilities. assistance from WHO in one or more areas hepatitis. Official government estimates of the of viral hepatitis prevention and control number and percentage of unnecessary (Annex C).

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Cyprus The Government of Cyprus reports as Population (in millions) (2011) 1.1 follows. Country classification (2012) -Gross national income per capita (PPP int $) (2011) National coordination $30 970 There is no written national strategy or Total health expenditure as % of GDP (2010) 5.97% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $1841.64 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $764.40 Life expectancy at birth (in years) (2009) hepatitis. 81 Human Development Index (2011) 0.866 There is no designated governmental Median age (in years) (2010) 34 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.5 ordinating and/or carrying out viral hepatitis-related activities. There are no people Screening, care and treatment working full-time on hepatitis-related ac- Prevention of transmission There is a national policy on hepatitis A Health professionals obtain the skills and tivities in any government agency/body. vaccination. competencies required to effectively care The government does not have a viral for people with viral hepatitis through onhepatitis prevention and control pro- The government has not established the the-job training. gramme that includes activities targeting goal of eliminating hepatitis B. There are national clinical guidelines for specific populations. Nationally, 0.4% of newborn infants in a the management of viral hepatitis. It is not Awareness-raising and partnerships given recent year received the first dose of known whether they include recommenThe government did not hold events for hepatitis B vaccine within 24 hours of birth dations for cases with HIV coinfection. World Hepatitis Day 2012 and has not and 96% of one-year-olds (ages 12–23 funded other viral hepatitis public aware- months) in a given recent year received The government does not have national ness campaigns since January 2011. policies relating to screening and referral three doses of hepatitis B vaccine. to care for hepatitis B or hepatitis C. The government does not collaborate There is a national policy that specifically with in-country civil society groups to targets mother-to-child transmission of People testing for both hepatitis B and develop and implement its viral hepatitis hepatitis B (Annex B). hepatitis C register by name, and there prevention and control programme. is open access to their names. HepatiThere is a specific national strategy and/or tis B and hepatitis C tests are not free of Evidence-based policy and data for policy/guidelines for preventing hepatitis charge for all individuals, but they are free action B and hepatitis C infection in health-care of charge for people living with HIV, pregThere is routine surveillance for viral hepa- settings. Health-care workers are not vac- nant women, blood donors and people titis. There is a national surveillance system cinated against hepatitis B prior to starting infected with either hepatitis B or hepafor the following types of acute hepatitis: work that might put them at risk of expo- titis C. Information was not provided on A, B, C, D and E, and for the following types sure to blood. whether hepatitis B or hepatitis C tests are of chronic hepatitis: B, C and D. compulsory for members of any specific There is a national policy on injection safeThere are standard case definitions for ty in health-care settings, which recom- group. hepatitis. Deaths, including from hepatitis, mends single-use syringes for therapeutic Publicly funded treatment for hepatitis B are reported to a central registry. No hepa- injections. Single-use or auto-disable sy- and hepatitis C is available to the entire titis case is reported as “undifferentiated” ringes, needles and cannulas are always population. The amount spent by the govor “unclassified” hepatitis. available in all health-care facilities. ernment on such treatment is not known. Liver cancer cases and cases with HIV/hep- Official government estimates of the The following drugs for treating hepatitis atitis coinfection are registered nationally. number and percentage of unneces- B are on the national essential medicines sary injections administered annually in list or subsidized by the government: inThe government publishes hepatitis dis- health-care settings are not known. terferon alpha, pegylated interferon, lamiease reports annually. vudine, adefovir dipivoxil, entecavir, telbiThere is a national infection control policy Hepatitis outbreaks are required to be re- for blood banks. All donated blood units vudine and tenofovir. The following drugs ported to the government and are further (including family donations) and blood for treating hepatitis C are on the national investigated. There is adequate laboratory products nationwide are screened for essential medicines list or subsidized by the government: pegylated interferon and capacity nationally to support investiga- hepatitis B and hepatitis C. ribavirin. tion of viral hepatitis outbreaks and other surveillance activities. There is no national policy relating to the The Government of Cyprus welcomes asprevention of viral hepatitis among peosistance from WHO in one or more areas There is no national public health research ple who inject drugs. of viral hepatitis prevention and control agenda for viral hepatitis. It is not known whether viral hepatitis serosurveys are The government does not have guidelines (Annex C). conducted regularly. that address how hepatitis A and hepatitis E can be prevented through food and water safety.

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Czech Republic Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of the Czech Republic reports as follows. 10.5 High-income $24 370 7.88% $2050.95 $1716.16 77 0.917 39 1.5 Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

National coordination There is a written national strategy or plan that focuses exclusively on the prevention and control of viral hepatitis. It includes components for surveillance, vaccination, prevention in general, prevention of transmission via injecting drug use, prevention of transmission in health-care settings, and treatment and care. There is no designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities. It is not known how many people work full-time on hepatitis-related activities in all government agencies/bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), people who inject drugs, workers at centres for people who inject drugs, newborns, adolescents, medical students, nurses and workers in selected social services, prison workers, emergency services workers, patients on regular dialysis, new clients in residences for people with poor health, and contacts of hepatitis B-infected patients and hepatitis B surface antigen (HBsAg)-positive carriers.

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. The government collaborates with the following in-country civil society groups to develop and implement its viral hepatitis prevention and control programme: patient associations.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C and E, but not for any type of chronic hepatitis.

There is a national policy relating to the prevention of viral hepatitis among people There are standard case definitions for who inject drugs. hepatitis. Deaths, including from hepatitis, are reported to a central registry. Less than The government has guidelines that ad1% of hepatitis cases are reported as “un- dress how hepatitis A and hepatitis E can be prevented through food and water differentiated” or “unclassified” hepatitis. safety. Liver cancer cases and cases with HIV/hepatitis coinfection are registered nationally. Screening, care and treatment Health professionals obtain the skills and The government publishes hepatitis dis- competencies required to effectively care ease reports weekly, monthly and annually. for people with viral hepatitis through schools for health professionals (pre-servHepatitis outbreaks are required to be re- ice education), on-the-job training and ported to the government and are further postgraduate training. investigated. There is adequate laboratory capacity nationally to support investiga- There are national clinical guidelines for tion of viral hepatitis outbreaks and other the management of viral hepatitis, which surveillance activities. include recommendations for cases with HIV coinfection. It is not known whether There is no national public health research there are national clinical guidelines for the agenda for viral hepatitis. Viral hepatitis se- management of HIV, which include recrosurveys are not conducted regularly. The ommendations for coinfection with viral most recent serosurvey was conducted in hepatitis. 2001 and targeted the general population. The government has national policies rePrevention of transmission lating to screening and referral to care for There is a national policy on hepatitis A hepatitis B and hepatitis C. vaccination. People testing for both hepatitis B and The government has not established the hepatitis C register by name; the names are goal of eliminating hepatitis B. kept confidential within the system. HepaNationally, less than 1% of newborn in- titis B and hepatitis C tests are not free of fants in a given recent year received the charge for all individuals, though they are first dose of hepatitis B vaccine within 24 for certain groups, but information was not hours of birth and 99% of one-year-olds provided regarding which groups. Hepati(ages 12–23 months) in a given recent year tis B and hepatitis C tests are compulsory received three doses of hepatitis B vaccine. for members of some specific groups but these groups were not identified. There is a national policy that specifically targets mother-to-child transmission of Publicly funded treatment for hepatitis B and hepatitis C is available to all people hepatitis B (Annex B). with national health insurance. Information It is not known whether there is a specific was not provided on the amount spent by national strategy and/or policy/guidelines the government on such treatment. for preventing hepatitis B and hepatitis C infection in health-care settings. Health- Information was not provided on whether care workers are vaccinated against hepa- any drug for treating hepatitis B or hepatititis B prior to starting work that might put tis C is on the national essential medicines list or subsidized by the government. them at risk of exposure to blood. There is a national policy on injection safe- The Government of the Czech Republic ty in health-care settings, which recom- did not indicate a need for assistance from mends single-use syringes for therapeutic WHO in relation to viral hepatitis preveninjections. Single-use or auto-disable sy- tion and control. ringes, needles and cannulas are always available in all health-care facilities.

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Denmark The Government of Denmark reports as Population (in millions) (2011) 5.6 follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination $41 900 There is a written national strategy or plan Total health expenditure as % of GDP (2010) 11.42% that focuses primarily on the prevention Per capita total health expenditure (PPP int $) (2010) $4537.07 and control of viral hepatitis, and also in- Per capita government health expenditure (PPP int $) (2010) $3861.32 tegrates other diseases. It includes compo- Life expectancy at birth (in years) (2009) 79 nents for surveillance, vaccination, preven- Human Development Index (2011) 0.926 tion in general, prevention of transmission Median age (in years) (2010) 41 via injecting drug use, prevention of trans- Total fertility rate per woman (2010) 1.9 mission in health-care settings, treatment and care, and coinfection with HIV. There is no national public health research There is a national policy relating to the There is no designated governmental unit/ agenda for viral hepatitis. Viral hepatitis prevention of viral hepatitis among peodepartment responsible solely for coordi- serosurveys are conducted regularly; the ple who inject drugs. nating and/or carrying out viral hepatitis- target populations are people who inject related activities. One third of one full-time drugs, pregnant women and children of The government has guidelines that adstaff position in all government agencies/ infected mothers. Information was not dress how hepatitis A and hepatitis E can bodies is allocated to work on hepatitis- provided on when the last serosurvey was be prevented through food and water safety. carried out. related activities. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), people who inject drugs and pregnant women.

Prevention of transmission

Screening, care and treatment

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. The government collaborates with the following in-country civil society groups to develop and implement its viral hepatitis prevention and control programme: Gadejuristen and AIDS-Fondet.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B and C, and for the following types of chronic hepatitis: B and C. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. The percentage of hepatitis cases reported as “undifferentiated” or “unclassified” hepatitis is not known. Liver cancer cases and cases with HIV/hepatitis coinfection are registered nationally. The government publishes hepatitis disease reports annually. Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory capacity nationally to support investigation of viral hepatitis outbreaks and other surveillance activities.

There is a national policy on hepatitis A Health professionals obtain the skills and competencies required to effectively care vaccination. for people with viral hepatitis through The government has not established the schools for health professionals (pre-servgoal of eliminating hepatitis B. ice education), on-the-job training and postgraduate training. Nationally, 90% of newborn children of hepatitis B-infected mothers in a given There are national clinical guidelines for recent year received the first dose of hepa- the management of viral hepatitis, which titis B vaccine within 24 hours of birth and include recommendations for cases with 64% of one-year-old children (ages 12–23 HIV coinfection. months) of hepatitis B-infected mothers in a given recent year received three doses of The government does not have national policies relating to screening and referral hepatitis B vaccine. to care for hepatitis B or hepatitis C. There is a national policy that specifically targets mother-to-child transmission of People testing for both hepatitis B and hepatitis C register by name; the names hepatitis B (Annex B). are kept confidential within the system. There is a specific national strategy and/or Hepatitis B and hepatitis C tests are free of policy/guidelines for preventing hepatitis charge for all individuals and not compulB and hepatitis C infection in health-care sory for members of any specific group. settings. Health-care workers are vaccinated against hepatitis B prior to starting Publicly funded treatment for hepatitis B work that might put them at risk of expo- and hepatitis C is available to the entire population. Information was not provided sure to blood. on the amount spent by the government There is a national policy on injection on such treatment. safety in health-care settings, but it is not known what type of syringes it recom- The following drugs for treating hepatitis B mends for therapeutic injections. Single- are on the national essential medicines list use or auto-disable syringes, needles and or subsidized by the government: intercannulas are always available in all health- feron alpha, pegylated interferon, lamivudine, adefovir dipivoxil, entecavir, telbivucare facilities. dine and tenofovir. The following drugs for No injection administered annually in treating hepatitis C are on the national eshealth-care settings is unnecessary, ac- sential medicines list or subsidized by the cording to official government estimates. government: interferon alpha, pegylated interferon, ribavirin, boceprevir and telThere is a national infection control policy aprevir. for blood banks. All donated blood units (including family donations) and blood The Government of Denmark did not inproducts nationwide are screened for dicate a need for assistance from WHO in hepatitis B and hepatitis C. relation to viral hepatitis prevention and control.

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Estonia Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Estonia reports as follows. 1.3 High-income $20 850 6.03% $1226.28 $964.80 75 0.890 40 1.7 There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

National coordination There is no written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis. There is no designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities. There are no people working full-time on hepatitis-related activities in any government agency/body. The government does not have a viral hepatitis prevention and control programme that includes activities targeting specific populations.

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. The government does not collaborate with in-country civil society groups to develop and implement its viral hepatitis prevention and control programme.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C, D and E, and for the following types of chronic hepatitis: B, C and D. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Less than 1% of hepatitis cases are reported as “undifferentiated” or “unclassified” hepatitis. Liver cancer cases are not registered nationally, but cases with HIV/hepatitis coinfection are. The government publishes hepatitis disease reports monthly and annually.

The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water Hepatitis outbreaks are required to be re- safety. ported to the government and are further investigated. There is adequate laboratory Screening, care and treatment capacity nationally to support outbreak in- Health professionals obtain the skills and vestigations and other surveillance activi- competencies required to effectively care ties for hepatitis A, hepatitis B and hepatitis for people with viral hepatitis through schools for health professionals (pre-servC, but not for hepatitis E. ice education). There is no national public health research agenda for viral hepatitis. Viral hepatitis se- There are national clinical guidelines for the management of viral hepatitis, but it rosurveys are not conducted regularly. is not known whether they include recomPrevention of transmission mendations for cases with HIV coinfection. There is a national policy on hepatitis A The government has national policies revaccination. lating to screening and referral to care for The government has not established the hepatitis B and hepatitis C. goal of eliminating hepatitis B. People testing for both hepatitis B and Nationally, 88% of newborn infants in a hepatitis C register by name; the names are given recent year received the first dose of kept confidential within the system. Hepahepatitis B vaccine within 24 hours of birth titis B and hepatitis C tests are not free of and 94% of one-year-olds (ages 12–23 charge for all individuals, but they are for months) in a given recent year received pregnant women, prisoners, donors and three doses of hepatitis B vaccine. people with medical insurance. Hepatitis B and hepatitis C tests are compulsory for There is a national policy that specifically blood donors. targets mother-to-child transmission of hepatitis B (Annex B). Publicly funded treatment for hepatitis B and hepatitis C is available to people There is a specific national strategy and/or covered by the Estonian Health Insurance policy/guidelines for preventing hepatitis Fund. Information was not provided on the B and hepatitis C infection in health-care amount spent by the government on such settings. Health-care workers are vaccinat- treatment. ed against hepatitis B prior to starting work that might put them at risk of exposure to The following drugs for treating hepatitis blood. B are on the national essential medicines list or subsidized by the government: interThere is a national policy on injection safe- feron alpha and pegylated interferon. The ty in health-care settings, which recom- following drugs for treating hepatitis C are mends single-use syringes for therapeutic on the national essential medicines list or injections. Single-use or auto-disable sy- subsidized by the government: interferon ringes, needles and cannulas are always alpha, pegylated interferon and ribavirin. available in all health-care facilities. The Government of Estonia welcomes Official government estimates of the assistance from WHO in one or more arnumber and percentage of unnecessary eas of viral hepatitis prevention and coninjections administered annually in health- trol (Annex C). care settings are not known.

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Finland The Government of Finland reports as Population (in millions) (2011) 5.4 follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination $36 670 There is no written national strategy or Total health expenditure as % of GDP (2010) 8.95% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $3280.90 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $2462.46 Life expectancy at birth (in years) (2009) hepatitis. 80 Human Development Index (2011) 0.911 There is no designated governmental Median age (in years) (2010) 42 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.9 ordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitis- drugs, men who have sex with men, sex Screening, care and treatment related activities in all government agen- workers and pregnant women. The last se- Health professionals obtain the skills and competencies required to effectively care cies/bodies. rosurvey was carried out in 2010. for people with viral hepatitis through The government has a viral hepatitis pre- Prevention of transmission schools for health professionals (pre-servvention and control programme that in- There is a national policy on hepatitis A ice education) and postgraduate training. cludes activities targeting the following vaccination. There are national clinical guidelines for specific populations: health-care workers (including health-care waste handlers), The government has not established the the management of viral hepatitis, but they do not include recommendations for people who inject drugs, migrants and goal of eliminating hepatitis B. prisoners. It is not known what percentage of new- cases with HIV coinfection. There are national clinical guidelines for the manageAwareness-raising and partnerships born infants nationally in a given recent ment of HIV, which include recommendayear received the fi rst dose of hepatitis B The government did not hold events for tions for coinfection with viral hepatitis. World Hepatitis Day 2012 and has not vaccine within 24 hours of birth or what funded other viral hepatitis public aware- percentage of one-year-olds (ages 12–23 The government has national policies remonths) nationally in a given recent year lating to screening and referral to care for ness campaigns since January 2011. received three doses of hepatitis B vaccine. hepatitis B and hepatitis C. The government collaborates with the following in-country civil society groups There is a national policy that specifically People testing for both hepatitis B and to develop and implement its viral hepa- targets mother-to-child transmission of hepatitis C register by name; the names titis prevention and control programme: hepatitis B (Annex B). are kept confidential within the system. A-Clinic Foundation and Helsinki DeaconThere is a specific national strategy and/or Hepatitis B and hepatitis C tests are free of ess Institute. policy/guidelines for preventing hepatitis charge for all individuals and are not comB and hepatitis C infection in health-care pulsory for members of any specific group.

Evidence-based policy and data for settings. Health-care workers are vacci- Publicly funded treatment for hepatitis B is action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A and B, and for the following types of chronic hepatitis: B, C and D.

nated against hepatitis B prior to starting available to the entire population. All legal work that might put them at risk of expo- residents are eligible for publicly funded sure to blood. treatment for hepatitis C, but there is preThere is a national policy on injection safe- screening according to clinically set critety in health-care settings, which recom- ria, and being an active IDU is among the contraindications for starting treatment. There are standard case definitions for mends single-use syringes for therapeutic The amount spent by the government on hepatitis. Deaths, including from hepatitis, injections. Single-use or auto-disable sy- publicly funded treatment for hepatitis B are reported to a central registry. The per- ringes, needles and cannulas are always and hepatitis C is not known. centage of hepatitis cases reported as “un- available in all health-care facilities. differentiated” or “unclassified” hepatitis is Official government estimates of the The following drugs for treating hepatitis not known. number and percentage of unneces- B are on the national essential medicines list or subsidized by the government: Liver cancer cases and cases with HIV/hep- sary injections administered annually in interferon alpha, pegylated interferon, health-care settings are not known. atitis coinfection are registered nationally. lamivudine and adefovir dipivoxil. The following drugs for treating hepatitis C are There is a national infection control policy The government publishes hepatitis disfor blood banks. All donated blood units on the national essential medicines list or ease reports annually. (including family donations) and blood subsidized by the government: interferon Hepatitis outbreaks are required to be re- products nationwide are screened for alpha, pegylated interferon, ribavirin, boceprevir and telaprevir. ported to the government and are further hepatitis B and hepatitis C. investigated. There is adequate laboratory capacity nationally to support investiga- There is no national policy relating to the The Government of Finland welcomes astion of viral hepatitis outbreaks and other prevention of viral hepatitis among peo- sistance from WHO in one or more areas of viral hepatitis prevention and control ple who inject drugs. surveillance activities. (Annex C). There is no national public health research The government has guidelines that adagenda for viral hepatitis. Viral hepatitis dress how hepatitis A and hepatitis E can serosurveys are conducted regularly; the be prevented through food and water target populations are people who inject safety. 115

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France Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of France reports as follows.

63.1 High-income $35 910 11.88% $4020.73 $3130.10 81 0.919 40 2

There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is a national policy relating to the prevention of viral hepatitis among people who inject drugs. The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

National coordination There is a written national strategy or plan that focuses exclusively on the prevention and control of viral hepatitis. It includes components for raising awareness, surveillance, vaccination, prevention in general, prevention of transmission via injecting drug use, prevention of transmission in health-care settings, and treatment and care. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitis-related activities: Bureau Infections par le VIH, IST et Hépatites (DGS-RI2). Information was not provided on how many staff members this office has. It is not known how many people work full-time on hepatitis-related activities in all government agencies/bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), people who inject drugs, migrants, prisoners and people living with HIV.

Liver cancer cases are not registered nationally, but cases with HIV/hepatitis coinfection Screening, care and treatment Health professionals obtain the skills and are. competencies required to effectively care for The government publishes hepatitis disease people with viral hepatitis through schools reports annually. for health professionals (pre-service education), on-the-job training and postgraduate Hepatitis outbreaks are required to be re- training. ported to the government and are further investigated. There is adequate laboratory There are national clinical guidelines for the capacity nationally to support investigation management of viral hepatitis, but they do of outbreaks and other surveillance activities. not include recommendations for cases with HIV coinfection. There are national clinical There is a national public health research guidelines for the management of HIV, which agenda for viral hepatitis. Viral hepatitis se- include recommendations for coinfection rosurveys are conducted regularly; the target with viral hepatitis. populations are the general population, prisoners, people who inject drugs and men who The government has national policies relathave sex with men. The last serosurvey was ing to screening and referral to care for hepacarried out in 2011. titis B and hepatitis C.

Prevention of transmission

Awareness-raising and partnerships The government held events for World Hepatitis Day 2012 but has not funded other viral hepatitis public awareness campaigns since January 2011. The government collaborates with the following in-country civil society groups to develop and implement its viral hepatitis prevention and control programme: Federation SOS-Hépatites, Hépatites Infos Services and Collectif Hépatites Virales.

People testing for both hepatitis B and hepaThere is a national policy on hepatitis A vac- titis C register by name; the names are kept cination. confidential within the system. Hepatitis B tests are not free of charge for all individuThe government has not established the goal als, but they are free of charge in specific of eliminating hepatitis B. preventive centres. Hepatitis C tests are free It is not known what percentage of newborn of charge for all individuals. Hepatitis B tests infants nationally in a given recent year re- are compulsory for people who begin health ceived the first dose of hepatitis B vaccine professional studies and for pregnant womwithin 24 hours of birth. In a given recent year, en. Hepatitis C tests are not compulsory for 53% of one-year-olds (ages 12–23 months) members of any specific group. received three doses of hepatitis B vaccine. Publicly funded treatment for hepatitis B and There is a national policy that specifically tar- hepatitis C is available to all participants in gets mother-to-child transmission of hepati- the national health insurance programme (“Sécurité Sociale”). tis B (Annex B). There is a specific national strategy and/or policy/guidelines for preventing hepatitis B and hepatitis C infection in health-care settings. Health-care workers are vaccinated against hepatitis B prior to starting work that might put them at risk of exposure to blood. There is a national policy on injection safety in health-care settings, which recommends single-use syringes for therapeutic injections. Single-use or auto-disable syringes, needles and cannulas are always available in all health-care facilities. In 2009, the national health insurance programme spent approximately €450 million (US$ 578.7 million) for the treatment of chronic hepatitis B and hepatitis C. The following drugs for treating hepatitis B are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon, lamivudine, adefovir dipivoxil, entecavir, telbivudine and tenofovir. The following drugs for treating hepatitis C are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon, ribavirin, boceprevir and telaprevir.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A and B, and for chronic hepatitis B.

There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. The percentage of Official government estimates of the number hepatitis cases reported as “undifferentiated” and percentage of unnecessary injections or “unclassified” hepatitis is not known. administered annually in health-care settings The Government of France welcomes assistance from WHO in one or more areas of viral are not known. hepatitis prevention and control (Annex C). 116

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Georgia The Government of Georgia reports as Population (in millions) (2011) 4.3 follows. Country classification (2012) Lower–middle-income Gross national income per capita (PPP int $) (2011) National coordination $5350 There is no written national strategy or Total health expenditure as % of GDP (2010) 10.13% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $522.03 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $123.38 Life expectancy at birth (in years) (2009) hepatitis. 71 Human Development Index (2011) 0.843 There is a designated governmental unit/ Median age (in years) (2010) 37 department responsible solely for coordi- Total fertility rate per woman (2010) 1.6 nating and/or carrying out viral hepatitisrelated activities. It has three staff members. It is part of the Surveillance Division investigated. There is adequate laboratory There is a national policy relating to the of the Communicable Diseases Depart- capacity nationally to support investiga- prevention of viral hepatitis among peoment within the National Center for Dis- tion of viral hepatitis outbreaks and other ple who inject drugs. ease Control and Public Health. There are surveillance activities. The government does not have guidelines 65 full-time equivalent staff members who work on hepatitis-related activities in all There is no national public health research that address how hepatitis A and hepatiagenda for viral hepatitis. Viral hepatitis se- tis E can be prevented through food and government agencies/bodies. water safety. rosurveys are not conducted regularly. The government does not have a viral Screening, care and treatment hepatitis prevention and control pro- Prevention of transmission gramme that includes activities targeting There is no national policy on hepatitis A Health professionals obtain the skills and vaccination. competencies required to effectively care specific populations. for people with viral hepatitis through Awareness-raising and partnerships The government has not established the schools for health professionals (pre-service education), on-the-job training and The government held events for World goal of eliminating hepatitis B. Hepatitis Day 2012 but has not funded Nationally, 93% of newborn infants in a postgraduate training. other viral hepatitis public awareness given recent year received the first dose of There are national clinical guidelines for campaigns since January 2011. hepatitis B vaccine within 24 hours of birth the management of viral hepatitis, which The government collaborates with the fol- and 89% of one-year-olds (ages 12–23 include recommendations for cases with lowing in-country civil society groups to months) in a given recent year received HIV coinfection. develop and implement its viral hepatitis three doses of hepatitis B vaccine. prevention and control programme: Be- There is a national policy that specifically The government has national policies remoni Public Union, Center for Information targets mother-to-child transmission of lating to screening and referral to care for hepatitis B and hepatitis C. and Counseling on Reproductive Health hepatitis B (Annex B). Tanadgoma, and Curatio International People testing for both hepatitis B and Foundation. There is no specific national strategy and/ hepatitis C register by name; the names are or policy/guidelines for preventing hepaEvidence-based policy and data for titis B and hepatitis C infection in health- kept confidential within the system. Hepatitis B and hepatitis C tests are not free of action care settings. Health-care workers are not There is routine surveillance for viral hepa- vaccinated against hepatitis B prior to charge for all individuals, but they are free titis. There is a national surveillance system starting work that might put them at risk of charge for pregnant women and blood donors. Hepatitis B and hepatitis C tests for the following types of acute hepatitis: of exposure to blood. are compulsory for blood donors. A, B, C and E, and for the following types of chronic hepatitis: B and C. There is a national policy on injection safe- Publicly funded treatment is not available ty in health-care settings, which recomThere are standard case definitions for mends single-use syringes for therapeutic for hepatitis B or hepatitis C. hepatitis. Deaths, including from hepatitis, injections. Single-use or auto-disable sy- The following drugs for treating hepatitis B are reported to a central registry. The per- ringes, needles and cannulas are always are on the national essential medicines list centage of hepatitis cases reported as “un- available in all health-care facilities. or subsidized by the government: interdifferentiated” or “unclassified” hepatitis is feron alpha, pegylated interferon, lamivunot known. Official government estimates of the dine, adefovir dipivoxil and tenofovir. The number and percentage of unnecesLiver cancer cases are not registered na- sary injections administered annually in following drugs for treating hepatitis C are on the national essential medicines list or tionally, but cases with HIV/hepatitis coin- health-care settings are not known. subsidized by the government: interferon fection are. alpha, pegylated interferon, ribavirin, boThere is a national infection control policy The government publishes hepatitis dis- for blood banks. All donated blood units ceprevir and telaprevir. ease reports annually. (including family donations) and blood The Government of Georgia welcomes Hepatitis outbreaks are required to be re- products nationwide are screened for assistance from WHO in one or more areas of viral hepatitis prevention and conported to the government and are further hepatitis B and hepatitis C. trol (Annex C).

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Germany Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 82.2 High-income $40 230 11.64% $4332.34 $3339.32 80 0.940 44 1.4 injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs. The government does not have guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

The Government of Germany reports as Hepatitis outbreaks are required to be refollows. ported to the government and are further investigated. There is adequate laboratory National coordination capacity nationally to support investigaThere is no written national strategy or plan tion of viral hepatitis outbreaks and other that focuses exclusively or primarily on the surveillance activities. prevention and control of viral hepatitis. There is no national public health research There is no designated governmental unit/ agenda for viral hepatitis. Viral hepatitis department responsible solely for coordi- serosurveys are conducted regularly; the nating and/or carrying out viral hepatitis- target populations are children aged 3–17 related activities. There is one full-time years and the general population. The last equivalent staff member who works on serosurvey was carried out in 2009–2011. hepatitis-related activities in all governPrevention of transmission ment agencies/bodies. There is a national policy on hepatitis A The government does not have a viral hep- vaccination, which recommends vaccinaatitis prevention and control programme tion for health-care workers (including that includes activities targeting specific health-care waste handlers). populations. However, hepatitis B vaccination is recommended for people who The government has not established the inject drugs, prisoners and people living goal of eliminating hepatitis B. with HIV. Information was not provided on the perAwareness-raising and partnerships centage of newborn infants nationally in The government did not hold events for a given recent year who received the first World Hepatitis Day 2012 and has not dose of hepatitis B vaccine within 24 hours funded other viral hepatitis public aware- of birth. In a given recent year, 90%–91% ness campaigns since January 2011. of one-year-olds (ages 12–23 months) received three doses of hepatitis B vaccine. The government does not collaborate with in-country civil society groups to develop There is a national policy that specifically and implement its viral hepatitis preven- targets mother-to-child transmission of tion and control programme. hepatitis B (Annex B).

Screening, care and treatment Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through schools for health professionals (pre-service education) and on-the-job training. There are national clinical guidelines for the management of viral hepatitis, which include recommendations for cases with HIV coinfection. The government has national policies relating to screening and referral to care for hepatitis B, but not for hepatitis C. People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are free of charge for all individuals and are not compulsory for members of any specific group.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C, D and E, and for chronic hepatitis C. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Information was not provided on the percentage of hepatitis cases reported as “undifferentiated” or “unknown” hepatitis. Liver cancer cases are registered nationally, but cases with HIV/hepatitis coinfection are not. The government publishes hepatitis disease reports annually.

Publicly funded treatment for hepatitis B and hepatitis C is available to all people with national health insurance. In 2010, the government spent €7.8 million (US$ 10 million) on outpatient care for hepatitis B and €1.8 million (US$ 2.3 million) on outpatient care for hepatitis C, not including There is a specific national strategy and/or drug costs. policy/guidelines for preventing hepatitis B and hepatitis C infection in health-care The following drugs for treating hepatitis settings. Health-care workers are vacci- B are on the national essential medicines nated against hepatitis B prior to starting list or subsidized by the government: interwork that might put them at risk of expo- feron alpha, pegylated interferon, lamivusure to blood. Hepatitis B vaccination is dine, adefovir dipivoxil, entecavir, telbivualso recommended for health-care waste dine and tenofovir. The following drugs for treating hepatitis C are on the national eshandlers. sential medicines list or subsidized by the There is a national policy on injection safety government: interferon alpha, pegylated in health-care settings but it is not known interferon, ribavirin, boceprevir and telwhat type of syringes it recommends for aprevir. therapeutic injections. Single-use or autodisable syringes, needles and cannulas are The Government of Germany did not inalways available in all health-care facilities. dicate a need for assistance from WHO in relation to viral hepatitis prevention and Official government estimates of the control. number and percentage of unnecessary

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Hungary The Government of Hungary reports as Population (in millions) (2011) 10.0 follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination $20 310 There is no written national strategy or Total health expenditure as % of GDP (2010) 7.33% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $1468.59 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $1018.85 Life expectancy at birth (in years) (2009) hepatitis. 74 Human Development Index (2011) 0.862 There is no designated governmental Median age (in years) (2010) 40 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.4 ordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitis- It is not known whether there is a national It is not known whether there is a national related activities in all government agen- public health research agenda for viral policy relating to the prevention of viral hepatitis. Viral hepatitis serosurveys are hepatitis among people who inject drugs. cies/bodies. not conducted regularly. It is not known whether the government The government does not have a viral has guidelines that address how hepahepatitis prevention and control pro- Prevention of transmission gramme that includes activities targeting There is a national policy on hepatitis A titis A and hepatitis E can be prevented vaccination. through food and water safety. specific populations.

Awareness-raising and partnerships

The government has not established the It is not known whether the government goal of eliminating hepatitis B. held events for World Hepatitis Day 2012 or has funded other viral hepatitis public It is not known what percentage of newawareness campaigns since January 2011. born infants nationally in a given recent year received the first dose of hepatitis B The government collaborates with the fol- vaccine within 24 hours of birth or what lowing in-country civil society group to percentage of one-year-olds (ages 12–23 develop and implement its viral hepatitis months) nationally in a given recent year prevention and control programme: Máj- received three doses of hepatitis B vaccine. moly Foundation. There is a national policy that specifically Evidence-based policy and data for targets mother-to-child transmission of hepatitis B (Annex B). action There is routine surveillance for viral hepatitis. There is a national surveillance system There is a specific national strategy and/or for the following types of acute hepatitis: policy/guidelines for preventing hepatitis A, B, C, D and E. Information was not pro- B and hepatitis C infection in health-care vided on whether there is a national sur- settings. Health-care workers are vacciveillance system for any type of chronic nated against hepatitis B prior to starting work that might put them at risk of expohepatitis. sure to blood. There are standard case definitions for hepatitis. Deaths, including from hepatitis, There is a national policy on injection are reported to a central registry. Informa- safety in health-care settings, but it is not tion was not provided on the percentage known what type of syringes it recomof hepatitis cases reported as “undifferen- mends for therapeutic injections. Singleuse or auto-disable syringes, needles and tiated” or “unknown” hepatitis. cannulas are always available in all healthLiver cancer cases are registered nation- care facilities. ally, but cases with HIV/hepatitis coinfecOfficial government estimates of the tion are not. number and percentage of unnecesThe government publishes hepatitis dis- sary injections administered annually in health-care settings are not known. ease reports weekly. Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory capacity nationally to support investigation of viral hepatitis outbreaks and other surveillance activities.

Screening, care and treatment Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through onthe-job training and postgraduate training. There are national clinical guidelines for the management of viral hepatitis. It is not known whether there are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral hepatitis. It is not known whether the government has national policies relating to screening and referral to care for hepatitis B or hepatitis C. People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are not free of charge, and are compulsory for certain health-care professionals. Publicly funded treatment is available for hepatitis B and hepatitis C, but information was not provided on who is eligible for such treatment. The amount spent by the government on publicly funded treatment for hepatitis B and hepatitis C is not known.

It is not known whether any drug for treating hepatitis B or hepatitis C is on the There is a national infection control policy national essential medicines list or subsifor blood banks. All donated blood units dized by the government. (including family donations) and blood products nationwide are screened for It is not known whether the Government hepatitis B and hepatitis C. of Hungary has a need for assistance from WHO in relation to viral hepatitis prevention and control.

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Ireland Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 4.5 High-income $34 180 9.19% $3703.96 $2561.56 80 0.959 35 2.1 products nationwide are screened for hepatitis B and hepatitis C. Information was not provided on whether there is a national policy relating to the prevention of viral hepatitis among people who inject drugs. The government does not have guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

The Government of Ireland reports as Hepatitis outbreaks are required to be refollows. ported to the government and are further investigated. There is adequate laboratory National coordination capacity nationally to support outbreak inThere is no written national strategy or plan vestigations and other surveillance activithat focuses exclusively or primarily on the ties for hepatitis A, hepatitis B and hepatitis prevention and control of viral hepatitis. C, but it is not known whether this is the There is no designated governmental unit/ case for hepatitis E.

Screening, care and treatment Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through schools for health professionals (pre-service education) and postgraduate training.

department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities. It is not known how many people work full-time on hepatitis-related activities in all government agencies/bod- Prevention of transmission There is a national policy on hepatitis A ies. vaccination. The government has a viral hepatitis prevention and control programme that in- The government has not established the cludes activities targeting the following goal of eliminating hepatitis B. specific populations: health-care workers (including health-care waste handlers), It is not known what percentage of newpeople who inject drugs, migrants and born infants nationally in a given recent year received the first dose of hepatitis B prisoners. vaccine within 24 hours of birth. Nationally, Awareness-raising and partnerships 90% of one-year-olds (ages 12–23 months) The government did not hold events for in a given recent year received three doses World Hepatitis Day 2012 and has not of hepatitis B vaccine. funded other viral hepatitis public awareThere is a national policy that specifically ness campaigns since January 2011. targets mother-to-child transmission of The government collaborates with the fol- hepatitis B (Annex B). lowing in-country civil society groups to develop and implement its viral hepatitis There is a specific national strategy and/or prevention and control programme: Posi- policy/guidelines for preventing hepatitis tive Action, Transfusion Positive and Irish B and hepatitis C infection in health-care settings. Health-care workers are vaccinatHaemophilia Society. ed against hepatitis B prior to starting work Evidence-based policy and data for that might put them at risk of exposure to action blood. There is routine surveillance for viral hepatitis. There is a national surveillance system It is not known whether there is a national for the following types of acute hepatitis: policy on injection safety in health-care A, B, and C, and for the following types of settings, and what type of syringes it recommends for therapeutic injections. It is chronic hepatitis: B and C. not known whether single-use or autoThere are standard case definitions for disable syringes, needles and cannulas are hepatitis. Deaths, including from hepatitis, always available in all health-care facilities. are reported to a central registry. No hepatitis case is reported as “undifferentiated” or Official government estimates of the number and percentage of unnecessary “unclassified” hepatitis. injections administered annually in healthLiver cancer cases are registered nationally, care settings are not known. but cases with HIV/hepatitis coinfection There is a national infection control policy are not. for blood banks. All donated blood units The government publishes hepatitis dis- (including family donations) and blood ease reports quarterly. 120

There are no national clinical guidelines for the management of viral hepatitis. It is not There is no national public health research known whether there are national clinical agenda for viral hepatitis. Viral hepatitis se- guidelines for the management of HIV, which include recommendations for coinrosurveys are not conducted regularly. fection with viral hepatitis. The government does not have national policies relating to screening and referral to care for hepatitis B or hepatitis C. People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are not free of charge for all individuals, but they are free of charge for people attending public clinics for drug users, women in antenatal care, people with sexually transmitted infections, and people seeking asylum. Hepatitis B and hepatitis C tests are not compulsory for members of any specific group. Publicly funded treatment is available for hepatitis B and hepatitis C. The following group is eligible for such treatment for hepatitis B: people with a medical card. The following group is eligible for such treatment for hepatitis C: people with a medical card or a Health Amendment Act card. Information was not provided on the amount spent by the government on publicly funded treatment for hepatitis B and hepatitis C. The following drugs for treating hepatitis B are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon, lamivudine, adefovir dipivoxil and entecavir. The following drugs for treating hepatitis C are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon, ribavirin, boceprevir and telaprevir. The Government of Ireland did not indicate a need for assistance from WHO in relation to viral hepatitis prevention and control.

