AN OVERVIEW OF POLICIES FOR PREVENTION, CARE AND TREATMENT OF HEPATITIS B AND C (part B)

Transcription

1 AN OVERVIEW OF POLICIES FOR PREVENTION, CARE AND TREATMENT OF HEPATITIS B AND C (part B) GEORGE PAPATHEODORIDIS, MD ASSOCIATE PROFESSOR IN MEDICINE AND GASTROENTEROLOGY, ATHENS UNIVERSITY MEDICAL SCHOOL HARRY JANSSEN, MD HEAD, LIVER UNIT, ROTTERDAM ERASMUS UNIVERSITY MEDICAL CENTER ANGELOS HATZAKIS, MD PROFESSOR OF EPIDEMIOLOGY & PREVENTIVE MEDICINE ATHENS UNIVERSITY MEDICAL SCHOOL

2 Contents Chronology related to Prevention, Care and Treatment of Hepatitis B and C in Europe and US WHO Resolution on Viral Hepatitis European Policies for Prevention, Care and Treatment of HBV and HCV US Policies for Prevention, Care and Treatment of Viral Hepatitis Hepatitis B and C Public Policy Association

3 CHRONOLOGY RELATED TO PREVENTION, CARE AND TREATMENT OF HEPATITIS B AND C IN EUROPE AND US

4 Chronology related to Prevention, Care & Treatment of Hepatitis B & C in Europe and US (1) A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States Part I: Immunization of Infants, Children and Adolescents CDC s MMWR Recommendations and Reports (December 2005) European Parliament Call for Action on Hepatitis B (T. Ulmer, April 2006). Presentation on Threats of Hepatitis B to the Management Board of ECDC (Hatzakis A, June 2006). A Hepatitis B stakeholders Forum in Turkey (September 2006). A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States Part II: Immunization of Adults CDC s MMWR Recommendations and Reports (December 2006) A workshop on The acute issue of chronic Hepatitis B at the Clingendael Institute, in the Netherlands (February 2007).

5 Chronology related to Prevention, Care & Treatment of Hepatitis B & C in Europe and US (2) AASLD Practice Guideline: Chronic Hepatitis B (February and June 2007) A Workshop on Policies to Tackle the Battle Against Hepatitis (French Senate, March 2007). European Parliament and European Council Call for Hepatitis Screening Programmes (March 2007). European Orientation towards Better Management of Hepatitis B in Europe (T. Ulmer, July 2007) Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection - CDC s MMWR Recommendations and Reports (September 2008) EASL Clinical Practice Guidelines: Management of Chronic Hepatitis B (October 2008)

6 Chronology related to Prevention, Care & Treatment of Hepatitis B & C in Europe and US (3) ELPA/EASL Expert Recommendations for the Promotion of Case-Finding for Hepatitis B and C (February 2009) ELPA s Report on screening awareness-building activities (Piorkowsky N, J Hepatol, 2009). The Dawn of a New Era: Transforming our Domestic Response to Hepatitis B & C (September 2009) Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B & C Institute of Medicine (January 2010) Meeting on the Identification and Management of Persons with Chronic Viral Hepatitis in Europe (VHPB, March 2010). World Hepatitis Alliance (WHA) Report on Global Hepatitis Policies (April 2010).

7 Chronology related to Prevention, Care & Treatment of Hepatitis B & C in Europe and US (4) WHO Resolution for Hepatitis (63 rd World Health Organization Assembly, May 2010). ECDC Technical Report on Hepatitis B and C Prevalence, Burden of Disease and Screening Policies in EU (September 2010). ECDC Technical Report on Surveillance and Prevention of HBV and HCV in Europe (October 2010). Hepatitis B and C Summit Conference and Call to Action (October 2010). Combating the Silent Epidemic of Viral Hepatitis: Action Plan for the Prevention, Care and Treatment of Viral Hepatitis U.S Department of Health & Human Services (2011) EASL Clinical Practice Guidelines: Management of Hepatitis C Virus Infection (March and June 2011)

8 Chronology related to Prevention, Care & Treatment of Hepatitis B & C in Europe and US (5) The State of Hepatitis B and C in Europe: Report from the Hepatitis B and C Summit Conference (Hatzakis A et al. JVH, September 2011). AASLD Updated Practice Guideline on Treatment of Genotype 1 Chronic Hepatitis C Virus Infection (October 2011) Cost-effectiveness of HCV birth-cohort screening Ann Intern Med (November 2011) WHO s Global Hepatitis Programme launched on World Hepatitis Day 2012 Conference for Hepatitis B and C in the Mediterranean and Balkan Countries (Hatzakis A et al. JVH, 2013).

