ASIA & VIRAL HEPATITIS

Transcription

1 meeting report ASIA & VIRAL HEPATITIS learning from china to enhance prevention & control efforts in asia hong kong april 28, 2010 convened by the asia and pacific alliance to eliminate viral hepatitis

2 Mission To create a sustainable coalition of public and private partners to eliminate the transmission of viral hepatitis infection and reduce the complications of chronic viral hepatitis infection by identifying and addressing the gaps, and sharing best practices through Advocacy Collaboration Education meeting report ASIA & VIRAL HEPATITIS Learning from China to Enhance Prevention and Control Efforts in Asia Hong Kong April 28, 2010 Convened by the Asia and Pacific Alliance to Eliminate Viral Hepatitis (APAVH) Printed and distributed by: Asia and Pacific Alliance to Eliminate Viral Hepatitis (APAVH) Palo Alto, California, USA

3 table of contents welcome John Ward apavh overview Samuel So new who resolutions & initiatives Steven Wiersma update on wpro regional goals & certification Karen Hennessey & Andy Hall epidemiology of viral hepatitis in china Hui Zhuang successful strategies & remaining challenges in birth dose & hep B coverage in china Liang Xiaofeng evaluation plans for gavi project in china & children s catch-up vaccination Cui Fuqiang impact of hep a use on disease incidence in china Cui Fuqiang hepatitis b in china: epidemiology, prevention & care accessibility Jidong Jia world health organization consultation on management of hbv in china Yvan Hutin & Lisa Cairns building partnerships with the provincial health department Yan Wang & Fengsheng Ding building partnerships with multinational companies in china Jean Wu & Stephen Maloy building partnerships with foundations Wangsheng Li panel discussion conclusion meeting agenda participants special thanks

4 apavh meeting The meeting Asia and Viral Hepatitis: Learning from China to Enhance Prevention and Control Efforts in Asia was held on Wednesday, April 28, 2010 in Hong Kong by the Asia and Pacific Alliance to Eliminate Viral Hepatitis (APAVH). Objectives To examine the successes and challenges of hepatitis B prevention and control activities that demonstrate China s leadership role in the Western Pacific Region; and To determine how APAVH can provide support and contribute to the efforts to meet control and elimination goals for hepatitis B in the Western Pacific Region. welcome: John Ward Dr. John Ward, Director of the Division of Viral Hepatitis at the US Centers for Disease Control and Prevention (CDC), opened the meeting on behalf of the Asia and Pacific Alliance to Eliminate Viral Hepatitis (APAVH). Dr. Ward welcomed participants to the APAVH Meeting in Hong Kong and thanked them for taking the time to share their expertise on improving hepatitis B control and prevention through immunization and treatment. Dr. Ward reflected that the goal of the meeting was to examine how APAVH works to meet control and elimination goals 4 for hepatitis B that were set by the Western Pacific region. Dr. Ward noted that resources dedicated to hepatitis B prevention and control are disproportionate as compared to scope of problem in Asia. In order to have maximum impact, governments and organizations need to work together to form a network of reliable, valuable partners; an alliance like APAVH provides a forum that certain groups often have problems accomplishing alone. A non-governmental partnership can bring more difficult issues to the forefront of discussion, such as stigma, and provide more resources for partnerships. Dr. Ward also acknowledged that China has made remarkable progress in achieving the hepatitis B regional goals set by the Western Pacific Regional Office (WPRO). China, with the largest burden of chronic hepatitis B prevalence, made significant achievements in infant vaccination. Dr. Ward s welcome set a positive tone to the meeting, which continued to examine China s leadership and success in hepatitis B control and prevention in the region. Dedicate resources to hepatitis B prevention