Chapter 6: WHO European Region

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Israel The Government of Israel reports as Population (in millions) (2011) 7.6 follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination $27 110 There is a written national strategy or plan Total health expenditure as % of GDP (2010) 7.63% that focuses primarily on the prevention Per capita total health expenditure (PPP int $) (2010) $2186.43 and control of viral hepatitis, and also in- Per capita government health expenditure (PPP int $) (2010) $1318.92 tegrates other diseases. It includes compo- Life expectancy at birth (in years) (2009) 82 nents for surveillance, vaccination, preven- Human Development Index (2011) 0.888 tion of transmission via injecting drug use, Median age (in years) (2010) 30 prevention of transmission in health-care Total fertility rate per woman (2010) 2.9 settings, treatment and care, and coinfection with HIV. There is no national public health research Screening, care and treatment There is no designated governmental agenda for viral hepatitis. Viral hepatitis se- Health professionals obtain the skills and competencies required to effectively care unit/department responsible solely for co- rosurveys are not conducted regularly. for people with viral hepatitis through ordinating and/or carrying out viral hepaschools for health professionals (pre-servtitis-related activities. It is not known how Prevention of transmission many people work full-time on hepatitis- There is a national policy on hepatitis A ice education), on-the-job training and postgraduate training. related activities in all government agen- vaccination. cies/bodies. The government has not established the There are national clinical guidelines for the management of viral hepatitis, but The government has a viral hepatitis pre- goal of eliminating hepatitis B. vention and control programme that in- Nationally, 98% of newborn infants in a information was not provided on whether cludes activities targeting the following given recent year received the first dose of they include recommendations for cases specific populations: health-care workers hepatitis B vaccine within 24 hours of birth with HIV coinfection. There are national (including health-care waste handlers), and 98% of one-year-olds (ages 12–23 clinical guidelines for the management of people who inject drugs, people living months) in a given recent year received HIV, which include recommendations for coinfection with viral hepatitis. with HIV and travellers. three doses of hepatitis B vaccine.

Awareness-raising and partnerships

There is a national policy that specifically The government did not hold events for targets mother-to-child transmission of World Hepatitis Day 2012 and has not hepatitis B (Annex B). funded other viral hepatitis public awareness campaigns since January 2011. There is a specific national strategy and/or policy/guidelines for preventing hepatitis The government does not collaborate B and hepatitis C infection in health-care with in-country civil society groups to settings. Health-care workers are vaccidevelop and implement its viral hepatitis nated against hepatitis B prior to starting prevention and control programme. work that might put them at risk of expoEvidence-based policy and data for sure to blood.

The government does not have national policies relating to screening and referral to care for hepatitis B or hepatitis C. People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are free of charge for all individuals, and are compulsory for blood donors and health-care workers. Publicly funded treatment is available for hepatitis B and hepatitis C. Information was not provided regarding who is eligible for this. The amount spent by the government on publicly funded treatment for hepatitis B and hepatitis C is not known. The following drugs for treating hepatitis B are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon, lamivudine, adefovir dipivoxil, entecavir, telbivudine and tenofovir. The following drugs for treating hepatitis C are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon, ribavirin, boceprevir and telaprevir.

action

There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B and C, but not for any type of chronic hepatitis. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Of hepatitis cases, 1% is reported as “undifferentiated” or “unclassified” hepatitis.

There is a national policy on injection safety in health-care settings, which recommends single-use syringes for therapeutic injections. Single-use or auto-disable syringes, needles and cannulas are always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known.

Liver cancer cases are registered nation- There is a national infection control policy ally, but cases with HIV/hepatitis coinfec- for blood banks. All donated blood units (including family donations) and blood tion are not. products nationwide are screened for The government publishes hepatitis dis- hepatitis B and hepatitis C. ease reports weekly. There is a national policy relating to the Hepatitis outbreaks are required to be re- prevention of viral hepatitis among peo- The Government of Israel did not indicate a need for assistance from WHO in relation ported to the government and are further ple who inject drugs. to viral hepatitis prevention and control. investigated. There is adequate laboratory capacity nationally to support outbreak in- The government has guidelines that advestigations and other surveillance activi- dress how hepatitis A and hepatitis E can ties for hepatitis A, hepatitis B and hepati- be prevented through food and water safety. tis C, but not for hepatitis E.

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Italy Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 60.8 High-income $32 400 9.53% $3021.72 $2345.36 82 0.914 43 1.4 injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is a national policy relating to the prevention of viral hepatitis among people who inject drugs. The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

The Government of Italy reports as follows. of hepatitis cases are reported as “undifferentiated” or “unclassified”, the followNational coordination ing information was provided: incidence There is no written national strategy or plan rate/100 000 of unclassified hepatitis: 0.1. that focuses exclusively or primarily on the prevention and control of viral hepatitis. Liver cancer cases and cases with HIV/ hepatitis coinfection are not registered naThere is no designated governmental unit/ tionally. department responsible solely for coordinating and/or carrying out viral hepatitis- The government publishes hepatitis disrelated activities. Information was not pro- ease reports annually. vided on how many people work full-time on hepatitis-related activities in all govern- Hepatitis outbreaks are required to be reported to the government and are further ment agencies/bodies. investigated. There is adequate laboratory The government has a viral hepatitis pre- capacity nationally to support investigavention and control programme that in- tion of viral hepatitis outbreaks and other cludes activities targeting the following surveillance activities. specific populations: health-care workers (including health-care waste handlers), There is no national public health research people who inject drugs, prisoners, part- agenda for viral hepatitis. Viral hepatitis seners of carriers of HBsAg and hepatitis C rosurveys are not conducted regularly. virus, people cohabiting with carriers of Prevention of transmission HBsAg or hepatitis C virus, people underThere is a national policy on hepatitis A going multiple blood transfusions, people vaccination. with haemophilia, people undergoing haemodialysis, people with chronic skin The government has not established the lesions of the hands (eczema, psoriasis), goal of eliminating hepatitis B. travellers to hepatitis B-endemic areas, police officers, firefighters, public officials and Nationally, all newborn children of hepatitis B-infected mothers in a given recent garbage disposal workers. year received the first dose of hepatitis B Awareness-raising and partnerships vaccine within 24 hours of birth, and 95% The government held events for World of one-year-olds (ages 12–23 months) in a Hepatitis Day 2012 but has not funded given recent year received three doses of other viral hepatitis public awareness cam- hepatitis B vaccine. paigns since January 2011. There is a national policy that specifically The government does not collaborate with targets mother-to-child transmission of in-country civil society groups to develop hepatitis B (Annex B). and implement its viral hepatitis prevention and control programme. There is no specific national strategy and/ or policy/guidelines for preventing hepatiEvidence-based policy and data for tis B and hepatitis C infection in health-care action settings. There is routine surveillance for viral hepatitis. There is a national surveillance system There is a national policy on injection safefor the following types of acute hepatitis: A, ty in health-care settings, which recomB, C, D and E, but not for any type of chronic mends single-use syringes for therapeutic hepatitis. injections. Single-use or auto-disable syringes, needles and cannulas are always There are standard case definitions for hep- available in all health-care facilities. atitis. Deaths, including from hepatitis, are reported to a central registry. In response Official government estimates of the to a question asking what percentage number and percentage of unnecessary

Screening, care and treatment Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through schools for health professionals (pre-service education) and postgraduate training. There are no national clinical guidelines for the management of viral hepatitis. Information was not provided on whether there are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral hepatitis. The government does not have national policies relating to screening and referral to care for hepatitis B or hepatitis C. People testing for hepatitis B and hepatitis C do not register by name. Hepatitis B and hepatitis C tests are free of charge for all individuals. Information was not provided on whether hepatitis B or hepatitis C tests are compulsory for members of any specific group. Publicly funded treatment is available for hepatitis B and hepatitis C. Information was not provided regarding who is eligible for this. Information was not provided on the amount spent by the government on publicly funded treatment for hepatitis B and hepatitis C. The following drugs for treating hepatitis B are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon, lamivudine, adefovir dipivoxil, entecavir, telbivudine and tenofovir. The following drugs for treating hepatitis C are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon, ribavirin, boceprevir and telaprevir. The Government of Italy did not indicate a need for assistance from WHO in relation to viral hepatitis prevention and control.

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Kyrgyzstan The Government of Kyrgyzstan reports as Population (in millions) (2011) follows. Country classification (2012) Gross national income per capita (PPP int $) (2011) National coordination There is a written national strategy or plan Total health expenditure as % of GDP (2010) that focuses exclusively on the prevention Per capita total health expenditure (PPP int $) (2010) and control of viral hepatitis. It includes Per capita government health expenditure (PPP int $) (2010) components for surveillance, vaccination, Life expectancy at birth (in years) (2009) prevention of transmission via injecting Human Development Index (2011) drug use, prevention of transmission in Median age (in years) (2010) health-care settings, and treatment and Total fertility rate per woman (2010) care. There is no designated governmental unit/department responsible solely for coordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitisrelated activities in all government agencies/bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: people who inject drugs and people living with HIV. 5.4 Low-income $2180 6.18% $140.26 $78.80 66 0.734 24 2.7

vestigations and other surveillance activi- There is a national policy relating to the ties for hepatitis A, hepatitis B, hepatitis C prevention of viral hepatitis among people who inject drugs. and hepatitis D, but not for hepatitis E. There is no national public health research The government has guidelines that adagenda for viral hepatitis. Viral hepatitis se- dress how hepatitis A and hepatitis E can be prevented through food and water rosurveys are not conducted regularly. safety.

Prevention of transmission

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. The government collaborates with the following in-country civil society groups to develop and implement its viral hepatitis prevention and control programme: nongovernmental organizations that work with sex workers, prisoners and people who inject drugs.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C and D, and for the following types of chronic hepatitis: B, C and D. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Of hepatitis cases, 20% are reported as “undifferentiated” or “unclassified” hepatitis. Liver cancer cases are not registered nationally, but cases with HIV/hepatitis coinfection are. The government publishes hepatitis disease reports monthly. Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory capacity nationally to support outbreak in-

There is no national policy on hepatitis A Screening, care and treatment Health professionals obtain the skills and vaccination. competencies required to effectively care The government has not established the for people with viral hepatitis through goal of eliminating hepatitis B. schools for health professionals (pre-service education), on-the-job training and Nationally, 93%–95% of newborn infants postgraduate training. in a given recent year received the first dose of hepatitis B vaccine within 24 hours There are national clinical guidelines for of birth and 98% of one-year-olds (ages the management of viral hepatitis, which 12–23 months) in a given recent year re- include recommendations for cases with ceived three doses of hepatitis B vaccine. HIV coinfection. There are national clinical guidelines for the management of HIV, There is a national policy that specifically which include recommendations for cointargets mother-to-child transmission of fection with viral hepatitis. hepatitis B (Annex B). The government does not have national There is no specific national strategy policies relating to screening and referral and/or policy/guidelines for preventing to care for hepatitis B or hepatitis C. hepatitis B and hepatitis C infection in health-care settings. Information was not People testing for both hepatitis B and provided on whether health-care workers hepatitis C register by name; the names are vaccinated against hepatitis B prior to are kept confidential within the system. starting work that might put them at risk Hepatitis B and hepatitis C tests are not of exposure to blood. free of charge and are not compulsory for members of any specific group. There is a national policy on injection safety in health-care settings, which recom- Publicly funded treatment is not available mends single-use syringes for therapeutic for hepatitis B or hepatitis C. injections. Single-use or auto-disable syringes, needles and cannulas are always The following drugs for treating hepatitis B are on the national essential medicines available in all health-care facilities. list or subsidized by the government: inOfficial government estimates of the terferon alpha, pegylated interferon, laminumber and percentage of unneces- vudine and tenofovir. The following drugs sary injections administered annually in for treating hepatitis C are on the national health-care settings are not known. essential medicines list or subsidized by the government: pegylated interferon and There is no national infection control ribavirin. policy for blood banks. All donated blood units (including family donations) and The Government of Kyrgyzstan welcomes blood products nationwide are screened assistance from WHO in one or more areas for hepatitis C, but not for hepatitis B. of viral hepatitis prevention and control (Annex C).

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Latvia Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 2.2 Upper–middle-income $17 700 6.68% $1092.52 $667.99 72 0.857 40 1.5 (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs. The government does not have guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

The Government of Latvia reports as Hepatitis outbreaks are required to be refollows. ported to the government and are further investigated. There is adequate laboratory National coordination capacity nationally to support investigaThere is no written national strategy or plan tion of viral hepatitis outbreaks and other that focuses exclusively or primarily on the surveillance activities. prevention and control of viral hepatitis. It is not known whether there is a national There is no designated governmental unit/ public health research agenda for viral department responsible solely for coordi- hepatitis. Viral hepatitis serosurveys are nating and/or carrying out viral hepatitis- not conducted regularly. The most recent related activities. It is not known how many serosurvey was conducted in 2000 and tarpeople work full-time on hepatitis-related geted pregnant women, boarding school activities in all government agencies/ students and new members of the military. bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), people who inject drugs, infants, adolescents, patients on dialysis and blood donors.

Screening, care and treatment Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through schools for health professionals (pre-service education) and on-the-job training. There are national clinical guidelines for the management of viral hepatitis, which include recommendations for cases with HIV coinfection. Information was not provided on whether there are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral hepatitis.

Prevention of transmission

Awareness-raising and partnerships The government held events for World Hepatitis Day 2012, but has not funded other viral hepatitis public awareness campaigns since January 2011. The government collaborates with the following in-country civil society groups to develop and implement its viral hepatitis prevention and control programme: Association HIV Latvia and the Hepatitis Association.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C and E, and for the following types of chronic hepatitis: B and C. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Of hepatitis cases, 3% are reported as “undifferentiated” or “unclassified” hepatitis. Liver cancer cases and cases with HIV/hepatitis coinfection are registered nationally.

There is no national policy on hepatitis A The government does not have national policies relating to screening and referral vaccination. to care for hepatitis B or hepatitis C. The government has established the goal of reducing hepatitis B among children by People testing for both hepatitis B and hepatitis C register by name; the names are 2011–2012. kept confidential within the system. HepaInformation was not provided on the per- titis B and hepatitis C tests are not free of centage of newborn infants in a given charge for all individuals, but they are free recent year who received the first dose of of charge at syringe exchange points for hepatitis B vaccine within 24 hours of birth. people who inject drugs. Hepatitis B and Nationally, 91% of one-year-olds (ages 12– hepatitis C tests are not compulsory for 23 months) in a given recent year received members of any specific group. three doses of hepatitis B vaccine. Publicly funded treatment is available for There is a national policy that specifically people chronically infected with hepatitis targets mother-to-child transmission of B and hepatitis C. For people with chronic hepatitis B (Annex B). hepatitis B, public funding covers inpatient hospital treatment. For people with chronThere is a specific national strategy and/or ic hepatitis C, public funding covers 75% policy/guidelines for preventing hepatitis of all treatment costs. The amount spent B and hepatitis C infection in health-care by the government on such treatment for settings. Health-care workers are vaccinat- hepatitis B and hepatitis C is not known. ed against hepatitis B prior to starting work that might put them at risk of exposure to The following drugs for treating hepatitis blood. B are on the national essential medicines list or subsidized by the government: interThere is a national policy on injection safe- feron alpha and lamivudine. The following ty in health-care settings, which recom- drugs for treating hepatitis C are on the mends single-use syringes for therapeutic national essential medicines list or subsiinjections. Single-use or auto-disable sy- dized by the government: interferon alpha, ringes, needles and cannulas are always pegylated interferon and ribavirin. available in all health-care facilities. The Government of Latvia welcomes asOfficial government estimates of the sistance from WHO in one or more areas number and percentage of unnecessary of viral hepatitis prevention and control injections administered annually in health- (Annex C). care settings are not known.

The government publishes hepatitis dis- There is a national infection control policy ease reports monthly and annually. for blood banks. All donated blood units 124

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Lithuania The Government of Lithuania reports as Population (in millions) (2011) 3.3 follows. Country classification (2012) Upper–middle-income Gross national income per capita (PPP int $) (2011) National coordination $19 640 There is no written national strategy or Total health expenditure as % of GDP (2010) 7.04% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $1299.46 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $954.93 Life expectancy at birth (in years) (2009) hepatitis. 73 Human Development Index (2011) 0.853 There is no designated governmental Median age (in years) (2010) 39 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.5 ordinating and/or carrying out viral hepatitis-related activities. It is not known how Screening, care and treatment many people work full-time on hepatitis- Prevention of transmission related activities in all government agen- There is no national policy on hepatitis A Health professionals obtain the skills and vaccination. competencies required to effectively care cies/bodies. for people with viral hepatitis through The government does not have a viral The government has not established the schools for health professionals (pre-servhepatitis prevention and control pro- goal of eliminating hepatitis B. ice education), on-the-job training and gramme that includes activities targeting postgraduate training. Nationally, 96% of newborn infants in a specific populations. given recent year received the first dose of There are national clinical guidelines for Awareness-raising and partnerships hepatitis B vaccine within 24 hours of birth the management of viral hepatitis, which The government held events for World and 95% of one-year-olds (ages 12–23 include recommendations for cases with Hepatitis Day 2012, but has not funded months) in a given recent year received HIV coinfection. Information was not proother viral hepatitis public awareness three doses of hepatitis B vaccine. vided on whether there are national clinicampaigns since January 2011. cal guidelines for the management of HIV, There is a national policy that specifically The government collaborates with in- targets mother-to-child transmission of which include recommendations for coinfection with viral hepatitis. country civil society groups to develop hepatitis B (Annex B). and implement its viral hepatitis prevenThe government does not have national tion and control programme. Information There is a specific national strategy and/or policies relating to screening and referral was not provided about the identity of the policy/guidelines for preventing hepatitis to care for hepatitis B or hepatitis C. B and hepatitis C infection in health-care civil society partners. settings. Health-care workers are vacci- People testing for both hepatitis B and Evidence-based policy and data for nated against hepatitis B prior to starting hepatitis C register by name; the names action work that might put them at risk of expo- are kept confidential within the system. There is routine surveillance for viral hepa- sure to blood. Hepatitis B and hepatitis C tests are not titis. There is a national surveillance system free of charge and are not compulsory for for the following types of acute hepatitis: There is a national policy on injection members of any specific group. A, B, C, D and E, and for the following types safety in health-care settings. Information was not provided on the type of syringes All people with health insurance are eligiof chronic hepatitis: B, C and D. it recommends for therapeutic injections. ble for publicly funded treatment for hepThere are standard case definitions for Single-use or auto-disable syringes, nee- atitis B and hepatitis C. The government hepatitis. Deaths, including from hepatitis, dles and cannulas are always available in spends LTL 14.6 million (€4.3 million; US$ are reported to a central registry. Of hepa- all health-care facilities. 5.6 million) annually on hepatitis B and titis cases, 7% are reported as “undifferenhepatitis C medications, and LTL 2.1 milOfficial government estimates of the tiated” or “unclassified” hepatitis. lion (€624 000; US$ 800 000) annually on number and percentage of unnecesLiver cancer cases are registered nation- sary injections administered annually in hepatitis B and hepatitis C outpatient and inpatient services. ally, but cases with HIV/hepatitis coinfec- health-care settings are not known. tion are not. The following drugs for treating hepatitis There is a national infection control policy The government does not publish hepati- for blood banks. All donated blood units B are on the national essential medicines list or subsidized by the government: intis disease reports. (including family donations) and blood terferon alpha, pegylated interferon, lamiproducts nationwide are screened for vudine, adefovir dipivoxil, entecavir and Hepatitis outbreaks are not required to be hepatitis B and hepatitis C. tenofovir. The following drugs for treating reported to the government. There is adequate laboratory capacity nationally to There is no national policy relating to the hepatitis C are on the national essential support investigation of viral hepatitis out- prevention of viral hepatitis among peo- medicines list or subsidized by the government: interferon alpha, pegylated inbreaks and other surveillance activities. ple who inject drugs. terferon and ribavirin. There is no national public health research The government does not have guidelines agenda for viral hepatitis. Viral hepatitis se- that address how hepatitis A and hepati- The Government of Lithuania welcomes rosurveys are not conducted regularly. tis E can be prevented through food and assistance from WHO in one or more areas of viral hepatitis prevention and control water safety. (Annex C).

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Luxembourg Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 0.5 High-income $64 260 7.77% $6743.02 $5691.67 81 0.854 39 1.6 There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is a national policy relating to the prevention of viral hepatitis among people who inject drugs.

It is not known whether the government has guidelines that address how hepatitis A and hepatitis E can be prevented The Government of Luxembourg reports The government does not publish hepati- through food and water safety. as follows. tis disease reports.

National coordination

Screening, care and treatment

Hepatitis outbreaks are required to be reThere is no written national strategy or plan ported to the government and are further that focuses exclusively or primarily on the investigated. There is adequate laboratory prevention and control of viral hepatitis. capacity nationally to support investigation of viral hepatitis outbreaks and other There is no designated governmental unit/ surveillance activities. department responsible solely for coordinating and/or carrying out viral hepatitis- There is no national public health research related activities. It is not known how many agenda for viral hepatitis. Viral hepatitis sepeople work full-time on hepatitis-related rosurveys are not conducted regularly. activities in all government agencies/ Prevention of transmission bodies. There is a national policy on hepatitis A The government has a viral hepatitis pre- vaccination. vention and control programme that includes activities targeting the following It is not known whether the government specific populations: health-care workers has established the goal of eliminating (including health-care waste handlers), hepatitis B. people who inject drugs and prisoners. It is not known what percentage of newAwareness-raising and partnerships born infants nationally in a given recent The government did not hold events for year received the first dose of hepatitis B World Hepatitis Day 2012 and has not vaccine within 24 hours of birth. Nationally, funded other viral hepatitis public aware- 94% of one-year-olds (ages 12–23 months) in a given recent year received three doses ness campaigns since January 2011. of hepatitis B vaccine. The government does not collaborate with in-country civil society groups to develop There is a national policy that specifically and implement its viral hepatitis preven- targets mother-to-child transmission of hepatitis B (Annex B). tion and control programme.

Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through schools for health professionals (pre-service education), on-the-job training and postgraduate training. There are no national clinical guidelines for the management of viral hepatitis or for the management of HIV, which include recommendations for coinfection with viral hepatitis. The government does not have national policies relating to screening and referral to care for hepatitis B or hepatitis C. People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are not free of charge. Hepatitis B tests are compulsory for health-care workers, who should subsequently be vaccinated. Hepatitis C tests are not compulsory for members of any specific group.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B and C, and for the following types of chronic hepatitis: B and C. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. The percentage of hepatitis cases reported as “undifferentiated” or “unclassified” hepatitis is not known.

Publicly funded treatment is available for hepatitis B and hepatitis C. People insured by the national health insurance system There is a specific national strategy and/or are eligible. The amount spent by the govpolicy/guidelines for preventing hepatitis ernment on publicly funded treatment for B and hepatitis C infection in health-care hepatitis B and hepatitis C is not known. settings. Health-care workers are vaccinat- The following drugs for treating hepatitis ed against hepatitis B prior to starting work B are on the national essential medicines that might put them at risk of exposure to list or subsidized by the government: interblood. feron alpha, pegylated interferon, lamivuThere is a national policy on injection safe- dine, adefovir dipivoxil and tenofovir. The ty in health-care settings, which recom- following drugs for treating hepatitis C are mends single-use syringes for therapeutic on the national essential medicines list or injections. Single-use or auto-disable sy- subsidized by the government: interferon ringes, needles and cannulas are always alpha, pegylated interferon, ribavirin, boceprevir and telaprevir. available in all health-care facilities. The Government of Luxembourg did not indicate a need for assistance from WHO in relation to viral hepatitis prevention and control.

Liver cancer cases and cases with HIV/hep- Official government estimates of the atitis coinfection are registered nationally. number and percentage of unnecessary injections administered annually in healthcare settings are not known.

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Malta The Government of Malta reports as Population (in millions) (2011) 0.4 follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination $24 480 There is no written national strategy or Total health expenditure as % of GDP (2010) 8.65% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $2261.40 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $1480.73 Life expectancy at birth (in years) (2009) hepatitis. 80 Human Development Index (2011) 0.866 There is no designated governmental Median age (in years) (2010) 39 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.3 ordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitis- There is no national public health research The government does not have guidelines related activities in all government agen- agenda for viral hepatitis. Viral hepatitis se- that address how hepatitis A and hepatitis E can be prevented through food and rosurveys are not conducted regularly. cies/bodies. water safety. The government has a viral hepatitis pre- Prevention of transmission vention and control programme that in- There is a national policy on hepatitis A Screening, care and treatment Health professionals obtain the skills and cludes activities targeting the following vaccination. competencies required to effectively care specific populations: health-care workers (including health-care waste handlers), The government has established the goal for people with viral hepatitis through people who inject drugs, prisoners and of eliminating hepatitis B but does not schools for health professionals (pre-servhave a specific timeframe for this. ice education). people living with HIV. Nationally, 15% of newborn infants in a The government held events for World given recent year received the first dose of Hepatitis Day 2012, but has not funded hepatitis B vaccine within 24 hours of birth other viral hepatitis public awareness and 82% of one-year-olds (ages 12–23 months) in a given recent year received campaigns since January 2011. three doses of hepatitis B vaccine. The government does not collaborate with in-country civil society groups to There is a national policy that specifically develop and implement its viral hepatitis targets mother-to-child transmission of hepatitis B (Annex B). prevention and control programme. Evidence-based policy and data for There is a specific national strategy and/or policy/guidelines for preventing hepatitis action There is routine surveillance for viral hepa- B and hepatitis C infection in health-care titis. There is a national surveillance system settings. Health-care workers are vaccifor the following types of acute hepatitis: nated against hepatitis B prior to starting A, B and C, and for the following types of work that might put them at risk of exposure to blood. chronic hepatitis: B and C.

Awareness-raising and partnerships

There are no national clinical guidelines for the management of viral hepatitis, but physicians have adopted the European clinical guidelines for the management of viral hepatitis. Information was not provided on whether there are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral hepatitis. The government does not have national policies relating to screening and referral to care for hepatitis B or hepatitis C.

There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Information was not provided on the percentage of hepatitis cases reported as “undifferentiated” or “unknown” hepatitis. Liver cancer cases are registered nationally, but cases with HIV/hepatitis coinfection are not. The government does not publish hepatitis disease reports. Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory capacity nationally to support outbreak investigations and other surveillance activities for hepatitis A, hepatitis B and hepatitis C, but not for hepatitis E.

People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are free of charge for all individuals and are not comThere is a national policy on injection safepulsory for members of any specific group. ty in health-care settings, which recommends single-use syringes for therapeutic Publicly funded treatment is available for injections. Single-use or auto-disable sy- hepatitis B and hepatitis C. Information ringes, needles and cannulas are always was not provided on who is eligible for this available in all health-care facilities. and the amount spent by the government on publicly funded treatment for hepatitis Official government estimates of the B and hepatitis C. number and percentage of unnecessary injections administered annually in The following drugs for treating hepatitis health-care settings are not known. B are on the national essential medicines list or subsidized by the government: inThere is a national infection control policy terferon alpha and lamivudine. The folfor blood banks. All donated blood units lowing drug for treating hepatitis C is on (including family donations) and blood the national essential medicines list or products nationwide are screened for subsidized by the government: interferon hepatitis B and hepatitis C. alpha. There is no national policy relating to the The Government of Malta did not indicate prevention of viral hepatitis among peoa need for assistance from WHO in relation ple who inject drugs. to viral hepatitis prevention and control.

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Montenegro Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Montenegro reports as follows. 0.6 Upper–middle-income $13 700 9.11% $1155.27 $776.01 75 0.831 36 1.7 Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

National coordination There is no written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis. There is no designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities. It is not known how many people work full-time on hepatitis-related activities in all government agencies/bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), people who inject drugs and children.

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. The government collaborates with the following in-country civil society groups to develop and implement its viral hepatitis prevention and control programme: NGO Juventas and NGO Cazas.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C, D and E, and for the following types of chronic hepatitis: B and C. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Of hepatitis cases, 18% are reported as “undifferentiated” or “unclassified” hepatitis. Liver cancer cases are not registered nationally, but cases with HIV/hepatitis coinfection are.

There is no national policy relating to the prevention of viral hepatitis among people The government publishes hepatitis dis- who inject drugs. ease reports in the annual report on comIt is not known whether the government municable diseases in Montenegro. has guidelines that address how hepaHepatitis outbreaks are required to be re- titis A and hepatitis E can be prevented ported to the government and are further through food and water safety. investigated. There is adequate laboratory capacity nationally to support investiga- Screening, care and treatment tion of viral hepatitis outbreaks and other Health professionals obtain the skills and competencies required to effectively care surveillance activities. for people with viral hepatitis through There is no national public health research schools for health professionals (pre-servagenda for viral hepatitis. Viral hepatitis ice education) and on-the-job training. serosurveys are conducted regularly; the target populations are people who inject There are no national clinical guidelines for drugs, men who have sex with men, sex the management of viral hepatitis. It is not workers and prisoners. The last serosurvey known whether there are national clinical guidelines for the management of HIV, was carried out in 2011. which include recommendations for coinPrevention of transmission fection with viral hepatitis. There is a national policy on hepatitis A The government has national policies revaccination. lating to screening and referral to care for The government has not established the hepatitis B and hepatitis C. goal of eliminating hepatitis B. People testing for both hepatitis B and Information was not provided on the per- hepatitis C register by name; the names centage of newborn infants nationally in are kept confidential within the system. a given recent year who received the first Hepatitis B and hepatitis C tests are free dose of hepatitis B vaccine within 24 hours of charge for all individuals covered by of birth. In a given recent year, 91% of one- national health insurance, and are compulyear-olds (ages 12–23 months) received sory for blood, organ and tissue donors. three doses of hepatitis B vaccine. Publicly funded treatment is available for There is a national policy that specifically hepatitis B and hepatitis C. The following targets mother-to-child transmission of people are eligible: individuals covered hepatitis B (Annex B). by national health insurance. The amount spent by the government on publicly fundThere is a specific national strategy and/or ed treatment for hepatitis B and hepatitis C policy/guidelines for preventing hepatitis is not known. B and hepatitis C infection in health-care settings. Health-care workers are vaccinat- The following drugs for treating hepatitis ed against hepatitis B prior to starting work B are on the national essential medicines that might put them at risk of exposure to list or subsidized by the government: blood. pegylated interferon and lamivudine. The following drugs for treating hepatitis C are There is a national policy on injection safe- on the national essential medicines list or ty in health-care settings, which recom- subsidized by the government: pegylated mends single-use syringes for therapeutic interferon and ribavirin. injections. Single-use or auto-disable syringes, needles and cannulas are always The Government of Montenegro welavailable in all health-care facilities. comes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

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Netherlands (the) The Government of the Netherlands Population (in millions) (2011) 16.7 reports as follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination $43 140 There is no written national strategy or Total health expenditure as % of GDP (2010) 11.92% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $5037.83 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $3991.24 Life expectancy at birth (in years) (2009) hepatitis. 81 Human Development Index (2011) 0.944 There is no designated governmental Median age (in years) (2010) 41 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.8 ordinating and/or carrying out viral hepatitis-related activities. There are two to three full-time equivalent staff members serosurveys are conducted regularly; the The government has guidelines that adwho work on hepatitis-related activities in target populations are the general popula- dress how hepatitis A and hepatitis E can tion and prisoners. The last serosurvey was be prevented through food and water all government agencies/bodies. safety. carried out in 2010. The government has a viral hepatitis preScreening, care and treatment vention and control programme that in- Prevention of transmission cludes activities targeting the following There is a national policy on hepatitis A Health professionals obtain the skills and competencies required to effectively care specific populations: health-care workers vaccination. for people with viral hepatitis through (including health-care waste handlers), people who inject drugs, migrants, pris- The government has not established the schools for health professionals (pre-service education), on-the-job training and oners, sex workers, people living with HIV goal of eliminating hepatitis B. postgraduate training. and men who have sex with men. Nationally, 99% of newborn infants in a Awareness-raising and partnerships given recent year received the first dose There are national clinical guidelines for The government held events for World of hepatitis B vaccine within 24 hours of the management of viral hepatitis, which Hepatitis Day 2012 and has funded other birth. It is not known what percentage include recommendations for cases with viral hepatitis public awareness cam- of one-year-olds (ages 12–23 months) HIV coinfection. There are national clininationally in a given recent year received cal guidelines for the management of HIV, paigns since January 2011 (Annex A). three doses of hepatitis B vaccine. which include recommendations for coinThe government collaborates with the folfection with viral hepatitis. lowing in-country civil society group to There is a national policy that specifically targets mother-to-child transmission of The government has national policies redevelop and implement its viral hepatitis lating to screening and referral to care for prevention and control programme: Na- hepatitis B (Annex B). hepatitis B and hepatitis C. tional Hepatitis Centrum. There is a specific national strategy and/or policy/guidelines for preventing hepatitis People testing for hepatitis B and hepatiEvidence-based policy and data for B and hepatitis C infection in health-care tis C do not register by name. Hepatitis B action There is routine surveillance for viral hepa- settings. Health-care workers are vacci- and hepatitis C tests are not free of charge titis. There is a national surveillance system nated against hepatitis B prior to starting for all individuals. Hepatitis B tests are free for the following types of acute hepatitis: work that might put them at risk of expo- of charge for patients attending sexusure to blood. ally transmitted infection (STI) clinics who A, B and C, and for chronic hepatitis B. meet specific criteria. Hepatitis C tests are There is no national policy on injection There are standard case definitions for free of charge for people living with HIV safety in health-care settings, although hepatitis. Deaths, including from hepatitis, and men who have sex with men. Hepatiare reported to a central registry. Of hepa- there is a policy on needle-stick injuries. tis B and hepatitis C tests are not compulSingle-use or auto-disable syringes, neetitis cases, 2% are reported as “undifferensory for members of any specific group. dles and cannulas are always available in tiated” or “unclassified” hepatitis. all health-care facilities. Publicly funded treatment for hepatitis B Liver cancer cases and cases with HIV/hepand hepatitis C is available to all people Offi cial government estimates of the atitis coinfection are registered nationally. with social health insurance. The amount number and percentage of unnecesspent by the government on such treatThe government publishes hepatitis dis- sary injections administered annually in ment for hepatitis B and hepatitis C is not health-care settings are not known. ease reports annually. known. Hepatitis outbreaks are required to be re- There is a national infection control policy It is not known whether any drug for treatported to the government and are further for blood banks. All donated blood units ing hepatitis B or hepatitis C is on the investigated. There is adequate laboratory (including family donations) and blood national essential medicines list or subsiproducts nationwide are screened for capacity nationally to support investigadized by the government. tion of viral hepatitis outbreaks and other hepatitis B and hepatitis C. surveillance activities. The Government of the Netherlands did There is a national policy relating to the not indicate a need for assistance from There is no national public health research prevention of viral hepatitis among peoWHO in relation to viral hepatitis prevenagenda for viral hepatitis. Viral hepatitis ple who inject drugs. tion and control.

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Poland Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 38.3 High-income $20 430 7.46% $1476.06 $1071.94 76 0.853 38 1.4 (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is a national policy relating to the prevention of viral hepatitis among people who inject drugs. The government does not have guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

The Government of Poland reports as The government publishes hepatitis dis- Screening, care and treatment follows. ease reports. Information was not provided Health professionals obtain the skills and competencies required to effectively care on how often these are published. National coordination for people with viral hepatitis through There is no written national strategy or plan Hepatitis outbreaks are required to be re- schools for health professionals (pre-servthat focuses exclusively or primarily on the ported to the government and are further ice education), on-the-job training and prevention and control of viral hepatitis. investigated. There is adequate laboratory postgraduate training. capacity nationally to support outbreak inThere is no designated governmental unit/ vestigations and other surveillance activi- There are national clinical guidelines for the department responsible solely for coordi- ties for hepatitis A, hepatitis B and hepatitis management of viral hepatitis, but they do nating and/or carrying out viral hepatitis- C, but not for hepatitis E. not include recommendations for cases related activities. It is not known how many with HIV coinfection. There are national people work full-time on hepatitis-related There is no national public health research clinical guidelines for the management of activities in all government agencies/ agenda for viral hepatitis. Viral hepatitis se- HIV, which include recommendations for bodies. rosurveys are not conducted regularly. coinfection with viral hepatitis. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers); people who inject drugs; people living with HIV; household contacts and other contacts of hepatitis B-infected persons; pre-surgical patients; and people at risk due to lifestyle, occupation, age and chronic diseases.

Prevention of transmission

The government has national policies reThere is a national policy on hepatitis A lating to screening and referral to care for vaccination. hepatitis B and hepatitis C. The government has not established the People testing for both hepatitis B and goal of eliminating hepatitis B. hepatitis C register by name; the names are kept confidential within the system. HepaIt is not known what percentage of new- titis B and hepatitis C tests are not free of born infants nationally in a given recent charge for all individuals, but they are free year received the first dose of hepatitis B of charge for blood and organ donors, vaccine within 24 hours of birth. In a given pregnant women, and everyone who has recent year, 98% of one-year-olds (ages public health insurance and is referred by a 12–23 months) received three doses of doctor. Hepatitis B and hepatitis C tests are hepatitis B vaccine. compulsory for blood and organ donors. There is a national policy that specifically Publicly funded treatment is available for targets mother-to-child transmission of hepatitis B and hepatitis C. Publicly insured hepatitis B (Annex B). patients are eligible for this based on mediThere is a specific national strategy and/or cal indications. The government spent Zl policy/guidelines for preventing hepatitis 65.5 million (US$ 20.1 million) on publicly B and hepatitis C infection in health-care funded treatment for hepatitis B in 2011. settings. Health-care workers are vaccinat- The amount spent by the government ed against hepatitis B prior to starting work on such treatment for hepatitis C is not that might put them at risk of exposure to known. blood. The following drugs for treating hepatitis There is a national policy on injection safe- B are on the national essential medicines ty in health-care settings. It is not known list or subsidized by the government: inwhat type of syringes it recommends for terferon alpha, pegylated interferon, lamitherapeutic injections. Single-use or auto- vudine, adefovir dipivoxil, entecavir and disable syringes, needles and cannulas are tenofovir. The following drugs for treating always available in all health-care facilities. hepatitis C are included on the national essential medicines list or subsidized by the Official government estimates of the government: interferon alpha, pegylated number and percentage of unnecessary interferon and ribavirin. injections administered annually in healthThe Government of Poland welcomes care settings are not known. assistance from WHO in one or more arThere is a national infection control policy eas of viral hepatitis prevention and confor blood banks. All donated blood units trol (Annex C).

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. The government does not collaborate with in-country civil society groups to develop and implement its viral hepatitis prevention and control programme.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C, D and E, and for the following types of chronic hepatitis: B, C and D. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Of hepatitis cases, 2% are reported as “undifferentiated” or “unclassified” hepatitis. Liver cancer cases are registered nationally, but cases with HIV/hepatitis coinfection are not.