9 WHO RESOLUTION ON VIRAL HEPATITIS

10 WHO Resolution on Viral Hepatitis 63 rd World Health Assembly (May 2010) TO PREVENT the transmission of hepatitis virus through safe and effective health strategies. TO IDENTIFY AND TREAT those people most at risk for hepatitis virus-related disease with safe and effective therapies. TO INTEGRATE proven public health strategies for preventing viral hepatitis across the health system. TO INNOVATE by developing new vaccines and technologies for use in viral hepatitis prevention.

11 WHO Resolution for Hepatitis 63 rd World Health Assembly (1) TO PREVENT the transmission of hepatitis virus through safe and effective health strategies. a) Immunization against hepatitis B virus infections: i) Protecting all persons against infection with hepatitis B virus through full immunization as early in life as possible. ii) iii) Increasing coverage of hepatitis B vaccination among health-care workers, travellers and other most-at-risk persons and ensuring access to post-exposure prophylaxis for bloodborne pathogens. Setting and achieving national goals for hepatitis B control appropriate to the epidemiologic situation.

12 WHO Resolution for Hepatitis 63 rd World Health Assembly (2) TO PREVENT the transmission of hepatitis virus through safe and effective health strategies. b) Safe health care to prevent transmission of hepatitis B and C viruses and other bloodborne pathogens: i) Ensuring safe blood supplies. ii) iii) Ensuring that all injections are safe and that wider infection-control practices are followed. Increasing awareness among communities and health-care workers of the opportunities to prevent viral hepatitis.

13 WHO Resolution for Hepatitis 63 rd World Health Assembly (3) TO PREVENT the transmission of hepatitis virus through safe and effective health strategies. c) Immunization and provision of safe blood and water, in order to prevent hepatitis A: i) Guiding implementation of hepatitis A vaccination to prevent hepatitis A in countries with shifting epidemiology. ii) Improving food safety by preparing and introducing international guidelines for the management of viruses and toxins in food.

14 WHO Resolution for Hepatitis 63 rd World Health Assembly (4) TO IDENTIFY AND TREAT those people most at risk for hepatitis virusrelated disease with safe and effective therapies. d) Identification and treatment of chronic hepatitis B and C in order to prevent progression to cirrhosis and liver cancer: i) Developing evidence and policy basis for screening and treatment for viral hepatitis. ii) iii) Formulating guidelines for treatment of chronic viral hepatitis, especially taking into consideration needs of resourse-constrained settings. Expanding care and treatment services for people chronically infected with hepatitis viruses.

15 WHO Resolution for Hepatitis 63 rd World Health Assembly (5) TO INTEGRATE proven public health strategies for preventing viral hepatitis across the health system. e) Integration of interventions for the prevention, treatment and care of hepatitis B and C virus infections (including access to sterile needles and syringes, hepatitis B vaccination and antiviral treatment) into existing services for those at risk for HIV infection and sexually transmitted infections and those who inject drugs, and into national cancer control programmes.

16 WHO Resolution for Hepatitis 63 rd World Health Assembly (6) TO INNOVATE by developing new vaccines and technologies for use in viral hepatitis prevention. f) Prioritization of new preventive strategies including development of vaccines for hepatitis C and E virus infection and technologies for vaccination, screening and health care, in order to prevent chronic liver disease and liver cancer.

17 The Scottish and French National Plans Summit Conference for HBV and HCV-Call to Action EUROPEAN POLICIES FOR PREVENTION, CARE AND TREATMENT OF HBV AND HCV

18 The Scottish and French National Plans for hepatitis (1) Scottish National Hepatitis C Plan Achievements: Managed Care Networks for HepC. National procurement of antivirals at reduced rates. Increase in numbers diagnosed, doubling of numbers treated. Fivefold increase in number of prisoners treated. New approaches for gauging incidence in IDUs. Hatzakis A et al. JVH 2011

19 The Scottish and French National Plans for hepatitis (2) French National Plan for Hepatitis B and C - Achievements: Increase in proportion of patients aware of HCV positivity from 24% to 56% ( ). Highest treatment rate for HepC in Europe (16% in 2005). Demonstrated impact on morbidity and mortality. Surveillance system implemented as part of National Public Health Plan. Hatzakis A et al. JVH 2011