5 executive summary Following a welcome from Dr. John Ward of the US Centers for Disease Control and Prevention (CDC), Dr. Samuel So of the Asian Liver Center at Stanford University emphasized the importance of mounting a comprehensive global hepatitis B prevention, awareness and treatment initiative, given that 41 countries alone account for 76% of the burden of the disease. This meeting was held to examine the successes and challenges of hepatitis B prevention and control activities that demonstrate China s leadership role in the Western Pacific and to determine how APAVH can contribute support and efforts to the hepatitis elimination goals of the Western Pacific. On a national level, China has shown much success in integrating hepatitis B into routine immunization programs they now have more available and accessible medicine, evidence based guidelines for treatment, and clinical pathways with early attempts at healthcare reform. However, there continues to be many issues to address, namely the availability and dissemination of treatment guidelines, financial access to healthcare, and the quality and safety of medicine. China also needs to focus more on increased screening for HBsAg and the administration of HBIG for infants born to HBsAg positive mothers, increased hospital delivery, and vaccination to high risk populations. China does not currently have a plan to reach remote areas outside of cold chain use, so working to train village doctors will also further global eradication of Hepatitis B. Given the scope of the problem in Asia, the current resources allocated to hepatitis B prevention are not enough. The World Health Organization (WHO) is willing to help develop an overall strategy for management of HBV infection in China. They have proposed a pilot project to assess the diagnostic and surveillance practice of one province. In fulfilling APAVH s mission to create a sustainable coalition to eliminate the transmission of viral hepatitis, it is also necessary to forge new partnerships with provincial health departments, multinational companies, and foundations. Collaborations with provincial health departments such that the Asian Liver Center has created with the Shandong Province Department of Health and with foundations such as the ZeShan Foundation all support the multi-prong strategy in eradicating hepatitis B on a global level. Strong connections with multinational companies are also essential in China, HBV carriers face significant discrimination at work and at school due to misunderstandings of how the disease can be spread. Despite a new law attempting to alleviate existing discriminating problems, the stigma still remains. Relationships with multinational companies will be useful in improving public awareness and interest in screening and vaccination. The meeting ended with a panel discussion addressing possible improvements to gaps and challenges in eliminating new transmission of viral hepatitis and reducing complications such as liver cancer. Further discussed was the role of APAVH in the current situation, including but not limited to promoting vaccination programs where they are not already established, facilitating access to treatment and insurance coverage, developing necessary funds and resources, extending communications with important government connections, and advocating hepatitis eradication through forums on the country level. Overall, despite the success and leaping improvements that the committee has made thus far, it is recognized that there continues to be a wide array of obstacles to overcome in the path towards global eradication of hepatitis B. With the developments of further advocacy, collaboration, and education, we can work to effectively improve the lives of citizens across the globe. 5

6 presentations Presentations from distinguished professors and public health officials discussed the current practices and advances on hepatitis prevention and control in China apavh overview Samuel So Dr. Samuel So, Director of the Asian Liver Center at Stanford University and Executive Secretary of the Asia and Pacific Alliance to Eliminate Viral Hepatitis (APAVH) provided an overview of APAVH to meeting participants by presenting background data highlighting the global burden of viral hepatitis, especially in the Western Pacific and South East Asia regions and by demonstrating the necessity to mount a comprehensive global hepatitis B prevention, awareness and treatment initiative. Hepatitis B and C are among the leading causes of preventable deaths in the world, but elimination of hepatitis B is feasible since there is an effective vaccine, and appropriate antiviral treatment of chronic viral hepatitis can reduce the associated risk of liver disease. The adoption of safe injection and transfusion practices in the healthcare settings can prevent each year an estimated 21 million new HBV infections and million new HCV infections. Worldwide, 1 in 12 people are living with chronic hepatitis B or C infections (350 million with chronic HBV, and 170 with chronic HCV), which is over ten times higher than those living with HIV/AIDS. Hepatitis B and C cause 78% of hepatocellular carcinoma and 57% of cirrhosis, and approximately a million deaths a year. While the hepatitis B vaccine is called the first anti-cancer vaccine, a term coined by the World Health Organization in 1981, many people continue to get infected 6 because they are not vaccinated. In 1992, WHO set a goal that by 1997, all countries would integrate infant HBV vaccination into their infant immunization programs; however, by 2001, only sixty-six percent of member countries had infant HBV immunization programs. In addition, many people are dying because they are not being treated. There is no global initiative to provide affordable antiviral treatment for chronic viral hepatitis, and no Global Fund or major foundation interest in supporting programs that lead to the elimination and control of viral hepatitis. Recently, the Institute of Medicine (IOM, US) released its 2010 IOM Report on viral hepatitis and liver cancer, which identified that morbidity and mortality related to hepatitis B and hepatitis C was a direct result of lack of public, provider and policy makers awareness about the extent and seriousness of viral hepatitis. As a result, there is a lack of public and private resources allocated to the prevention, education and treatment of chronic viral hepatitis Dr. So points to the fact that unlike HIV/AIDS or breast cancer, there is virtually no global celebrity that help to raise funds to fight viral hepatitis or liver cancer.