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Republic of Moldova (the) The Government of the Republic of Moldova reports as follows.

National coordination There is a written national strategy or plan that focuses exclusively on the prevention and control of viral hepatitis. It includes components for raising awareness, surveillance, vaccination, prevention in general, prevention of transmission via injecting drug use, prevention of transmission in health-care settings, treatment and care, and coinfection with HIV. There is a designated governmental unit/department responsible solely for coordinating and/or carrying out viral hepatitis-related activities: the National Center for Public Health Laboratory for Epidemiology of Viral Hepatitis. It has seven staff members. There are 29 full-time equivalent staff members who work on hepatitis-related activities in all government agencies/bodies.

Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010)

3.5 Lower–middle-income $3640 11.68% $360.40 $165.05 69 0.746 35 1.5

capacity nationally to support investigation There is a national policy relating to the preof viral hepatitis outbreaks and other surveil- vention of viral hepatitis among people who lance activities. inject drugs. The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

There is a national public health research agenda for viral hepatitis. Viral hepatitis serosurveys are conducted regularly; the target populations are children under the age of 17 years, the general population, people who inject drugs, patients on haemodialysis, blood donors and family members of those with The government has a viral hepatitis preven- hepatitis B and hepatitis C. The last serosurtion and control programme that includes vey was carried out in 2012. activities targeting the following specific populations: health-care workers (including Prevention of transmission health-care waste handlers), people who in- There is no national policy on hepatitis A vacject drugs, migrants, prisoners, people living cination. with HIV, contacts of people with acute and The government has established the goal of chronic viral hepatitis, and medical students. reducing hepatitis B to a level that achieves Awareness-raising and partnerships parity with the European Union average by The government held events for World Hepa- 2016. titis Day 2012 and has funded other viral hepatitis public awareness campaigns since January 2011 (Annex A). The government collaborates with the following in-country civil society group to develop and implement its viral hepatitis prevention and control programme: Politics and Analytics in Health. Nationally, 99.5% of newborn infants in a given recent year received the first dose of hepatitis B vaccine within 24 hours of birth and 99.3% of one-year-olds (ages 12–23 months) in a given recent year received three doses of hepatitis B vaccine. There is a national policy that specifically targets mother-to-child transmission of hepatitis B (Annex B).

Screening, care and treatment Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through schools for health professionals (pre-service education), on-the-job training, postgraduate training, and at conferences and seminars. There are national clinical guidelines for the management of viral hepatitis, but they do not include recommendations for cases with HIV coinfection. There are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral hepatitis. The government has national policies relating to screening and referral to care for hepatitis B and hepatitis C. People testing for both hepatitis B and hepatitis C register by name, and there is open access to their names. Hepatitis B and hepatitis C tests are free of charge for all individuals, and are compulsory for health-care workers, patients on haemodialysis, donors and those in regular contact with people infected with hepatitis B or hepatitis C.

Evidence-based policy and data for action There is a specific national strategy and/or There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C, D and E, and for the following types of chronic hepatitis: B, C and D.

There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Of hepatitis cases, 7.6% are reported as “undifferentiated” or “unclassified” hepatitis. Liver cancer cases are registered nationally, but cases with HIV/hepatitis coinfection are not. The government publishes hepatitis disease reports monthly and annually. Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory

policy/guidelines for preventing hepatitis B and hepatitis C infection in health-care settings. Health-care workers are vaccinated Publicly funded treatment for hepatitis B and against hepatitis B prior to starting work that hepatitis C is available to all people with namight put them at risk of exposure to blood. tional health insurance. The amount spent by the government on such treatment is not There is no national policy on injection safety known. in health-care settings. Single-use or autodisable syringes, needles and cannulas are The following drugs for treating hepatitis B always available in all health-care facilities. are on the national essential medicines list or subsidized by the government: pegylated inOfficial government estimates of the number terferon and lamivudine. The following drugs and percentage of unnecessary injections for treating hepatitis C are on the national administered annually in health-care settings essential medicines list or subsidized by the are not known. government: pegylated interferon and ribavirin. There is a national infection control policy for blood banks. All donated blood units (includ- The Government of the Republic of Moldova ing family donations) and blood products welcomes assistance from WHO in one or nationwide are screened for hepatitis B and more areas of viral hepatitis prevention and hepatitis C. control (Annex C).

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Russian Federation (the) Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of the Russian Federation reports as follows.

National coordination There is a written national strategy or plan that focuses primarily on the prevention and control of viral hepatitis, and also integrates other diseases. It includes components for raising awareness, surveillance, vaccination, prevention in general, prevention of transmission via injecting drug use, prevention of transmission in health-care settings, treatment and care, and coinfection with HIV. The following designated governmental units/departments are responsible solely for coordinating and/or carrying out viral hepatitis-related activities: Central Research Institute of Epidemiology Reference Center for Viral Hepatitis and Expert Group on Viral Hepatitis of the Ministry of Health. Information was not provided regarding the number of staff members. It is not known how many people work full-time on hepatitis-related activities in all government agencies/bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), people who inject drugs, people living with HIV, food industry workers, and sewage and sanitation workers.

There is a national policy relating to the prevention of viral hepatitis among people who respectively, are reported as “undifferenti- inject drugs. ated” or “unclassified” hepatitis. The government has guidelines that address Liver cancer cases and cases with HIV/hepati- how hepatitis A and hepatitis E can be prevented through food and water safety. tis coinfection are registered nationally. The government publishes hepatitis disease Screening, care and treatment Health professionals obtain the skills and reports monthly and annually. competencies required to effectively care for Hepatitis outbreaks are required to be re- people with viral hepatitis through schools ported to the government and are further for health professionals (pre-service educainvestigated. There is adequate laboratory tion), on-the-job training and postgraduate capacity nationally to support outbreak in- training. vestigations and other surveillance activities for hepatitis A, hepatitis B and hepatitis C but It is not known whether there are national clinical guidelines for the management of not for hepatitis E. viral hepatitis, but there are for the manageThere is no national public health research ment of HIV, which include recommendaagenda for viral hepatitis. Viral hepatitis sero- tions for coinfection with viral hepatitis. surveys are conducted regularly. Target populations include children, the general popu- The government has national policies relatlation, people who inject drugs and select ing to screening and referral to care for hepapopulations such as health-care workers and titis B and hepatitis C. patients who are thought to be at increased risk for viral hepatitis. The last serosurvey was People testing for both hepatitis B and hepatitis C register by name; the names are kept carried out in 2012. confidential within the system. Hepatitis B and hepatitis C tests are not free of charge for Prevention of transmission There is a national policy on hepatitis A vac- all individuals, but they are free of charge for donors, pregnant women, recipients of blood cination. and blood components, and newborns of The government has established the goal of women with acute and chronic hepatitis eliminating hepatitis B but the timeframe has B. Hepatitis B and hepatitis C tests are comnot yet been set. pulsory for selected populations, including It is not known what percentage of newborn health-care workers and patients who are infants nationally in a given recent year re- thought to be at increased risk for viral hepaceived the first dose of hepatitis B vaccine titis. within 24 hours of birth. In a given recent year, Publicly funded treatment is available for 97.3% of one-year-olds (ages 12–23 months) hepatitis B and hepatitis C. The amount spent received three doses of hepatitis B vaccine. by the government on such treatment is not There is a national policy that specifically tar- known. The following drugs for treating hepatitis B are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon, lamivudine, entecavir and telbivudine. The following drugs for treating hepatitis C are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon and ribavirin. The Government of the Russian Federation welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

142.8 Upper–middle-income $20 560 5.07% $998.36 $619.73 68 0.777 38 1.5

Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

Awareness-raising and partnerships The government held events for World Hepatitis Day 2012 and has funded other viral hepatitis public awareness campaigns since January 2011 (Annex A).

The government collaborates with the following in-country civil society group to de- gets mother-to-child transmission of hepativelop and implement its viral hepatitis pre- tis B (Annex B). vention and control programme: Together There is a specific national strategy and/or against Hepatitis. policy/guidelines for preventing hepatitis B Evidence-based policy and data for and hepatitis C infection in health-care setaction tings. Health-care workers are vaccinated There is routine surveillance for viral hepatitis. against hepatitis B prior to starting work that There is a national surveillance system for the might put them at risk of exposure to blood. following types of acute hepatitis: A, B and C, and for the following types of chronic hepa- There is a national policy on injection safety in health-care settings, which recommends titis: B and C. single-use syringes for therapeutic injections. There are standard case definitions for Single-use or auto-disable syringes, neehepatitis. Deaths, including from hepatitis, dles and cannulas are always available in all are reported to a central registry. Of acute health-care facilities. and chronic hepatitis cases, 5.7% and 1.3%, 132

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San Marino The Government of San Marino reports as Population (in millions) (2011) 0.03 follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination -There is no written national strategy or Total health expenditure as % of GDP (2010) 7.13% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $2853.17 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $2435.42 Life expectancy at birth (in years) (2009) hepatitis. 83 Human Development Index (2011) -There is no designated governmental Median age (in years) (2010) -unit/department responsible solely for co- Total fertility rate per woman (2010) 1.5 ordinating and/or carrying out viral hepatitis-related activities. Information was not provided on how many people work Prevention of transmission tis E can be prevented through food and full-time on hepatitis-related activities in There is no national policy on hepatitis A water safety. vaccination. all government agencies/bodies.

Screening, care and treatment

The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific population: health-care workers (including health-care waste handlers).

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. The government does not collaborate with in-country civil society groups to develop and implement its viral hepatitis prevention and control programme.

Evidence-based policy and data for action There is no routine surveillance for viral hepatitis. There are no standard case definitions for hepatitis. Information was not provided on whether deaths, including from hepatitis, are reported to a central registry. No hepatitis case is reported as “undifferentiated” or “unclassified” hepatitis. Liver cancer cases and cases with HIV/hepatitis coinfection are registered nationally. The government does not publish hepatitis disease reports. Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory capacity nationally to support investigation of viral hepatitis outbreaks and other surveillance activities. There is no national public health research agenda for viral hepatitis. Viral hepatitis serosurveys are not conducted regularly.

The government has not established the Health professionals obtain the skills and competencies required to effectively care goal of eliminating hepatitis B. for people with viral hepatitis through onNationally, less than 1% of newborn in- the-job training. fants in a given recent year received the first dose of hepatitis B vaccine within 24 There are no national clinical guidelines hours of birth and 89% of one-year-olds for the management of viral hepatitis. In(ages 12–23 months) in a given recent year formation was not provided on whether received three doses of hepatitis B vaccine. there are national clinical guidelines for the management of HIV, which include There is a national policy that specifically recommendations for coinfection with vitargets mother-to-child transmission of ral hepatitis. hepatitis B (Annex B). The government does not have national There is a specific national strategy and/or policies relating to screening and referral policy/guidelines for preventing hepatitis to care for hepatitis B or hepatitis C. B and hepatitis C infection in health-care settings. Health-care workers are vacci- People testing for both hepatitis B and nated against hepatitis B prior to starting hepatitis C register by name; the names work that might put them at risk of expo- are kept confidential within the system. Hepatitis B and hepatitis C tests are free of sure to blood. charge for all individuals and are compulThere is a national policy on injection safe- sory for blood donors. ty in health-care settings, which recommends single-use syringes for therapeutic Publicly funded treatment is available for injections. Single-use or auto-disable sy- hepatitis B and hepatitis C. Information ringes, needles and cannulas are always was not provided on who is eligible for this or on the amount spent by the govavailable in all health-care facilities. ernment on publicly funded treatment for Official government estimates of the hepatitis B and hepatitis C. number and percentage of unnecessary injections administered annually in The following drugs for treating hepatitis B are on the national essential medicines list health-care settings are not known. or subsidized by the government: interThere is a national infection control policy feron alpha, pegylated interferon, lamivufor blood banks. All donated blood units dine, adefovir dipivoxil and entecavir. The (including family donations) and blood following drugs for treating hepatitis C are products nationwide are screened for on the national essential medicines list or hepatitis B and hepatitis C. subsidized by the government: interferon alpha, pegylated interferon and ribavirin. There is no national policy relating to the prevention of viral hepatitis among peo- The Government of San Marino welcomes ple who inject drugs. assistance from WHO in one or more areas of viral hepatitis prevention and control The government does not have guidelines (Annex C). that address how hepatitis A and hepati-

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Serbia Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 9.9 Upper–middle-income $11 540 10.36% $1169.07 $723.31 74 0.824 38 1.6 (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. It is not known whether there is a national policy relating to the prevention of viral hepatitis among people who inject drugs. The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

The Government of Serbia reports as Hepatitis outbreaks are required to be refollows. ported to the government and are further investigated. There is adequate laboratory National coordination capacity nationally to support outbreak inThere is no written national strategy or plan vestigations and other surveillance activithat focuses exclusively or primarily on the ties for hepatitis A, hepatitis B and hepatitis prevention and control of viral hepatitis. C, but not for hepatitis E. There is no designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities. It is not known how many people work full-time on hepatitis-related activities in all government agencies/bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), people who inject drugs and people living with HIV. There is a national public health research agenda for viral hepatitis. Viral hepatitis serosurveys are conducted regularly; the target populations are men who have sex with men, sex workers and Roma youth. The last serosurvey was carried out in 2010.

Screening, care and treatment Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through schools for health professionals (pre-service education), on-the-job training and postgraduate specialization. There are national clinical guidelines for the management of viral hepatitis, which include recommendations for cases with HIV coinfection. There are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral hepatitis.

Prevention of transmission

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. The government collaborates with the following in-country civil society group to develop and implement its viral hepatitis prevention and control programme: NGO HRONOS.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C and E, and for the following types of chronic hepatitis: B and C. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Less than 1% of hepatitis cases are reported as “undifferentiated” or “unclassified” hepatitis. Liver cancer cases and cases with HIV/hepatitis coinfection are registered nationally. The government publishes hepatitis disease reports annually.

There is no national policy on hepatitis A The government has national policies relating to screening and referral to care for vaccination. hepatitis B and hepatitis C. The government has not established the People testing for both hepatitis B and goal of eliminating hepatitis B. hepatitis C register by name; the names are It is not known what percentage of new- kept confidential within the system. Hepaborn infants nationally in a given recent titis B and hepatitis C tests are not free of year received the first dose of hepatitis B charge for all individuals, but they are free vaccine within 24 hours of birth. In a given of charge for pregnant women, people livrecent year, 96% of one-year-olds (ages ing with HIV, patients who are referred and 12–23 months) received three doses of patients on haemodialysis. Hepatitis B and hepatitis B vaccine. hepatitis C tests are compulsory for blood donors, voluntary donors of tissues and There is a national policy that specifically organs, pregnant women and patients on targets mother-to-child transmission of haemodialysis. hepatitis B (Annex B). Publicly funded treatment for hepatitis B There is a specific national strategy and/or and hepatitis C is available to all people policy/guidelines for preventing hepatitis with health insurance. Information was not B and hepatitis C infection in health-care provided on the amount spent by the govsettings. Health-care workers are vaccinat- ernment on such treatment. ed against hepatitis B prior to starting work that might put them at risk of exposure to The following drugs for treating hepatitis blood. B are on the national essential medicines list or subsidized by the government: interThere is a national policy on injection safe- feron alpha, lamivudine, adefovir dipivoxil ty in health-care settings, which recom- and tenofovir. The following drugs for mends single-use syringes for therapeutic treating hepatitis C are on the national esinjections. Single-use or auto-disable sy- sential medicines list or subsidized by the ringes, needles and cannulas are always government: pegylated interferon and available in all health-care facilities. ribavirin. Official government estimates of the The Government of Serbia welcomes asnumber and percentage of unnecessary sistance from WHO in one or more areas injections administered annually in health- of viral hepatitis prevention and control care settings are not known. (Annex C). There is a national infection control policy for blood banks. All donated blood units

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Slovakia The Government of Slovakia reports as Population (in millions) (2011) 5.5 follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination $22 130 There is no written national strategy or Total health expenditure as % of GDP (2010) 8.79% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $2060.24 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $1356.77 Life expectancy at birth (in years) (2009) hepatitis. 75 Human Development Index (2011) 0.875 There is no designated governmental Median age (in years) (2010) 37 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.3 ordinating and/or carrying out viral hepatitis-related activities. It is not known how Screening, care and treatment many people work full-time on hepatitis- Prevention of transmission related activities in all government agen- There is a national policy on hepatitis A Health professionals obtain the skills and vaccination. competencies required to effectively care cies/bodies. for people with viral hepatitis through The government has a viral hepatitis pre- It is not known whether the government postgraduate training. vention and control programme that in- has established the goal of eliminating There are national clinical guidelines for cludes activities targeting the following hepatitis B. the management of viral hepatitis. It is not specific populations: health-care workers (including health-care waste handlers), Information was not provided on the per- known whether there are national clinical people who inject drugs and people living centage of newborn infants nationally guidelines for the management of HIV, in a given recent year who received the which include recommendations for coinwith HIV. first dose of hepatitis B vaccine within 24 fection with viral hepatitis. Awareness-raising and partnerships hours of birth or the percentage of oneThe government did not hold events for year-olds nationally (ages 12–23 months) The government does not have national World Hepatitis Day 2012 and has not in a given recent year who received three policies relating to screening and referral funded other viral hepatitis public aware- doses of hepatitis B vaccine. to care for hepatitis B or hepatitis C. ness campaigns since January 2011. There is a national policy that specifically People testing for both hepatitis B and The government does not collaborate targets mother-to-child transmission of hepatitis C register by name; the names with in-country civil society groups to hepatitis B (Annex B). are kept confidential within the system. develop and implement its viral hepatitis Hepatitis B and hepatitis C tests are free of There is no specific national strategy charge for all individuals and are not comprevention and control programme. and/or policy/guidelines for preventing pulsory for members of any specific group. Evidence-based policy and data for hepatitis B and hepatitis C infection in action health-care settings. Information was not Publicly funded treatment is available There is routine surveillance for viral hepa- provided on whether health-care workers for hepatitis B, but information was not titis. There is a national surveillance system are vaccinated against hepatitis B prior to provided on who is eligible for this. Infor the following types of acute hepatitis: starting work that might put them at risk formation was not provided on whether A, B, C, D and E, and for the following types of exposure to blood. publicly funded treatment is available for of chronic hepatitis: B, C and D. hepatitis C, or on the amount spent by the It is not known whether there is a national government on such treatment for hepatiThere are standard case definitions for policy on injection safety in health-care tis B and hepatitis C. hepatitis. Deaths, including from hepatitis, settings. Single-use or auto-disable syringare reported to a central registry. The per- es, needles and cannulas are always avail- The following drugs for treating hepatitis centage of hepatitis cases reported as “un- able in all health-care facilities. B are on the national essential medicines differentiated” or “unclassified” hepatitis is list or subsidized by the government: Official government estimates of the pegylated interferon, lamivudine, adefovir not known. number and percentage of unneces- dipivoxil, entecavir, telbivudine and tenoLiver cancer cases and cases with HIV/hep- sary injections administered annually in fovir. The following drugs for treating hepatitis coinfection are registered nationally. health-care settings are not known. atitis C are on the national essential mediThe government publishes hepatitis dis- There is a national infection control policy cines list or subsidized by the government: interferon alpha, pegylated interferon, ease reports monthly. for blood banks. All donated blood units ribavirin, boceprevir and telaprevir. (including family donations) and blood Hepatitis outbreaks are required to be re- products nationwide are screened for The Government of Slovakia welcomes ported to the government and are further hepatitis B and hepatitis C. assistance from WHO in one or more arinvestigated. There is adequate laboratory capacity nationally to support investiga- It is not known whether there is a national eas of viral hepatitis prevention and contion of viral hepatitis outbreaks and other policy relating to the prevention of viral trol (Annex C). surveillance activities. hepatitis among people who inject drugs. It is not known whether there is a national public health research agenda for viral hepatitis or whether viral hepatitis serosurveys are conducted regularly. The government does not have guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

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Slovenia Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Slovenia reports as follows.

2.0 High-income $26 510 9.41% $2551.56 $1879.49 79 0.935 42 1.4

and cannulas are always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is a national policy relating to the prevention of viral hepatitis among people who inject drugs.

National coordination There is a written national strategy or plan that focuses primarily on the prevention and control of viral hepatitis, and also integrates other diseases. It includes components for raising awareness, surveillance, vaccination, prevention in general, prevention of transmission via injecting drug use, prevention of transmission in health-care settings, treatment and care, and coinfection with HIV. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitis-related activities. It is a special national multidisciplinary expert team. However, there are no people working full-time on hepatitis-related activities in any government agency/body. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), people who inject drugs, prisoners, people living with HIV and people undergoing immunosuppressive therapy.

There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. No hepatitis case is reported as “undifferentiated” or “unclassified” hepatitis.

The government has guidelines that address Liver cancer cases and cases with HIV/hepati- how hepatitis A and hepatitis E can be prevented through food and water safety. tis coinfection are registered nationally. The government publishes hepatitis disease Screening, care and treatment Health professionals obtain the skills and reports monthly. competencies required to effectively care for Hepatitis outbreaks are required to be re- people with viral hepatitis through schools ported to the government and are further for health professionals (pre-service educainvestigated. There is adequate laboratory tion), on-the-job training, postgraduate traincapacity nationally to support investigation ing and viral hepatitis conferences. of viral hepatitis outbreaks and other surveilThere are national clinical guidelines for the lance activities. management of viral hepatitis, which include There is a national public health research recommendations for cases with HIV coinagenda for viral hepatitis. Viral hepatitis fection. There are national clinical guidelines serosurveys are conducted every six to 12 for the management of HIV, which include months; the target populations are the gen- recommendations for coinfection with viral eral population, people who inject drugs, hepatitis. blood donors, health-care workers and pregnant women. Information was not provided The government has national policies relaton when the last serosurvey was carried out. ing to screening and referral to care for hepatitis B and hepatitis C.

There is a national policy on hepatitis A vac- People testing for both hepatitis B and hepatitis C register by name, and there is open accination. cess to their names. Hepatitis B and hepatitis Awareness-raising and partnerships The government has not established the goal C tests are not free of charge for all individuThe government did not hold events for als, but they are free of charge for pregnant of eliminating hepatitis B. World Hepatitis Day 2012 and has not fundwomen, prisoners, people who inject drugs ed other viral hepatitis public awareness Information was not provided on the per- and family members of hepatitis B carriers. campaigns since January 2011. However, an centage of newborn infants nationally in a Hepatitis B and hepatitis C tests are compulexpert team sanctioned by the government given recent year who received the first dose sory for health-care workers. has prepared events for World Hepatitis Day of hepatitis B vaccine within 24 hours of birth since 2008. These have included mass media or the percentage of one-year-olds nationally Publicly funded treatment is available for awareness campaigns on prevention and (ages 12–23 months) in a given recent year hepatitis B and hepatitis C. Everyone with control, as well as anonymous free testing for who received three doses of hepatitis B vac- national health insurance is eligible for this. hepatitis B and hepatitis C. Information was not provided on the amount cine. spent by the government on such treatment. The government collaborates with the fol- There is a national policy that specifically tarlowing in-country civil society groups to de- gets mother-to-child transmission of hepati- The following drugs for treating hepatitis B velop and implement its viral hepatitis pre- tis B (Annex B). are on the national essential medicines list vention and control programme: Stigma and or subsidized by the government: interferon Legebitra. There is a specific national strategy and/or alpha, pegylated interferon, lamivudine, policy/guidelines for preventing hepatitis B adefovir dipivoxil, entecavir, telbivudine and Evidence-based policy and data for and hepatitis C infection in health-care set- tenofovir. The following drugs for treating action tings. Health-care workers are vaccinated hepatitis C are on the national essential mediThere is routine surveillance for viral hepatitis. against hepatitis B prior to starting work that cines list or subsidized by the government: inThere is a national surveillance system for the might put them at risk of exposure to blood. terferon alpha, pegylated interferon, ribavirin following types of acute hepatitis: A, B, C, D and boceprevir. and E, and for the following types of chronic There is a national policy on injection safety hepatitis: B, C and D. in health-care settings, which recommends The Government of Slovenia welcomes assistsingle-use syringes for therapeutic injections. ance from WHO in one or more areas of viral Single-use or auto-disable syringes, needles hepatitis prevention and control (Annex C). 136

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Spain The Government of Spain reports as Population (in millions) (2011) 46.5 follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination $31 400 There is no written national strategy or Total health expenditure as % of GDP (2010) 9.54% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $3027.24 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $2204.28 Life expectancy at birth (in years) (2009) hepatitis. 82 Human Development Index (2011) 0.878 There is no designated governmental Median age (in years) (2010) 40 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.5 ordinating and/or carrying out viral hepatitis-related activities. Information was Screening, care and treatment not provided on how many people work Prevention of transmission full-time on hepatitis-related activities in There is a national policy on hepatitis A Health professionals obtain the skills and vaccination. competencies required to effectively care all government agencies/bodies. for people with viral hepatitis through The government has a viral hepatitis pre- Information was not provided on whether schools for health professionals (pre-servvention and control programme that the government has established the goal ice education), on-the-job training and includes activities targeting the follow- of eliminating hepatitis B. postgraduate training. ing specific populations: health workers (including health-care waste handlers), Nationally, 96.6% of newborn infants in a There are national clinical guidelines for people who inject drugs and people living given recent year received the first dose of the management of viral hepatitis, which hepatitis B vaccine within 24 hours of birth include recommendations for cases with with HIV. and 96.6% of one-year-olds (ages 12–23 HIV coinfection. There are national cliniAwareness-raising and partnerships months) in a given recent year received cal guidelines for the management of HIV, The government did not hold events for three doses of hepatitis B vaccine. which include recommendations for coinWorld Hepatitis Day 2012 and has not fection with viral hepatitis. funded other viral hepatitis public aware- There is a national policy that specifically targets mother-to-child transmission of ness campaigns since January 2011. The government has national policies rehepatitis B (Annex B). lating to screening and referral to care for The government does not collaborate hepatitis B and hepatitis C. with in-country civil society groups to There is a specific national strategy and/or policy/guidelines for preventing hepatitis develop and implement its viral hepatitis People testing for hepatitis B and hepatitis B and hepatitis C infection in health-care C do not register by name. Hepatitis B and prevention and control programme. settings. Health-care workers are vacci- hepatitis C tests are free of charge for all Evidence-based policy and data for nated against hepatitis B prior to starting individuals and are compulsory for blood action work that might put them at risk of expo- donors. There is routine surveillance for viral hepa- sure to blood. titis. There is a national surveillance system Publicly funded treatment for hepatitis B for the following types of acute hepatitis: There is a national policy on injection safe- and hepatitis C is available to all people A, B and C, but not for any type of chronic ty in health-care settings, which recom- with health insurance. The government mends single-use syringes for therapeutic spends €13 329 (US$ 17 140) on such hepatitis. injections. Single-use or auto-disable sy- treatment for hepatitis B per patient per There are standard case definitions for ringes, needles and cannulas are always year, and €39 940 (US$ 51 359) for hepatihepatitis. Deaths, including from hepatitis, available in all health-care facilities. tis C per patient per year. are reported to a central registry. Of hepatitis cases, 27% are reported as “undiffer- Official government estimates of the The following drugs for treating hepatitis B number and percentage of unneces- are on the national essential medicines list entiated” or “unclassified” hepatitis. sary injections administered annually in or subsidized by the government: interLiver cancer cases and cases with HIV/hep- health-care settings are not known. feron alpha, pegylated interferon, lamivuatitis coinfection are registered nationally. dine, adefovir dipivoxil, entecavir, telbivuThere is a national infection control policy The government publishes hepatitis dis- for blood banks. All donated blood units dine and tenofovir. The following drugs for treating hepatitis C are on the national esease reports annually. (including family donations) and blood sential medicines list or subsidized by the products nationwide are screened for government: interferon alpha, pegylated Hepatitis outbreaks are required to be re- hepatitis B and hepatitis C. interferon, ribavirin, boceprevir and telported to the government and are further investigated. There is adequate laboratory There is a national policy relating to the aprevir. capacity nationally to support outbreak prevention of viral hepatitis among peoThe Government of Spain did not indicate investigations and other surveillance ac- ple who inject drugs. a need for assistance from WHO in relation tivities for hepatitis A, B and C, but it is not known whether this is the case for hepa- The government has guidelines that ad- to viral hepatitis prevention and control. dress how hepatitis A and hepatitis E can titis E. be prevented through food and water There is a national public health research safety. agenda for viral hepatitis. Viral hepatitis serosurveys are not conducted regularly.

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Sweden Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 9.4 High-income $42 200 9.63% $3756.86 $3046.78 81 0.936 41 1.9 Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

There is a national policy relating to the prevention of viral hepatitis among people The Government of Sweden reports as Liver cancer cases are registered nationally, who inject drugs. follows. but cases with HIV/hepatitis coinfection The government does not have guidelines are not. National coordination that address how hepatitis A and hepatitis There is no written national strategy or plan The government publishes hepatitis dis- E can be prevented through food and wathat focuses exclusively or primarily on the ease reports annually and, if needed, dur- ter safety. prevention and control of viral hepatitis. ing outbreaks. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities: Swedish Institute for Communicable Disease Control, Coordination of HIV and STI Prevention Unit. It has two staff members. It is not known how many people work full-time on hepatitisrelated activities in all government agencies/bodies.

Screening, care and treatment

Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory capacity nationally to support investigation of outbreaks and other surveillance activities.

Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through postgraduate training. There are national clinical guidelines for the management of viral hepatitis, which include recommendations for cases with HIV coinfection. Information was not provided on whether there are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral hepatitis. The government has national policies relating to screening and referral to care for hepatitis B and hepatitis C. People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are free of charge for all individuals and are compulsory for blood donors. Publicly funded treatment for hepatitis B and hepatitis C is available to the entire population. The amount spent by the government on such treatment is not known. The following drugs for treating hepatitis B are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon, lamivudine, adefovir dipivoxil, entecavir, telbivudine and tenofovir. The following drugs for treating hepatitis C are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon, ribavirin, boceprevir and telaprevir. The Government of Sweden did not indicate a need for assistance from WHO in relation to viral hepatitis prevention and control.

There is no national public health research agenda for viral hepatitis. Viral hepatitis serosurveys are conducted regularly; the target population is children aged 14–16 The government has a viral hepatitis pre- years. The last serosurvey was carried out vention and control programme that in- in 2007. cludes activities targeting the following specific populations: health-care workers Prevention of transmission (including health-care waste handlers), There is no national policy on hepatitis A people who inject drugs, migrants, prison- vaccination. ers, people living with HIV, men who have The government has established the goal sex with men, and partners and children of of reducing hepatitis B by 2016. hepatitis B-infected people. Awareness-raising and partnerships It is not known what percentage of newThe government held events for World born infants nationally in a given recent Hepatitis Day 2012 and has funded other year received the first dose of hepatitis B viral hepatitis public awareness campaigns vaccine within 24 hours of birth, or what percentage of one-year-olds (ages 12–23 since January 2011 (Annex A). months) nationally in a given recent year The government collaborates with the fol- received three doses of hepatitis B vaccine. lowing in-country civil society groups to develop and implement its viral hepatitis There is a national policy that specifically prevention and control programme: Con- targets mother-to-child transmission of victus; the Swedish Drug Users Union; and hepatitis B (Annex B). the Swedish Federation for Rights, Inde- There is a specific national strategy and/or pendence, Health and Equality. policy/guidelines for preventing hepatitis Evidence-based policy and data for B and hepatitis C infection in health-care settings. Health-care workers are vaccinataction There is routine surveillance for viral hepa- ed against hepatitis B prior to starting work titis. There is a national surveillance system that might put them at risk of exposure to for the following types of acute hepatitis: A, blood. B, C, D and E, and for the following types of There is a national policy on injection safechronic hepatitis: B, C and D. ty in health-care settings, which recomThere are standard case definitions for mends auto-disable syringes for therapeuhepatitis. Deaths, including from hepatitis, tic injections. Single-use or auto-disable are reported to a central registry. No hepa- syringes, needles and cannulas are always titis case is reported as “undifferentiated” or available in all health-care facilities. “unclassified” hepatitis.

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Switzerland The Government of Switzerland reports as Population (in millions) (2011) 7.7 follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination $52 570 There is no written national strategy or Total health expenditure as % of GDP (2010) 11.52% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $5394.04 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $3183.56 Life expectancy at birth (in years) (2009) hepatitis. 82 Human Development Index (2011) 0.926 There is no designated governmental Median age (in years) (2010) 41 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.5 ordinating and/or carrying out viral hepatitis-related activities. Information was Screening, care and treatment not provided on how many people work Prevention of transmission full-time on hepatitis-related activities in There is a national policy on hepatitis A Health professionals obtain the skills and vaccination. competencies required to effectively care all government agencies/bodies. for people with viral hepatitis through The government has a viral hepatitis pre- The government has not established the schools for health professionals (pre-servvention and control programme that in- goal of eliminating hepatitis B. ice education), on-the-job training and cludes activities targeting the following postgraduate training. specific population: people who inject Information was not provided on the percentage of newborn infants nationally in There are national clinical guidelines for drugs. a given recent year who received the first the management of viral hepatitis, but Awareness-raising and partnerships dose of hepatitis B vaccine within 24 hours they do not include recommendations The government did not hold events for of birth. In a given recent year, 30% of one- for cases with HIV coinfection. There are World Hepatitis Day 2012 and has not year-olds (ages 12–23 months) received no national clinical guidelines for the funded other viral hepatitis public aware- three doses of hepatitis B vaccine. management of HIV, which include recness campaigns since January 2011. ommendations for coinfection with viral There is no national policy that specifically The government collaborates with the fol- targets mother-to-child transmission of hepatitis. lowing in-country civil society group to hepatitis B, but there are recommenda- The government does not have national develop and implement its viral hepatitis tions about this issue. policies relating to screening and referral prevention and control programme: Swiss to care for hepatitis B or hepatitis C. There is a specifi c national strategy and/or Experts in Viral Hepatitis (SEVHep). policy/guidelines for preventing hepatitis People testing for both hepatitis B and Evidence-based policy and data for B and hepatitis C infection in health-care hepatitis C register by name; the names action settings. Health-care workers are vacci- are kept confidential within the system. There is routine surveillance for viral hepa- nated against hepatitis B prior to starting Hepatitis B and hepatitis C tests are not titis. There is a national surveillance system work that might put them at risk of expo- free of charge for all individuals, but they for the following types of acute hepatitis: sure to blood. are free of charge for health-care workers, A, B and C, and for the following types of and organ and blood donors. Hepatitis B There is no national policy on injection chronic hepatitis: B and C. and hepatitis C tests are not compulsory safety in health-care settings. Single-use There are standard case definitions for or auto-disable syringes, needles and can- for members of any specific group. hepatitis. Deaths, including from hepatitis, nulas are always available in all health-care Publicly funded treatment is not available are reported to a central registry. No hepa- facilities. for hepatitis B or hepatitis C. titis case is reported as “undifferentiated” Official government estimates of the The following drugs for treating hepatitis or “unclassified” hepatitis. number and percentage of unneces- B are on the national essential medicines Liver cancer cases and cases with HIV/ sary injections administered annually in list or subsidized by the government: hepatitis coinfection are not registered health-care settings are not known. pegylated interferon, lamivudine, adefovir nationally. dipivoxil, entecavir, telbivudine and tenoThere is a national infection control policy The government publishes hepatitis dis- for blood banks. All donated blood units fovir. The following drugs for treating hepatitis C are on the national essential mediease reports weekly. (including family donations) and blood cines list or subsidized by the government: products nationwide are screened for pegylated interferon, ribavirin, boceprevir Hepatitis outbreaks are required to be re- hepatitis B and hepatitis C. and telaprevir. ported to the government and are further investigated. There is adequate laboratory There is a national policy relating to the capacity nationally to support investiga- prevention of viral hepatitis among peo- The Government of Switzerland did not indicate a need for assistance from WHO tion of outbreaks and other surveillance ple who inject drugs. in relation to viral hepatitis prevention and activities. The government has guidelines that ad- control. There is no national public health research dress how hepatitis A and hepatitis E can agenda for viral hepatitis. Viral hepatitis se- be prevented through food and water rosurveys are not conducted regularly. safety.

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Tajikistan Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 7.0 Low-income $1937 5.98% $128.43 $34.24 68 0.726 20 3.3 Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

It is not known whether there is a national policy relating to the prevention of viral The Government of Tajikistan reports as Hepatitis outbreaks are required to be re- hepatitis among people who inject drugs. follows. ported to the government and are further investigated. There is adequate laboratory The government has guidelines that adNational coordination capacity nationally to support investiga- dress how hepatitis A and hepatitis E can There is no written national strategy or plan tion of outbreaks and other surveillance be prevented through food and water that focuses exclusively or primarily on the activities. safety. prevention and control of viral hepatitis. There is no national public health research Screening, care and treatment There is no designated governmental unit/ agenda for viral hepatitis. Viral hepatitis Health professionals obtain the skills and department responsible solely for coordi- serosurveys are conducted regularly; the competencies required to effectively care nating and/or carrying out viral hepatitis- target populations are people who inject for people with viral hepatitis through related activities. Information was not pro- drugs, men who have sex with men, sex schools for health professionals (pre-servvided on how many people work full-time workers, prisoners, pregnant women and ice education), on-the-job training and on hepatitis-related activities in all govern- people living with HIV. The last serosurvey postgraduate training. ment agencies/bodies. was carried out in 2011. There are no national clinical guidelines The government does not have a viral hep- Prevention of transmission for the management of viral hepatitis, atitis prevention and control programme There is no national policy on hepatitis A but there are for the management of HIV, that includes activities targeting specific vaccination. which include recommendations for coinpopulations. fection with viral hepatitis. The government has not established the Awareness-raising and partnerships goal of eliminating hepatitis B. The government does not have national The government did not hold events for policies relating to screening and referral World Hepatitis Day 2012 and has not Nationally, 98% of newborn infants in a to care for hepatitis B or hepatitis C. funded other viral hepatitis public aware- given recent year received the first dose of ness campaigns since January 2011. hepatitis B vaccine within 24 hours of birth People testing for both hepatitis B and and 96% of one-year-olds (ages 12–23 hepatitis C register by name; the names are The government does not collaborate with months) in a given recent year received kept confidential within the system. Hepain-country civil society groups to develop three doses of hepatitis B vaccine. titis B and hepatitis C tests are not free of and implement its viral hepatitis prevencharge for all individuals, but they are free tion and control programme. There is no national policy that specifically of charge for people living with HIV and targets mother-to-child transmission of blood donors. Hepatitis B and hepatitis C Evidence-based policy and data for hepatitis B. tests are compulsory for blood donors and action medical staff. There is routine surveillance for viral hepa- There is a specific national strategy and/or titis. There is a national surveillance system policy/guidelines for preventing hepatitis Publicly funded treatment is not available for the following types of acute hepatitis: A, B and hepatitis C infection in health-care for hepatitis B or hepatitis C. B, C, D and E, and for the following types of settings. Health-care workers are vaccinatchronic hepatitis: B and C. ed against hepatitis B prior to starting work No drug for treating hepatitis B is on the that might put them at risk of exposure to national essential medicines list or subsiThere are standard case definitions for blood. dized by the government. The following hepatitis. Deaths, including from hepatitis, drug for treating hepatitis C is on the naare reported to a central registry. No hepa- There is a national policy on injection safe- tional essential medicines list or subsidized titis case is reported as “undifferentiated” or ty in health-care settings, which recom- by the government: ribavirin. “unclassified” hepatitis. mends single-use syringes for therapeutic injections. Single-use or auto-disable The Government of Tajikistan welcomes Liver cancer cases and cases with HIV/hep- syringes, needles and cannulas are not assistance from WHO in one or more areas atitis coinfection are registered nationally. always available in all health-care facilities. of viral hepatitis prevention and control (Annex C). The government publishes hepatitis disease reports annually.