20 The Scottish and French National Plans for hepatitis (3) Scottish National Hepatitis C Plan Lessons learned: four elements needed to secure plan: Epidemiological data Clinical leadership Therapeutic developments Patient advocacy Hatzakis A et al. JVH 2011

21 The Scottish and French National Plans for hepatitis (4) French National Plan for Hepatitis B and C Lessons learned: Migrants can be reached with outreach campaigns. Ensure referral to secondary care. HCV campaings can increase testing through GPs. Motivation of quantifiable goals, e.g. 65% of patients with HepB aware of their infection (HepC: 75%). Need to strengthen network between hospitals, GPs and physicians in special settings.

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23 The Steering Group of the Hepatitis B and Hepatitis C Summit Conference, together with its partner associations, calls on the EU Member States and the European Commission to: 1. Improve awareness of the threat posed by Hepatitis B and Hepatitis C. 2. Integrate prevention programmes for Hepatitis B and Hepatitis C into existing public health frameworks. 3. Enhance surveillance for Hepatitis B and Hepatitis C across Europe. 4. Support the development and integration of cost-effective technologies and procedures for use in viral hepatitis prevention, control and management, including screening of high risk individuals according to scientific and epidemiological based evidence. 5. Ensure universal access to early counseling and treatment for persons infected with Hepatitis B or Hepatitis C. 6. Expand research resources for hepatitis B and hepatitis C.

24 Improve awareness of the threat posed by Hepatitis B and Hepatitis C The message that Hepatitis B and C pose a significant threat to public health and are the leading cause of liver cancer must be continually reinforced to policymakers and to the general public. Innovative and sensitive public health campaigns are needed to ensure that individuals are made aware of the risks of Hepatitis B and C infection and transmission. At the same time, care should be taken to de-stigmatise viral hepatitis and encourage the social integration of people infected with Hepatitis B and C.

25 Integrate prevention programmes for Hepatitis B and Hepatitis C into existing public health frameworks Vaccination programmes against Hepatitis B should be integrated into routine health programmes in order to reach as many individuals as possible. At the same time, existing vaccination policies against Hepatitis B should be reassessed to ensure that they reflect current epidemiology and reach at-risk target groups. Beside universal hepatitis B vaccination programmes aimed at reaching newborn, infants, and/or children, critical target groups include: household contacts of people infected with HBV, migrants, intravenous drug users, prisoners, health care workers, blood donors, pregnant women and newborns and people infected with HIV. Hepatitis C testing and treatment of injecting drug users, amongst whom most current Hepatitis C transmission is occurring, should be considered a public health imperative and fully integrated into national substance misuse programmes.

26 Enhance surveillance for Hepatitis B and Hepatitis C across Europe Comprehensive and enhanced surveillance of Hepatitis B and C should be developed and implemented at the EU-level under the coordination of the European Centre for Disease Prevention and Control. National protocols for disease surveillance must be harmonised with the EU framework for hepatitis B and C surveillance, which may include chronic cases of Hepatitis B and C in order to convey the full burden that they pose

27 Support the development and integration of cost-effective technologies and procedures for use in viral hepatitis prevention, control and management, including screening of high risk individuals according to scientific and epidemiological based evidence. Strengthen health systems in order to adequately provide local populations with the most cost-effective and affordable interventions in accordance with the local epidemiological situations. Screening of high risk individuals should be prioritized. Legal and ethical implications should be always considered.

28 Ensure universal access to early counselling and treatment for persons infected with Hepatitis B or Hepatitis C Currently available treatments are potentially curative, reducing mortality from cirrhosis and liver cancer. Universal and equal access to Hepatitis B and Hepatitis C counselling and possible therapy must be considered a priority across Europe for their public health impact to be reduced. Leadership from national governments is necessary to dispel the myth that Hepatitis B and C are untreatable, and to actively promote the availability and early use of effective treatments for affected individuals in accordance with European guidelines and treatment protocols.

29 Expand research resources for Hepatitis B and Hepatitis C National and EU-level research funding organisations are urged to allocate explicit funds towards research on the epidemiology, prevention and treatment of Hepatitis B and C. Liver disease, including Hepatitis B and C, should become a priority area for future research within the 7 th and 8 th Research Framework Programmes of the EU.