7 Asia and Pacific Alliance to Eliminate Viral Hepatitis (APAVH) Regional initiative First anti-cancer vaccine; save lives The WHO s Western Pacific and South East Asia regions have the greatest burden of chronic HBV infection in the world with 41 countries accounting for seventy-six percent of the burden of disease. Some of the challenges in HBV prevention and control in the region include, timely birth dose, GAVI funding for monovalent hepatitis B vaccine ending in 2010, providing nationwide free catch-up vaccination for unvaccinated children and healthcare workers, routine screening of pregnant women for HBsAg, providing newborns to HBsAg positive women hepatitis B immune globulin in addition to hepatitis B vaccine at birth, employee health plans might not cover antiviral treatment for chronic infection, no access to affordable antiviral drug treatment, and no regional or national campaigns to raise hepatitis B awareness or education. The Asia and Pacific Alliance to Eliminate Viral Hepatitis (APAVH) is a regional initiative that was launched in November 2008 working towards the goal of eliminating the transmission of viral hepatitis infection and reducing the complications of chronic viral hepatitis infection. The mission of APAVH is to create a sustainable coalition of public and private partners to eliminate the transmission of viral hepatitis infection and re- Advocate. duce the complications Collaborate. of chronic Educate. viral hepatitis infection by identifying and addressing gaps, and sharing best practices through ACE: Advocacy Collaboration Education Dr. So gave examples of the impact of past successful public and private partnerships notably that of GAVI in increasing access to hepatitis B vaccines for the GAVI eligible countries, and in the Philippines and China spearheaded by the Asian Liver Center. For example, private donations and government collaboration helped to bring the largest free catch-up hepatitis B vaccination for the approximately 600,000 unprotected school children in the entire province of Qinghai, China between The success of the program led to the Chinese government in 2009 to scale up the program nationwide to provide free hepatitis B vaccination for the approximately 85 million unvaccinated children under the age of 15 years. APAVH became the first hepatitis program endorsed by the Clinton Global Initiative, Asia, and received seed funding from the Zeshan Foundation, a non-profit family foundation in Hong Kong. Working in partnership with the WHO, Geneva and Western Pacific Region, APAVH is helping to fund a full time WHO position in the region that focus on viral hepatitis. APAVH was invited to participate in the WPRO TAG meeting in Manila and the GAVI partners meeting in Hanoi in 2009, and the WHO Global Immunization Meeting in Geneva in Laos has been identified as one of the countries that is lagging behind in meeting the regional hepatitis B immunization goals. At the invitation of WPRO and Laotian Ministry of Health, APAVH visited Laos in 2010 and is working to develop an awareness national campaign to promote infant and hepatitis B immunization. Another APAVH project is working in collaboration with the Shandong provincial health department on the development, implementation, and evaluation of a model hepatitis B prevention and control education and training program. 7

8 ACE: Advocacy Collaboration Education COMPREHENSIVE STRATEGY TO PREVENT & CONTROL HEP B: Eliminate transmission to unprotected persons Vaccination (newborns, healthcare workers, catchup vaccination for children and adults) Safe injections and blood banking Eliminate stigma and discrimination Education Legislation Reduce complications of chronic infection Early detection Access to affordable medical management 8