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The former Yugoslav Republic of Macedonia The Government of the former Yugoslav 2.1 Republic of Macedonia reports as follows. Population (in millions) (2011) Country classification (2012) Upper–middle-income Gross national income per capita (PPP int $) (2011) National coordination $11 090 There is no written national strategy or Total health expenditure as % of GDP (2010) 7.09% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $790.97 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $504.26 Life expectancy at birth (in years) (2009) hepatitis. 74 Human Development Index (2011) 0.776 There is no designated governmental Median age (in years) (2010) 36 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.4 ordinating and/or carrying out viral hepatitis-related activities. It is not known how Screening, care and treatment many people work full-time on hepatitis- Prevention of transmission related activities in all government agen- There is no national policy on hepatitis A Health professionals obtain the skills and vaccination. competencies required to effectively care cies/bodies. for people with viral hepatitis through The government has a viral hepatitis pre- The government has established the goal schools for health professionals (pre-servvention and control programme that in- of eliminating hepatitis B but did not pro- ice education), on-the-job training and cludes activities targeting the following vide information about a specific time- postgraduate training. specific populations: health-care workers frame for this. There are national clinical guidelines for (including health-care waste handlers), people who inject drugs and people living Nationally, 98% of newborn infants in a the management of viral hepatitis, but given recent year received the first dose of they do not include recommendations for with HIV. hepatitis B vaccine within 24 hours of birth cases with HIV coinfection. There are naAwareness-raising and partnerships and 96% of one-year-olds (ages 12–23 tional clinical guidelines for the manageThe government did not hold events for months) in a given recent year received ment of HIV, which include recommendaWorld Hepatitis Day 2012 and has not three doses of hepatitis B vaccine. tions for coinfection with viral hepatitis. funded other viral hepatitis public awareThere is a national policy that specifi cally ness campaigns since January 2011. The government has national policies retargets mother-to-child transmission of lating to screening and referral to care for The government collaborates with the fol- hepatitis B (Annex B). hepatitis B and hepatitis C. lowing in-country civil society groups to There is a specifi c national strategy and/or develop and implement its viral hepatitis People testing for both hepatitis B and prevention and control programme: Hep- policy/guidelines for preventing hepatitis hepatitis C register by name; the names B and hepatitis C infection in health-care are kept confidential within the system. ta and HOPS. settings. Health-care workers are vacci- Hepatitis B and hepatitis C tests are not Evidence-based policy and data for nated against hepatitis B prior to starting free of charge for all individuals, but they action work that might put them at risk of expo- are free of charge for people who inject There is routine surveillance for viral hepa- sure to blood. drugs, blood donors and people living titis. There is a national surveillance system with HIV. Hepatitis B and hepatitis C tests for the following types of acute hepatitis: There is a national policy on injection safe- are not compulsory for members of any A, B and C, but not for any type of chronic ty in health-care settings, which recom- specific group. mends single-use syringes for therapeutic hepatitis. injections. Single-use or auto-disable sy- Publicly funded treatment is available for There are standard case definitions for ringes, needles and cannulas are always hepatitis B and hepatitis C, but informahepatitis. Deaths, including from hepatitis, available in all health-care facilities. tion was not provided on who is eligible are reported to a central registry. Of hepafor this, or on the amount spent by the titis cases, 9% are reported as “undifferen- Official government estimates of the government on such treatment. number and percentage of unnecestiated” or “unclassified” hepatitis. sary injections administered annually in The following drugs for treating hepatitis Liver cancer cases and cases with HIV/hep- health-care settings are not known. B are on the national essential medicines atitis coinfection are registered nationally. list or subsidized by the government: inThere is a national infection control policy The government publishes hepatitis dis- for blood banks. All donated blood units terferon alpha, pegylated interferon and lamivudine. The following drugs for treatease reports weekly. (including family donations) and blood ing hepatitis C are on the national essenproducts nationwide are screened for tial medicines list or subsidized by the Hepatitis outbreaks are required to be re- hepatitis B and hepatitis C. government: interferon alpha, pegylated ported to the government and are further investigated. There is adequate laboratory There is a national policy relating to the interferon and ribavirin. capacity nationally to support outbreak in- prevention of viral hepatitis among peoThe Government of the former Yugoslav vestigations and other surveillance activi- ple who inject drugs. Republic of Macedonia welcomes asties for hepatitis A, hepatitis B and hepatisistance from WHO in one or more arThe government has guidelines that adtis C, but not for hepatitis E. dress how hepatitis A and hepatitis E can eas of viral hepatitis prevention and conThere is no national public health research be prevented through food and water trol (Annex C). agenda for viral hepatitis. Viral hepatitis se- safety. rosurveys are not conducted regularly.

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Turkey Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Turkey reports as follows. 73.6 Upper–middle-income $16 940 6.74% $1029.14 $773.95 75 0.704 28 2.1 There is a national policy relating to the prevention of viral hepatitis among people who inject drugs. The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

Screening, care and treatment

National coordination

There is a written national strategy or plan that focuses exclusively on the prevention and control of hepatitis B. It includes components for raising awareness, surveillance, vaccination, prevention in general, prevention of transmission via injecting drug use, and prevention of transmission There is no national public health research agenda for viral hepatitis. Viral hepatitis sein health-care settings. rosurveys are not conducted regularly. There is no designated governmental unit/ department responsible solely for coordi- Prevention of transmission nating and/or carrying out viral hepatitis- There is a national policy on hepatitis A related activities. It is not known how many vaccination. people work full-time on hepatitis-related The government has not established the activities in all government agencies/ goal of eliminating hepatitis B. bodies. Nationally, 97% of newborn infants in a The government has a viral hepatitis pregiven recent year received the first dose of vention and control programme that inhepatitis B vaccine within 24 hours of birth cludes activities targeting the following and 96% of one-year-olds (ages 12–23 specific populations: health-care workers months) in a given recent year received (including health-care waste handlers), three doses of hepatitis B vaccine. people who inject drugs and prisoners. Awareness-raising and partnerships There is a national policy that specifically The government did not hold events for targets mother-to-child transmission of World Hepatitis Day 2012, but has funded hepatitis B (Annex B).

Health professionals obtain the skills and competencies required to effectively care for people with viral hepatitis through The government publishes hepatitis dis- schools for health professionals (pre-servease reports monthly. ice education), on-the-job training and postgraduate training. Hepatitis outbreaks are required to be reported to the government and are further There are no national clinical guidelines investigated. There is adequate laboratory for the management of viral hepatitis or capacity nationally to support investiga- for the management of HIV, which include tion of outbreaks and other surveillance recommendations for coinfection with viactivities. ral hepatitis. The government does not have national policies relating to screening and referral to care for hepatitis B or hepatitis C. People testing for both hepatitis B and hepatitis C register by name, and there is open access to their names. Hepatitis B and hepatitis C tests are not free of charge for all individuals, but they are free of charge for all of the defined risk groups. Hepatitis B and hepatitis C tests are compulsory for blood donors, transplant providers and preoperative patients. Publicly funded treatment for hepatitis B and hepatitis C is available to everyone under the age of 18 years and to those 18 years or older if they have health insurance. (In Turkey, 99% of people have health insurance.) The government spends €85 million (US$ 109.3 million) annually on drugs for publicly funded treatment for hepatitis B and hepatitis C. It is not known how much the government spends on other components of publicly funded treatment.

other viral hepatitis public awareness cam- There is a specific national strategy and/or paigns since January 2011 (Annex A). policy/guidelines for preventing hepatitis The government collaborates with the fol- B and hepatitis C infection in health-care lowing in-country civil society group to settings. Health-care workers are vaccinatdevelop and implement its viral hepatitis ed against hepatitis B prior to starting work The following drugs for treating hepatitis prevention and control programme: Viral that might put them at risk of exposure to B are on the national essential medicines blood. Hepatitle Savaşım Derneği. list or subsidized by the government: interferon alpha, pegylated interferon, lamivuThere is a national policy on injection safeEvidence-based policy and data for ty in health-care settings, which recom- dine, adefovir dipivoxil, entecavir, telbivuaction dine and tenofovir. The following drugs for There is routine surveillance for viral hepa- mends single-use syringes for therapeutic treating hepatitis C are on the national esinjections. Single-use or auto-disable sytitis. There is a national surveillance system sential medicines list or subsidized by the for the following types of acute hepatitis: A, ringes, needles and cannulas are always government: interferon alpha, pegylated available in all health-care facilities. B, C, D and E, but not for any type of chronic interferon, ribavirin, boceprevir and telhepatitis. Official government estimates of the aprevir. There are standard case definitions for number and percentage of unnecessary The Government of Turkey did not indicate hepatitis. Deaths, including from hepatitis, injections administered annually in healtha need for assistance from WHO in relation care settings are not known. are reported to a central registry. The perto viral hepatitis prevention and control. centage of hepatitis cases reported as “un- There is a national infection control policy differentiated” or “unclassified” hepatitis is for blood banks. All donated blood units not known. (including family donations) and blood Liver cancer cases are registered nationally, products nationwide are screened for hepbut cases with HIV/hepatitis coinfection atitis B and hepatitis C. are not. 142

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Ukraine The Government of Ukraine reports as Population (in millions) (2011) 45.2 follows. Country classification (2012) Lower–middle-income Gross national income per capita (PPP int $) (2011) National coordination $7040 There is no written national strategy or Total health expenditure as % of GDP (2010) 7.72% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $518.90 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $293.84 Life expectancy at birth (in years) (2009) hepatitis. 68 Human Development Index (2011) 0.810 There is no designated governmental Median age (in years) (2010) 39 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.4 ordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitis- serosurveys are conducted regularly; the The government has guidelines that adrelated activities in all government agen- target population is people who inject dress how hepatitis A and hepatitis E can drugs. The last serosurvey was carried out be prevented through food and water cies/bodies. safety. in 2011. The government does not have a viral Screening, care and treatment hepatitis prevention and control pro- Prevention of transmission gramme that includes activities targeting There is a national policy on hepatitis A Health professionals obtain the skills and vaccination. competencies required to effectively care specific populations. for people with viral hepatitis through Awareness-raising and partnerships The government has not established the schools for health professionals (pre-servIt is not known whether the government goal of eliminating hepatitis B. ice education), on-the-job training and held events for World Hepatitis Day 2012. postgraduate training. Nationally, 70% of newborn infants in a It has not funded other viral hepatitis public awareness campaigns since January given recent year received the first dose There are no national clinical guidelines of hepatitis B vaccine within 24 hours of for the management of viral hepatitis, 2011. birth. Among children who had received but there are for the management of HIV, The government collaborates with the fol- the first dose within 24 hours of birth, which include recommendations for coinlowing in-country civil society groups to 70%–80% of one-year-olds (ages 12–23 fection with viral hepatitis. develop and implement its viral hepatitis months) in a given recent year received The government has national policies reprevention and control programme: NGO three doses of hepatitis B vaccine. lating to screening and referral to care for “Stop Hepatitis” and Office IRF in Ukraine. There is a national policy that specifically hepatitis B and hepatitis C. Evidence-based policy and data for targets mother-to-child transmission of hepatitis B (Annex B). People testing for both hepatitis B and action hepatitis C register by name; the names There is routine surveillance for viral hepatitis. There is a national surveillance system There is a specific national strategy and/or are kept confidential within the system. for the following types of acute hepatitis: policy/guidelines for preventing hepatitis Hepatitis B and hepatitis C tests are not A, B and C, and for the following types of B and hepatitis C infection in health-care free of charge for all individuals, but they settings. Health-care workers are vacci- are free of charge for pregnant women, chronic hepatitis: B and C. nated against hepatitis B prior to starting blood donors and military conscripts. There are no standard case definitions for work that might put them at risk of expo- Hepatitis B and hepatitis C tests are comhepatitis. Hepatitis deaths are not report- sure to blood. pulsory for pregnant women, blood doed to a central registry. Information was nors and military conscripts. There is a national policy on injection safenot provided on the percentage of hepatitis cases reported as “undifferentiated” or ty in health-care settings, which recom- Publicly funded treatment is not available mends single-use syringes for therapeutic for hepatitis B or hepatitis C. “unknown” hepatitis. injections. Single-use or auto-disable syLiver cancer cases are registered nation- ringes, needles and cannulas are always The following drugs for treating hepatitis B are on the national essential medicines ally, but cases with HIV/hepatitis coinfec- available in all health-care facilities. list or subsidized by the government: intion are not. Official government estimates of the terferon alpha, pegylated interferon, lamiThe government does not publish hepati- number and percentage of unneces- vudine and tenofovir. The following drugs sary injections administered annually in for treating hepatitis C are on the national tis disease reports. health-care settings are not known. essential medicines list or subsidized by Hepatitis outbreaks are required to be rethe government: pegylated interferon and ported to the government and are further There is a national infection control policy ribavirin. investigated. There is adequate laboratory for blood banks. All donated blood units (including family donations) and blood capacity nationally to support outbreak inThe Government of Ukraine welcomes asvestigations and other surveillance activi- products nationwide are screened for sistance from WHO in one or more areas ties for hepatitis A, hepatitis B and hepati- hepatitis B and hepatitis C. of viral hepatitis prevention and control tis C, but information was not provided on (Annex C). There is no national policy relating to the whether this is the case for hepatitis E. prevention of viral hepatitis among peoThere is no national public health research ple who inject drugs. agenda for viral hepatitis. Viral hepatitis

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United Kingdom of Great Britain and Northern Ireland (the) Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 62.4 High-income $36 010 9.64% $3479.56 $2918.89 80 0.879 40 1.9 syringes, needles and cannulas are always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

The Government of the United Kingdom of are reported to a central registry. No hepaGreat Britain and Northern Ireland reports titis case is reported as “undifferentiated” or There is a national policy relating to the prevention of viral hepatitis among people as follows. “unclassified” hepatitis. who inject drugs. National coordination Liver cancer cases are registered nationally, There is a written national strategy or plan but cases with HIV/hepatitis coinfection The government has guidelines that address how hepatitis A and hepatitis E can that focuses exclusively on the preven- are not. be prevented through food and water tion and control of hepatitis C. It includes components for raising awareness, surveil- The government publishes hepatitis dis- safety. lance, prevention in general, prevention of ease reports quarterly and annually. Screening, care and treatment transmission via injecting drug use, prevention of transmission in health-care set- Hepatitis outbreaks are not required to Health professionals obtain the skills and tings, treatment and care, and coinfection be reported to the government. There is competencies required to effectively care adequate laboratory capacity nationally for people with viral hepatitis through with HIV. to support investigation of outbreaks and schools for health professionals (pre-service education), on-the-job training and There is no designated governmental unit/ other surveillance activities. postgraduate training. department responsible solely for coordinating and/or carrying out viral hepatitis- There is no national public health research related activities. It is not known how many agenda for viral hepatitis. Viral hepatitis There are no national clinical guidelines people work full-time on hepatitis-related serosurveys are conducted regularly; the for the management of viral hepatitis, activities in all government agencies/ target populations are people who inject but there are for the management of HIV, drugs, female sex workers and men who which include recommendations for coinbodies. have sex with men. The last serosurvey was fection with viral hepatitis. The government has a viral hepatitis pre- carried out in 2011. The government has national policies revention and control programme that inPrevention of transmission lating to screening and referral to care for cludes activities targeting the following There is a national policy on hepatitis A hepatitis B and hepatitis C. specific populations: health-care workers vaccination. (including health-care waste handlers), People testing for both hepatitis B and people who inject drugs, migrants, prison- The government has not established the hepatitis C register by name; the names ers, the homeless, people living with HIV, goal of eliminating hepatitis B. are kept confidential within the system. people at risk for STI and pregnant women Hepatitis B and hepatitis C tests are free of Information was not provided on the per(antenatal screening). charge for all individuals, and are compulcentage of newborn infants nationally in sory for health-care workers who wish to Awareness-raising and partnerships a given recent year who received the first The government did not hold events for dose of hepatitis B vaccine within 24 hours do exposure-prone procedures. World Hepatitis Day 2012, but has funded of birth or the percentage of one-year-olds Publicly funded treatment for hepatitis B other viral hepatitis public awareness cam- nationally (ages 12–23 months) in a given and hepatitis C is available to the entire paigns since January 2011 (Annex A). recent year who received three doses of population. The amount spent by the government on such treatment is not known. The government collaborates with the fol- hepatitis B vaccine. lowing in-country civil society groups to There is a national policy that specifically The following drugs for treating hepatitis B develop and implement its viral hepatitis targets mother-to-child transmission of are on the national essential medicines list prevention and control programme: Hepa- hepatitis B (Annex B). or subsidized by the government: interfertitis C Trust, Addaction, British Liver Trust, on alpha, pegylated interferon, lamivudine, Exchange Supplies, Needle Exchange Fo- There is a specific national strategy and/or adefovir dipivoxil, entecavir and tenofovir. rum and Injecting Advice. policy/guidelines for preventing hepatitis The following drugs for treating hepatitis B and hepatitis C infection in health-care Evidence-based policy and data for settings. Health-care workers are vaccinat- C are on the national essential medicines list or subsidized by the government: interaction ed against hepatitis B prior to starting work There is routine surveillance for viral hepa- that might put them at risk of exposure to feron alpha, pegylated interferon, ribavirin, boceprevir and telaprevir. titis. There is a national surveillance system blood. for the following types of acute hepatitis: A, The Government of the United Kingdom of B, C and E, and for the following types of There is a national policy on injection Great Britain and Northern Ireland did not chronic hepatitis: B and C. safety in health-care settings, but it is not indicate a need for assistance from WHO in known what type of syringes it recomThere are standard case definitions for mends for therapeutic injections. It is not relation to viral hepatitis prevention and hepatitis. Deaths, including from hepatitis, known whether single-use or auto-disable control. 144

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Uzbekistan The Government of Uzbekistan reports as Population (in millions) (2011) follows. Country classification (2012) Gross national income per capita (PPP int $) (2011) National coordination There is a written national strategy or plan Total health expenditure as % of GDP (2010) that focuses primarily on the prevention Per capita total health expenditure (PPP int $) (2010) and control of viral hepatitis, and also in- Per capita government health expenditure (PPP int $) (2010) tegrates other diseases. It includes com- Life expectancy at birth (in years) (2009) ponents for vaccination, prevention in Human Development Index (2011) general and prevention of transmission in Median age (in years) (2010) Total fertility rate per woman (2010) health-care settings. There is no designated governmental unit/department responsible solely for coordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitisrelated activities in all government agencies/bodies. The government does not have a viral hepatitis prevention and control programme that includes activities targeting specific populations. 27.8 Lower–middle-income $3420 5.31% $168.36 $87.39 69 0.736 24 2.4

There is a national public health research There is a national policy relating to the agenda for viral hepatitis. Viral hepatitis prevention of viral hepatitis among people who inject drugs. serosurveys are not conducted regularly.

Prevention of transmission

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. The government does not collaborate with in-country civil society groups to develop and implement its viral hepatitis prevention and control programme.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B and C, and for the following types of chronic hepatitis: B, C and D. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. The percentage of hepatitis cases reported as “undifferentiated” or “unclassified” hepatitis is not known. It is not known whether liver cancer cases are registered nationally. Cases with HIV/ hepatitis coinfection are not registered nationally. The government publishes hepatitis disease reports monthly. Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory capacity nationally to support investigation of outbreaks and other surveillance activities.

The government has guidelines that adThere is no national policy on hepatitis A dress how hepatitis A and hepatitis E can vaccination. be prevented through food and water safety. The government has not established the Screening, care and treatment goal of eliminating hepatitis B. Health professionals obtain the skills and Nationally, approximately 90% of newborn competencies required to effectively care infants in a given recent year received the for people with viral hepatitis through first dose of hepatitis B vaccine within 24 schools for health professionals (pre-servhours of birth and approximately 90% of ice education) and postgraduate training. one-year-olds (ages 12–23 months) in a given recent year received three doses of There are national clinical guidelines for the management of viral hepatitis, which hepatitis B vaccine. include recommendations for cases with There is a national policy that specifically HIV coinfection. There are national clinitargets mother-to-child transmission of cal guidelines for the management of HIV, hepatitis B (Annex B). which include recommendations for coinfection with viral hepatitis. There is no specific national strategy and/or policy/guidelines for preventing The government has national policies rehepatitis B and hepatitis C infection in lating to screening and referral to care for health-care settings. Information was not hepatitis B and hepatitis C. provided on whether health-care workers are vaccinated against hepatitis B prior to People testing for both hepatitis B and starting work that might put them at risk hepatitis C register by name, and there is of exposure to blood. open access to their names. Hepatitis B and hepatitis C tests are not free of charge. There is a national policy on injection safe- Information was not provided on whether ty in health-care settings, which recom- hepatitis B or hepatitis C tests are free of mends single-use syringes for therapeutic charge for any specific group. Hepatitis B injections. Single-use or auto-disable sy- and hepatitis C tests are not compulsory ringes, needles and cannulas are always for members of any specific group. available in all health-care facilities. Publicly funded treatment is not available Official government estimates of the for hepatitis B or hepatitis C. number and percentage of unnecessary injections administered annually in No drug for treating hepatitis B or hepatitis health-care settings are not known. C is on the national essential medicines list or subsidized by the government. There is a national infection control policy for blood banks. All donated blood units The Government of Uzbekistan welcomes (including family donations) and blood assistance from WHO in one or more areas products nationwide are screened for of viral hepatitis prevention and control hepatitis B and hepatitis C. (Annex C).

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Chapter 7:

WHO South-East Asia Region

Eleven Member States make up the World Health Organization (WHO) South-East Asia Region, which has a total population of 1.83 billion.1 India, with a population of 1.24 billion, accounts for approximately two thirds of the Region’s population.1 The South-East Asia Region hosts one fourth of the world’s population and carries about 30% of the world’s total disease burden.2 In 2009, life expectancy at birth for the South-East Asia Region was 65 years.3 The greatest contributors to morbidity and mortality are noncommunicable diseases: cardiovascular diseases and cancer account for about 30% and 9% of deaths, respectively.4 Agestandardized mortality rates (2008) indicate that communicable diseases account for about 30% of deaths.1 The South-East Asia Region has high child mortality, with three fourths of these deaths resulting from diarrhoeal diseases, pneumonia and neonatal conditions.5 The Region is home to more than two thirds of the world’s malnourished children.5 Unsafe water and inadequate sanitation and hygiene pose major health risks to both children and adults; the Region has the highest incidence of diarrhoeal disease in the world.5 Responses to the WHO/Alliance survey were received from all 11 Member States in the South-East Asia Region (100%). Box 1. Responses to the 2012 Global Hepatitis Survey: WHO South-East Asia Region

Viral hepatitis in the WHO South-East Asia Region The endemicity of hepatitis A in the Region ranges from low (<50% exposed by the age of 30 years) in the eastern areas to high (>90% exposed by the age of 10 years) in the southern areas.a Approximately 14 million cases of hepatitis E infection occur annually in the Region, which accounts for more than half the global burden. Indeed, the prevalence of hepatitis E is estimated to be above 25% in those >50 years of age.b The seroprevalence of hepatitis B in the young age groups of 0–14 years is 1.2%–1.4%. However, in adults, the serpoprevalence is higher, at above 5%.c There are up to 50 million people with chronic hepatitis C infection in the South Asia.d Because of the asymptomatic nature of chronic hepatitis B and hepatitis C, most people infected with these are not aware of their status until they have symptoms of cirrhosis or liver cancer many years later.c,d

Member States that submitted surveys: • Bangladesh • Bhutan • Democratic People’s Republic of Korea • India • Indonesia • Maldives • Myanmar • Nepal • Sri Lanka • Thailand • Timor-Leste

a

1 2

World population prospects: the 2010 Revision. New York, United Nations, Department of Economic and Social Affairs, Population Division, 2011. 11 questions about the 11 SEAR countries. New Delhi, Department of Health Systems Development, WHO Regional Office for South-East Asia, 2007. Available at: http://www.searo.who.int/entity/health_situation_trends/documents/11_ health_questions_about_11_SEAR_countries.pdf (accessed on 13 May 2013). 3 World health statistics 2012. Geneva, WHO, 2012. Available at: http://www.who. int/gho/publications/world_health_statistics/2012/en/ (accessed on 13 May 2013). 4 Health situation in the South-East Asia Region 2001–2007. New Delhi, WHO Regional Office for South-East Asia, 2008. Available at: http://203.90.70.117/ PDS_DOCS/B3226.pdf (accessed on 13 May 2013). 5 Dhillon PK et al. Status of epidemiology in the WHO South-East Asia region: burden of disease, determinants of health and epidemiological research, workforce and training capacity. International Journal of Epidemiology, 2012, 41(3):847–860.

Jacobsen K. The global prevalence of hepatitis A virus infection and susceptibility: a systematic review. Geneva, Department of Immunization, Vaccines and Biologicals, World Health Organization, 2010 [WHO/IVB 10.01]. b Rein DB et al. The global burden of hepatitis E virus genotypes 1 and 2 in 2005. Hepatology, 2012, 55:988–997. c Ott JJ, Stevens, GA, Groeger J, Wiersma ST. Global epidemiology of hepatitis B virus infection: new estimates of age-specific HBsAg seroprevalence and endemicity. Vaccine, 2012, 30:2212–2219. d Mohd Hanafiah K, Groeger J, Flaxman AD, Wiersma ST. Global epidemiology of hepatitis C virus infection: new estimates of age-specific antibody to HCV seroprevalence. Hepatology, 2013, 57:1333–1342.

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National coordination Four responding Member States (36.4%) reported the existence of a written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis (Figure 1). Three of the four Member States with a strategy or plan (Democratic People’s Republic of Korea, India and Indonesia) reported that it focuses exclusively on viral hepatitis, and one (Myanmar) reported that it addresses other diseases as well. Figure 1. Responses to the question, “Is there a written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis?”

States that provided data for this question, the number ranged from 0 to 49 (median, 30.5), with Myanmar reporting the largest number. Nine responding Member States (81.8%) reported that they have a viral hepatitis prevention and control programme that includes activities targeting specific populations. The populations most commonly targeted were health-care workers, including healthcare waste handlers (77.8% of responding Member States within this subset) and people who inject drugs (44.4% of responding Member States within this subset). The following populations were each targeted by one third of responding Member States within this subset: migrants, prisoners and people living with HIV. Groups identified less frequently included indigenous populations, low-income populations, those who are uninsured and those who are homeless.

Awareness-raising and partnerships One responding Member State (9.1%) reported that it had held events for World Hepatitis Day 2012 (28 July). Since January 2011, three responding Member States (27.3%) had funded some type of viral hepatitis public awareness campaign other than World Hepatitis Day (Table 1). Four responding Member States (36.4%) reported that they collaborated with civil society groups within their countries to develop and implement the governmental viral hepatitis prevention and control programme. For example, Bangladesh reported collaborating with the Liver Foundation of Bangladesh, and Myanmar reported collaborating with health-care provider associations and with the Myanmar Red Cross Association. (Further examples can be found in the summaries of country findings later in this chapter.) Table 1. Topics of public awareness campaigns on viral Yes No No data

hepatitis held in Member States since January 2011 (N=3) Democratic People’s Republic of Korea General information about hepatitis and its transmission Vaccination for hepatitis A and hepatitis B Importance of knowing one’s hepatitis B and hepatitis C status Safe water and good sanitation Safer sex practices Harm reduction for people who inject drugs Safe workplace practices X X X X Indonesia Myanmar

The four Member States that reported the existence of a strategy or plan were asked about its specific components. All four reported the inclusion of components for raising awareness, surveillance, vaccination, general prevention, prevention of transmission in health-care settings, and treatment and care. Three reported the inclusion of a component for the prevention of transmission via injecting drug use. Three responding Member States (27.3%) reported that they have a governmental unit or department responsible solely for viral hepatitis-related activities. Member States that did so were asked to indicate the number of staff members in the unit or department. Responses ranged from 4 to 20 (median, 4), with Myanmar reporting the largest number. Member States were asked to report the number of people working full-time on hepatitis-related activities in all government agencies or bodies. Among the three Member

X

X X

X X

X X X X X

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Evidence-based policy and data for action Six responding Member States (54.5%) reported that they have routine surveillance for viral hepatitis; details appear in Table 2. Seven responding Member States (63.6%) indicated that their countries have standard case definitions for hepatitis infection and seven (63.6%) indicated that their countries have a central registry for the reporting of deaths, including hepatitis deaths. Two Member States reported on the proportion of hepatitis cases and deaths registered as “undifferentiated” or “unclassified” hepatitis. One reported this to be 25.1% and the other less than 5.0%. Additional survey findings about surveillance are presented in Table 3. Table 2. Types of surveillance in Member States that reported the existence of routine surveillance for viral hepatitis (N=6) No Yes (%) No (%) Do not know response (%) (%) There is a national surveillance system for acute hepatitis infection for the following forms of hepatitis: hepatitis A hepatitis B hepatitis C hepatitis D hepatitis E There is a national surveillance system for chronic hepatitis infection for the following forms of hepatitis: hepatitis B hepatitis C hepatitis D 33.3 33.3 0 66.7 66.7 83.3 0 0 0 0 0 16.7 83.3 100 83.3 33.3 33.3 0 0 0 33.3 33.3 0 0 0 0 0 16.7 0 16.7 33.3 33.3

Member States were asked how often hepatitis disease reports are published. Of the responding Member States, 45.5% said that reports are not published. Among the six Member States with published reports, one said reports are published weekly, one weekly and annually, two monthly and annually, and one annually. The sixth said reports are published in journal articles. Three responding Member States (27.3%, Democratic People’s Republic of Korea, Indonesia and Myanmar) reported the existence of a national public health research agenda for viral hepatitis. Two responding Member States (18.2%, the Democratic People’s Republic of Korea and Myanmar) reported that viral hepatitis serosurveys are conducted regularly. Myanmar indicated that serosurveys take place at least once per year. The Democratic People’s Republic of Korea said that its serosurveys target children under the age of 17 years, while Myanmar said that its serosurveys target children over the age of 5 years and the general population. The most recent serosurvey in the Democratic People’s Republic of Korea was conducted in 2009, and the most recent one in Myanmar was conducted in 2010.

Prevention of transmission No responding Member State reported that they have a national policy on hepatitis A vaccination. Two responding Member States (18.2%) reported that they have established the goal of eliminating hepatitis B (Figure 2). Member States with this goal were asked to specify the timeframe in which they seek to eliminate hepatitis B. The Democratic People’s Republic of Korea said by 2016, and Sri Lanka said by 2015. Member States were asked to report, for a given recent year, the percentage of newborn infants who had received the first dose of hepatitis B vaccine within 24 hours of birth. Among the seven governments providing this information, responses ranged from 0% to 99.9% (median, 75.4%). Governments were Figure 2. Responses to the question, “Has your government established the goal of eliminating hepatitis B?” (N=11)

Table 3. Data registration and surveillance (N=11) No Yes (%) No (%) Do not know response (%) (%) Liver cancer cases are registered nationally Cases with HIV/hepatitis coinfection are registered nationally Hepatitis outbreaks are reported If YES – Hepatitis outbreaks are further investigated (N=115) 63.6 45.5 81.8 100 36.4 36.4 18.2 0 0 18.2 0 0 0 0 0 0

Yes (18.2%)

No (81.8%)

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also asked to report, for a given recent year, the percentage of one-year-olds (ages 12–23 months) who had received three doses of hepatitis B vaccine. Among the eight governments providing this information, responses ranged from 38.0% to 99.0% (median, 93.9%). Seven responding governments (63.6%) reported the existence of a national policy that specifically targets mother-to-child transmission of hepatitis B; details are presented in Table 4. Five governments with such a policy indicated that one component of the policy calls for screening of all pregnant women for hepatitis B. Seven governments with such a policy indicated that one component of the policy calls for administering the second and third doses of hepatitis B vaccine to all infants within 12 months of birth. Table 4. Activities called for in national policy targeting mother-to-child transmission of hepatitis B (N=7) All infants receive the first dose of hepatitis B vaccine within 24 hours of birth All pregnant women found to have hepatitis B are counselled Health-care providers follow up with all pregnant women found to have hepatitis B during pregnancy for the purpose of encouraging them to give birth at health-care facilities Upon delivery, all infants born to women with hepatitis B receive hepatitis B immunoglobulin

the policy recommends for therapeutic injections. Single-use syringes are recommended in 90.0% of policies, and autodisable syringes in half of policies (Figure3). Figure 3. Proportion of responding Member States with national policies on injection safety in health-care settings which recommend single-use syringes and auto-disable syringes for therapeutic injections (N=10) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Single-use syringesa a

All pregnant women are screened for hepatitis B

Auto-disable syringesa

Respondents could select both “single-use syringes” and “auto-disable syringes”.

Bhutan Democratic People’s Republic of Korea India Maldives Myanmar Nepal Thailand TOTAL

X X

X X

X X

X

X X X

Ten responding Member States (90.9%) reported that singleuse or auto-disable syringes, needles and cannulas are always available in all health-care facilities. Member States were asked for official estimates of the number and percentage of unnecessary injections administered annually in health-care settings (e.g. injections that are given when an equivalent oral medication is available). Ten Member States reported that the figures are not known and one did not reply. Additional findings relating to the prevention of hepatitis transmission are presented in Table 5.

X X X 5

X X X X 6

X X

X

X X

X 4 3

X 6

Screening, care and treatment Five responding Member States (45.5%) reported the existence of a specific national strategy and/or policy for preventing hepatitis B and hepatitis C infection in health-care settings. Five responding Member States (45.5%) reported that healthcare workers are vaccinated against hepatitis B prior to starting work that might put them at risk of exposure to blood. Ten responding Member States (90.9%) reported the existence of a national policy on injection safety in health-care settings. These ten Member States were asked which types of syringes Member States were asked how health professionals in their countries obtain the skills and competencies required to effectively care for people with viral hepatitis. Eight Member States indicated that these are obtained in schools for health professionals (pre-service education) and on-the-job training. Four responding Member States (36.4%) reported the existence of national clinical guidelines for the management of viral hepatitis (Figure 4). Two of these four responding Member States (50.0%) indicated that the guidelines include recommendations for cases with HIV coinfection.

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Table 5. Hepatitis prevention: policies, practices and

guidelines (N=11) Yes (%) There is a national infection control policy for blood banks All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B All donated blood units (including family donations) and blood products nationwide are screened for hepatitis C There is a national policy relating to the prevention of viral hepatitis among people who inject drugs The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety 100 No (%) 0 Do not know (%) 0

Three responding Member States (27.3%) indicated that they have a national policy relating to screening and referral to care for hepatitis B. Two (18.2%) reported having such a policy for hepatitis C. Regarding hepatitis B testing, ten responding Member States (90.9%) indicated that people register by name for testing. Eight of the ten members of that subset (80.0%) indicated that the names are kept confidential. Five responding Member States (45.5%) reported that the hepatitis B test is free of charge for all individuals. Among the six other Member States, Myanmar and Thailand reported that the hepatitis B test is free of charge for members of specific groups. Groups identified included blood donors and pregnant women. Six responding Member States (54.5%) reported that the hepatitis B test is compulsory for members of specific groups. Groups identified included blood donors and people living with HIV. Regarding hepatitis C testing, ten responding Member States (90.9%) indicated that people register by name for testing. Eight of the ten members of that subset (80.0%) indicated that the names are kept confidential. Five responding Member States (45.5%) reported that the hepatitis C test is free of charge for all individuals. Among the six other Member States, Myanmar and Thailand reported that the hepatitis C test is free of charge for members of specific groups. Groups identified included blood donors and pregnant women. Six responding Member States (54.5%) reported that the hepatitis C test is compulsory for members of specific groups. Groups identified included blood donors and people living with HIV. Six responding Member States (54.5%) reported that publicly funded treatment is available for hepatitis B and six (54.5%) that publicly funded treatment is available for hepatitis C. Information was not provided by any Member State regarding the amount spent on publicly funded treatment for hepatitis B and hepatitis C. Nine responding Member States (81.8%) reported that at least one available drug for treating hepatitis B is on the national essential medicines list (Table 6). The drugs most commonly reported were lamivudine, interferon alpha, tenofovir and pegylated interferon. Seven responding Member States (63.6%) reported that at least one available drug for treating hepatitis C is on the national essential medicines list. The drugs most commonly reported were interferon alpha, pegylated interferon and ribavirin.

90.9

9.1

0

81.8

9.1

9.1

18.2

63.6

18.2

45.5

54.5

0

Figure 4. Responses to the question, “Are there national

clinical guidelines for the management of viral hepatitis?” (N=11) Do not know 9.1%

Yes (36.4%) No (54.5%)

World Health Organization assistance 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 the national plan for viral hepatitis prevention and control (81.8%), estimating the national burden of viral hepatitis (81.8%) and conducting viral hepatitis surveillance (81.8%) (Table 7). Responses from individual Member States appear in Annex C.

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Table 6. Proportion of Member States reporting drugs for

treating hepatitis B and C on national essential medicines lists or subsidized by governments Drugs for treating hepatitis B % of Member States reporting its inclusion (N=12) 63.6 45.5 45.5 36.4 36.4 36.4 27.3 % of Member States reporting its inclusion (N=12) 54.5 45.5 45.5 27.3 18.2

Lamivudine Interferon alpha Tenofovir Pegylated interferon Entecavir Adefovir dipivoxil Telbivudine Drugs for treating hepatitis C

Ribavirin Pegylated interferon Interferon alpha Telaprevir Boceprevir

Table 7. Viral hepatitis control and prevention: areas in which Member States indicated interest in receiving WHO assistance

(N=11) Awareness-raising, partnerships and resource mobilization (first WHO strategic axis) Developing the national plan for viral hepatitis prevention and control Integrating viral hepatitis programmes into other health services Awareness-raising Evidence-based policy and data for action (second WHO strategic axis) Viral hepatitis surveillance Estimating the national burden of viral hepatitis Developing tools to assess the effectiveness of interventions Assessing the economic impact of viral hepatitis Prevention of transmission (third WHO strategic axis) Increasing coverage of the birth dose of the hepatitis B vaccine Screening, care and treatment (fourth WHO strategic axis) Increasing access to treatment Increasing access to diagnostics Improving laboratory quality Developing education/training programmes for health professionals a

81.8% 63.6% 72.7% 81.8% 81.8% 63.6% 54.5% 54.5% 54.5% 63.6% 0%a 63.6%

N=26 (This response option was not included in the survey completed by Member States of the South-East Asia Region.)