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31 Institute of Medicine Report US Action Plan for the Prevention, Treatment and Care of Viral Hepatitis US POLICIES FOR PREVENTION, CARE AND TREATMENT OF VIRAL HEPATITIS

32 Summary findings of the Institute of Medicine Report (1) In 2010, the US Centres for Disease Control and Prevention (CDC), along with the Department of Health and Human Services and other federal bodies, asked the Institute of Medicine to identify missed opportunities related to the prevention and control of HBV and HCV infections. The ensuing report has relevance far beyond the US context. Summary findings and recommendations are summarized below:

33 Summary findings of the Institute of Medicine Report (2) Factors that impede current efforts to prevent and control hepatitis B and hepatitis C are as follows: There is a lack of knowledge and awareness about chronic viral hepatitis on the part of health care and social service providers. There is a lack of knowledge and awareness about chronic viral hepatitis among at-risk populations, members of the public and policy makers. There is insufficient understanding about the extent and seriousness of this public health problem, so inadequate public resources are being allocated to prevention, control and surveillance programmes.

34 Summary findings of the Institute of Medicine Report (3) The consequences of this situation are as follows: Inadequate disease surveillance systems underreport acute and chronic infections, so the full extent of the problem is unknown. At-risk people do not know that they are at risk or how to prevent becoming infected. At-risk people may not have access to preventive services. Chronically infected people do not know that they are infected. Many health care providers do not screen people for risk factors or do not know how to manage infected people. Infected people often have inadequate access to testing, social support and medical management services. There is suboptimal coverage of HBV vaccination.

35 Allocation of research funds towards HCV, HBV and HIV in the United States Number of people infected (million) Proportion of those unaware of their condition (%) National Institutes of Health research funds (US million dollars, 2011 figures) HIV HCV HBV

36 US DEPARTMENT OF HEALTH AND HUMAN SERVICES COMBATING THE SILENT EPIDEMIC OF VIRAL HEPATITIS Action Plan for the Prevention, Care and Treatment of Viral Hepatitis

37 Vision and Purpose Full implementation of Viral Hepatitis Action Plan by 2020 could result in: An increase in the proportion of persons who are aware of their hepatitis B virus infection, from 33% to 66%. An increase in the proportion of persons who are aware of their hepatitis C virus infection, from 45% to 66%. A 25% reduction in the number of new cases of HCV infection. Elimination of mother-to-child transmission of HBV.

38 1) EDUCATING Providers and Communities to Reduce Health Disparities. 2) IMPROVING Testing, Care and Treatment to Prevent Liver Disease and Cancer. 3) STRENGTHENING Surveillance to Detect Viral Hepatitis Transmission and Disease. 4) ELIMINATING Transmission of Vaccine-Preventable Viral Hepatitis. 5) REDUCING Viral Hepatitis Caused by drug-use Behaviors. 6) PROTECTING Patients and Workers from Health-Care Associated Viral Hepatitis.

39 1. EDUCATING Providers and Communities to Reduce Health Disparities Build a US health-care workforce prepared to prevent and diagnose viral hepatitis and provide care and treatment to infected persons Decrease health disparities by educating communities about the benefits of viral hepatitis prevention, care and treatment.

40 2. IMPROVING Testing, Care and Treatment to Prevent Liver Disease and Cancer Identify persons infected with viral hepatitis early in the course of their disease Link and refer persons infected with viral hepatitis to care and treatment Improve access to and quality of care and treatment for persons infected with viral hepatitis Advance research to facilitate viral hepatitis prevention and enhance care and treatment for infected persons.

41 3. STRENGTHENING Surveillance to Detect Viral Hepatitis Transmission and Disease Build a network of state and local surveillance systems with sufficient capacity to monitor viral hepatitis and disease Monitor viral-hepatitis-associated health disparities Monitor provision and impact of viral hepatitis prevention, care and treatment services Develop and implement new technologies and laboratory procedures to improve viral hepatitis surveillance.

42 4. ELIMINATING Transmission of Vaccine-Preventable Viral Hepatitis Eliminate mother-to-child transmission of hepatitis B Achieve universal hepatitis A and hepatitis B vaccination for vulnerable adults Design and test new or improved viral hepatitis vaccines and determine the indications for their optimal use.