9 new WHO resolutions & initiatives Steven Wiersma Dr. Steve Wiersma, Medical Officer and Hepatitis Focal Point at the World Health Organization (WHO), updated participants on the status of WHO viral hepatitis initiatives and discussed the new WHO Resolution and recent actions. In January 2009, Brazil requested that the World Health Assembly (WHA) take action on viral hepatitis at the WHO Executive Board. In October 2009, the WHO Eastern Mediterranean Regional Office (ERMO) Regional Committee passed a Resolution. 1 In January 2010, the WHO Executive Board was again asked to develop a comprehensive approach to viral hepatitis with a new focus on screening and treatment for chronic viral hepatitis. The Resolution was introduced by Brazil, Columbia, Indonesia, and was adopted by Executive Board Members. 2 In May 2010, the sixty-third WHA passed the WHO Executive Resolution will raise global awareness of World Hepatitis Day, which is scheduled for July 28, 2011, and provide support for the development of comprehensive strategies, surveillance, safe injection, screening diagnosis, affordable treatment and tools for developing countries. 3 The Resolution calls for global awareness through World Hepatitis Day; comprehensive strategies and time-bound goals; strengthened disease surveillance; prevention tools, including safe injection and blood safety and immunization; screening, diagnosis and treatment that is integrated, cost-effective and affordable; and a tool for developing country situations. Moving forward, WHO needs to develop a partnership program and mobilize more resources and garner further attention for viral hepatitis. WHO must respond to the needs of patients and Member States with a clear mandate from the WHA. WHO is currently working on a hepatitis atlas to organize and track hepatitis policies and activities in different countries. Now that viral hepatitis is on the agenda, the vast majority of country governments consider it an urgent public health issue. While the majority (70%) of countries report having policy and goals in place, many policies may only be a handful of unconnected programs. Dr. Wiersma reported that sixty percent of countries with goals want assistance from WHO in this area. Governments want to tackle viral hepatitis, but they need help. 4 In addition, WHO will include surveillance in its hepatitis atlas. Eighty-two percent of countries report having surveillance in place, however, only one-third of countries have no prevalence data available. Sixty-nine percent of member countries request WHO assistance with surveillance and tools to assess the effectiveness of interventions is the most widely request form of WHO assistance (from approximately 75% of countries). Dr. Wiersma reflected that therefore, surveillance needs strengthening. 4 Dr. Wiersma also demonstrated the need for strengthening prevention. While ninety-five percent of countries have a hepatitis B immunization policy, mostly for infants, only half of them have an immunization policy for at-risk groups. Eighty-two percent of countries report that they have a strategy to preventing infection in healthcare settings; however, there are still 6.7 billion unsafe injections and 23 million new viral hepatitis infections each year from unsafe injections. In addition, 6 million units of blood are not screened for hepatitis B. 4 The availability of screening varies substantially across the world. Forty percent live in countries where screening is accessible to less than fifty percent of the population. More than half of the population lives in countries with no provision for free testing. Four out of five low income countries and almost one in three high income countries would welcome assistance to increase access to treatment. Therefore, Dr. Weirsma reflected that most patients are undiagnosed and untreated. Questions were raised after the presentation about the outcome of the WHO Resolution. Dr. Wiersma responded that unfortunately, the WHO will currently not be able to take on any new programs because of the recent economic crisis, but with pressure and a strong call for progress, the WHO will be required to take further action in the future, which could include meetings and new reports. In addition, the question of who participants need to put pressure on was raised. Dr. Wiersma observed that for years hepatitis B has been a side show that was very much disconnected within WHO. If countries do wan WHO the assist them, they too much be willing to contribute resources. One participant observed that this might be an opportunity for collaboration with HIV/ AIDS groups and resources. 1. The growing threats of hepatitis B and C in the Eastern Mediterranean Region: a call for action. Regional Committee for the Eastern Mediterranean, World Health Organization. October EMRC56R5.pdf. 2. Viral hepatitis. Sixty-Third World Health Assembly, World Health Organization. 23 January apps.who.int/gb/ ebwha/pdf_files/eb126/b126_r16-en.pdf 3. Viral hepatitis. Sixty-Third World Health Assembly, World Health Organization. 21 May apps.who.int/gb/ebwha/ pdf_files/wha63/a63_r18-en.pdf 4. Global Hepatitis Update World Health Organization. 9