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WHO South-East Asia Region: COUNTRY SUMMARIES

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Bangladesh Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 150.4 Low-income $1940 3.48% $148.45 $66.43 65 0.500 24 2.2 Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. Not all donated blood units and blood products nationwide are screened for hepatitis B. It is not known whether all donated blood units (including family donations) and blood products nationwide are screened for hepatitis C.

The Government of Bangladesh reports as The government publishes hepatitis dis- There is no national policy relating to the follows. ease reports in journals. prevention of viral hepatitis among people who inject drugs. National coordination Hepatitis outbreaks are not reported to the There is no written national strategy or plan government. There is inadequate labora- The government does not have guidelines that focuses exclusively or primarily on the tory capacity nationally to support investi- that address how hepatitis A and hepatitis prevention and control of viral hepatitis. gation of outbreaks and other surveillance E can be prevented through food and waactivities. ter safety. There is no designated governmental unit/ department responsible solely for coordi- There is no national public health research Screening, care and treatment nating and/or carrying out viral hepatitis- agenda for viral hepatitis. Viral hepatitis se- It is not known how health professionals related activities. It is not known how many rosurveys are not conducted regularly. obtain the skills and competencies repeople work full-time on hepatitis-related quired to effectively care for people with activities in all government agencies/bod- Prevention of transmission viral hepatitis. There is no national policy on hepatitis A ies. vaccination. There are no national clinical guidelines for The government does not have a viral hepthe management of viral hepatitis. atitis prevention and control programme The government has not established the The government does not have national that includes activities targeting specific goal of eliminating hepatitis B. policies relating to screening and referral populations. Information was not provided on the per- to care for hepatitis B or hepatitis C. Awareness-raising and partnerships centage of newborn infants nationally in The government did not hold events for a given recent year who received the first People testing for hepatitis B and hepatitis World Hepatitis Day 2012 and has not dose of hepatitis B vaccine within 24 hours C do not register by name. Hepatitis B and funded other viral hepatitis public aware- of birth or the percentage of one-year-olds hepatitis C tests are not free of charge, and nationally (ages 12–23 months) in a given are compulsory for blood donors. ness campaigns since January 2011. recent year who received three doses of Publicly funded treatment is not available The government collaborates with the fol- hepatitis B vaccine. for hepatitis B or hepatitis C. lowing in-country civil society group to develop and implement its viral hepatitis There is no national policy that specifically prevention and control programme: Liver targets mother-to-child transmission of The following drugs for treating hepatitis B drugs are on the national essential hepatitis B. Foundation of Bangladesh. medicines list: interferon alpha, pegylated Evidence-based policy and data for There is no specific national strategy and/ interferon, lamivudine, adefovir dipivoxil, or policy for preventing hepatitis B and entecavir, telbivudine and tenofovir. The action There is no routine surveillance for viral hepatitis C infection in health-care settings. following drugs for treating hepatitis C are Health-care workers are not vaccinated on the national essential medicines list: inhepatitis. against hepatitis B prior to starting work terferon alpha, pegylated interferon, ribaThere are no standard case definitions for that might put them at risk of exposure to virin, boceprevir and telaprevir. hepatitis. Hepatitis deaths are not reported blood. to a central registry. The percentage of The Government of Bangladesh welcomes hepatitis cases reported as “undifferentiat- There is no national policy on injection assistance from WHO in one or more areas ed” or “unclassified” hepatitis is not known. safety in health-care settings. Single-use of viral hepatitis prevention and control or auto-disable syringes, needles and can- (Annex C). Liver cancer cases and cases with HIV/ nulas are always available in all health-care hepatitis coinfection are not registered na- facilities. tionally.

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Bhutan The Government of Bhutan reports as Population (in millions) (2011) 0.7 follows. Country classification (2012) Lower–middle-income Gross national income per capita (PPP int $) (2011) National coordination $5570 There is no written national strategy or Total health expenditure as % of GDP (2010) 5.19% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $274.76 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $238.57 Life expectancy at birth (in years) (2009) hepatitis. 63 Human Development Index (2011) 0.552 There is no designated governmental Median age (in years) (2010) 25 unit/department responsible solely for co- Total fertility rate per woman (2010) 2.4 ordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitis- There is adequate laboratory capacity na- There is a national infection control policy related activities in all government agen- tionally to support investigation of viral for blood banks. All donated blood units hepatitis outbreaks and other surveillance (including family donations) and blood cies/bodies. products nationwide are screened for activities. The government has a viral hepatitis prehepatitis B and hepatitis C. vention and control programme that in- There is no national public health research cludes activities targeting the following agenda for viral hepatitis. Viral hepatitis se- There is a national policy relating to the prevention of viral hepatitis among peospecific populations: health-care workers rosurveys are not conducted regularly. ple who inject drugs. (including health-care waste handlers), people who inject drugs, migrants, prison- Prevention of transmission ers, the homeless, people living with HIV, There is no national policy on hepatitis A The government does not have guidelines that address how hepatitis A and hepatilow-income populations, the uninsured, vaccination. indigenous people and pregnant women. The government has not established the tis E can be prevented through food and water safety. Awareness-raising and partnerships goal of eliminating hepatitis B. The government did not hold events for Nationally, 29% of newborn infants in a Screening, care and treatment World Hepatitis Day 2012 and has not given recent year received the first dose Health professionals obtain the skills and funded other viral hepatitis public aware- of hepatitis B vaccine within 24 hours of competencies required to effectively care for people with viral hepatitis through ness campaigns since January 2011. birth, based on a policy introduced in mid- schools for health professionals (pre-servThe government does not collaborate 2011, and 93% of one-year-olds (ages 12– ice education) and on-the-job training. with in-country civil society groups to 23 months) in a given recent year received There are no national clinical guidelines develop and implement its viral hepatitis three doses of hepatitis B vaccine. for the management of viral hepatitis. prevention and control programme. There is a national policy that specifically Evidence-based policy and data for targets mother-to-child transmission of The government does not have national hepatitis B (Annex B). policies relating to screening and referral action There is routine surveillance for viral hepa- There is no specific national strategy and/ to care for hepatitis B or hepatitis C. titis. There is a national surveillance system or policy for preventing hepatitis B and People testing for both hepatitis B and for acute hepatitis B, but not for any type hepatitis C infection in health-care sethepatitis C register by name, and there of chronic hepatitis. tings. However, health-care workers are is open access to their names. Hepatitis There are no standard case definitions for vaccinated against hepatitis B prior to B and hepatitis C tests are free of charge hepatitis. Hepatitis deaths are not report- starting work that might put them at risk for all individuals, and are compulsory for blood donors and people living with HIV. ed to a central registry. The percentage of of exposure to blood. hepatitis cases reported as “undifferentiat- There is a national policy on injection safePublicly funded treatment is not available ed” or “unclassified” hepatitis is not known. ty in health-care settings, which recomfor hepatitis B or hepatitis C. Liver cancer cases are not registered na- mends single-use syringes for therapeutic The following drug for treating hepatitis B tionally, but cases with HIV/hepatitis coin- injections. Single-use or auto-disable syringes, needles and cannulas are always is on the national essential medicines list: fection are. lamivudine. No drug for treating hepatitis available in all health-care facilities. C is on the national essential medicines The government publishes hepatitis disOfficial government estimates of the list. ease reports annually. number and percentage of unnecesHepatitis outbreaks are reported to the sary injections administered annually in The Government of Bhutan welcomes assistance from WHO in one or more areas government and are further investigated. health-care settings are not known. of viral hepatitis prevention and control (Annex C).

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Democratic People’s Republic of Korea Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 24.5 Low-income ---$45.68 70 -33 2.0 Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B, but not for hepatitis C.

There is no national policy relating to the prevention of viral hepatitis among people The Government of the Democratic Liver cancer cases are registered nationally, who inject drugs. People’s Republic of Korea reports as but cases with HIV/hepatitis coinfection The government has guidelines that adfollows. are not. dress how hepatitis A and hepatitis E can National coordination The government does not publish hepati- be prevented through food and water There is a written national strategy or plan tis disease reports. safety. that focuses exclusively on the prevention and control of viral hepatitis. It includes Hepatitis outbreaks are reported to the Screening, care and treatment components for raising awareness, surveil- government and are further investigated. Health professionals obtain the skills and lance, vaccination, prevention in general, There is adequate laboratory capacity na- competencies required to effectively care prevention of transmission in health-care tionally to support investigation of viral for people with viral hepatitis through hepatitis outbreaks and other surveillance schools for health professionals (pre-servsettings, and treatment and care. activities. ice education) and on-the-job training. There is a designated governmental unit/ department responsible solely for coordi- There is a national public health research There are national clinical guidelines for nating and/or carrying out viral hepatitis- agenda for viral hepatitis. Viral hepatitis the management of viral hepatitis, but related activities. The name of this office serosurveys are conducted regularly; the they do not include recommendations for was not provided. It has four staff mem- target population is children under the age cases with HIV coinfection. bers. It is not known how many people of 17 years. The last serosurvey was carried The government has national policies rework full-time on hepatitis-related activi- out in 2009. lating to screening and referral to care for ties in all government agencies/bodies. Prevention of transmission hepatitis B and hepatitis C. The government has a viral hepatitis pre- There is no national policy on hepatitis A People testing for both hepatitis B and vention and control programme that in- vaccination. hepatitis C register by name; the names cludes activities targeting the following The government has established the goal are kept confidential within the system. specific population: health-care workers, of eliminating hepatitis B by 2016. Hepatitis B and hepatitis C tests are free of including health-care waste handlers. charge for all individuals and are not comAwareness-raising and partnerships Nationally, more than 90% of newborn pulsory for members of any specific group. The government did not hold events for infants in a given recent year received the World Hepatitis Day 2012, but has funded first dose of hepatitis B vaccine within 24 Publicly funded treatment is available for other viral hepatitis public awareness cam- hours of birth and more than 90% of one- hepatitis B and hepatitis C. Information year-olds (ages 12–23 months) in a given was not provided on who is eligible for paigns since January 2011 (Annex A). recent year received three doses of hepa- this. Information was not provided on the amount spent by the government on pubThe government collaborates with the fol- titis B vaccine. licly funded treatment. lowing in-country civil society groups to develop and implement its viral hepatitis There is a national policy that specifically prevention and control programme: mass targets mother-to-child transmission of The following drugs for treating hepatitis B are on the national essential medicines list: media and community and social organi- hepatitis B (Annex B). interferon alpha and pegylated interferon. zations. There is a specific national strategy and/ The following drugs for treating hepatitis C Evidence-based policy and data for or policy for preventing hepatitis B and are on the national essential medicines list: hepatitis C infection in health-care settings. interferon alpha and pegylated interferon. action There is routine surveillance for viral hepa- However, health-care workers are not vactitis. There is a national surveillance system cinated against hepatitis B prior to starting The Government of the Democratic Peofor the following types of acute hepatitis: work that might put them at risk of expo- ple’s Republic of Korea welcomes assistance from WHO in one or more areas of A, B and C, and for the following types of sure to blood. viral hepatitis prevention and control chronic hepatitis: B and C. There is a national policy on injection (Annex C). There are standard case definitions for safety in health-care settings, which rechepatitis. Deaths, including from hepatitis, ommends single-use and auto-disable syare reported to a central registry. Informa- ringes for therapeutic injections. However, tion was not provided on the percentage single-use or auto-disable syringes, neeof hepatitis cases reported as “undifferenti- dles and cannulas are not always available in all health-care facilities. ated” or “unknown” hepatitis.

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India The Government of India reports as Population (in millions) (2011) 1241.5 follows. Country classification (2012) Lower–middle-income Gross national income per capita (PPP int $) (2011) National coordination $3590 There is a written national strategy or plan Total health expenditure as % of GDP (2010) 4.05% that focuses exclusively on the prevention Per capita total health expenditure (PPP int $) (2010) $132.20 and control of viral hepatitis. It includes Per capita government health expenditure (PPP int $) (2010) $38.57 components for raising awareness, surveil- Life expectancy at birth (in years) (2009) 65 lance, vaccination, prevention in general, Human Development Index (2011) 0.547 prevention of transmission via injecting Median age (in years) (2010) 25 drug use, prevention of transmission in Total fertility rate per woman (2010) 2.6 health-care settings, and treatment and care. hepatitis outbreaks and other surveillance (including family donations) and blood products nationwide are screened for There is a designated governmental unit/ activities. hepatitis B and hepatitis C. department responsible solely for coordinating and/or carrying out viral hepatitis- There is no national public health research related activities. It has four staff members. agenda for viral hepatitis. Viral hepatitis se- It is not known whether there is a national policy relating to the prevention of viral It is not known how many people work rosurveys are not conducted regularly. hepatitis among people who inject drugs. full-time on hepatitis-related activities in Prevention of transmission all government agencies/bodies. There is no national policy on hepatitis A The government has guidelines that address how hepatitis A and hepatitis E can The government has a viral hepatitis pre- vaccination. vention and control programme that in- The government has not established the be prevented through food and water safety. cludes activities targeting the following goal of eliminating hepatitis B. specific population: health-care workers, Screening, care and treatment including health-care waste handlers. It is not known what percentage of new- Health professionals obtain the skills and born infants nationally in a given recent Awareness-raising and partnerships year received the first dose of hepatitis B competencies required to effectively care It is not known whether the government vaccine within 24 hours of birth or what for people with viral hepatitis through onheld events for World Hepatitis Day 2012 percentage of one-year-olds (ages 12–23 the-job training. or funded other viral hepatitis public months) nationally in a given recent year It is not known whether there are national awareness campaigns since January 2011. received three doses of hepatitis B vaccine. clinical guidelines for the management of The government does not collaborate There is a national policy that specifically viral hepatitis. with in-country civil society groups to targets mother-to-child transmission of The government does not have national develop and implement its viral hepatitis hepatitis B (Annex B). policies relating to screening and referral prevention and control programme. to care for hepatitis B or hepatitis C. It is not known whether there is a specific Evidence-based policy and data for national strategy and/or policy for prevent- People testing for both hepatitis B and action ing hepatitis B and hepatitis C infection in hepatitis C register by name; the names There is no routine surveillance for viral health-care settings. However, health-care are kept confidential within the system. hepatitis. workers are vaccinated against hepatitis B Hepatitis B and hepatitis C tests are free of There are standard case definitions for prior to starting work that might put them charge for all individuals and are compulsory for blood donors. hepatitis. Hepatitis deaths are not report- at risk of exposure to blood. ed to a central registry. The percentage of There is a national policy on injection safe- Publicly funded treatment is not available hepatitis cases reported as “undifferentiat- ty in health-care settings, which recom- for hepatitis B or hepatitis C. ed” or “unclassified” hepatitis is not known. mends auto-disable syringes for therapeuThe following drug for treating hepatitis B Liver cancer cases and cases with HIV/hep- tic injections. Single-use or auto-disable is on the national essential medicines list: atitis coinfection are registered nationally. syringes, needles and cannulas are always lamivudine. The following drug for treatavailable in all health-care facilities. ing hepatitis C is on the national essential The government does not publish hepatiOfficial government estimates of the medicines list: ribavirin. tis disease reports. number and percentage of unnecesHepatitis outbreaks are reported to the sary injections administered annually in The Government of India welcomes assistance from WHO in one or more areas government and are further investigated. health-care settings are not known. of viral hepatitis prevention and control There is inadequate laboratory capacity nationally to support investigation of viral There is a national infection control policy (Annex C). for blood banks. All donated blood units

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Indonesia Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 242.3 Lower–middle-income $4500 2.61% $112.07 $55.01 68 0.617 28 2.1 Information was not provided on official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

It is not known whether there is a national policy relating to the prevention of viral The Government of Indonesia reports as Liver cancer cases are registered nationally, hepatitis among people who inject drugs. follows. but it is not known whether cases with HIV/ The government has guidelines that adhepatitis coinfection are. National coordination dress how hepatitis A and hepatitis E can There is a written national strategy or plan The government publishes hepatitis dis- be prevented through food and water that focuses exclusively on the prevention ease reports monthly and annually. safety. and control of viral hepatitis. It includes components for raising awareness, surveil- Hepatitis outbreaks are reported to the Screening, care and treatment lance, vaccination, prevention in general, government and are further investigated. Health professionals obtain the skills and prevention of transmission via injecting There is adequate laboratory capacity na- competencies required to effectively care drug use, prevention of transmission in tionally to support investigation of out- for people with viral hepatitis through schools for health professionals (pre-servhealth-care settings, and treatment and breaks and other surveillance activities. ice education) and on-the-job training. care. There is a national public health research There is no designated governmental unit/ agenda for viral hepatitis. Viral hepatitis se- There are no national clinical guidelines for the management of viral hepatitis. department responsible solely for coordi- rosurveys are not conducted regularly. nating and/or carrying out viral hepatitisPrevention of transmission The government does not have national related activities. There are 12 full-time There is no national policy on hepatitis A policies relating to screening and referral equivalent staff members who work on vaccination. to care for hepatitis B or hepatitis C. hepatitis-related activities in all government agencies/bodies. The government has not established the People testing for both hepatitis B and goal of eliminating hepatitis B. hepatitis C register by name; the names are The government has a viral hepatitis prevention and control programme that in- Information was not provided on the per- kept confidential within the system. Hepacludes activities targeting the following centage of newborn infants nationally in titis B and hepatitis C tests are not free of specific population: health-care workers, a given recent year who received the first charge. Information was not provided on whether hepatitis B or hepatitis C tests are including health-care waste handlers. dose of hepatitis B vaccine within 24 hours compulsory for members of any specific Awareness-raising and partnerships of birth. Nationally, 94% of one-year-olds group. The government held events for World (ages 12–23 months) in a given recent year Hepatitis Day 2012 and has funded other received three doses of hepatitis B vaccine. Government employees are eligible for viral hepatitis public awareness campaigns There is a national policy that specifically publicly funded treatment for hepatitis B and hepatitis C. Information was not prosince January 2011 (Annex A). targets mother-to-child transmission of vided on the amount spent by the government on such treatment. Information was not provided on whether hepatitis B (Annex B). the government collaborates with in- There is no specific national strategy and/ country civil society groups to develop and or policy for preventing hepatitis B and The following drugs for treating hepatitis B implement its viral hepatitis prevention hepatitis C infection in health-care settings. are on the national essential medicines list: pegylated interferon, lamivudine, adefovir and control programme. Health-care workers are not vaccinated dipivoxil and telbivudine. The following Evidence-based policy and data for against hepatitis B prior to starting work drugs for treating hepatitis C are on the that might put them at risk of exposure to national essential medicines list: pegylated action There is no routine surveillance for viral blood. interferon and ribavirin. hepatitis. There is a national policy on injection The Government of Indonesia welcomes There are standard case definitions for safety in health-care settings, which rec- assistance from WHO in one or more areas hepatitis. Deaths, including from hepatitis, ommends single-use and auto-disable of viral hepatitis prevention and control are reported to a central registry. Informa- syringes for therapeutic injections. Single- (Annex C). tion was not provided on the percentage use or auto-disable syringes, needles and of hepatitis cases reported as “undifferenti- cannulas are always available in all healthcare facilities. ated” or “unknown” hepatitis.

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Maldives The Government of the Maldives reports Population (in millions) (2011) 0.3 as follows. Country classification (2012) Upper–middle-income Gross national income per capita (PPP int $) (2011) National coordination $7430 There is no written national strategy or Total health expenditure as % of GDP (2010) 6.33% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $464 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $280.69 Life expectancy at birth (in years) (2009) hepatitis. 75 Human Development Index (2011) 0.661 There is no designated governmental Median age (in years) (2010) 25 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.8 ordinating and/or carrying out viral hepatitis-related activities. Information was not provided on how many people work There is no national public health research There is no national policy relating to the full-time on hepatitis-related activities in agenda for viral hepatitis. Viral hepatitis prevention of viral hepatitis among people who inject drugs. serosurveys are not conducted regularly. all government agencies/bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: people who inject drugs, migrants and prisoners.

Prevention of transmission

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. The government collaborates with the following in-country civil society groups to develop and implement its viral hepatitis prevention and control programme: nongovernmental organizations that work with injecting drug users and other highrisk populations.

The government does not have guidelines There is no national policy on hepatitis A that address how hepatitis A and hepativaccination. tis E can be prevented through food and water safety. The government has not established the goal of eliminating hepatitis B. Screening, care and treatment Health professionals obtain the skills and Nationally, 98% of newborn infants in a competencies required to effectively care given recent year received the first dose of for people with viral hepatitis through onhepatitis B vaccine within 24 hours of birth the-job training. and 96% of one-year-olds (ages 12–23 months) in a given recent year received There are no national clinical guidelines for the management of viral hepatitis. three doses of hepatitis B vaccine. There is a national policy that specifically The government does not have national targets mother-to-child transmission of policies relating to screening and referral to care for hepatitis B or hepatitis C. hepatitis B (Annex B). People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are free of charge for all individuals and are compulsory for pregnant women, pre-surgical patients and foreign nationals applying for work visas. Publicly funded treatment for hepatitis B and hepatitis C is available to the entire population. The amount spent by the government on such treatment is not known. The following drugs for treating hepatitis B are on the national essential medicines list: lamivudine and tenofovir. No drug for treating hepatitis C is on the national essential medicines list. The Government of the Maldives welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

There is a specific national strategy and/ or policy for preventing hepatitis B and Evidence-based policy and data for hepatitis C infection in health-care settings. Health-care workers are vaccinated action There is no routine surveillance for viral against hepatitis B prior to starting work that might put them at risk of exposure to hepatitis. blood. There are no standard case definitions for hepatitis. Deaths, including from hepatitis, There is a national policy on injection safeare reported to a central registry. The per- ty in health-care settings, which recomcentage of hepatitis cases reported as “un- mends single-use syringes for therapeutic differentiated” or “unclassified” hepatitis is injections. Single-use or auto-disable syringes, needles and cannulas are always not known. available in all health-care facilities. Liver cancer cases are not registered nationally, but cases with HIV/hepatitis Official government estimates of the number and percentage of unnecescoinfection are. sary injections administered annually in The government does not publish hepati- health-care settings are not known. tis disease reports. There is a national infection control policy Hepatitis outbreaks are not reported to the for blood banks. All donated blood units government. There is adequate laboratory (including family donations) and blood capacity nationally to support investiga- products nationwide are screened for tion of viral hepatitis outbreaks and other hepatitis B and hepatitis C. surveillance activities.

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Myanmar Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Myanmar reports as follows. 48.3 Low-income -1.97% $34.41 $4.19 64 0.483 28 2.0 Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

National coordination There is a written national strategy or plan that focuses primarily on the prevention and control of viral hepatitis, and also integrates other diseases. It includes components for raising awareness, surveillance, vaccination, prevention in general, prevention of transmission via injecting drug use, prevention of transmission in health-care settings, and treatment and care. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities. It has 20 staff members. There are 49 full-time equivalent staff members who work on hepatitis-related activities in all government agencies/ bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers), people who inject drugs, migrants, prisoners, the homeless, people living with HIV, low-income populations, the uninsured and indigenous people.

Prevention of transmission

There is a national policy relating to the prevention of viral hepatitis among people There are standard case definitions for who inject drugs. hepatitis. Deaths, including from hepatitis, are reported to a central registry. Less than The government has guidelines that ad5% of hepatitis cases are reported as “un- dress how hepatitis A and hepatitis E can be prevented through food and water differentiated” or “unclassified” hepatitis. safety. Liver cancer cases and cases with HIV/hepatitis coinfection are registered nationally. Screening, care and treatment Health professionals obtain the skills and The government publishes hepatitis dis- competencies required to effectively care ease reports monthly and annually. for people with viral hepatitis through schools for health professionals (pre-servHepatitis outbreaks are reported to the ice education), on-the-job training, postgovernment and are further investigated. graduate training and continuing medical There is adequate laboratory capacity na- education activities. tionally to support investigation of viral hepatitis outbreaks and other surveillance There are national clinical guidelines for activities. the management of viral hepatitis, which include recommendations for cases with There is a national public health research HIV coinfection. agenda for viral hepatitis. Viral hepatitis serosurveys are conducted regularly; the The government has national policies remost recent one was in 2010. lating to screening and referral to care for hepatitis B and hepatitis C.

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012, but has funded other viral hepatitis public awareness campaigns since January 2011 (Annex A). The government collaborates with the following in-country civil society groups to develop and implement its viral hepatitis prevention and control programme: Myanmar Medical Association, Myanmar Health Assistant Association, Myanmar Nurses’ Association, Myanmar Maternal and Child Welfare Association and Myanmar Red Cross Association.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B and C, and for the following types of chronic hepatitis: B and C.

There is no national policy on hepatitis A People testing for both hepatitis B and vaccination. hepatitis C register by name; the names are kept confidential within the system. HepaThe government has not established the titis B and hepatitis C tests are not free of goal of eliminating hepatitis B. charge for everyone, but they are free for Nationally, 10% of newborn infants in a pregnant women and blood donors. Hepagiven recent year received the first dose of titis B and hepatitis C tests are compulsory hepatitis B vaccine within 24 hours of birth for pregnant women, blood donors and and 38% of one-year-olds (ages 12–23 people applying for employment. months) in a given recent year received Publicly funded treatment is available for three doses of hepatitis B vaccine. hepatitis B and hepatitis C. Information There is a national policy that specifically was not provided on who is eligible for it, targets mother-to-child transmission of or on the amount spent by the government on such treatment. hepatitis B (Annex B). There is a specific national strategy and/ The following drugs for treating hepatitis or policy for preventing hepatitis B and B are on the national essential medicines hepatitis C infection in health-care settings. list: interferon alpha, pegylated interferon, Health-care workers are vaccinated against lamivudine, adefovir dipivoxil, entecavir, hepatitis B prior to starting work that might telbivudine and tenofovir. The following drugs for treating hepatitis C are on the put them at risk of exposure to blood. national essential medicines list: interferon There is a national policy on injection safe- alpha, pegylated interferon and ribavirin. ty in health-care settings, which recommends single-use syringes for therapeutic The Government of Myanmar welcomes injections. Single-use or auto-disable sy- assistance from WHO in one or more areas ringes, needles and cannulas are always of viral hepatitis prevention and control (Annex C). available in all health-care facilities.

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Nepal The Government of Nepal reports as Population (in millions) (2011) 30.5 follows. Country classification (2012) Low-income Gross national income per capita (PPP int $) (2011) National coordination $1260 There is no written national strategy or Total health expenditure as % of GDP (2010) 5.52% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $66.68 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $22.03 Life expectancy at birth (in years) (2009) hepatitis. 67 Human Development Index (2011) 0.458 There is no designated governmental Median age (in years) (2010) 21 unit/department responsible solely for co- Total fertility rate per woman (2010) 2.7 ordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitis- Prevention of transmission The government does not have guidelines related activities in all government agen- There is no national policy on hepatitis A that address how hepatitis A and hepativaccination. cies/bodies. tis E can be prevented through food and water safety. The government has a viral hepatitis pre- The government has not established the Screening, care and treatment vention and control programme that in- goal of eliminating hepatitis B. Health professionals obtain the skills and cludes activities targeting the following specific populations: people who inject It is not known what percentage of new- competencies required to effectively care born infants nationally in a given recent for people with viral hepatitis through drugs and people living with HIV. year received the first dose of hepatitis B schools for health professionals (pre-servAwareness-raising and partnerships vaccine within 24 hours of birth or what ice education) and on-the-job training. The government did not hold events for percentage of one-year-olds (ages 12–23 World Hepatitis Day 2012 and has not months) nationally in a given recent year There are no national clinical guidelines funded other viral hepatitis public aware- received three doses of hepatitis B vaccine. for the management of viral hepatitis. ness campaigns since January 2011. There is a national policy that specifically The government does not have national The government does not collaborate targets mother-to-child transmission of policies relating to screening and referral with in-country civil society groups to hepatitis B (Annex B). to care for hepatitis B or hepatitis C. develop and implement its viral hepatitis There is no specific national strategy and/ People testing for both hepatitis B and prevention and control programme. or policy for preventing hepatitis B and hepatitis C register by name, and there is Evidence-based policy and data for hepatitis C infection in health-care set- open access to their names. Hepatitis B action tings. Health-care workers are not vacci- and hepatitis C tests are not free of charge There is no routine surveillance for viral nated against hepatitis B prior to starting and are not compulsory for members of hepatitis. work that might put them at risk of expo- any specific group. sure to blood. There are standard case definitions for Publicly funded treatment is not available hepatitis. Deaths, including from hepatitis, There is a national policy on injection safe- for hepatitis B or hepatitis C. are reported to a central registry. Informa- ty in health-care settings, which recomtion was not provided on the percentage mends single-use syringes for therapeutic The following drugs for treating hepatitis of hepatitis cases reported as “undifferen- injections. Single-use or auto-disable sy- B are on the national essential medicines tiated” or “unknown” hepatitis. ringes, needles and cannulas are always list: interferon alpha, pegylated interferon, lamivudine, adefovir dipivoxil, entecavir, available in all health-care facilities. Liver cancer cases and cases with HIV/heptelbivudine and tenofovir. The following atitis coinfection are registered nationally. Official government estimates of the drugs for treating hepatitis C are on the number and percentage of unneces- national essential medicines list: interferThe government does not publish hepati- sary injections administered annually in on alpha, pegylated interferon, ribavirin, tis disease reports. boceprevir and telaprevir. health-care settings are not known. Hepatitis outbreaks are reported to the There is a national infection control policy The Government of Nepal welcomes asgovernment and are further investigated. for blood banks. All donated blood units sistance from WHO in one or more areas There is adequate laboratory capacity na- (including family donations) and blood of viral hepatitis prevention and control tionally to support investigation of viral products nationwide are screened for (Annex C). hepatitis outbreaks and other surveillance hepatitis B and hepatitis C. activities. There is no national policy relating to the There is no national public health research prevention of viral hepatitis among peoagenda for viral hepatitis. Viral hepatitis ple who inject drugs. serosurveys are not conducted regularly.

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Sri Lanka Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 21.0 Lower–middle-income $5520 2.95% $148.45 $66.43 71 0.691 31 2.3 ommends single-use and auto-disable syringes for therapeutic injections. Singleuse or auto-disable syringes, needles and cannulas are always available in all healthcare facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known.

There is a national infection control policy for blood banks. All donated blood units The Government of Sri Lanka reports as Liver cancer cases are registered nationally, (including family donations) and blood follows. but it is not known whether cases with HIV/ products nationwide are screened for hephepatitis coinfection are. atitis B and hepatitis C.

National coordination

There is no written national strategy or plan The government publishes hepatitis dis- There is no national policy relating to the that focuses exclusively or primarily on the ease reports weekly, as well as in a quar- prevention of viral hepatitis among people prevention and control of viral hepatitis. terly epidemiological bulletin. who inject drugs. There is no designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities. Information was not provided on how many people work full-time on hepatitis-related activities in all government agencies/bodies. Hepatitis outbreaks are reported to the government and are further investigated. There is inadequate laboratory capacity nationally to support investigation of viral hepatitis outbreaks and other surveillance activities. The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

Screening, care and treatment

Health professionals obtain the skills and There is no national public health research competencies required to effectively care The government has a viral hepatitis pre- agenda for viral hepatitis. Viral hepatitis se- for people with viral hepatitis through vention and control programme that in- rosurveys are not conducted regularly. schools for health professionals (pre-servcludes activities targeting the following ice education) and on-the-job training. Prevention of transmission specific populations: children (through the Expanded Programme on Immunization) There is no national policy on hepatitis A There are national clinical guidelines for the management of viral hepatitis, but it and health-care workers, including health- vaccination. is not known whether they include recomcare waste handlers. The government has established the goal mendations for cases with HIV coinfection. Awareness-raising and partnerships of eliminating hepatitis B by 2015. The government does not have national The government held a conference for World Hepatitis Day 2012, but has not Nationally, no newborn infant in a given re- policies relating to screening and referral funded other viral hepatitis public aware- cent year received the first dose of hepati- to care for hepatitis B or hepatitis C. tis B vaccine within 24 hours of birth. Howness campaigns since January 2011. ever, 99% of one-year-olds (ages 12–23 People testing for both hepatitis B and The government does not collaborate with months) in a given recent year received hepatitis C register by name; the names are kept confidential within the system. Hepain-country civil society groups to develop three doses of hepatitis B vaccine. titis B and hepatitis C tests are not free of and implement its viral hepatitis prevenThere is no national policy that specifically charge and are not compulsory for memtion and control programme. targets mother-to-child transmission of bers of any specific group. Evidence-based policy and data for hepatitis B. action Publicly funded treatment is not available There is routine surveillance for viral hepa- There is a specific national strategy and/ for hepatitis B or hepatitis C. titis. There is a national surveillance system or policy for preventing hepatitis B and for the following types of acute hepatitis: A, hepatitis C infection in health-care set- The following drug for treating hepatitis B B, C, D and E, but not for any type of chronic tings. Health-care workers are vaccinated is on the national essential medicines list: against hepatitis B prior to starting work interferon alpha. The following drug for hepatitis. that might put them at risk of exposure treating hepatitis C is on the national esThere are standard case definitions for to blood; vaccinations are arranged with- sential medicines list: interferon alpha. hepatitis. Deaths, including from hepatitis, in groups and are provided on request The Government of Sri Lanka welcomes are reported to a central registry. The per- through pharmacies. assistance from WHO in one or more arcentage of hepatitis cases reported as “undifferentiated” or “unclassified” hepatitis is There is a national policy on injection eas of viral hepatitis prevention and consafety in health-care settings, which rec- trol (Annex C). not known.

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Thailand The Government of Thailand reports as Population (in millions) (2011) 69.5 follows. Country classification (2012) Upper–middle-income Gross national income per capita (PPP int $) (2011) National coordination $8360 There is no written national strategy or Total health expenditure as % of GDP (2010) 3.88% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $329.71 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $247.42 Life expectancy at birth (in years) (2009) hepatitis. 70 Human Development Index (2011) 0.682 There is no designated governmental unit/ Median age (in years) (2010) 34 department responsible solely for coordi- Total fertility rate per woman (2010) 1.6 nating and/or carrying out viral hepatitisrelated activities. There are no people Screening, care and treatment working full-time on hepatitis-related ac- Prevention of transmission There is no national policy on hepatitis A Health professionals obtain the skills and tivities in any government agency/body. vaccination. competencies required to effectively care The government has a viral hepatitis prefor people with viral hepatitis through vention and control programme that in- The government has not established the schools for health professionals (pre-servcludes activities targeting the following goal of eliminating hepatitis B. ice education), on-the-job training and specific population: health-care workers, technical seminars. Nationally, 99% of newborn infants in a including health-care waste handlers. given recent year received the first dose of There are national clinical guidelines for Awareness-raising and partnerships hepatitis B vaccine within 24 hours of birth the management of viral hepatitis, which The government did not hold events for and 98% of one-year-olds (ages 12–23 include recommendations for cases with World Hepatitis Day 2012 and has not months) in a given recent year received HIV coinfection. funded other viral hepatitis public aware- three doses of hepatitis B vaccine. ness campaigns since January 2011. The government has national policies reThere is a national policy that specifically lating to screening and referral to care for The government does not collaborate targets mother-to-child transmission of hepatitis B, but not for hepatitis C. with in-country civil society groups to hepatitis B (Annex B). develop and implement its viral hepatitis People testing for both hepatitis B and There is a specific national strategy and/or hepatitis C register by name; the names prevention and control programme. policy for preventing hepatitis B and hepa- are kept confidential within the system. Evidence-based policy and data for titis C infection in health-care settings, but Hepatitis B and hepatitis C tests are not action it addresses only vaccination for health- free of charge for all individuals, but they There is routine surveillance for viral hepa- care workers. Health-care workers are not are for pregnant women, blood donors titis. There is a national surveillance system vaccinated against hepatitis B prior to and civil servants. Hepatitis C tests are free for the following types of acute hepatitis: starting work that might put them at risk of charge for blood donors. Hepatitis B A, B, C, D and E, but not for any type of of exposure to blood. and hepatitis C tests are compulsory for chronic hepatitis. blood donors. There is a national policy on injection safeThere are standard case definitions for ty in health-care settings, which recom- Publicly funded treatment is available for hepatitis. Deaths, including from hepatitis, mends single-use syringes for therapeutic hepatitis B and hepatitis C. Patients under are reported to a central registry. Of hepa- injections. Single-use or auto-disable sy- the universal coverage scheme are eligititis cases, 25% are reported as “undiffer- ringes, needles and cannulas are always ble. However, only lamivudine and tenofoentiated” or “unclassified” hepatitis. available in all health-care facilities. vir are included in the universal coverage Liver cancer cases and cases with HIV/hep- Official government estimates of the package for hepatitis B, and major drugs atitis coinfection are registered nationally. number and percentage of unneces- for treating hepatitis C are not included. The amount spent by the government on sary injections administered annually in publicly funded treatment for hepatitis B The government publishes hepatitis dis- health-care settings are not known. and hepatitis C is not known. ease reports weekly and annually. There is a national infection control policy Hepatitis outbreaks are reported to the for blood banks. All donated blood units The following drugs for treating hepatitis government and are further investigated. (including family donations) and blood B are on the national essential medicines There is adequate laboratory capacity na- products nationwide are screened for list: lamivudine and tenofovir. No drug for treating hepatitis C is on the national estionally to support investigation of viral hepatitis B and hepatitis C. sential medicines list. hepatitis outbreaks and other surveillance activities. There is no national policy relating to the The Government of Thailand welcomes prevention of viral hepatitis among peoassistance from WHO in one or more areas There is no national public health research ple who inject drugs. of viral hepatitis prevention and control agenda for viral hepatitis. Viral hepatitis serosurveys are not conducted regularly. The government does not have guidelines (Annex C). The most recent serosurvey, which tar- that address how hepatitis A and hepatigeted the general population, was carried tis E can be prevented through food and out in 2004. water safety.

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Timor-Leste Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Timor-Leste reports as follows. 1.2 Lower–middle-income $5200 9.12% $83.98 $46.88 67 0.495 17 6.2 Official government estimates of the number and percentage of unnecessary injections administered annually in healthcare settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

National coordination There is no written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis.

There is no designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities. It is not known how many people work full-time on hepatitis-related activities in all government agencies/ Prevention of transmission bodies. There is no national policy on hepatitis A The government does not have a viral hep- vaccination. atitis prevention and control programme that includes activities targeting specific The government has not established the goal of eliminating hepatitis B. populations.