43 5. REDUCING Viral Hepatitis Caused by drug-use Behaviors Ensure that persons who inject drugs have access to viral hepatitis prevention, care and treatments services Mobilize community resources to prevent viral hepatitis caused by injection-drug use Provide persons who inject drugs with access to care and substance abuse treatment to prevent transmission and progression of disease Expand access to and delivery of hepatitis prevention, care and treatment services in correctional settings Advance research to improve prevention of viral hepatitis among persons who use drugs.

44 6. PROTECTING Patients and Workers from Health-Care Associated Viral Hepatitis Reduce transmission of viral hepatitis to patients resulting from misuse of medical devises and drugs Reduce iatrogenic transmission of viral hepatitis associated with blood, organs and tissues Reduce occupational transmission of viral hepatitis Enhance understanding of the preventable causes of viral hepatitis transmission in health-care settings.

45 Viral Hepatitis Centers of Excellence 1. Prevention (vaccination, testing, education, counseling). 2. Surveillance and linkage to electronic medical records. 3. Surveys on marginalized and high risk populations. 4. Evaluation of access to care. 5. IDU hepatitis activities such as: a. Gathering and analysis public health and law enforcement data. b. Raise awareness among policy makers and stakeholders. c. Assist educational efforts. d. Increase access to substance abuse treatment. e. Expand access to testing, vaccination and risk reduction interventions for IDUs. f. Develop syringe service programmes. 6. Research (new modes of transmission, new agents etc.).

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47 Hepatitis Public Policies in Europe Lack of unified comprehensive political strategy Lack of sufficient data to support a comprehensive political strategy Fractured and poorly coordinated stakeholder base Hatzakis A, 2008

48 HBV involves several Policy Areas Health Policy (vaccination, diagnosis, screening, prevention, treatment) Social Policy (adoption, pregnancy, schools, institutionalized living, drug abuse) HBV policy Civil Liberties Policy (migration, travel)

49 Current luck of coherent Hep B policy leads to poor management of Hepatitis B CHANGE AGENTS! POOR MANAGEMENT OF PREVENTION, DIAGNOSIS, TREATMENT OF HEP B Physicians LOW AWARENESS OF BURDEN AND INFECTIOUSNESS OF DISEASE Citizens, NGOs, patients FUNDING CONSTRAINTS LEAD TO LACK OF RESOURCES FOR MANAGEMENT OF HEP B Budget holders LOW PRIORITY FOR MOST POLICY MAKERS AND GOVERNMENTS Policy makers

50 Aims 1. To contribute and advocate to the development of a European strategy against HBV and HCV. 2. To monitor and support the implementation of this strategy at European and national level. 3. To promote the WHO global strategy for prevention and control of hepatitis. 4. To contribute to the communication and actions of hepatitis stakeholders.

51 European Strategy on HBV and HCV Main targets: Surveillance Prevention Early Diagnosis Access to Care Should involve: European Leadership Public Health Networks Advocacy Groups Prioritized HBV, HCV Research T. Ulmer and Hepatitis B Expert Group, 2007

52 Research priorities Prevalence of HBV and HCV in Europe (EU 27) Burden of HBV and HCV disease in Europe (EU 27) Cost effectiveness of HBV and HCV screening Migration and HBV/HCV in Europe: Barriers to prevention and treatment Hatzakis A, 2008

53 NGO sector National governments Private sector Regional bodies Summit HBV/HCV HEPBCPPA Medical associations International agencies EU institutions

54 Directors Prof. Angelos Hatzakis, Co-Chair, Athens University Medical School (Greece) Prof. Massimo Colombo, Co-Chair, University of Milan (Italy) Charles Gore, Co-Chair, World Hepatitis Alliance (UK) Prof. Rafael Esteban, Treasurer, Vall d Hebron University (Spain) Members Prof. Maria Buti, Vall d Hebron University Hospital (Spain) Dr. Manuel Carballo, International Centre for Migration and Health (ICMH) Prof. Antonio Craxi, University of Palermo (Italy) Prof. Pierre van Damme, Viral Hepatitis Prevention Board & University of Antwerp (Belgium) Prof. Gamal Esmat, Cairo University Medical School, (Egypt) Dr. David Goldberg, Health Protection Scotland Centre for Virus Research, Glasgow (Scotland)