10 routine immunizations for newborn certification of control Drs. Karen Hennessey and Andy Hall observed that immunization is one of multiple strategies to prevent and control hepatitis B. The primary prevention of hepatitis B transmission is through routine or universal immunization of infants, catch-up immunization of children born before vaccine introduction, and targeted immunization of high risk adults, safe blood banking, and safe injection practices. The secondary form of prevention is through treatment. They noted that successful childhood immunization programs have had a significant impact by protecting infants and children who are most susceptible to become chronically infected. In addition, successful childhood immunization programs have significant impact for countries because once countries achieve good vaccination coverage, it rarely declines, and that over time, these cohorts will turn into generations of people protected against chronic hepatitis B infection. In the Western Pacific Region, hepatitis B seroprevalance in almost all countries was greater than eight percent before vaccine introduction in The Western Pacific Regional Office (WPRO) set an interim regional goal that all countries have a less than two percent chronic infection among five year old children by 2012, with a plan to adopt a goal of less than one percent in the future. 1 The strategic areas for 2012 hepatitis B control in the Western Pacific include achieving high immunization coverage, documenting the impact through serosurveys, certification of control, and through advocacy and social mobilization. update on WPRO regional goals & certification Karen Hennessey Drs. Hennessey and Hall updated participants on evaluating immunization programs by setting guidelines for the most effective and most efficient practices. For the first time, the World Health Organization (WHO) has set targets for certification of control, which stresses an ongoing commitment to viral hepatitis control. 2 There remains a need to demonstrate good coverage and ongoing coverage. After certification, efforts must be maintained and made even better through advocacy and social mobilization. There are eight countries within WPRO that seem to have good immunization coverage and need to apply for certification. During the discussion, a question was raised about how China views the certification process. The major issue identified with the certification process is that if China reaches the certification standard, then there is the potential for the government to reduce the resources for hepatitis B control. Even though China has reached certain milestones in reducing HBsAg prevalence in young children, it still needs more resources for control. Another question was raised about countries following up with serologic surveys rather than just going with coverage rates to reach the goals. The guidelines say that there needs to be validation with coverage. Countries are interested in conducting serologic surveys, especially if they can use it as advocacy tool to understand where they are and how close to the target they may be. Interest in serologic surveys are not a barrier; however, resources and technical assistance will need to be mobilized. & Andy Hall IMMUNIZATION IS ONE OF MANY STRATEGEES TO PREVENT AND CONTROL HEPATITIS B: PRIMARY PREVENTION immunization infants children born before vaccine introduction high-risk adults safe blood banks safe injections SECONDARY PREVENTION treatment REGIONAL UPDATE: PRIORITY COUNTRIES countries that have not yet achieved the immunization coverage needed to meet the hepatitis B control goal 5 large countries (CAM, LAO, PNG, PHL, VTN) 5 PIC (FSM, KIR, SAM, SOL, VAN) KEY ACTIVITIES implement strategies to improve routine immunization implement strategies to reach non-facility births for birth dose coverage conduct awareness and training on birth dose advocacy and education on the importance and impact of hepatitis 1. Western Pacific Regional Plan for Hepatitis B Control through Immunization. Regional Office for the Western Pacific. World Health Organization. Manila, Philippines, December Accessed on July Guidelines for Certification of Achievements of Hepatitis B Control Goal in the Western Pacific Regions. Regional Office for the Western Pacific. World Health Organization. Manila, Philippines, April Accessed on July