There is no national policy relating to the prevention of viral hepatitis among people The government does not publish hepati- who inject drugs. tis disease reports. The government does not have guidelines Hepatitis outbreaks are reported to the that address how hepatitis A and hepatitis government and are further investigated. E can be prevented through food and waThere is inadequate laboratory capacity ter safety. nationally to support investigation of viral hepatitis outbreaks and other surveillance Screening, care and treatment Health professionals obtain the skills and activities. competencies required to effectively care There is no national public health research for people with viral hepatitis through agenda for viral hepatitis. Viral hepatitis se- schools for health professionals (pre-servrosurveys are not conducted regularly. ice education) and on-the-job training. There are no national clinical guidelines for the management of viral hepatitis. The government does not have national policies relating to screening and referral to care for hepatitis B or hepatitis C. People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are free of charge for all individuals and are not compulsory for members of any specific group.

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011.

Nationally, no newborn infant in a given recent year received the first dose of hepatitis B vaccine within 24 hours of birth. In a given recent year, 67% of one-year-olds (ages 12–23 months) received three doses of hepatitis B vaccine.

The government does not collaborate with in-country civil society groups to develop There is a national policy that specifically Publicly funded treatment is available for and implement its viral hepatitis preven- targets mother-to-child transmission of hepatitis B and hepatitis C. Information hepatitis B (Annex B). was not provided on the amount spent by tion and control programme. the government on such treatment. There is no specifi c national strategy and/ Evidence-based policy and data for or policy for preventing hepatitis B and Information was not provided on whether action There is routine surveillance for viral hepa- hepatitis C infection in health-care settings. any drug for treating hepatitis B or hepatititis. There is a national surveillance system Health-care workers are not vaccinated tis C is on the national essential medicines for the following types of acute hepatitis: against hepatitis B prior to starting work list. A, B and C, but not for any type of chronic that might put them at risk of exposure to The Government of Timor-Leste welcomes blood. hepatitis. assistance from WHO in one or more areas There are no standard case definitions for There is a national policy on injection safe- of viral hepatitis prevention and control hepatitis. Hepatitis deaths are not reported ty in health-care settings, but this policy (Annex C). to a central registry. The percentage of is only for the immunization programme. hepatitis cases reported as “undifferentiat- It recommends single-use syringes for ed” or “unclassified” hepatitis is not known. therapeutic injections. Single-use or autodisable syringes, needles and cannulas are Liver cancer cases and cases with HIV/ always available in all health-care facilities. hepatitis coinfection are not registered nationally.

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Chapter 8:

WHO Western Pacific Region

Twenty-seven Member States make up the Western Pacific Region, which has a total population of 1.8 billion. The population of China accounts for approximately three fourths of this total.1 The Western Pacific Region encompasses countries at different levels of socioeconomic development, and includes six highincome countries.2 It also includes geographically isolated Pacific Island Countries with poor infrastructure.3 Health indicators for the Region vary widely. Across countries, the median life expectancy at birth is 70 years. However, it is 8–11 years lower in five countries of the Region, while Japan’s life expectancy of 83 years is the highest in the world.4 Similarly, the median under-five mortality rate across countries is 19 per 1000 population, while the highest country rate is 83 per 1000 population (Papua New Guinea) and the lowest is 3 per 1000 (Japan and Singapore).4 Noncommunicable diseases caused 80% of deaths in the Western Pacific Region in 2008,5 with cardiovascular diseases accounting for almost half of the deaths from noncommunicable diseases.6 Among WHO regions, the Western Pacific Region has the highest prevalence of daily tobacco smoking among men (46%); it also has the highest rates of lung cancer among both sexes (combined).7 Alcohol is another major risk factor, particularly in low- and middle-income countries in the Region.4 Liver cancer rates in the Region are far higher than in other regions.7 Responses to the WHO/Alliance survey were received from 15 of the 27 Member States in the Region (55.6%). Box 1. Responses to the 2012 Global Hepatitis Survey: WHO Western Pacific Region

Viral hepatitis in the WHO Western Pacific Region Very low prevalence rates (<50% of population exposed by the age of 30 years) for hepatitis A have been consistently reported from high-income Asia–Pacific countries and Australasia (Australia and New Zealand). Very little information is available from island nations in the Region, though they appear, on average, to have an intermediate prevalence rate.a Similarly, for hepatitis E, studies are scarce; however, prevalence estimates above 5% are not reported in the Region.b In this Region, with the exception of Australia, Japan and New Zealand where the chronic hepatitis B infection rate varies from 2% to 4%, countries have an estimated rate of 5%–7% or more.c The Region accounts for 48% of global liver cancer cases among men and 62% among women. Moreover, liver cancer is the third most common cause of cancer mortality among men in the Region.d For hepatitis C infection, prevalence estimates are 2.6% for the Region.e Although strategies have been implemented to reduce the risk factors for hepatitis C infection, unsafe blood transfusion, unsafe injections and injecting drug use are the major routes of transmission in the Region. a

Member States that submitted surveys: • Australia • Brunei Darussalam • Cambodia • China • Japan • Kiribati • Cook Islands • Fiji • Marshall Islands • Micronesia (Federated States of) • Lao People’s Democratic Republic • Malaysia • Mongolia • New Zealand • Nauru • Niue • Palau • Philippines • Papua New Guinea • Singapore • Solomon Islands • Tonga • Viet Nam

Member States that did not submit surveys: • Republic of Korea • Samoa • Tuvalu • Vanuatu

Jacobsen KH, Wiersma ST. Hepatitis A virus seroprevalence by age and world region, 1990 and 2005. Vaccine, 2010, 28:6653–6657. b Aggarwal R. The global prevalence of hepatitis E virus infection and susceptibility: a systematic review. Geneva, World Health Organization, 2010. c Ott JJ, Stevens, GA, Groeger J, Wiersma ST. Global epidemiology of hepatitis B virus infection: new estimates of age-specific HBsAg seroprevalence and endemicity. Vaccine, 2012, 30:2212–2219. d GLOBOCAN 2008 [web site]. Lyon, France, International Agency for Research on Cancer, World Health Organization, 2008. Available at: http:// globocan.iarc.fr/ (accessed on 07 June 2013). e Mohd Hanafiah K, Groeger J, Flaxman AD, Wiersma ST. Global epidemiology of hepatitis C virus infection: New estimates of age-specific antibody to HCV seroprevalence. Hepatology, 2013, 57:1333–1342.

1

International human development indicators. Population, total both sexes (thousands). New York, United Nations Development Programme, 2011. Available at: http://hdrstats.undp.org/en/indicators/306.html (accessed29 October 2012] 2 The World Bank. Country and lending groups [web site]. Available at: http://data. worldbank.org/about/country-classifications/country-and-lending-groups (accessed on 14 May 2013). 3 Country cooperation strategy at a glance: Pacific Island Countries. Geneva, World Health Organization, 2011. Available at: http://www.who.int/countryfocus/ cooperation_strategy/ccsbrief_pci_en.pdf (accessed on 14 May 2013). 4 Blakely T et al. Health status and epidemiological capacity and prospects: WHO Western Pacific Region. International Journal of Epidemiology, 2011, 40(4):1109–1121.

5

World health statistics 2012. Geneva, WHO, 2012. Available at: http://www.who. int/entity/healthinfo/EN_WHS2012_Full.pdf (accessed on 14 May 2013). 6 Causes of death 2008 summary tables. Geneva, Health Statistics and Informatics Department, World Health Organization, May 2011. Available at: http://www. who.int/entity/gho/mortality_burden_disease/global_burden_disease_ DTH6_2008.xls (accessed on 14 May 2013). 7 Global status report on noncommunicable diseases 2010. Geneva, WHO, 2011. Available at: http://whqlibdoc.who.int/publications/2011/9789240686458_eng. pdf (accessed on 14 May 2013).

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National coordination Ten responding Member States (66.7%) reported the existence of a written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis (Figure 1). One of the ten Member States with a strategy or plan (Mongolia) reported that it focuses exclusively on viral hepatitis, and five (Brunei Darussalam, Cambodia, Lao People’s Democratic Republic, Malaysia and Tonga) reported that it addresses other diseases as well. Two countries (China and Kiribati) reported that the strategy or plan addresses only hepatitis B, and two (Australia and Japan) reported that it addresses hepatitis B and hepatitis C. Figure 1. Responses to the question, “Is there a written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis?”

asked to indicate the number of staff members in the unit or department. Responses (N=5) ranged from 0.1 (New Zealand) to 80 (Cambodia) (median, 7). Member States were asked to report the number of people working full-time on hepatitis-related activities in all government agencies or bodies. Among the six Member States that provided data for this question, the number ranged from 0 to 84 (median, 0.5), with Mongolia reporting the largest number. Thirteen responding Member States (86.7%) reported that they have a viral hepatitis prevention and control programme that includes activities targeting specific populations. The populations most commonly targeted are health-care workers, including health-care waste handlers (69.2% of responding Member States within this subset) and people who inject drugs (46.2% of responding Member States within this subset). Groups identified less frequently included indigenous populations, lowincome populations, prisoners, migrants, people living with HIV, those who are uninsured and those who are homeless.

Awareness-raising and partnerships Six responding Member States (40.0%) reported that they had held events for World Hepatitis Day 2012 (28 July). Since January 2011, nine responding Member States (60.0%) had funded some type of viral hepatitis public awareness campaign other than World Hepatitis Day (Table 1). Eight responding Member States (53.3%) reported that they collaborated with civil society groups within their countries to develop and implement the governmental viral hepatitis prevention and control programme. For example, China reported collaborating with the Wu Jieping Medical Foundation and Chinese Foundation for Hepatitis Prevention and Control, while Malaysia reported collaborating with the Malaysian Liver Foundation. (Further examples can be found in the summaries of country findings later in this chapter.)

Evidence-based policy and data for action Yes No No response No data

Twelve responding Member States (80.0%) reported that they have routine surveillance for viral hepatitis; details appear in Table 2. Twelve responding Member States (80.0%) indicated that their countries have standard case definitions for hepatitis infection and 12 (80.0%) indicated that their countries have a central registry for the reporting of deaths, including hepatitis deaths. Seven Member States reported on the proportion of hepatitis cases and deaths registered as “undifferentiated” or “unclassified” hepatitis. The reported proportions ranged from 0% to 30.0% (median, 1.0%). Additional survey findings about surveillance are presented in Table 3. Member States were asked how often hepatitis disease reports are published. Of the responding Member States, 33.3% reported that they publish hepatitis disease reports annually; 13.3%, monthly; and 13.3%, weekly. No hepatitis disease report is published by 33.3% of responding Member States.

The ten Member States that reported the existence of a strategy or plan were asked about its specific components. All ten reported the inclusion of components for raising awareness, vaccination and general prevention. Nine reported the inclusion of a component for prevention of transmission in health-care settings, eight reported the inclusion of a component for surveillance and seven reported the inclusion of a component for treatment and care. Five reported the inclusion of components for coinfection with HIV and the prevention of transmission via injecting drug use. Five responding Member States (33.3%) reported that they have a governmental unit or department responsible solely for viral hepatitis-related activities. Member States that did so were

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Table 1. Topics of public awareness campaigns on viral hepatitis held in Member States since January 2011 (N=9)

Table 3. Data registration and surveillance (N=15) No Yes (%) No (%) Do not know response (%) (%) Liver cancer cases are registered nationally 73.3 26.7 93.3 100 20.0 66.7 0 0 6.7 6.7 6.7 0 0 0 0 0

Lao People’s Democratic Republic

Brunei Darussalam

New Zealand

Mongolia

Australia

Malaysia

Tonga X X X X X X X 0 8.3 8.3 8.3

Japan

China

Cases with HIV/hepatitis coinfection are registered nationally Hepatitis outbreaks are reported If YES – Hepatitis outbreaks are further investigated (N=115)

General information about hepatitis and its transmission Vaccination for hepatitis A and hepatitis B Importance of knowing one’s hepatitis B and hepatitis C status Safe water and good sanitation Safer sex practices Harm reduction for people who inject drugs Safe workplace practices Other a a

X

X X

X X

X

X X

X X

X

Five responding Member States (33.3%, Australia, Cambodia, China, Japan, Lao People’s Democratic Republic) reported the existence of a national public health research agenda for viral hepatitis. Six responding Member States (40.0%) reported that viral hepatitis serosurveys are conducted regularly. Among this subset of responding Member States, two (Australia and Lao People’s Democratic Republic) indicated that serosurveys take place every five years. Two Member States in the same subset (Lao People’s Democratic Republic and Singapore) reported that the most recent viral hepatitis serosurvey was carried out in 2012.

X X X X X X

X X

Prevention of transmission Five responding Member States (33.3%) reported that they have a national policy on hepatitis A vaccination. Nine responding Member States (60.0%) reported that they have established the goal of eliminating or reducing hepatitis B (Figure 2). Member States with this goal were asked to specify the timeframe in which they seek to eliminate or reduce hepatitis B. Of the six Member States that answered this question, three (Brunei Darussalam, China and Mongolia) said 2012 and three (Cambodia, Lao People’s Democratic Republic and Papua New Guinea) said 2017. Member States were asked to report, for a given recent year, the percentage of newborn infants who had received the first dose of hepatitis B vaccine within 24 hours of birth. Among the 13 Member States that provided this information, responses ranged from 0% to 98.0% (median, 55.0%). Member States were also asked to report, for a given recent year, the percentage of one-year-olds (ages 12–23 months) who had received three doses of hepatitis B vaccine. Among the 15 Member States that provided this information, responses ranged from 0% to 98.8% (median, 93.0%). Fifteen responding Member States (100%) reported the existence of a national policy that specifically targets motherto-child transmission of hepatitis B; details are presented in Table 4. One third of Member States with such a policy (33.3%) indicated that one component of the policy calls for screening of all pregnant women for hepatitis B. 169

Details can be found in the summaries of country findings later in this chapter.

Table 2. Types of surveillance in Member States that reported the existence of routine surveillance for viral hepatitis (N=12) No Yes (%) No (%) Do not know response (%) (%) There is a national surveillance system for acute hepatitis infection for the following forms of hepatitis: hepatitis A hepatitis B hepatitis C hepatitis D hepatitis E There is a national surveillance system for chronic hepatitis infection for the following forms of hepatitis: hepatitis B hepatitis C hepatitis D 58.3 41.7 25.0 33.2 50.0 58.3 0 0 0 75.0 91.7 75.0 25.0 50.0 8.3 8.3 16.7 41.7 25.0 0 0 0 0 0 16.7

33.3 25.0

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Figure 2. Responses to the question, “Has your government

established the goal of eliminating hepatitis B?” (N=15) Do not know 6.7%

Table 4. Activities called for in national policy targeting mother-to-child transmission of hepatitis B (N=15) All infants receive the first dose of hepatitis B vaccine within 24 hours of birth X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 5 6 5 8 15 X X All pregnant women found to have hepatitis B are counselled Health-care providers follow up with all pregnant women found to have hepatitis B during pregnancy for the purpose of encouraging them to give birth at health-care facilities X Upon delivery, all infants born to women with hepatitis B receive hepatitis B immunoglobulin X X X X

No (33.3%) Yes a (60.0%) Australia Brunei Darussalam Cambodia a

One Member State that answered ”yes” to this question (Australia) added a comment indicating that the goal relates to reducing rather than eliminating hepatitis B.

China Japan Kiribati Lao People’s Democratic Republic Malaysia Mongolia New Zealand Papua New Guinea Singapore Solomon Islands Tonga Viet Nam TOTAL

Fourteen responding Member States (91.3%) reported the existence of a specific national strategy and/or policy/guidelines for preventing hepatitis B and hepatitis C infection in healthcare settings. Eleven responding Member States (73.3%) reported that healthcare workers are vaccinated against hepatitis B prior to starting work that might put them at risk of exposure to blood. Twelve responding Member States (80.0%) reported the existence of a national policy on injection safety in healthcare settings. These Member States were asked which types of syringes the policy recommends for therapeutic injections. Single-use syringes are recommended in 100% of policies, and auto-disable syringes in 16.7% (Figure 3). Twelve responding Member States (80.0%) reported that singleuse or auto-disable syringes, needles and cannulas are always available in all health-care facilities. Member States were asked for official estimates of the number and percentage of unnecessary injections administered annually in health-care settings (e.g. injections that are given when an equivalent oral medication is available). Twelve Member States reported that the figures are not known and one (Tonga) reported that no unnecessary injection is administered annually in health-care settings. Cambodia reported that 50.0% of the total injections that are administered annually in healthcare settings are unnecessary and Mongolia reported that 68.0% are unnecessary. Additional findings relating to the prevention of hepatitis transmission are presented in Table 5.

Screening, care and treatment Member States were asked how health professionals in their countries obtain the skills and competencies required to effectively care for people with viral hepatitis. Responding Member States most frequently indicated that these are obtained in schools for health professionals (pre-service education, 80.0%). Additionally, on-the-job training was identified in 66.7% of responses, and postgraduate training in 53.3%. Nine responding Member States (60.0%) reported the existence of national clinical guidelines for the management of viral hepatitis (Figure 4). Two of these nine Member States indicated that the guidelines include recommendations for cases with HIV coinfection. Five of 11 responding Member States (45.5%) indicated that there are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral hepatitis.

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Figure 3. Proportion of responding Member States with

national policies on injection safety in health-care settings which recommend single-use syringes and auto-disable syringes for therapeutic injections (N=12) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Single-use syringesa a

Figure 4. Responses to the question, “Are there national clinical guidelines for the management of viral hepatitis?” (N=15)

No (40.0%) Yes (60.0%)

Auto-disable syringesa

Respondents could select both “single-use syringes” and “auto-disable syringes”.

Ten responding Member States (66.7%) indicated that they have a national policy relating to screening and referral to care for hepatitis B. Five (33.3%) reported having such a policy for hepatitis C. Regarding hepatitis B testing, 13 responding Member States (86.7%) indicated that people register by name for testing. Twelve members of that subset (92.3%) indicated that the names are kept confidential. Seven responding Member States (46.7%) reported that the hepatitis B test is free of charge for all individuals. Among the eight other Member States, three (37.5%) reported that the hepatitis B test is free of charge for members of specific groups. Groups identified included blood donors and health-care workers. Seven responding Member States (46.7%) reported that the hepatitis B test is compulsory for members of specific groups. Groups identified included blood donors, health-care workers, pregnant women and imprisoned people who inject drugs. Regarding hepatitis C testing, 10 responding Member States (66.7%) indicated that people register by name for testing. All members of that subset (100%) indicated that the names are kept confidential. Four responding Member States (26.7%) reported that the hepatitis C test is free of charge for all individuals. Among the eight other Member States that answered the question, three (37.5%) reported that the hepatitis C test is free of charge for members of specific groups. Groups identified included blood donors and health-care workers. Seven responding Member States (46.7%) reported that the hepatitis C test is compulsory for members of specific groups. Groups identified included blood donors, pregnant women and imprisoned people who inject drugs. Eight responding Member States (53.3%) reported that publicly funded treatment is available for hepatitis B and seven (46.7%) that publicly funded treatment is available for hepatitis C. One responding Member State reported the amount spent on publicly funded treatment for hepatitis B and hepatitis C. Details can be found in the summaries of country findings later in this chapter (see New Zealand). 171

Table 5. Hepatitis prevention: policies, practices and

guidelines (N=15) Yes (%) There is a national infection control policy for blood banks All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B All donated blood units (including family donations) and blood products nationwide are screened for hepatitis C There is a national policy relating to the prevention of viral hepatitis among people who inject drugs The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety 86.7 No (%) 6.7 Do not know (%) 6.7

100

0

0

80.0

13.3

6.7

33.3

53.3

13.3

46.7

40.0

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Table 6. Proportion of Member States reporting drugs for

treating hepatitis B and C on national essential medicines lists or subsidized by governments Drugs for treating hepatitis B % of Member States reporting its inclusion (N=12) 60.0 53.3 40.0 40.0 40.0 33.3 20.0 % of Member States reporting its inclusion (N=12) 46.7 40.0 40.0 6.7 0.0

Eleven responding Member States (73.3%) reported that at least one available drug for treating hepatitis B is on the national essential medicines list or subsidized by the government (Table 6). The drugs most commonly reported were lamivudine and interferon alpha. Eight responding governments (53.3%) reported that at least one available drug for treating hepatitis C is on the national essential medicines list or subsidized by the government. The drugs most commonly reported were ribavirin, interferon alpha and pegylated interferon.

Lamivudine Interferon alpha Tenofovir Pegylated interferon Entecavir Adefovir dipivoxil Telbivudine Drugs for treating hepatitis C

World Health Organization assistance 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: increasing access to treatment (46.7%), increasing access to diagnostics (46.7%), improving laboratory capacity (46.7%) and developing education/training programmes for health professionals (46.7%) (Table 7). Responses from individual Member States appear in Annex C.

Ribavirin Pegylated interferon Interferon alpha Telaprevir Boceprevir

Table 7. Viral hepatitis control and prevention: areas in which Member States indicated interest in receiving WHO assistance

(N=15) Awareness-raising, partnerships and resource mobilization (first WHO strategic axis) Developing the national plan for viral hepatitis prevention and control Integrating viral hepatitis programmes into other health services Awareness-raising Evidence-based policy and data for action (second WHO strategic axis) Viral hepatitis surveillance Estimating the national burden of viral hepatitis Developing tools to assess the effectiveness of interventions Assessing the economic impact of viral hepatitis Prevention of transmission (third WHO strategic axis) Increasing coverage of the birth dose of the hepatitis B vaccine Screening, care and treatment (fourth WHO strategic axis) Increasing access to treatment Increasing access to diagnostics Improving laboratory quality Developing education/training programmes for health professionals 40.0% 40.0% 33.3% 33.3% 26.7% 13.3% 20.0% 40.0% 46.7% 46.7% 46.7% 46.7%

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Australia Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Australia reports as follows.

There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and Evidence-based policy and data for hepatitis C.

22.6 High-income $38 110 8.73% $3441.04 $2339.68 82 0.929 37 1.9

There is no national policy on injection safety in health-care settings. Single-use or autodisable syringes, needles and cannulas are always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known.

action

National coordination There is a written national strategy or plan that focuses exclusively on the prevention and control of hepatitis B and hepatitis C. It includes components for raising awareness, surveillance, vaccination, prevention in general, prevention of transmission via injecting drug use, prevention of transmission in health-care settings, treatment and care, and coinfection with HIV. There is no designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitis-related activities in all government agencies/bodies.

There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C, D and E, and for the following types of chronic hepatitis: B, C and D.

There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

The government has guidelines that address how hepatitis A and hepatitis E can be preThere are standard case definitions for hepa- vented through food and water safety. titis. Deaths, including from hepatitis, are reported to a central registry. No hepatitis case Screening, care and treatment is reported as “undifferentiated” or “unclassi- Health professionals obtain the skills and competencies required to effectively care for fied” hepatitis. people with viral hepatitis through schools Liver cancer cases are registered nationally, for health professionals (pre-service educabut cases with HIV/hepatitis coinfection are tion), on-the-job training and postgraduate not. training.

The government publishes hepatitis disease There are no national clinical guidelines for reports annually. the management of viral hepatitis or for the management of HIV, which include recHepatitis outbreaks are required to be reThe government has a viral hepatitis prevenommendations for coinfection with viral tion and control programme that includes ported to the government and are further hepatitis. activities targeting the following specific investigated. It is not known whether there populations: health-care workers (including is adequate laboratory capacity nationally to The government has national policies relathealth-care waste handlers), people who in- support investigation of viral hepatitis out- ing to screening and referral to care for hepatitis B and hepatitis C. ject drugs, migrants, prisoners, the homeless, breaks and other surveillance activities. people living with HIV, indigenous people, pregnant women, men who have sex with There is a national public health research People testing for both hepatitis B and hepamen, sex workers, partners and other house- agenda for viral hepatitis. Viral hepatitis se- titis C register by name; the names are kept hold and intimate contacts of people who rosurveys are conducted regularly; the target confidential within the system. Hepatitis B have chronic hepatitis B infection, people population is the general population. The last tests are not free of charge for all individuals, but they are free for high-risk groups. Hepatravelling to and from high-prevalence coun- serosurvey was carried out in 2007–2008. titis C tests are not free of charge. Hepatitis B tries, people with mental health issues, and Prevention of transmission children born to mothers who have tested There is a national policy on hepatitis A vac- and hepatitis C tests are not compulsory for members of any specific group. positive for hepatitis B infection. cination. Awareness-raising and partnerships The government has established the goal of Publicly funded treatment is available for The government held events for World Hepa- eliminating hepatitis B but the timeframe is hepatitis B and hepatitis C. The following people are eligible: medicare holders. Infortitis Day 2012 and has funded other viral not specified. mation was not provided on the amount hepatitis public awareness campaigns since January 2011 (Annex A). It is not known what percentage of newborn spent by the government on such treatment infants nationally in a given recent year re- for hepatitis B and hepatitis C. The government collaborates with the fol- ceived the first dose of hepatitis B vaccine lowing in-country civil society groups to de- within 24 hours of birth. In a given recent year, The following drugs for treating hepatitis B velop and implement its viral hepatitis pre- 92% of one-year-olds (ages 12–23 months) are on the national essential medicines list or subsidized by the government: interferon vention and control programme: Ministerial received three doses of hepatitis B vaccine. alpha, pegylated interferon, lamivudine, Advisory Committee on Blood Borne Viruses and Sexually Transmissible Infections, Blood There is a national policy that specifically tar- adefovir dipivoxil, entecavir, telbivudine and Borne Viruses and Sexually Transmissible In- gets mother-to-child transmission of hepati- tenofovir. The following drugs for treating hepatitis C are on the national essential medifections Standing Committee, Australian Na- tis B (Annex B). cines list or subsidized by the government: tional Council on Drugs, Hepatitis Australia, Australian Society for HIV Medicine, and Aus- There is a specific national strategy and/or interferon alpha, pegylated interferon and tralian Injecting and Illicit Drug Users League policy/guidelines for preventing hepatitis B ribavirin. and hepatitis C infection in health-care setIncorporated. tings. Health-care workers are vaccinated The Government of Australia did not indicate against hepatitis B prior to starting work that a need for assistance from WHO in relation to might put them at risk of exposure to blood. viral hepatitis prevention and control.

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Brunei Darussalam The Government of Brunei Darussalam Population (in millions) (2011) 0.4 reports as follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination -There is a written national strategy or plan Total health expenditure as % of GDP (2010) 2.84% that focuses primarily on the prevention Per capita total health expenditure (PPP int $) (2010) $1448.74 and control of viral hepatitis, and also in- Per capita government health expenditure (PPP int $) (2010) $1229.77 tegrates other diseases. It includes com- Life expectancy at birth (in years) (2009) 77 ponents for raising awareness, surveil- Human Development Index (2011) 0.838 lance, vaccination, prevention in general, Median age (in years) (2010) 29 prevention of transmission via injecting Total fertility rate per woman (2010) 2.0 drug use, prevention of transmission in health-care settings, treatment and care, vestigations and other surveillance activi- The government has guidelines that adand coinfection with HIV. ties for hepatitis A, hepatitis B and hepati- dress how hepatitis A and hepatitis E can There is no designated governmental tis C, but it is not known if this is the case be prevented through food and water safety. unit/department responsible solely for co- for hepatitis E. ordinating and/or carrying out viral hepatitis-related activities. It is not known how There is no national public health research Screening, care and treatment many people work full-time on hepatitis- agenda for viral hepatitis. Viral hepatitis se- Health professionals obtain the skills and competencies required to effectively care related activities in all government agen- rosurveys are not conducted regularly. for people with viral hepatitis through cies/bodies. Prevention of transmission schools for health professionals (pre-servThe government has a viral hepatitis pre- There is a national policy on hepatitis A ice education), on-the-job training and postgraduate training. vention and control programme that in- vaccination. cludes activities targeting the following The government has established the goal There are national clinical guidelines for specific populations: health-care workers of eliminating hepatitis B by 2012. the management of viral hepatitis, but not (including health-care waste handlers), people who inject drugs, migrants, prison- Nationally, 95% of newborn infants in a for the management of HIV, which include ers, people living with HIV, pregnant wom- given recent year received the first dose of recommendations for coinfection with viral hepatitis. en, blood donors and blood recipients. hepatitis B vaccine within 24 hours of birth and 93% of one-year-olds (ages 12–23 The government has national policies reAwareness-raising and partnerships months) in a given recent year received lating to screening and referral to care for The government did not hold events for three doses of hepatitis B vaccine. hepatitis B and hepatitis C. World Hepatitis Day 2012, but has funded other viral hepatitis public awareness There is a national policy that specifically People testing for both hepatitis B and campaigns since January 2011 (Annex A). targets mother-to-child transmission of hepatitis C register by name; the names hepatitis B (Annex B). are kept confidential within the system. The government does not collaborate with in-country civil society groups to There is a specific national strategy and/or Hepatitis B and hepatitis C tests are not develop and implement its viral hepatitis policy/guidelines for preventing hepatitis free of charge for all individuals, but they are free for citizens, permanent residents prevention and control programme. B and hepatitis C infection in health-care and all children under the age of 12 years. settings. Health-care workers are vacciEvidence-based policy and data for nated against hepatitis B prior to starting Hepatitis B and hepatitis C tests are not compulsory for members of any specific action work that might put them at risk of expogroup. There is routine surveillance for viral hepa- sure to blood. titis. There is a national surveillance system for the following types of acute hepatitis: There is a national policy on injection safe- Publicly funded treatment is available for A, B and C, and for the following types of ty in health-care settings, which recom- hepatitis B and hepatitis C. The following groups are eligible: citizens, permanent chronic hepatitis: B and C. mends single-use syringes for therapeutic residents and all children under the age injections. Single-use or auto-disable syThere are standard case definitions for ringes, needles and cannulas are always of 12 years. The amount spent by the government on publicly funded treatment for hepatitis. Deaths, including from hepatitis, available in all health-care facilities. hepatitis B and hepatitis C is not known. are reported to a central registry. Information was not provided on the percentage Official government estimates of the of hepatitis cases reported as “undifferen- number and percentage of unneces- The following drugs for treating hepatitis B are on the national essential medicines tiated” or “unknown” hepatitis. sary injections administered annually in list or subsidized by the government: inhealth-care settings are not known. terferon alpha, pegylated interferon and Liver cancer cases are registered nationally, but cases with HIV/hepatitis coinfec- There is a national infection control policy lamivudine. The following drugs for treattion are not. for blood banks. All donated blood units ing hepatitis C are on the national essen(including family donations) and blood tial medicines list or subsidized by the The government does not publish hepati- products nationwide are screened for government: interferon alpha, pegylated tis disease reports. interferon and ribavirin. hepatitis B and hepatitis C. Hepatitis outbreaks are required to be re- There is a national policy relating to the ported to the government and are further prevention of viral hepatitis among peoinvestigated. There is adequate laboratory ple who inject drugs. capacity nationally to support outbreak inThe Government of Brunei Darussalam did not indicate a need for assistance from WHO in relation to viral hepatitis prevention and control.

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Cambodia Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 14.3 Low-income $2230 5.61% $121.08 $45.08 61 0.523 23 2.6 syringes for therapeutic injections. Singleuse or auto-disable syringes, needles and cannulas are always available in all healthcare facilities. Fifty percent of injections administered annually in health-care settings are unnecessary, according to official government estimates.

There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood The Government of Cambodia reports as ferentiated” or “unclassified” hepatitis is products nationwide are screened for follows. not known. hepatitis B and hepatitis C.

National coordination There is a written national strategy or plan that focuses primarily on the prevention and control of viral hepatitis, and also integrates other diseases. It includes components for raising awareness, surveillance, vaccination, prevention in general, prevention of transmission via injecting drug use, prevention of transmission in health-care settings, treatment and care, and coinfection with HIV. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities: the National Immunization Programme. It has 80 staff members. There is one full-time equivalent staff member who works on hepatitis-related activities in all government agencies/ bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific population: newborn children.

Liver cancer cases are registered nation- There is no national policy relating to the ally, but cases with HIV/hepatitis coinfec- prevention of viral hepatitis among peotion are not. ple who inject drugs. The government published hepatitis dis- The government does not have guideease reports in 2006 and 2011. lines that address how hepatitis A and hepatitis E can be prevented through Hepatitis outbreaks are required to be re- food and water safety. ported to the government and are further investigated. There is adequate laboratory Screening, care and treatment capacity nationally to support investiga- Health professionals obtain the skills and tion of viral hepatitis outbreaks and other competencies required to effectively care surveillance activities. for people with viral hepatitis through schools for health professionals (pre-servThere is a national public health research ice education) and on-the-job training. agenda for viral hepatitis. Viral hepatitis serosurveys are conducted regularly; the There are national clinical guidelines for target population is children under the the management of viral hepatitis, but age of 5 years. Information was not pro- they do not include recommendations for vided on when the last serosurvey was cases with HIV coinfection. There are nacarried out. tional clinical guidelines for the management of HIV, which include recommendaPrevention of transmission tions for coinfection with viral hepatitis. There is no national policy on hepatitis A vaccination. The government has national policies relating to screening and referral to care for The government has established the goal hepatitis B and hepatitis C. of eliminating hepatitis B by 2017. People testing for both hepatitis B and Nationally, 68% of newborn infants in a hepatitis C register by name; the names given recent year received the first dose are kept confidential within the system. of hepatitis B vaccine within 24 hours of Hepatitis B and hepatitis C tests are free of birth and 94% of one-year-olds (ages 12– charge for all individuals, and are compul23 months) in a given recent year received sory for blood donors. three doses of hepatitis B vaccine. Publicly funded treatment is available for There is a national policy that specifically hepatitis B and hepatitis C. Low-income targets mother-to-child transmission of people are eligible. The amount spent by hepatitis B (Annex B). the government on such treatment is not There is a specific national strategy and/or known. policy/guidelines for preventing hepatitis No drug for treating hepatitis B or hepatiB and hepatitis C infection in health-care tis C is on the national essential medicines settings. Health-care workers are not vac- list or subsidized by the government. cinated against hepatitis B prior to starting work that might put them at risk of The Government of Cambodia welcomes exposure to blood. assistance from WHO in one or more areas of viral hepatitis prevention and control There is a national policy on injection (Annex C). safety in health-care settings, which recommends single-use and auto-disable

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. The government collaborates with the following in-country civil society groups to develop and implement its viral hepatitis prevention and control programme: PATH and the Reproductive and Child Health Alliance.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis; it is based on syndromic reporting for jaundice. There are no standard case definitions for hepatitis. Hepatitis deaths are not reported to a central registry. The percentage of hepatitis cases reported as “undif-

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China The Government of China reports as Population (in millions) (2011) 1347.6 follows. Country classification (2012) Upper–middle-income Gross national income per capita (PPP int $) (2011) National coordination $16 330 There is a written national strategy or plan Total health expenditure as % of GDP (2010) 5.07% that focuses exclusively on the preven- Per capita total health expenditure (PPP int $) (2010) $378.91 tion and control of hepatitis B. It includes Per capita government health expenditure (PPP int $) (2010) $203.09 components for raising awareness, surveil- Life expectancy at birth (in years) (2009) 74 lance, vaccination, prevention in general, Human Development Index (2011) 0.687 prevention of transmission via injecting Median age (in years) (2010) 35 drug use, prevention of transmission in Total fertility rate per woman (2010) 1.6 health-care settings, and treatment and care. capacity nationally to support outbreak in- There is a national policy relating to the There is a designated governmental unit/ vestigations and other surveillance activi- prevention of viral hepatitis among peodepartment responsible solely for coordi- ties for hepatitis A, hepatitis B and hepati- ple who inject drugs. nating and/or carrying out viral hepatitis- tis C, but not for hepatitis E. The government does not have guidelines related activities. The name of this office was not provided. It has seven staff mem- There is a national public health research that address how hepatitis A and hepatibers. There are seven full-time equivalent agenda for viral hepatitis. Viral hepatitis tis E can be prevented through food and staff members who work on hepatitis- serosurveys are conducted regularly; the water safety. related activities in all government agen- target populations are children and the Screening, care and treatment general population. The last serosurvey cies/bodies. Health professionals obtain the skills and was carried out in 2006. competencies required to effectively care The government has a viral hepatitis prefor people with viral hepatitis through vention and control programme that in- Prevention of transmission cludes activities targeting the following There is a national policy on hepatitis A schools for health professionals (pre-service education), on-the-job training and specific populations: health-care workers vaccination. (including health-care waste handlers) The government has established the goal postgraduate training. and people who inject drugs. of eliminating hepatitis B by 2012. There are national clinical guidelines for Awareness-raising and partnerships Nationally, 91% of newborn infants in a the management of viral hepatitis, which The government held events for World given recent year received the first dose of include recommendations for cases with Hepatitis Day 2012 and has funded other hepatitis B vaccine within 24 hours of birth HIV coinfection. viral hepatitis public awareness cam- and 94% of one-year-olds (ages 12–23 The government has national policies repaigns since January 2011 (Annex A). months) in a given recent year received lating to screening and referral to care for hepatitis B, but not for hepatitis C. The government collaborates with the fol- three doses of hepatitis B vaccine. lowing in-country civil society groups to There is a national policy that specifically People testing for both hepatitis B and develop and implement its viral hepatitis targets mother-to-child transmission of hepatitis C register by name; the names prevention and control programme: the hepatitis B (Annex B). are kept confidential within the system. Wu Jieping Medical Foundation and the Hepatitis B and hepatitis C tests are not Chinese Foundation for Hepatitis Preven- There is a specific national strategy and/or free of charge for all individuals. They are tion and Control. policy/guidelines for preventing hepatitis free for certain groups, but information B and hepatitis C infection in health-care Evidence-based policy and data for settings. Health-care workers are vacci- was not provided on which groups. Hepatitis B and hepatitis C tests are not compulaction nated against hepatitis B prior to starting There is routine surveillance for viral hepa- work that might put them at risk of expo- sory for members of any specific group. titis. There is a national surveillance system sure to blood. Publicly funded treatment is available for for the following types of acute hepatitis: hepatitis B, but not for hepatitis C. InformaA, B, C and E, and for the following types of There is a national policy on injection safe- tion was not provided on who is eligible or chronic hepatitis: B and C. ty in health-care settings, which recom- the amount spent by the government on mends single-use syringes for therapeutic There are standard case definitions for injections. Single-use or auto-disable sy- such treatment. hepatitis. Deaths, including from hepatitis, ringes, needles and cannulas are always The following drugs for treating hepatitis are reported to a central registry. Informa- available in all health-care facilities. B are on the national essential medicines tion was not provided on the percentage list or subsidized by the government: inof hepatitis cases reported as “undifferen- Official government estimates of the terferon alpha, pegylated interferon, lamitiated” or “unknown” hepatitis. number and percentage of unneces- vudine, adefovir dipivoxil, entecavir, telbisary injections administered annually in vudine and tenofovir. The following drug Liver cancer cases and cases with HIV/hep- health-care settings are not known. for treating hepatitis C is on the national atitis coinfection are registered nationally. essential medicines list or subsidized by There is a national infection control policy The government publishes hepatitis dis- for blood banks. All donated blood units the government: ribavirin. ease reports monthly. (including family donations) and blood The Government of China welcomes asHepatitis outbreaks are required to be re- products nationwide are screened for sistance from WHO in one or more areas of viral hepatitis prevention and control ported to the government and are further hepatitis B and hepatitis C. (Annex C). investigated. There is adequate laboratory

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Japan Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Japan reports as follows. 126.5 High-income $35 330 9.49% $3203.74 $2643.96 83 0.901 45 1.4 There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

National coordination There is a written national strategy or plan that focuses exclusively on the prevention and control of hepatitis B and hepatitis C. It includes components for raising awareness, vaccination, prevention in general, prevention of transmission in health-care settings, and treatment and care. There is a designated governmental unit/ department responsible solely for coordinating and/or carrying out viral hepatitisrelated activities: the Office for Promotion of Hepatitis Measures within the Health Service Bureau of the Ministry of Health, Labour and Welfare. It has 12 staff members. There are two full-time equivalent staff members who work on hepatitisrelated activities in all government agencies/bodies. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific population: health-care workers (including health-care waste handlers).