55 Members (continued) Prof. Harry Janssen, Rotterdam Erasmus University Medical Center (Netherlands) Achim Kautz, European Liver Patients Association (ELPA) (Germany) Prof. Patrick Marcellin, University of Paris (France) Prof. George Papatheodoridis, Athens University Medical School (Greece) Prof. Howard Thomas, Imperial College (UK) Prof. Mark Thursz, Imperial College (UK) Nurdan Tozun, Acibadem University (Turkey) Heiner Wedemeyer, Hannover Medical School (Germany) Affiliated Members Nikos Dedes, NGO Positive Voice (Greece) Corporate Secretary Marilyn Clark

56 Implementation of Call to Action (1) 1) National events to promote the Call to Action 2) Scientific publications to promote Hepatitis Public Policies (Hatzakis A et al, JVH 2011) 3) Preparation of educational and promotional material (A. Hatzakis, H. Janssen) 4) Newsletter (M. Colombo). 5) Working Group on Migration and HBV/HCV policies (M. Carballo)

57 Implementation of Call to Action (2) 6) Working Group on Hepatitis and Millennium Development Goals (H. Thomas, C. Gore) (Meeting, December 22, 2011, London, UK). 7) Summit Conference for Mediterranean, Balkan and FSU countries (December 5-7, 2012, Nicosia, Cyprus). 8) Meeting on the cost-effectiveness for HBV/HCV screening (in collaboration with VHPB and ECDC) (2013). 9) Ongoing dialogue with European and International Institutions (EU Parliament, Health and Research Commissioners, DG Sanco, DG Research, ECDC, EMCDDA, WHO-Europe) in collaboration with EASL and ELPA.

58 Panel 1: WHO Framework for Global Action on Viral Hepatitis The Framework for Global Action has four domains: Axis One: Increase engagement through awareness, partnerships and mobilizing resources Axis Two: Evidence-based policy and data for action Axis Three: Prevention of virus transmission by the promotion of vaccination and behavioural and structural interventions Axis Four: Screening, care and treatment; develop guidelines and advocate and negotiate for price reductions for treatment, assist countries in developing national strategies. A Hatzakis et al. JVH 2013

59 WHO s Global Hepatitis Programme launched on World Hepatitis Day 2012 Prevention and Control of Viral Hepatitis Infection: Framework for Global Action. This sets out four axes for action: 1. Partnership, mobilization and communication 2. Data for policy and action 3. Prevention 4. Screening, care and treatment.

60 Axis 1 WHO s Global Hepatitis Programme 1. Involve all sectors of society in the fight against hepatitis B and C organize technically backed briefings for senior policy makers in all government sectors work with all stakeholders to mobilize the necessary funding to implement the action plan involve non-governmental organizations representing key risk groups in decision making 2. Place the fight against hepatitis B and C in a Right to Health framework adopt and use human rights approaches that have been developed in HIV/AIDS link human rights approach to public health principles and health benefits ensure that those living with hepatitis B and C are aware of their rights 3. Actively participate in World Hepatitis Day work with experts, civil society and healthcare providers to raise hepatitis awareness create public health campaigns around the impact of hepatitis B and C on health take all necessary measures, including legislation, to tackle stigma and discrimination

61 Axis 2 WHO s Global Hepatitis Programme 4. Improve awareness of the health and economic impact of hepatitis B and C develop robust national databases on hepatitis B and C and liver cancer emphasize hepatitis B and C in all medical and nursing education curricula make policy makers more aware of the economic impact of untreated hepatitis B and C 5. Strengthen surveillance of hepatitis B and C in all countries in these regions promote routine centralized hepatitis reporting with standardized case definitions promote national and inter-country use of standard routine surveillance protocols monitor and evaluate the effectiveness of prevention and control interventions 6. Build inter-country research capacities dedicated to hepatitis B and C promote and fund research on epidemiology and factors affecting hepatitis B and C promote and fund research on ways of preventing and managing hepatitis B and C promote and fund collaborative inter-country research using common protocols

62 Axes 3 & 4 WHO s Global Hepatitis Programme 7. Make prevention of hepatitis B and C a central part of public health action ensure high coverage of universal neo-natal HBV vaccination, especially birth dose ensure HBV vaccination of healthcare workers and other risk groups develop tailored initiatives for injecting drug users and other special risk groups 8. Invest in better case detection and treatment programmes in primary health care develop protocols on case detection and contact prevention for PHC develop special training programs for PHC staff based on standardized new protocols ensure referral for people who need to be seen at a secondary or tertiary level 9. Develop out-reach programmes to ensure more voluntary counselling and testing develop/adapt voluntary counselling and testing (VCT) protocols and train national staff identify ways of encouraging/incentivising high risk people to be tested, including screening ensure that policies on hepatitis B and C VCT include access to and retention in treatment