Prevention of transmission

The government does not have guidelines that address how hepatitis A and hepatitis E can be prevented through Liver cancer cases are registered nation- food and water safety. ally, but cases with HIV/hepatitis coinfecScreening, care and treatment tion are not. It is not known how health professionals The government publishes hepatitis dis- obtain the skills and competencies reease reports weekly. quired to effectively care for people with viral hepatitis. Hepatitis outbreaks are required to be reported to the government. There is ad- There are national clinical guidelines for equate laboratory capacity nationally to the management of viral hepatitis, but support investigation of viral hepatitis they do not include recommendations for outbreaks and other surveillance activi- cases with HIV coinfection. There are naties. tional clinical guidelines for the management of HIV, which include recommendaThere is a national public health research tions for coinfection with viral hepatitis. agenda for viral hepatitis. It is not known whether viral hepatitis serosurveys are The government has national policies reconducted regularly. lating to screening and referral to care for hepatitis B and hepatitis C.

Awareness-raising and partnerships The government held events for World Hepatitis Day 2012 and has funded other viral hepatitis public awareness campaigns since January 2011 (Annex A). The government collaborates with the following in-country civil society groups to develop and implement its viral hepatitis prevention and control programme: the Japan Hepatitis Council and the Viral Hepatitis Research Foundation of Japan.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C, D and E, but not for any type of chronic hepatitis. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Of hepatitis cases, 5.6% are reported as “undifferentiated” or “unclassified” hepatitis.

There is no national policy on hepatitis A People testing for hepatitis B and hepativaccination. tis C do not register by name. Hepatitis B and hepatitis C tests are free of charge for The government has not established the all individuals and are not compulsory for goal of eliminating hepatitis B. members of any specific group. Nationally, no newborn infant in a given Publicly funded treatment is available for recent year received the first dose of hep- hepatitis B and hepatitis C. The following atitis B vaccine within 24 hours of birth group is eligible for such treatment for and no one-year-old (age 12–23 months) hepatitis B: patients receiving interferon in a given recent year received three dos- therapy or nucleoside analogue therapy. es of hepatitis B vaccine. The following group is eligible for publicly There is a national policy that specifically funded treatment for hepatitis C: patients targets mother-to-child transmission of receiving interferon therapy. Information was not provided on the amount spent hepatitis B (Annex B). by the government on such treatment for There is a specific national strategy and/or hepatitis B and hepatitis C. policy/guidelines for preventing hepatitis B and hepatitis C infection in health-care The following drugs for treating hepatitis settings. Health-care workers are vacci- B are on the national essential medicines nated against hepatitis B prior to starting list or subsidized by the government: work that might put them at risk of expo- pegylated interferon, lamivudine, adefovir dipivoxil and entecavir. The following sure to blood. drugs for treating hepatitis C are on the It is not known whether there is a national national essential medicines list or subpolicy on injection safety in health-care sidized by the government: interferon settings, or whether single-use or auto- alpha, pegylated interferon, ribavirin and disable syringes, needles and cannulas telaprevir. are always available in all health-care faThe Government of Japan did not indicate cilities. a need for assistance from WHO in relation Official government estimates of the to viral hepatitis prevention and control. number and percentage of unnecessary injections administered annually in health-care settings are not known.

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Kiribati The Government of Kiribati reports as Population (in millions) (2011) follows. Country classification (2012) Gross national income per capita (PPP int $) (2011) National coordination There is a written national strategy or plan Total health expenditure as % of GDP (2010) that focuses exclusively on the prevention Per capita total health expenditure (PPP int $) (2010) and control of hepatitis B. It includes com- Per capita government health expenditure (PPP int $) (2010) ponents for raising awareness, vaccina- Life expectancy at birth (in years) (2009) tion, prevention in general, prevention of Human Development Index (2011) transmission in health-care settings, and Median age (in years) (2010) Total fertility rate per woman (2010) treatment and care. There is no designated governmental unit/department responsible solely for coordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitisrelated activities in all government agencies/bodies. The government does not have a viral hepatitis prevention and control programme that includes activities targeting specific populations. 0.1 Lower–middle-income $3300 11.25% $257.53 $212.03 68 0.624 -2.9

tigation of viral hepatitis outbreaks and products nationwide are screened for hepatitis B and hepatitis C. other surveillance activities. There is no national public health research It is not known whether there is a national agenda for viral hepatitis. Viral hepatitis se- policy relating to the prevention of viral hepatitis among people who inject drugs. rosurveys are not conducted regularly.

Prevention of transmission

Awareness-raising and partnerships It is not known whether the government held events for World Hepatitis Day 2012. It has not funded other viral hepatitis public awareness campaigns since January 2011. The government collaborates with the following in-country civil society group to develop and implement its viral hepatitis prevention and control programme: the Kiribati Family Health Association.

Evidence-based policy and data for action There is no specific national strategy and/ The government has national policies reThere is routine surveillance for viral hepaor policy/guidelines for preventing hepatitis. There is a national surveillance system titis B and hepatitis C infection in healthfor acute hepatitis B, but not for any type care settings. Health-care workers are not of chronic hepatitis. vaccinated against hepatitis B prior to There are standard case definitions for starting work that might put them at risk hepatitis. Deaths, including from hepatitis, of exposure to blood. are reported to a central registry. Informa- There is a national policy on injection safetion was not provided on the percentage ty in health-care settings, which recomof hepatitis cases reported as “undifferen- mends single-use syringes for therapeutic tiated” or “unknown” hepatitis. injections. Single-use or auto-disable sy-

The government has guidelines that adThere is no national policy on hepatitis A dress how hepatitis A and hepatitis E can vaccination. be prevented through food and water safety. It is not known whether the government has established the goal of eliminating Screening, care and treatment Health professionals obtain the skills and hepatitis B. competencies required to effectively care Information was not provided on the per- for people with viral hepatitis through centage of newborn infants nationally in schools for health professionals (pre-serva given recent year who received the first ice education) and postgraduate training. dose of hepatitis B vaccine within 24 hours of birth. In a given recent year, 77.9% of There are no national clinical guidelines one-year-olds (ages 12–23 months) re- for the management of viral hepatitis. Information was not provided on whether ceived three doses of hepatitis B vaccine. there are national clinical guidelines for There is a national policy that specifically the management of HIV, which include targets mother-to-child transmission of recommendations for coinfection with vihepatitis B (Annex B). ral hepatitis. lating to screening and referral to care for hepatitis B, but not for hepatitis C. People testing for both hepatitis B and hepatitis C register by name; the names are kept confidential within the system. Hepatitis B and hepatitis C tests are free of charge for all individuals, and are compulsory for blood donors, pregnant women, sailors and overseas workers. Publicly funded treatment is not available for hepatitis B or hepatitis C. No drug for treating hepatitis B or hepatitis C is on the national essential medicines list or subsidized by the government. The Government of Kiribati welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

Liver cancer cases are not registered na- ringes, needles and cannulas are always tionally, but cases with HIV/hepatitis coin- available in all health-care facilities. fection are. Official government estimates of the The government does not publish hepati- number and percentage of unnecessary injections administered annually in tis disease reports. health-care settings are not known. Hepatitis outbreaks are required to be reported to the government and are further There is a national infection control policy investigated. There is inadequate labora- for blood banks. All donated blood units tory capacity nationally to support inves- (including family donations) and blood

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Lao People’s Democratic Republic Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 6.3 Lower–middle-income $2580 44.47% $97.15 $32.34 63 0.524 21 2.7 cannulas are always available in all healthcare facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

The Government of Lao People’s Demo- Liver cancer cases and cases with HIV/ cratic Republic reports as follows. hepatitis coinfection are not registered It is not known whether there is a national policy relating to the prevention of viral nationally. National coordination hepatitis among people who inject drugs. There is a written national strategy or plan It is not known whether the government It is not known whether the government that focuses primarily on the prevention publishes hepatitis disease reports. has guidelines that address how hepaand control of viral hepatitis, and also integrates other diseases. It includes com- Hepatitis outbreaks are required to be titis A and hepatitis E can be prevented ponents for raising awareness, surveil- reported to the government and are fur- through food and water safety. lance, vaccination, prevention in general ther investigated. There is inadequate and prevention of transmission in health- laboratory capacity nationally to support Screening, care and treatment hepatitis B outbreak investigations and Health professionals obtain the skills and care settings. other surveillance activities. Information competencies required to effectively care There is no designated governmental was not provided on whether there is for people with viral hepatitis through unit/department responsible solely for adequate laboratory capacity nationally schools for health professionals (pre-servcoordinating and/or carrying out viral to support investigation of other types of ice education) and on-the-job training. hepatitis-related activities. Information viral hepatitis outbreaks and other surveilThere are national clinical guidelines for was not provided on how many people lance activities. the management of viral hepatitis, but it work full-time on hepatitis-related activiis not known whether they include recThere is a national public health research ties in all government agencies/bodies. agenda for viral hepatitis. Viral hepatitis ommendations for cases with HIV coinThe government has a viral hepatitis pre- serosurveys are conducted regularly; the fection. vention and control programme that in- target populations are children aged 5–9 cludes activities targeting the following years and women aged 15–45 years. The It is not known whether the government has national policies relating to screening specific populations: health-care workers last serosurvey was carried out in 2012. and referral to care for hepatitis B. Infor(including health-care waste handlers), mation was not provided on whether the Prevention of transmission newborns and children. There is no national policy on hepatitis A government has national policies relating to screening and referral to care for hepaAwareness-raising and partnerships vaccination. titis C. The government did not hold events for World Hepatitis Day 2012, but has funded The government has established the goal People testing for hepatitis B register by other viral hepatitis public awareness of eliminating hepatitis B by 2017. name. Information was not provided on campaigns since January 2011 (Annex A). Nationally, 20% of newborn infants in a whether their names are kept confidenThe government does not collaborate given recent year received the first dose tial within the system. Hepatitis B tests are with in-country civil society groups to of hepatitis B vaccine within 24 hours of not free of charge. Information was not develop and implement its viral hepatitis birth and 79% of one-year-olds (ages 12– provided on whether people testing for 23 months) in a given recent year received hepatitis C register by name, or whether prevention and control programme. three doses of hepatitis B vaccine. hepatitis C tests are free of charge for all Evidence-based policy and data for individuals. Information was not provided There is a national policy that specifi cally action on whether hepatitis B or hepatitis C tests There is routine surveillance for viral targets mother-to-child transmission of are compulsory for members of any spehepatitis. There is a national surveillance hepatitis B (Annex B). cific group. system for the following types of acute There is no specifi c national strategy hepatitis: B, C and E. Information was not Publicly funded treatment is not available provided on whether there is a national and/or policy/guidelines for preventing for hepatitis B or hepatitis C. surveillance system for any type of chron- hepatitis B and hepatitis C infection in health-care settings. Health-care workers The following drug for treating hepatitis B ic hepatitis. are vaccinated against hepatitis B prior to is on the national essential medicines list There are standard case definitions for starting work that might put them at risk or subsidized by the government: interhepatitis. Deaths, including from hepati- of exposure to blood. feron alpha. No drug for treating hepatitis tis, are reported to a central registry. The C is on the national essential medicines percentage of hepatitis cases reported as There is a national policy on injection list or subsidized by the government. “undifferentiated” or “unclassified” hepati- safety in health-care settings, which recommends single-use and auto-disable The Government of Lao People’s Demotis is not known. syringes for therapeutic injections. Single- cratic Republic welcomes assistance from use or auto-disable syringes, needles and WHO in one or more areas of viral hepatitis prevention and control (Annex C). 180

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GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Malaysia The Government of Malaysia reports as Population (in millions) (2011) 28.9 follows. Country classification (2012) Upper–middle-income Gross national income per capita (PPP int $) (2011) National coordination $15 650 There is a written national strategy or plan Total health expenditure as % of GDP (2010) 4.39% that focuses primarily on the prevention Per capita total health expenditure (PPP int $) (2010) $641.13 and control of viral hepatitis, and also in- Per capita government health expenditure (PPP int $) (2010) $355.92 tegrates other diseases. It includes com- Life expectancy at birth (in years) (2009) 73 ponents for raising awareness, surveil- Human Development Index (2011) 0.761 lance, vaccination, prevention in general, Median age (in years) (2010) 26 prevention of transmission via injecting Total fertility rate per woman (2010) 2.6 drug use, prevention of transmission in health-care settings, treatment and care, ties for hepatitis A, hepatitis B and hepati- The government has guidelines that adand coinfection with HIV. dress how hepatitis A and hepatitis E can be tis C, but not for hepatitis E. prevented through food and water safety. There is no designated governmental unit/department responsible solely for co- There is no national public health research ordinating and/or carrying out viral hepa- agenda for viral hepatitis. Viral hepatitis se- Screening, care and treatment Health professionals obtain the skills and titis-related activities. It is not known how rosurveys are not conducted regularly. competencies required to effectively care many people work full-time on hepatitis- Prevention of transmission related activities in all government agen- There is no national policy on hepatitis A for people with viral hepatitis through schools for health professionals (pre-servcies/bodies. vaccination. ice education), on-the-job training and The government has a viral hepatitis pre- The government has not established the postgraduate training. vention and control programme that in- goal of eliminating hepatitis B. There are no national clinical guidelines cludes activities targeting the following specific populations: health-care workers Nationally, 91.13% of newborn infants in a for the management of viral hepatitis, (including health-care waste handlers), given recent year received the first dose of but there are for the management of HIV, people who inject drugs and blood do- hepatitis B vaccine within 24 hours of birth which include recommendations for coinfection with viral hepatitis. nors. and 97.37% of one-year-olds (ages 12–23 months) in a given recent year received The government has national policies reAwareness-raising and partnerships three doses of hepatitis B vaccine. lating to screening and referral to care for The government held events for World Hepatitis Day 2012 and has funded other There is a national policy that specifically hepatitis B and hepatitis C. viral hepatitis public awareness cam- targets mother-to-child transmission of People testing for both hepatitis B and paigns since January 2011 (Annex A). hepatitis B (Annex B). hepatitis C register by name; the names The government collaborates with the fol- There is a specific national strategy and/or are kept confidential within the system. lowing in-country civil society group to policy/guidelines for preventing hepatitis Hepatitis B and hepatitis C tests are not develop and implement its viral hepatitis B and hepatitis C infection in health-care free of charge for all individuals, but they prevention and control programme: the settings. Health-care workers are vacci- are free for health-care workers following exposure. Hepatitis B tests are compulsory Malaysian Liver Foundation. nated against hepatitis B prior to starting for health-care workers and blood donors. work that might put them at risk of expoHepatitis C tests are compulsory for blood Evidence-based policy and data for sure to blood. donors. action There is routine surveillance for viral hepa- There is a national policy on injection safetitis. There is a national surveillance system ty in health-care settings, which recom- Publicly funded treatment for hepatitis B for the following types of acute hepatitis: mends single-use syringes for therapeutic and hepatitis C is available to Malaysian A, B and C, and for the following types of injections. Single-use or auto-disable sy- citizens who seek care at certain public hospitals. Information was not provided on the chronic hepatitis: B and C. ringes, needles and cannulas are always amount spent by the government on such available in all health-care facilities. treatment for hepatitis B and hepatitis C. There are standard case definitions for hepatitis. Deaths, including from hepatitis, Official government estimates of the are reported to a central registry. Of hepa- number and percentage of unneces- The following drugs for treating hepatitis B titis cases, 2% are reported as “undifferen- sary injections administered annually in are on the national essential medicines list or subsidized by the government: intertiated” or “unclassified” hepatitis. health-care settings are not known. feron alpha, pegylated interferon, lamivuLiver cancer cases and cases with HIV/hep- There is a national infection control policy dine, adefovir dipivoxil, entecavir, telbivuatitis coinfection are registered nationally. for blood banks. All donated blood units dine and tenofovir. The following drugs for (including family donations) and blood treating hepatitis C are on the national esThe government publishes hepatitis dis- products nationwide are screened for sential medicines list or subsidized by the ease reports annually. government: interferon alpha, pegylated hepatitis B and hepatitis C. interferon and ribavirin. Hepatitis outbreaks are required to be re- There is a national policy relating to the ported to the government and are further prevention of viral hepatitis among peo- The Government of Malaysia did not ininvestigated. There is adequate laboratory ple who inject drugs. dicate a need for assistance from WHO in capacity nationally to support outbreak inrelation to viral hepatitis prevention and vestigations and other surveillance activicontrol.

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Mongolia Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 2.8 Lower–middle-income $4290 5.44% $217.53 $119.84 69 0.653 25 2.5 According to official government estimates, 68% of injections administered annually in health-care settings are unnecessary. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

There is no national policy relating to the prevention of viral hepatitis among peoThe Government of Mongolia reports as Liver cancer cases are registered nation- ple who inject drugs. follows. ally, but cases with HIV/hepatitis coinfecThe government has guidelines that adtion are not. National coordination dress how hepatitis A and hepatitis E can There is a written national strategy or plan The government publishes hepatitis dis- be prevented through food and water that focuses exclusively on the prevention ease reports monthly. safety. and control of viral hepatitis. It includes components for raising awareness, sur- Hepatitis outbreaks are required to be re- Screening, care and treatment veillance, vaccination, prevention in gen- ported to the government and are further Health professionals obtain the skills and eral, prevention of transmission in health- investigated. There is adequate laboratory competencies required to effectively care capacity nationally to support outbreak for people with viral hepatitis through care settings and coinfection with HIV. investigations and other surveillance schools for health professionals (pre-servThere is a designated governmental unit/ activities for hepatitis A, hepatitis B and ice education). department responsible solely for coordi- hepatitis C, but not for hepatitis E. There are national clinical guidelines for nating and/or carrying out viral hepatitisrelated activities: Hepatitis Surveillance Information was not provided on whether the management of viral hepatitis, but Unit, National Center for Communicable there is a national public health research they do not include recommendations for Diseases. It has five staff members. There agenda for viral hepatitis. Viral hepatitis cases with HIV coinfection. are 84 full-time equivalent staff members serosurveys are not conducted regularly. The government does not have national who work on hepatitis-related activities in Prevention of transmission policies relating to screening and referral all government agencies/bodies. There is a national policy on hepatitis A to care for hepatitis B or hepatitis C. The government does not have a viral vaccination. People testing for hepatitis B and hepatihepatitis prevention and control proThe government has established the goal tis C do not register by name. Hepatitis B gramme that includes activities targeting of eliminating hepatitis B by 2012. and hepatitis C tests are not free of charge specific populations. and are not compulsory for members of Awareness-raising and partnerships Nationally, 96.2% of newborn infants in a any specific group. The government held events for World given recent year received the first dose Hepatitis Day 2012 and has funded other of hepatitis B vaccine within 24 hours of Publicly funded treatment is not available viral hepatitis public awareness cam- birth and 98.8% of one-year-olds (ages for hepatitis B or hepatitis C, but hospitali12–23 months) in a given recent year re- zation for acute hepatitis is free of charge. paigns since January 2011 (Annex A). ceived three doses of hepatitis B vaccine. The following drug for treating hepatitis The government does not collaborate with in-country civil society groups to There is a national policy that specifically B is on the national essential medicines develop and implement its viral hepatitis targets mother-to-child transmission of list or subsidized by the government: hepatitis B (Annex B). lamivudine. The following drug for treatprevention and control programme. ing hepatitis C is on the national essential Evidence-based policy and data for There is a specific national strategy and/or medicines list or subsidized by the govpolicy/guidelines for preventing hepatitis action ernment: ribavirin. There is routine surveillance for viral B and hepatitis C infection in health-care hepatitis. There is a national surveillance settings. However, health-care workers The Government of Mongolia welcomes system for the following types of acute are not vaccinated against hepatitis B pri- assistance from WHO in one or more areas hepatitis: A, B and C, and for the following or to starting work that might put them at of viral hepatitis prevention and control risk of exposure to blood. (Annex C). types of chronic hepatitis: B, C and D. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Of hepatitis cases, 1.1% is reported as “undifferentiated” or “unclassified” hepatitis. There is a national policy on injection safety in health-care settings, which recommends single-use syringes for therapeutic injections. Single-use or auto-disable syringes, needles and cannulas are always available in all health-care facilities.

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New Zealand The Government of New Zealand reports Population (in millions) (2011) 4.4 as follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination $28 930 There is no written national strategy or Total health expenditure as % of GDP (2010) 10.10% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $3020.05 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $2513.32 Life expectancy at birth (in years) (2009) hepatitis. 81 Human Development Index (2011) 0.908 There is a designated governmental unit/ Median age (in years) (2010) 37 department responsible solely for coordi- Total fertility rate per woman (2010) 2.2 nating and/or carrying out viral hepatitisrelated activities: the Public Health, Sector Capability and Implementation Business There is no national public health research The government has guidelines that adUnit of the Ministry of Health. It has one agenda for viral hepatitis. Viral hepatitis dress how hepatitis A and hepatitis E can tenth of one full-time staff member. It is serosurveys are conducted regularly; the be prevented through food and water not known how many people work full- target population is people who inject safety. time on hepatitis-related activities in all drugs. The last serosurvey was carried out Screening, care and treatment in 2009. government agencies/bodies. Health professionals obtain the skills and competencies required to effectively care The government has a viral hepatitis pre- Prevention of transmission vention and control programme that in- There is a national policy on hepatitis A for people with viral hepatitis through schools for health professionals (pre-servcludes activities targeting the following vaccination. ice education), on-the-job training and specific population: people who inject The government has not established the postgraduate training. drugs. goal of eliminating hepatitis B. There are no national clinical guidelines Awareness-raising and partnerships The government held events for World Nationally, no newborn infant in a given for the management of viral hepatitis, Hepatitis Day 2012 and has funded other recent year received the first dose of hepa- but there are for the management of HIV, viral hepatitis public awareness cam- titis B vaccine within 24 hours of birth. In which include recommendations for coina given recent year, 93% of one-year-olds fection with viral hepatitis. paigns since January 2011 (Annex A). (ages 12–23 months) received three doses The government does not have national The government collaborates with the of hepatitis B vaccine. policies relating to screening and referral following in-country civil society groups to develop and implement its viral hepa- There is a national policy that specifically to care for hepatitis B or hepatitis C. titis prevention and control programme: targets mother-to-child transmission of People testing for both hepatitis B and the Hepatitis Foundation of New Zealand, hepatitis B (Annex B). Needle Exchange New Zealand and the There is a specific national strategy and/or hepatitis C register by name; the names are kept confidential within the system. Hepatitis C Support Group. policy/guidelines for preventing hepatitis Hepatitis B and hepatitis C tests are free of Evidence-based policy and data for B and hepatitis C infection in health-care charge for all individuals. Hepatitis B tests settings. Health-care workers are vacci- are compulsory for blood donors and imaction There is routine surveillance for viral hepa- nated against hepatitis B prior to starting migrants, and hepatitis C tests for blood titis. There is a national surveillance system work that might put them at risk of expo- donors. for the following types of acute hepatitis: sure to blood. A, B, C, D and E, and for chronic hepatitis D. There is a national policy on injection safe- Publicly funded treatment for hepatitis B and hepatitis C is available to some segThere are standard case definitions for ty in health-care settings, which recom- ments of the population, but information hepatitis. Deaths, including from hepatitis, mends single-use syringes for therapeutic was not provided on who is eligible. In fisare reported to a central registry. Of hepa- injections. Single-use or auto-disable sy- cal year 2011/2012, the government spent titis cases, 6.4% are reported as “undiffer- ringes, needles and cannulas are always NZ$ 16 080 000 (US$ 13 026 971) on such available in all health-care facilities. treatment for hepatitis B and hepatitis C. entiated” or “unclassified” hepatitis. Liver cancer cases are registered nation- Official government estimates of the ally, but cases with HIV/hepatitis coinfec- number and percentage of unnecessary injections administered annually in tion are not. health-care settings are not known. The government publishes hepatitis disThere is a national infection control policy ease reports annually. for blood banks. All donated blood units Hepatitis outbreaks are required to be re- (including family donations) and blood ported to the government and are further products nationwide are screened for investigated. There is adequate laboratory hepatitis B and hepatitis C. capacity nationally to support investigation of viral hepatitis outbreaks and other There is no national policy relating to the prevention of viral hepatitis among peosurveillance activities. ple who inject drugs. The following drugs for treating hepatitis B are on the national essential medicines list or subsidized by the government: lamivudine, adefovir dipivoxil, entecavir and tenofovir. The following drugs for treating hepatitis C are on the national essential medicines list or subsidized by the government: interferon alpha, pegylated interferon and ribavirin. The Government of New Zealand did not indicate a need for assistance from WHO in relation to viral hepatitis prevention and control.

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Papua New Guinea Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 7.0 Lower–middle-income $2570 3.58% $87.71 $62.76 63 0.466 20 4.0 sary injections administered annually in health-care settings are not known. There is no national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B, but not for hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

The Government of Papua New Guinea The government does not publish hepati- It is not known whether the government has guidelines that address how hepareports as follows. tis disease reports. titis A and hepatitis E can be prevented National coordination Hepatitis outbreaks are required to be re- through food and water safety. There is no written national strategy or ported to the government and are further plan that focuses exclusively or prima- investigated. There is inadequate labora- Screening, care and treatment rily on the prevention and control of viral tory capacity nationally to support inves- It is not known how health professionals hepatitis. tigation of viral hepatitis outbreaks and obtain the skills and competencies required to effectively care for people with other surveillance activities. There is no designated governmental viral hepatitis. unit/department responsible solely for There is no national public health research coordinating and/or carrying out viral agenda for viral hepatitis. Viral hepatitis There are no national clinical guidelines hepatitis-related activities. There are no serosurveys are not conducted regularly. for the management of viral hepatitis or for the management of HIV, which include people working full-time on hepatitis-rerecommendations for coinfection with vilated activities in any government agen- Prevention of transmission There is no national policy on hepatitis A ral hepatitis. cies/bodies. vaccination. The government has national policies reThe government has a viral hepatitis prevention and control programme that in- The government has established the goal lating to screening and referral to care for hepatitis B, but not for hepatitis C. cludes activities targeting the following of eliminating hepatitis B by 2017. specific population: health-care workers Nationally, 31% of newborn infants in a People testing for hepatitis B register by (including health-care waste handlers). given recent year received the first dose name; the names are kept confidential Awareness-raising and partnerships of hepatitis B vaccine within 24 hours of within the system. Hepatitis B tests are The government did not hold events for birth and 61% of one-year-olds (ages 12– free of charge for all individuals and not World Hepatitis Day 2012 and has not 23 months) in a given recent year received compulsory for members of any specific group. Information was not provided on funded other viral hepatitis public aware- three doses of hepatitis B vaccine. whether people testing for hepatitis C regness campaigns since January 2011. There is a national policy that specifically ister by name, whether the tests are free The government does not collaborate targets mother-to-child transmission of of charge for all individuals or compulsory with in-country civil society groups to hepatitis B (Annex B). for members of any specific group. develop and implement its viral hepatitis There is no specifi c national strategy Publicly funded treatment is not available prevention and control programme. and/or policy/guidelines for preventing for hepatitis B or hepatitis C. Evidence-based policy and data for hepatitis B and hepatitis C infection in health-care settings. However, a hepatitis The following drugs for treating hepatitis action There is no routine surveillance for viral B vaccination programme for health-care B are on the national essential medicines workers was planned for February 2013. hepatitis. list or subsidized by the government: lamivudine and tenofovir. No drug for There is a national policy on injection safeThere are no standard case definitions treating hepatitis C is on the national esfor hepatitis. Hepatitis deaths are not re- ty in health-care settings, which recom- sential medicines list or subsidized by the ported to a central registry. Information mends single-use syringes for therapeutic government. was not provided on the percentage of injections. Single-use or auto-disable syhepatitis cases reported as “undifferenti- ringes, needles and cannulas are not al- The Government of Papua New Guinea ways available in all health-care facilities. welcomes assistance from WHO in one or ated” or “unknown” hepatitis. more areas of viral hepatitis prevention Liver cancer cases and cases with HIV/ Official government estimates of the and control (Annex C). hepatitis coinfection are not registered number and percentage of unnecesnationally.

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Singapore The Government of Singapore reports as Population (in millions) (2011) 5.2 follows. Country classification (2012) High-income Gross national income per capita (PPP int $) (2011) National coordination $59 380 There is no written national strategy or Total health expenditure as % of GDP (2010) 3.96% plan that focuses exclusively or prima- Per capita total health expenditure (PPP int $) (2010) $2272.64 rily on the prevention and control of viral Per capita government health expenditure (PPP int $) (2010) $824.98 Life expectancy at birth (in years) (2009) hepatitis. 82 Human Development Index (2011) 0.866 There is no designated governmental Median age (in years) (2010) 38 unit/department responsible solely for co- Total fertility rate per woman (2010) 1.3 ordinating and/or carrying out viral hepatitis-related activities. There are no people working full-time on hepatitis-related ac- tion. The last serosurvey was carried out tis E can be prevented through food and in 2012. water safety. tivities in any government agency/body. The government has a viral hepatitis prevention and control programme that includes activities targeting the following specific populations: health-care workers (including health-care waste handlers) and people who inject drugs.

Prevention of transmission

Awareness-raising and partnerships The government did not hold events for World Hepatitis Day 2012 and has not funded other viral hepatitis public awareness campaigns since January 2011. The government does not collaborate with in-country civil society groups to develop and implement its viral hepatitis prevention and control programme.

Evidence-based policy and data for action There is routine surveillance for viral hepatitis. There is a national surveillance system for the following types of acute hepatitis: A, B, C and E, and for chronic hepatitis B. There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. No hepatitis case is reported as “undifferentiated” or “unclassified” hepatitis. Liver cancer cases are registered nationally, but cases with HIV/hepatitis coinfection are not. The government publishes hepatitis disease reports weekly and annually. Hepatitis outbreaks are required to be reported to the government and are further investigated. There is adequate laboratory capacity nationally to support investigation of viral hepatitis outbreaks and other surveillance activities.

There is no national public health research agenda for viral hepatitis. Viral hepatitis serosurveys are conducted regularly; the target populations are children under the The government does not have guidelines age of 17 years and the general popula- that address how hepatitis A and hepati-

There is no national policy on hepatitis A Health professionals obtain the skills and vaccination. competencies required to effectively care for people with viral hepatitis through The government has not established the schools for health professionals (pre-servgoal of eliminating hepatitis B. ice education), on-the-job training and Nationally, 31% of newborn infants in a postgraduate training. given recent year received the first dose of There are national clinical guidelines for hepatitis B vaccine within 24 hours of birth the management of viral hepatitis, which and 61% of one-year-olds (ages 12–23 include recommendations for cases with months) in a given recent year received HIV coinfection. three doses of hepatitis B vaccine. The government has national policies reThere is a national policy that specifically lating to screening and referral to care for targets mother-to-child transmission of hepatitis B, but not for hepatitis C. hepatitis B (Annex B). People testing for both hepatitis B and There is a specific national strategy and/or hepatitis C register by name; the names policy/guidelines for preventing hepatitis are kept confidential within the system. B and hepatitis C infection in health-care Hepatitis B and hepatitis C tests are not settings. Health-care workers are vacci- free of charge. Hepatitis B tests are comnated against hepatitis B prior to starting pulsory for injecting drug users in prison work that might put them at risk of expo- settings, and hepatitis C tests for healthsure to blood. care workers and injecting drug users in There is a national policy on injection safe- prison settings. ty in health-care settings, which recom- Publicly funded treatment for hepatitis B mends single-use syringes for therapeutic and hepatitis C is available to the entire injections. Single-use or auto-disable sy- population. The amount spent by the govringes, needles and cannulas are always ernment on such treatment is not known. available in all health-care facilities. The following drugs for treating hepatitis B Official government estimates of the are on the national essential medicines list number and percentage of unneces- or subsidized by the government: intersary injections administered annually in feron alpha, pegylated interferon, lamivuhealth-care settings are not known. dine, adefovir dipivoxil and entecavir. The There is a national infection control policy following drugs for treating hepatitis C are for blood banks. All donated blood units on the national essential medicines list or (including family donations) and blood subsidized by the government: interferon products nationwide are screened for alpha and pegylated interferon. hepatitis B and hepatitis C. The Government of Singapore did not inThere is a national policy relating to the dicate a need for assistance from WHO in prevention of viral hepatitis among peo- relation to viral hepatitis prevention and control. ple who inject drugs.

Screening, care and treatment

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Solomon Islands Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) 7.0 Lower–middle-income $2350 8.55% $227.32 $212.30 71 0.510 20 4.2 It is not known whether there is a national infection control policy for blood banks. All donated blood units and blood products nationwide are screened for hepatitis B, but it is not known whether all donated blood units (including family donations) and blood products nationwide are screened for hepatitis C. There is no national policy relating to the prevention of viral hepatitis among people who inject drugs.

The Government of Solomon Islands re- The government does not publish hepati- The government does not have guideports as follows. tis disease reports. lines that address how hepatitis A and hepatitis E can be prevented through National coordination It is not known whether hepatitis out- food and water safety. There is no written national strategy or breaks are required to be reported to the plan that focuses exclusively or prima- government. There is adequate labora- Screening, care and treatment rily on the prevention and control of viral tory capacity nationally to support inves- Health professionals obtain the skills and hepatitis. tigation of viral hepatitis outbreaks and competencies required to effectively care other surveillance activities. for people with viral hepatitis through onThere is no designated governmental the-job training. unit/department responsible solely for There is no national public health research coordinating and/or carrying out viral agenda for viral hepatitis. Viral hepatitis There are no national clinical guidelines hepatitis-related activities. It is not known serosurveys are not conducted regularly. for the management of viral hepatitis. Inhow many people work full-time on hepformation was not provided on whether atitis-related activities in all government Prevention of transmission there are national clinical guidelines for There is no national policy on hepatitis A the management of HIV, which include agencies/bodies. vaccination. recommendations for coinfection with The government has a viral hepatitis previral hepatitis. The government has not established the vention and control programme that ingoal of eliminating hepatitis B. cludes activities targeting the following The government does not have national specific population: all children under the Nationally, 24% of newborn infants in a policies relating to screening and referral age of 12 months. given recent year received the first dose to care for hepatitis B or hepatitis C. Awareness-raising and partnerships of hepatitis B vaccine within 24 hours of People testing for hepatitis B register by The government did not hold events for birth and 77% of one-year-olds (ages 12– name; the names are kept confidential World Hepatitis Day 2012 and has not 23 months) in a given recent year received within the system. Hepatitis B tests are funded other viral hepatitis public aware- three doses of hepatitis B vaccine. free of charge for all individuals and are ness campaigns since January 2011. There is a national policy that specifically not compulsory for members of any specific group. Information was not provided The government does not collaborate targets mother-to-child transmission of on whether people testing for hepatitis C hepatitis B (Annex B). with in-country civil society groups to register by name, whether the tests are develop and implement its viral hepatitis free of charge for all individuals or whethThere is no specifi c national strategy and/ prevention and control programme. or policy/guidelines for preventing hepa- er they are compulsory for members of Evidence-based policy and data for titis B and hepatitis C infection in health- any specific group. care settings. action Publicly funded treatment is not available There is no routine surveillance for viral for hepatitis B or hepatitis C. It is not known whether there is a national hepatitis. policy on injection safety in health-care It is not known whether there are stand- settings. Single-use or auto-disable sy- No drug for treating hepatitis B or hepatiard case definitions for hepatitis. Hepatitis ringes, needles and cannulas are not al- tis C is on the national essential medicines deaths are not reported to a central regis- ways available in all health-care facilities. list or subsidized by the government. try. Information was not provided on the The Government of Solomon Islands welpercentage of hepatitis cases reported as Official government estimates of the comes assistance from WHO in one or number and percentage of unneces“undifferentiated” or “unknown” hepatitis. sary injections administered annually in more areas of viral hepatitis prevention and control (Annex C). It is not known whether liver cancer cases health-care settings are not known. and cases with HIV/hepatitis coinfection are registered nationally.

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Tonga The Government of Tonga reports as Population (in millions) (2011) 0.1 follows. Country classification (2012) Lower–middle-income Gross national income per capita (PPP int $) (2011) National coordination $5000 There is a written national strategy or plan Total health expenditure as % of GDP (2010) 5.07% that focuses primarily on the prevention Per capita total health expenditure (PPP int $) (2010) $229.18 and control of viral hepatitis, and also in- Per capita government health expenditure (PPP int $) (2010) $186.78 tegrates other diseases. It includes compo- Life expectancy at birth (in years) (2009) 71 nents for raising awareness, surveillance, Human Development Index (2011) 0.704 Median age (in years) (2010) vaccination and prevention in general. 21 Total fertility rate per woman (2010) 3.9 There is no designated governmental unit/department responsible solely for coordinating and/or carrying out viral hepa- There is no national public health research There is no national policy relating to the titis-related activities. There are no people agenda for viral hepatitis. Viral hepatitis se- prevention of viral hepatitis among peoworking full-time on hepatitis-related ac- rosurveys are not conducted regularly, but ple who inject drugs. they are conducted when donor funding tivities in any government agency/body. is available. The target population is chil- The government has guidelines that adThe government has a viral hepatitis pre- dren aged 5–6 years. The last serosurvey dress how hepatitis A and hepatitis E can be prevented through food and water vention and control programme that in- was carried out in 2010. safety. cludes activities targeting the following specific populations: health-care workers Prevention of transmission (including health-care waste handlers), There is no national policy on hepatitis A Screening, care and treatment Health professionals obtain the skills and vaccination. newborns and infants. competencies required to effectively care Awareness-raising and partnerships The government has established the goal for people with viral hepatitis through The government did not hold events for of eliminating hepatitis B but did not pro- schools for health professionals (pre-servWorld Hepatitis Day 2012, but has fund- vide information about a specific time- ice education), on-the-job training and postgraduate training. ed other viral hepatitis public awareness frame for this. campaigns since January 2011 (Annex A). Nationally, 98% of newborn infants in a There are national clinical guidelines for The government collaborates with the fol- given recent year received the first dose the management of viral hepatitis, but lowing in-country civil society group to of hepatitis B vaccine within 24 hours of they do not include recommendations for develop and implement its viral hepatitis birth and 98% of one-year-olds (ages 12–3 cases with HIV coinfection. prevention and control programme: Ton- months) in a given recent year received The government has national policies rethree doses of hepatitis B vaccine. ga Red Cross Society. lating to screening and referral to care for Evidence-based policy and data for There is a national policy that specifically hepatitis B, but not for hepatitis C. targets mother-to-child transmission of action People testing for both hepatitis B and There is routine surveillance for viral hepa- hepatitis B (Annex B). hepatitis C register by name; the names titis. There is a national surveillance system for the following types of acute hepatitis: A There is a specific national strategy and/or are kept confidential within the system. policy/guidelines for preventing hepatitis Hepatitis B tests are free of charge for all and B, and for chronic hepatitis B. B and hepatitis C infection in health-care individuals. Information was not provided There are standard case definitions for settings. Health-care workers are vacci- on whether hepatitis C tests are free of hepatitis. Deaths, including from hepatitis, nated against hepatitis B prior to starting charge for all individuals. Hepatitis B and are reported to a central registry. Of hepa- work that might put them at risk of expo- hepatitis C tests are compulsory for migrants. titis cases, 30% are reported as “undiffer- sure to blood. entiated” or “unclassified” hepatitis. There is a national policy on injection safe- Publicly funded treatment is not available Liver cancer cases are registered nation- ty in health-care settings, which recom- for hepatitis B or hepatitis C. ally, but cases with HIV/hepatitis coinfec- mends single-use syringes for therapeutic injections. Single-use or auto-disable sy- The following drug for treating hepatitis B tion are not. ringes, needles and cannulas are always is on the national essential medicines list or subsidized by the government: interThe government publishes hepatitis dis- available in all health-care facilities. feron alpha. No drug for treating hepatitis ease reports annually. No injection administered annually in C is on the national essential medicines list Hepatitis outbreaks are required to be re- health-care settings is unnecessary, ac- or subsidized by the government. ported to the government and are further cording to official government estimates. The Government of Tonga welcomes asinvestigated. There is adequate laboratory capacity nationally to support outbreak in- There is a national infection control policy sistance from WHO in one or more areas vestigations and other surveillance activi- for blood banks. All donated blood units of viral hepatitis prevention and control ties for hepatitis A and hepatitis B, but not (including family donations) and blood (Annex C). products nationwide are screened for for hepatitis C and hepatitis E. hepatitis B, but not for hepatitis C.

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Viet Nam Population (in millions) (2011) Country classification (2012) Gross national income per capita (PPP int $) (2011) Total health expenditure as % of GDP (2010) Per capita total health expenditure (PPP int $) (2010) Per capita government health expenditure (PPP int $) (2010) Life expectancy at birth (in years) (2009) Human Development Index (2011) Median age (in years) (2010) Total fertility rate per woman (2010) The Government of Viet Nam reports as follows. 88.8 Lower–middle-income $3250 6.84% $215.34 $81.49 72 0.593 28 1.8 Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known. There is a national infection control policy for blood banks. All donated blood units (including family donations) and blood products nationwide are screened for hepatitis B and hepatitis C.

National coordination There is no written national strategy or plan that focuses exclusively or primarily on the prevention and control of viral hepatitis.

There is no designated governmental unit/department responsible solely for coordinating and/or carrying out viral hepatitis-related activities. It is not known how many people work full-time on hepatitis-related activities in all government Prevention of transmission There is no national policy on hepatitis A agencies/bodies. vaccination. The government has a viral hepatitis prevention and control programme that in- The government has established the goal cludes activities targeting the following of eliminating hepatitis B but did not provide information about a specific timespecific population: newborns. frame for this.

There is a national policy relating to the prevention of viral hepatitis among peoThe government does not publish hepati- ple who inject drugs. tis disease reports. The government does not have guideHepatitis outbreaks are required to be re- lines that address how hepatitis A and ported to the government and are further hepatitis E can be prevented through investigated. There is adequate laboratory food and water safety. capacity nationally to support investigation of viral hepatitis outbreaks and other Screening, care and treatment Health professionals obtain the skills and surveillance activities. competencies required to effectively care There is no national public health research for people with viral hepatitis through agenda for viral hepatitis. Viral hepatitis schools for health professionals (pre-servserosurveys are not conducted regularly. ice education).

Awareness-raising and partnerships

The government did not hold events for World Hepatitis Day 2012. It is not known whether the government has funded other viral hepatitis public awareness campaigns since January 2011. The government does not collaborate with in-country civil society groups to develop and implement its viral hepatitis prevention and control programme.

Evidence-based policy and data for action There is no routine surveillance for viral hepatitis.

There are standard case definitions for hepatitis. Deaths, including from hepatitis, are reported to a central registry. Information was not provided on the There is a national policy on injection safepercentage of hepatitis cases reported as ty in health-care settings, which recom“undifferentiated” or “unknown” hepatitis. mends single-use syringes for therapeutic injections. Single-use or auto-disable syLiver cancer cases and cases with HIV/ ringes, needles and cannulas are always hepatitis coinfection are registered na- available in all health-care facilities. tionally.

There are national clinical guidelines for the management of viral hepatitis. Information was not provided on whether these guidelines include recommendations for cases with HIV coinfection. There are national clinical guidelines for the management of HIV, which include recommendations for coinfection with viral Nationally, 55% of newborn infants in a hepatitis. given recent year received the first dose The government does not have national of hepatitis B vaccine within 24 hours of policies relating to screening and referral birth and 95% of one-year-olds (ages 12– to care for hepatitis B or hepatitis C. 23 months) in a given recent year received three doses of hepatitis B vaccine. People testing for both hepatitis B and hepatitis C register by name; the names There is a national policy that specifically are kept confidential within the system. targets mother-to-child transmission of Hepatitis B and hepatitis C tests are not hepatitis B (Annex B). free of charge, and are compulsory for There is a specific national strategy and/or blood donors. policy/guidelines for preventing hepatitis Publicly funded treatment is not available B and hepatitis C infection in health-care for hepatitis B or hepatitis C. settings. Health-care workers are not vaccinated against hepatitis B prior to start- No drug for treating hepatitis B or hepatiing work that might put them at risk of tis C is on the national essential medicines exposure to blood. list or subsidized by the government. The Government of Viet Nam welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control (Annex C).

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ANNEXES

189

ANNEX A

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

ANNEX A: Primary topics or messages of public health awareness campaigns on viral hepatitis held since January 2011a

Importance of knowing one’s hepatitis B/ hepatitis C status

Safe water and good sanitation

Harm reduction for people who inject drugs

General information about hepatitis

Safe workplace practices

Vaccination for hepatitis A/ hepatitis B

WHO Region

Safer sex practices

Afghanistan Albania Andorra Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Bhutan Brazil Brunei Darussalam Bulgaria Cambodia Cameroon Canada Chad China Colombia Comoros Costa Rica Côte d’Ivoire Croatia Cuba Cyprus Czech Republic Democratic People’s Republic of Korea Denmark Djibouti Dominican Republic Ecuador Egypt a

EMRO EURO EURO AMRO AMRO EURO WPRO EURO EURO AMRO EMRO SEARO AMRO EURO EURO SEARO AMRO WPRO EURO WPRO AFRO AMRO AFRO WPRO AMRO AFRO AMRO AFRO EURO AMRO EURO EURO SEARO EURO EMRO AMRO AMRO EMRO

X X X

X X

X X X

X X X X X

X

X

X

X

X

X

X

X

X

X X

X X

X

X

X X

X X

X X X

X X

X X

X X X

X

X

X

X

X

X

X

X

X

The table lists all 126 Member States that responded to the survey, including Member States that did not provide responses to this survey question (i.e. Member States that did not report any primary topics or messages). Responses were provided by 36 Member States.

190

Other X X

ANNEX A

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Importance of knowing one’s hepatitis B/ hepatitis C status

Safe water and good sanitation

Harm reduction for people who inject drugs

General information about hepatitis

Safe workplace practices

Vaccination for hepatitis A/ hepatitis B

WHO Region

Safer sex practices

El Salvador Estonia Finland France Georgia Germany Grenada Guatemala Guyana Honduras Hungary India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kiribati Kuwait Kyrgyzstan Lao People’s Democratic Republic Latvia Lebanon Lithuania Luxembourg Malaysia Maldives Mali Malta Mauritania Mexico Mongolia Montenegro Myanmar

AMRO EURO EURO EURO EURO EURO AMRO AMRO AMRO AMRO EURO SEARO SEARO EMRO EMRO EURO EURO EURO AMRO WPRO EMRO WPRO EMRO EURO WPRO EURO EMRO EURO EURO WPRO SEARO AFRO EURO AFRO AMRO WPRO EURO SEARO

X X X X

X

X X X X

X X

X X X X X X X

X

X

X

X

X

X

X

X

X

X

X

Other X X

191

ANNEX A

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

ANNEX A: Primary topics or messages of public health awareness campaigns on viral hepatitis held since January 2011 (continued)

Importance of knowing one’s hepatitis B/ hepatitis C status

Safe water and good sanitation

Harm reduction for people who inject drugs

General information about hepatitis

Safe workplace practices

Vaccination for hepatitis A/ hepatitis B

WHO Region

Safer sex practices

Nepal Netherlands New Zealand Nicaragua Nigeria Oman Pakistan Panama Papua New Guinea Paraguay Peru Poland Qatar Republic of Moldova Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia San Marino Serbia Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syrian Arab Republic Tajikistan Thailand The former Yugoslav Republic of Macedonia

SEARO EURO WPRO AMRO AFRO EMRO EMRO AMRO WPRO AMRO AMRO EURO EMRO EURO EURO AFRO AMRO AMRO EURO EURO AFRO WPRO EURO EURO WPRO EMRO AFRO EMRO EURO SEARO EMRO AMRO EURO EURO EMRO EURO SEARO EURO

X X X

X X

X X

X X

X

X

X

X

X

X X X

X X X

X X X X X X X X X

X X X

X

X

X

X

X

X X

X X X X X

192

Other X X X X

ANNEX A

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Importance of knowing one’s hepatitis B/ hepatitis C status

Safe water and good sanitation

Harm reduction for people who inject drugs

General information about hepatitis

Safe workplace practices X X X

Vaccination for hepatitis A/ hepatitis B

WHO Region

Safer sex practices

Timor-Leste Tonga Turkey Ukraine United Kingdom of Great Britain and Northern Ireland United Republic of Tanzania United States of America Uruguay Uzbekistan Viet Nam Yemen Zimbabwe

SEARO WPRO EURO EURO EURO AFRO AMRO AMRO EURO WPRO EMRO AFRO

X X

X

X X

X

X X

X X

X

X

X

X

X

X

X

Other

193

ANNEX B

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

ANNEX B: Components of national policies that target mother-to-child transmission of hepatitis Ba

Upon delivery, all infants born to women with hepatitis B receive hepatitis B immunoglobulin X X X X X X

Health-care providers follow up with all pregnant women found to have hepatitis B during pregnancy for the purpose of encouraging them to give birth at health-care facilities

Afghanistan Albania Andorra Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Bhutan Brazil Brunei Darussalam Bulgaria Cambodia Cameroon Canada Chad China Colombia Comoros Costa Rica Côte d’Ivoire Croatia Cuba Cyprus Czech Republic Democratic People’s Republic of Korea Denmark Djibouti Dominican Republic Ecuador Egypt a

EMRO EURO EURO AMRO AMRO EURO WPRO EURO EURO AMRO EMRO SEARO AMRO EURO EURO SEARO AMRO WPRO EURO WPRO AFRO AMRO AFRO WPRO AMRO AFRO AMRO AFRO EURO AMRO EURO EURO SEARO EURO EMRO AMRO AMRO EMRO

X X X X X X X X X X X X X X X X X

X X X X X X X X

X X X

X X X X

X X X

X X X

X X X X

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

The table lists all 126 Member States that responded to the survey, including Member States that did not provide responses to this survey question (i.e. Member States that did not report having a policy with any of the specified activities). Responses were provided by 96 Member States.

194

All infants receive the first dose of hepatitis B vaccine within 24 hours of birth X X X X X X X X X X X X X

All pregnant women found to have hepatitis B are counselled

WHO Region

All pregnant women are screened for hepatitis B

ANNEX B

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Upon delivery, all infants born to women with hepatitis B receive hepatitis B immunoglobulin

Health-care providers follow up with all pregnant women found to have hepatitis B during pregnancy for the purpose of encouraging them to give birth at health-care facilities

El Salvador Estonia Finland France Georgia Germany Grenada Guatemala Guyana Honduras Hungary India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kiribati Kuwait Kyrgyzstan Lao People’s Democratic Republic Latvia Lebanon Lithuania Luxembourg Malaysia Maldives Mali Malta Mauritania Mexico Mongolia Montenegro Myanmar

AMRO EURO EURO EURO EURO EURO AMRO AMRO AMRO AMRO EURO SEARO SEARO EMRO EMRO EURO EURO EURO AMRO WPRO EMRO WPRO EMRO EURO WPRO EURO EMRO EURO EURO WPRO SEARO AFRO EURO AFRO AMRO WPRO EURO SEARO

X X X X X X X X

X X X X X X X X X X X X X X X X X X X X X X

X X

X X

X

X X X

X X X X

X X X X X X

X X X X X

X X X X X X X X X X X X

X

X

X X

X X

X X X X X

X X X

X X X

X X X

X X

X

All infants receive the first dose of hepatitis B vaccine within 24 hours of birth X X X X X X X X X X X X X X X X X X X X X 195

All pregnant women found to have hepatitis B are counselled

WHO Region

All pregnant women are screened for hepatitis B

ANNEX B

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

ANNEX B: Components of national policies that target mother-to-child transmission of hepatitis B (continued)

Upon delivery, all infants born to women with hepatitis B receive hepatitis B immunoglobulin

Health-care providers follow up with all pregnant women found to have hepatitis B during pregnancy for the purpose of encouraging them to give birth at health-care facilities

Nepal Netherlands New Zealand Nicaragua Nigeria Oman Pakistan Panama Papua New Guinea Paraguay Peru Poland Qatar Republic of Moldova Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia San Marino Serbia Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syrian Arab Republic Tajikistan Thailand The former Yugoslav Republic of Macedonia

SEARO EURO WPRO AMRO AFRO EMRO EMRO AMRO WPRO AMRO AMRO EURO EMRO EURO EURO AFRO AMRO AMRO EURO EURO AFRO WPRO EURO EURO WPRO EMRO AFRO EMRO EURO SEARO EMRO AMRO EURO EURO EMRO EURO SEARO EURO

X X X X X X X X

X

X X X X

X X X X

X X X

X X

X X X X X

X X X X X

X X X X X

X X X X X X X

X

X

X

X X

X X

X X

X X

X

X X X

X X

196

All infants receive the first dose of hepatitis B vaccine within 24 hours of birth X X X X X X X X X X X X X X X

All pregnant women found to have hepatitis B are counselled

WHO Region

All pregnant women are screened for hepatitis B

Timor-Leste SEARO Tonga WPRO Turkey EURO Ukraine EURO United Kingdom of Great Britain and Northern Ireland EURO United Republic of Tanzania AFRO AMRO United States of America AMRO Uruguay EURO Uzbekistan WPRO Viet Nam EMRO Yemen AFRO Zimbabwe WHO Region X X X X X X X X X X X X X X X X X X X X X X X

All pregnant women are screened for hepatitis B All pregnant women found to have hepatitis B are counselled Health-care providers follow up with all pregnant women found to have hepatitis B during pregnancy for the purpose of encouraging them to give birth at health-care facilities Upon delivery, all infants born to women with hepatitis B receive hepatitis B immunoglobulin All infants receive the first dose of hepatitis B vaccine within 24 hours of birth

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

ANNEX B

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ANNEX C

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

ANNEX C: Areas in which Member States indicated that they might want assistance from the World Health Organization for the prevention and control of viral hepatitisa Integrating viral hepatitis programmes into other health services Developing education/ training programmes for health professionals X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

Developing the national plan for viral hepatitis prevention and control

Estimating the national burden of viral hepatitis

Assessing the economic impact of viral hepatitis

Developing tools to assess the effectiveness of interventions

Increasing coverage of the birth dose of the hepatitis B vaccine

Improving laboratory quality

Increasing access to treatment

Increasing access to diagnostics

Awareness-raising

Viral hepatitis surveillance

WHO Region

Afghanistan Albania Andorra Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Bhutan Brazil Brunei Darussalam Bulgaria Cambodia Cameroon Canada Chad China Colombia Comoros Costa Rica Côte d’Ivoire Croatia Cuba Cyprus Czech Republic Democratic People’s Republic of Korea Denmark Djibouti Dominican Republic Ecuador Egypt a

EMRO EURO EURO AMRO AMRO EURO WPRO EURO EURO AMRO EMRO SEARO AMRO EURO EURO SEARO AMRO WPRO EURO WPRO AFRO AMRO AFRO WPRO AMRO AFRO AMRO AFRO EURO AMRO EURO EURO SEARO EURO EMRO AMRO AMRO EMRO

X X

X X

X X

X

X X

X X

X X

X X

X X

X X

X X

X

X X

X

X X X X X X X X X X X X

X X X X

X X X X X X X X X X X X X X X

X X X

X

X

X

X

X

X

X X

X X X X X

X X X X

X X X

X

X X X

X X

X X X

X

X

X

The table lists all 126 Member States responding to the survey, including Member States that did not provide responses to this survey question (i.e. Member States that did not indicate an interest in receiving specific forms of assistance). Responses were provided by 100 Member States.

198

Other X X X X

ANNEX C

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

Integrating viral hepatitis programmes into other health services

Developing education/ training programmes for health professionals X X X X X X X X X X X X X X X X X X X X X X X X

Developing the national plan for viral hepatitis prevention and control

Estimating the national burden of viral hepatitis

Assessing the economic impact of viral hepatitis

Developing tools to assess the effectiveness of interventions

Increasing coverage of the birth dose of the hepatitis B vaccine

Improving laboratory quality

Increasing access to treatment

Increasing access to diagnostics

Awareness-raising

Viral hepatitis surveillance

WHO Region

El Salvador Estonia Finland France Georgia Germany Grenada Guatemala Guyana Honduras Hungary India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kiribati Kuwait Kyrgyzstan Lao People’s Democratic Republic Latvia Lebanon Lithuania Luxembourg Malaysia Maldives Mali Malta Mauritania Mexico Mongolia Montenegro Myanmar

AMRO EURO EURO EURO EURO EURO AMRO AMRO AMRO AMRO EURO SEARO SEARO EMRO EMRO EURO EURO EURO AMRO WPRO EMRO WPRO EMRO EURO WPRO EURO EMRO EURO EURO WPRO SEARO AFRO EURO AFRO AMRO WPRO EURO SEARO

X X

X

X X X

X

X

X

X

X

X

X

X

X X

X X X X X X X X X X X X X X X X X X X X X X X X

X X X X X X X X X X X X X X X X X X X X X

X X X X X X X X

X X X X X X

X X

X X

X X

X X

X

X X

X X

X X

X

X

X X

X

X X X X X X

X

X X X X X X X X X X X X X X X X X X X X X X X X X X X X

X X

X X X X

X

X

X

X

X X

X X

X X

X X X X

X X X

X X X

X

X X

X X X X X X

X X X X

X X X X X

X

X X X X X X X

X

Other 199

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ANNEX C: Areas in which Member States indicated that they might want assistance from the World Health Organization for the prevention and control of viral hepatitis (continued)

Integrating viral hepatitis programmes into other health services

Developing education/ training programmes for health professionals X X X X X X X X X X X X X X X X X X X X X X X

Developing the national plan for viral hepatitis prevention and control

Estimating the national burden of viral hepatitis

Assessing the economic impact of viral hepatitis

Developing tools to assess the effectiveness of interventions

Increasing coverage of the birth dose of the hepatitis B vaccine

Improving laboratory quality

Increasing access to treatment

Increasing access to diagnostics

Awareness-raising

Viral hepatitis surveillance

WHO Region

Nepal Netherlands New Zealand Nicaragua Nigeria Oman Pakistan Panama Papua New Guinea Paraguay Peru Poland Qatar Republic of Moldova Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia San Marino Serbia Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syrian Arab Republic Tajikistan Thailand The former Yugoslav Republic of Macedonia

SEARO EURO WPRO AMRO AFRO EMRO EMRO AMRO WPRO AMRO AMRO EURO EMRO EURO EURO AFRO AMRO AMRO EURO EURO AFRO WPRO EURO EURO WPRO EMRO AFRO EMRO EURO SEARO EMRO AMRO EURO EURO EMRO EURO SEARO EURO

X

X

X

X

X

X

X

X

X

X

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

X X X X X X X X X X

X X X X X X

X X X X X

X

X

X X X X X X

X X X X X X

X X X X X X

X X X X X X

X X X X X X

X X X X X X

X X X X X X

X X X

X X X X X

X X X X X X

X X

X X

X

X

X X X X

X X X

X X

X X

X X X

X X X

X X

X

X

X X

X X

X

X

X

200

Other X X X X X X X X

Timor-Leste SEARO Tonga WPRO Turkey EURO Ukraine EURO United Kingdom of Great Britain and Northern Ireland EURO United Republic of Tanzania AFRO United States of America AMRO Uruguay AMRO Uzbekistan EURO Viet Nam WPRO Yemen EMRO Zimbabwe AFRO WHO Region X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

Developing the national plan for viral hepatitis prevention and control Integrating viral hepatitis programmes into other health services Awareness-raising Viral hepatitis surveillance Estimating the national burden of viral hepatitis Developing tools to assess the effectiveness of interventions Assessing the economic impact of viral hepatitis Increasing coverage of the birth dose of the hepatitis B vaccine Increasing access to treatment Increasing access to diagnostics Improving laboratory quality Developing education/ training programmes for health professionals Other

GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

ANNEX C

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GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

ANNEX D: Study methodology and limitations

This report is based on a survey of all Member States of the World Health Organization (WHO). The survey was written in English and piloted across 13 WHO Member States. After feedback was incorporated into a final version, the survey was translated into French, Spanish, Portuguese and Russian. Responses to the survey were sought from the identified focal point for viral hepatitis at the national department or ministry of health in each WHO Member State. These individuals were identified both through direct communication with government agencies and through international, regional and country offices of WHO. Data collection took place from July 2012 to February 2013. The global, regional and country summaries in this report were developed using the completed survey responses supplemented by any additional details received. Quantitative data presented in tables and figures may total slightly less or slightly more than 100% due to the rounding of decimals. For country summaries that report the amount spent on publicly funded treatment for hepatitis B and hepatitis C, the United States dollar amount was calculated by converting from the local currency using the average 2012 exchange rate (1 January 2012–31 December 2012). The source for historical exchange rates was http://www.oanda.com/currency/average. Country summaries are prefaced by additional country data intended to provide an overview of the context in which policy and programme development takes place. Sources for these data are provided in Table 1. A number of study limitations may have influenced the findings presented in this report. Of the 194 Member States, 126 responded to the survey (64.9%), while 68 did not provide responses. The research team’s inability to obtain responses from some countries may be attributable to the lack of any clear national focal point or department leading viral hepatitis prevention and control efforts. Hence, countries with weak national viral hepatitis programmes may be underrepresented in the survey findings and the full extent of any gap in the policy response to hepatitis may not be reflected in the report. Furthermore, the survey asked only about the existence of national policies, strategies and programmes; it did not seek to assess their quality or impact. Caution must be exercised in using survey findings to draw conclusions about implementation, service uptake and health outcomes. Linguistic and definitional considerations should also be highlighted. As the survey was limited to the aforementioned five languages, although mitigated by many WHO country offices that provided assistance to respondents, this may have affected both response rates and respondents’ thorough and clear understanding of the questions. Furthermore, some terms used in the survey may be understood differently in different regions and countries.

Finally, the data included here are those reported by the identified focal point from each Member State. It was not possible to verify the data submitted prior to publication of this report. Table 1. Sources for country context data Population (in millions) World population prospects: the 2010 revision. New York, United Nations, Department of Economic and Social Affairs, Population Division, 2011. The World Bank. Country and lending groups (web site). http:// data.worldbank.org/about/countryclassifications/country-and-lendinggroups (accessed 15 October 2012). The World Bank. GNI per capita, PPP (current international $)(web site). http://data.worldbank.org/indicator/ NY.GNP.PCAP.PP.CD/countries?displa y=default3Fcid3DEXT_BoletinES_W_ EXT (accessed 15 October 2012). The WHO Global Health Observatory (web site). http://apps.who.int/ gho/data/node.main (accessed 15 October 2012). The WHO Global Health Observatory (web site). http://apps.who.int/ gho/data/node.main (accessed 15 October 2012). The WHO Global Health Observatory (web site). http://apps.who.int/gho/ data/node.main(accessed 15 October 2012). The WHO Global Health Observatory (web site). http://apps.who.int/ gho/data/node.main (accessed 15 October 2012). Human development Index tables. Human development report 2011 – sustainability and equity: a better future for all. United Nations Development Programme, 2011. hdr.undp.org/en/media/HDR_2011_ Statistical_Tables.xls (accessed 15 May 2013). The WHO Global Health Observatory (web site). http://apps.who.int/ gho/data/node.main (accessed 15 October 2012). The WHO Global Health Observatory (web site). http://apps.who.int/ gho/data/node.main (accessed 15 October 2012).

Country classification

Gross national income per capita (purchasing power parity in international dollars [PPP int $])

Total health expenditure as % of GDP

Per capita total health expenditure (PPP int $)

Per capita government health expenditure (PPP int $) Life expectancy at birth

Human Development Index

Median age

Total fertility rate per woman

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ANNEX E: Responding to viral hepatitis: the World Health Organization/World Hepatitis Alliance 2012 survey of national governments

Your cooperation is requested in gathering data that will enable the World Health Organization and the World Hepatitis Alliance to assess the response to viral hepatitis at the global, regional and national levels. This information is vital for measuring progress, identifying gaps and guiding future efforts. Please fully answer all questions in English. You may provide supporting information in any language. If you do not know the answer to a question, please make every effort to find the information. Please submit the completed survey, along with all supporting information, to obaran@who.int with a cc to hepatitis@cphiv.dk.

1. In your country, is there a written national strategy or plan

that focuses exclusively or primarily on the prevention and control of viral hepatitis?a ( ) yes a

( ) no

( ) do not know

Please e-mail us the relevant supporting information, including if you have a strategy or plan for other diseases which includes viral hepatitis.

If yes – Is the strategy or plan exclusive for viral hepatitis or does it also address other diseases (e.g. HIV, sexually transmitted infections)? a. ( ) exclusive for viral hepatitis b. ( ) only for hepatitis B c. ( ) only for hepatitis C d. ( ) integrated with other diseases e. ( ) do not know Please indicate whether the following are components of the strategy or plan: 1. Raising awareness 2. Surveillance 3. Vaccination 4. Prevention in general 5. Prevention of transmission via injecting drug use 6. Prevention of transmission in health-care settings 7. Treatment and care 8. Coinfection with HIV ( ) yes ( ) yes ( ) yes ( ) yes ( ) yes ( ) no ( ) do not know ( ) no ( ) do not know ( ) no ( ) do not know ( ) no ( ) do not know ( ) no ( ) do not know

Contact information First name Last name Position Organization Street address City Postal code / zip code Country Phone number E-mail address Web site Where appropriate, please give the names and contact details of colleagues who provided supporting information.

( ) yes

( ) no ( ) do not know

( ) yes ( ) yes

( ) no ( ) do not know ( ) no ( ) do not know

2. Is there a designated governmental unit/department

responsible only for coordinating and/or carrying out viral hepatitis-related activities? ( ) yes ( ) no ( ) do not know a. If yes, how many staff members does it have? b. Name of unit/department 3. How many people work full-time (or how many full-

time equivalent staff ) on hepatitis-related activities in all government agencies/bodies? people ( ) do not know

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4. Did your government hold events for World Hepatitis Day

7. Does your government collaborate with any civil society group

2012?a ( ) yes a

( ) no

( ) do not know

Please e-mail us the relevant supporting information.

within your country (such as patient groups or national or local nongovernmental organizations) to develop and implement its viral hepatitis prevention and control programme? If yes, please name major partners. ( ) yes ( ) no major partners a. b. c. 8. Is there routine surveillance for viral hepatitis?

5. Has your government funded any public viral hepatitis

awareness campaign since January 2011, other than World Hepatitis Day?a ( ) yes a

( ) no

( ) do not know

Please e-mail us the relevant supporting information (including the names of the campaigns).

If yes, what were the primary topics or messages of the campaigns? a. ( ) General information about hepatitis and its transmission b. ( ) Vaccination for hepatitis A and hepatitis B c. ( ) Importance of knowing one’s hepatitis B and hepatitis C status d. ( ) Safe water and good sanitation e. ( ) Safer sex practices f. ( ) Harm reduction for people who inject drugs g. ( ) Safe workplace practices h. ( ) Other – please specify: a. b. c. 6. Does your government have a viral hepatitis prevention and

( ) yes

( ) no

( ) do not know

If yes, please answer the following questions regarding viral hepatitis surveillance. If no, please proceed to Question 11. 9. Is there a national surveillance system for the following types

of acute viral hepatitis infection? Please check all that apply. ( ) yes a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis D e. Hepatitis E ( ) no ( ) yes ( ) yes ( ) yes ( ) yes ( ) yes ( ) do not know ( ) no ( ) do not know ( ) no ( ) do not know ( ) no ( ) do not know ( ) no ( ) do not know ( ) no ( ) do not know

10. Is there a national surveillance system for chronic hepatitis

infection? Please check all that apply. ( ) yes ( ) no ( ) yes ( ) yes ( ) yes ( ) do not know ( ) no ( ) do not know ( ) no ( ) do not know ( ) no ( ) do not know a. Hepatitis B b. Hepatitis C c. Hepatitis D

control programme that includes activities targeting specific populations? ( ) yes ( ) no ( ) do not know If yes, please indicate which populations: a. ( ) Health workers (including health-care waste handlers) b. ( ) People who inject drugs c. ( ) Migrants d. ( ) Prisoners e. ( ) The homeless f. ( ) People living with HIV g. ( ) Low-income populations h. ( ) The uninsured i. ( ) Indigenous people j. ( ) Other - (please specify):

If yes, please e-mail us the definitions and/or source used. 11. Are there standard case definitions for hepatitis infections?

( ) yes

( ) no

( ) do not know

12. Are deaths, including from hepatitis, reported to a central

registry? ( ) yes ( ) no ( ) do not know

13. What percentage of hepatitis cases are reported as

“undifferentiated” or “unclassified” hepatitis? ( ) yes ( ) no ( ) do not know

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14. Are liver cancer cases registered nationally?

20. Is there adequate laboratory capacity nationally to support

( ) yes 15. Are

( ) no

( ) do not know

investigation of viral hepatitis outbreaks and other surveillance activities? ( ) yes ( ) no ( ) yes ( ) yes ( ) yes ( ) yes ( ) do not know ( ) no ( ) do not know ( ) no ( ) do not know ( ) no ( ) do not know ( ) no ( ) do not know a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis E

cases with HIV/hepatitis coinfection registered nationally? ( ) no ( ) do not know

( ) yes

16. How often are hepatitis disease reports published?

a. ( ) weekly

b. ( ) monthly

c. ( ) annually e. ( ) other: 21. Is there a national hepatitis A vaccination policy?

d. ( ) no reports published

( ) yes 17. Are hepatitis outbreaks required to be reported to the

( ) no

( ) do not know

government? ( ) yes ( ) yes ( ) no ( ) no ( ) do not know ( ) do not know a. If yes, are they further investigated?

If yes, does the policy address vaccination for the following groups? Please check all that apply. a. ( ) Travellers to highly endemic countries b. ( ) Military personnel c. ( ) Children, as part of the national routine vaccination programme d. ( ) Ecological and sanitary workers e. ( ) Other – please specify: 22. Has your government established the goal of eliminating

18. Is there a national public health research agenda for viral

hepatitis?a ( ) yes a

( ) no

( ) do not know

Please e-mail us the relevant documentation, including information about the budget and networks involved.

hepatitis B? ( ) yes ( ) no ( ) do not know a. If yes, in what timeframe (e.g. an end date)?

19. Are viral hepatitis serosurveys conducted regularly?

( ) yes If yes – a. How often?

( ) no

( ) do not know 23. Nationally, what percentage of newborn infants in a given

b. When was the last one carried out? c. Please specify the target populations: 1. ( ) Children (please specify age group): 2. ( ) General population 3. ( ) People who inject drugs 4. ( ) Men who have sex with men 5. ( ) Other groups:

recent year received the first dose of hepatitis B vaccine within 24 hours of birth?

24. Nationally, what percentage of one-year-olds (ages 12–23

months) in a given recent year received three doses of hepatitis B vaccine?

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25. Nationally, what percentage of one-year-olds (ages 12–23

29. What are your government’s official estimates of the number

months) in a given recent year received three doses of hepatitis B vaccine? Is there a national policy that specifically targets mother-tochild transmission of hepatitis B? Please check the following if the policy calls for any of these activities: a. ( ) All pregnant women are screened for hepatitis B b. ( ) All pregnant women found to have hepatitis B are counselled c. ( ) Health-care providers follow up with all pregnant women found to have hepatitis B during pregnancy for the purpose of encouraging them to give birth at health-care facilities d. ( ) Upon delivery, all infants born to women with hepatitis B receive hepatitis B immunoglobulin e. ( ) All infants receive the first dose of hepatitis B vaccine within 24 hours of birth f. ( ) All infants receive the second and third doses of hepatitis B vaccine within 12 months of birth 26. Is there a specific national strategy and/or policy/guidelines

and percentage of unnecessary injections administered annually in health-care settings? (e.g. injections that are given when an equivalent oral medication is available) a. Number b. Percentage (as a proportion of total injections administered annually in health-care settings) ( ) do not know ( ) do not know

30. Is there a national infection control policy for blood banks?a

( ) yes a

( ) no

( ) do not know

Please e-mail us the relevant supporting information, including the percentage of blood donations screened for hepatitis B virus, hepatitis C virus and HIV.

31. Are all donated blood units (including family donations) and

blood products nationwide screened for hepatitis B? ( ) yes ( ) no ( ) do not know for preventing hepatitis B and hepatitis C infection in healthcare settings? ( ) yes ( ) no ( ) do not know a. If yes, are health workers vaccinated against hepatitis B prior to starting work that might put them at risk of exposure to blood? ( ) yes ( ) no ( ) do not know

32. Are all donated blood units (including family donations) and

blood products nationwide screened for hepatitis C? ( ) yes ( ) no ( ) do not know

33. Is there a national policy relating to the prevention of viral

hepatitis among people who inject drugs?a 27. Is there a national policy on injection safety in health-care

( ) yes a

( ) no

( ) do not know

settings? ( ) yes ( ) no ( ) do not know a. If yes, what type of syringes does the policy recommend for therapeutic injections? 1. ( ) single-use syringes 2. ( ) auto-disable syringes 3. ( ) do not know 28. Are single-use or auto-disable syringes, needles and cannulas

Please e-mail us the relevant supporting information.

34. Does your government have guidelines that address how

hepatitis A and hepatitis E can be prevented through food and water safety? ( ) yes ( ) no ( ) do not know

35. How do health professionals in your country obtain the skills

and competencies required to effectively care for people with viral hepatitis? a. ( ) schools for health professionals (pre-service education) b. ( ) on-the-job training c. ( ) postgraduate training d. ( ) other: e. ( ) do not know

always available in all health-care facilities? ( ) yes ( ) no ( ) do not know

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36. Does your government have a national policy relating to

39. Is publicly funded treatment available for hepatitis B?

screening and referral to care for the following?a ( ) yes a. Hepatitis B b. Hepatitis C a

( ) yes

( ) no

( ) do not know

( ) no ( ) yes ( ) yes

( ) do not know ( ) no ( ) no ( ) do not know ( ) do not know

a. If yes, who is eligible for publicly funded treatment for hepatitis B? Please specify:

Please e-mail us the relevant supporting information.

40. Is publicly funded treatment available for hepatitis C?

37. Please answer the following questions about hepatitis B

( ) yes

( ) no

( ) do not know

and hepatitis C testing in your country. Please check the appropriate boxes. a. Hepatitis B b. Hepatitis C 1. When testing, do people register by name? 2. If people register by name, are their names kept confidential within the system, or is there open access to the names? 3. Is the test free of charge for all individuals? 4. Is the test free of charge for members of any specific group? 5. Is the test compulsory for members of any specific group? ( ) yes ( ) no ( ) confidential ( ) open access ( ) yes ( ) no ( ) confidential ( ) open access

a. If yes, who is eligible for publicly funded treatment for hepatitis C? Please specify:

41. How much does the government spend on publicly funded

treatment for hepatitis B and hepatitis C? (Please indicate currency. Please also indicate whether the amount is for one or both of the infections.)

42. Which of the following drugs for treating hepatitis B and

( ) yes ( ) no ( ) yes (please indicate): ( ) no ( ) yes (please indicate): ( ) no

( ) yes ( ) no ( ) yes (please indicate): ( ) no ( ) yes (please indicate): ( ) no

hepatitis C are on the national essential medicines list or subsidized by the government? (Please check all that apply.) a. Available drugs for treating hepatitis B: 1. ( ) Interferon alpha 2. ( ) Pegylated interferon 3. ( ) Lamivudine (Epivir-HBV, Zeffix or Heptodin) 4. ( ) Adefovir dipivoxil (Hepsera) 5. ( ) Entecavir (Baraclude) 6. ( ) Telbivudine (Tyzeka, Sebivo) 7. ( ) Tenofovir (Viread) 8. ( ) Other:

38. Are there national clinical guidelines for the management of

viral hepatitis?a ( ) yes a

b. Available drugs for treating hepatitis C: 1. ( ) Interferon alpha 2. ( ) Pegylated interferon 3. ( ) Ribavirin 4. ( ) Boceprevir (Victrelis) 5. ( ) Telaprevir (Incivo, Incivek) 6. ( ) Other:

( ) no

( ) do not know

Please e-mail us the relevant supporting information.

a. If yes, do they include recommendations for cases with HIV coinfection? ( ) yes ( ) no ( ) do not know b. If no, are there national clinical guidelines for the management of HIV,which include recommendations for coinfection with viral hepatitis? ( ) yes ( ) no ( ) do not know

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GLOBAL POLICY REPORT ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS

43. Please indicate in which areas, if any, your government might

want assistance from the World Health Organization for the prevention and control of viral hepatitis: a. ( ) Developing the national plan for viral hepatitis prevention and control b. ( ) Viral hepatitis surveillance c. ( ) Increasing coverage of the birth dose of the hepatitis B vaccine d. ( ) Estimating the national burden of viral hepatitis e. ( ) Developing tools to assess the effectiveness of interventions f. ( ) Increasing access to treatment g. ( ) Increasing access to diagnostics h. ( ) Improving laboratory quality i. ( ) Awareness-raising j. ( ) Developing education/training programmes for health professionals k. ( ) Assessing the economic impact of viral hepatitis l. ( ) Integrating viral hepatitis programmes into other health services m. ( ) Other – please specify:

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