63 Axes 3 & 4 (continued) WHO s Global Hepatitis Programme 10. Explore innovative ways of reaching all vulnerable and underserved groups identify the most vulnerable groups and their barriers to healthcare, including migrants give special attention to groups with highest rates of transmission and burden of disease ensure equity of access to hepatitis prevention and control measures 11. Ensure universal access to treatment strengthen treatment policies and health systems capacities in treatment adopt international guidelines and recommendations on treatment train healthcare providers in hepatitis B and C management 12. Create community based programmes for people living with viral hepatitis assess the needs of people living with hepatitis B and C, especially vulnerable groups train and support community based groups to improve living with hepatitis B and C ensure the integration of community based groups into the national action plan

64 J Viral Hepat., 2013

65 LESSONS FOR SUCCESS FROM THE DEVELOPMENT OF NATIONAL AND REGIONAL HEPATITIS STRATEGIES AND RESPONSES (1) At both international and national levels, viral hepatitis is cross-cutting it will involve people working across a variety of disciplines and services to come together as problem-solving teams in order to address complex systemic problems. Collaboration and involvement of all stakeholder groups has proved successful in influencing government to give greater priority to viral hepatitis in a wide range of European and countries at all levels of economic development. Patient associations have proved highly influential political actors in several countries and at EU level; support for the development of patient advocacy is a key element in the promotion of wider access to hepatitis diagnosis and treatment. The generation of evidence through research has been critical in making the case for scaling up hepatitis treatment in countries that have taken the boldest steps towards expanding screening and treatment; a greater emphasis on advocacy for enhanced research support at the national and international levels is needed. A Hatzakis et al. JVH 2013

66 LESSONS FOR SUCCESS FROM THE DEVELOPMENT OF NATIONAL AND REGIONAL HEPATITIS STRATEGIES AND RESPONSES (2) Development of independent national guidelines on treatment which adopt international standards also acts as a form of pressure on governments. Comparative `benchmarking` of national performance through independent audits, such as the Hepatitis Care Index developed by the European Liver Patients Association, can also act to raise standards and generate debate. A consistent framework is needed for disaggregating and tracking resource allocations at country level in order to monitor performance. Opportunities to leverage health system resources to support viral hepatitis services should be examined. For example, given the high rate of HIV and HCV coinfection, how can HIV-related infrastructure be used to improve hepatitis care? A Hatzakis et al. JVH 2013

67 Conference for Hepatitis B and C in the Mediterranean and Balkan Countries: Call to Action (1) Endorsed by: Takis Hatzigeorgiou MEP Stephen Hughes MEP Alojz Peterle MEP Viral Hepatitis Prevention Board European Association for the Study of the Liver European Liver Patients Association World Hepatitis Alliance International Centre for Health, Migration and Development Hepatitis B and C Public Policy Association.

68 Conference for Hepatitis B and C in the Mediterranean and Balkan Countries: Call to Action (2) The Steering Group of the Conference on Hepatitis B and Hepatitis C in Mediterranean and Balkan Countries, together with its partner associations, calls on the countries of these regions to create national viral hepatitis strategies and action plans and, in particular, to: 1. Involve all sectors of society in the fight against hepatitis B and C 2. Place the fight against hepatitis B and C within a Right to Health framework 3. Actively participate in World Hepatitis Day 4. Improve awareness of the health and economic impact of hepatitis B and C 5. Strengthen surveillance of hepatitis B and C 6. Build inter-country research capacities dedicated to hepatitis B and C

69 Conference for Hepatitis B and C in the Mediterranean and Balkan Countries: Call to Action (3) The Steering Group of the Conference on Hepatitis B and Hepatitis C in Mediterranean and Balkan Countries, together with its partner associations, calls on the countries of these regions to create national viral hepatitis strategies and action plans and, in particular, to: 7. Make prevention and control of hepatitis B and C a key part of public health action 8. Invest in better case detection and treatment programmes in primary health care 9. Develop outreach programmes to ensure more voluntary counselling and testing 10. Explore innovative ways of reaching all vulnerable groups, including migrants 11. Ensure universal access to treatment 12. Create community-based programmes to support people living with viral hepatitis

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