11 epidemiology of viral hepatitis in china Hui Zhuang Dr. Hui Zhuang provided an extensive review on the epidemiology of viral hepatitis in China. The incidence of hepatitis A has significantly decreased in all age groups since 1993, after the introduction of the Hepatitis A vaccine. When the vaccine was introduced, incidence was as high as 80/100,000 persons in the group 5 9 years of age and 70/100,000 persons in the group 0 4 years of age. By 2007, all age groups in almost all provinces saw incidence drop to under 20/100,000 persons. The number of vaccine doses used has risen from approximately 10 million to more than 20 million. 1 Prevalence of chronic hepatitis B infection nationally has also declined from nearly 10% in 1992 to just over 7% in 2006 largely due to the drop of chronic infection in children due to immunization efforts. 2,3 All provinces have seen declines in prevalence with some provinces dropping as much as five percent. 4 Infection rates among children under 15 have seen declines by as much as 10% and perinatal and horizontal transmissions have decreased from nearly 10% to less than one percent. 4 Acute hepatitis B infection has dropped from 20/100,000 persons in 1990 to less than 5/100,000 in Prevalence of hepatitis C has also decreased for a number of reasons including blood donor screening, use of auto-disable syringes and public education. The incidence of hepatitis E has maintained a low level during the last 10 years in China. Decrease in prevalenc perinatal transmission, horizontal transmission viral hepatitis in china During the discussion, questions were raised about reports of acute hepatitis B infection increasing in adults. Dr. Hui dismissed this notion since the data is most likely representing a mix of acute and chronic infection. According to Dr. Hui, efforts are underway in China to better define acute and chronic hepatitis B infection. 1. Cui FQ, et al. J Epidemiol 2009;19(4): WHO. Available at: 3. Xia GL, Liu CB, Cao HL, et al. Prevalence of hepatitis B and C virus infections in the general Chinese population. Results from a nationwide cross-sectional seroepidemologic study of hepatitis A, B, C, D, and E virus infections in China, International Hepatology Communications 1996;5: Dai ZC, Qi GM. Beijing: Sci Tech Literature Publishing House, 1997: Liang X, et al. J Infect Dis 2009; 200: Gong XH, et al. Chin J Hepatol (Chin) 2003; 11:

12 STRATEGIES successful strategies and remaining challenges in birth dose of hepb 3 coverage in china Liang Xiaofeng 12 increase in hospital delivery improve availability of vaccine build bridges between delivery service (material and child health) and vaccination service (epi) increase the awareness on importance of timely birth dose among providers and parents intensify training supervision and monitoring subsidy to village doctors Financial incentives, hospital births, hepatitis training Dr. Liang Xiaofeng, Director of the National Immumization Program at the China Centers for Disease Control, discussed how endemic hepatitis B virus infection has long been a serious health problem in China. With a national prevalence of HBsAg of 9.8% in 1992 and perinatal transmission accounting for a large number of cases, China has made strong efforts to establish universal infant immunization. Dr. Liang presented on the successful strategies implemented in China that have resulted in steadily increasing birth dose and 3 dose coverage between 1992 and ,2,3 Reaching births at home and in the migrant population is essential in birth dose coverage in China. Because of financial incentives for delivering in county hospitals, China has seen an increase in hospital births and thus, increased coverage. In 2006, a national serosurvey was conducted to evaluate the progress in the prevention of hepatitis B in China. 4 Participants were selected through multistage random sampling and interviewed by trained staff to collect demographic information and immunization history. Results showed steadily increasing birth dose and 3 dose coverage, resulting in decreasing HBsAg prevalence in children. China has made great achievement in integrating HepB into routine immunization programs, resulting in high immunization coverage and timely birth dose. Next steps for China includes increased screening for HBsAg and administration of HBIG for infants born to HBsAg positive mothers, increased hospital delivery, and focus on vaccination to high risk populations such as university students, soldiers and families in urban areas who live in crowded conditions. During the discussion, questions were raised about addressing and reaching the remote rural populations to improve birth dose administration, especially for those giving birth at home. Dr. Liang reflected that China does not currently have a plan to use hepatitis B vaccine outside the cold chain in the remote area; however, if village doctors are properly trained and educated then they can give the birth dose immediately at home. Participants expressed that they were impressed with the way China has handled moving births from home into facilities to increase coverage. Dr. Liang also notes that there is a financial incentive to give birth in a county hospital, which is reflected in the very high percentage of births in hospitals. In addition, a question about text messaging was raised; it is not an effective means of communication since it is not encouraged. 1. Ministry of Health. National plan for hepatitis B control and treatment in 2006 to 2010 [Chinese]. Beijing, China: Ministry of Health; January 28, Xiaofeng Liang, et al. Evaluation of the Impact of Hepatitis B Vaccination among Children Born during in China. Journal of Infectious Disease, 2009, 200 (1): Xiaofeng Liang, et al. Epidemiological serosurvey of Hepatitis B in China Declining HBV prevalence due to Hepatitis B vaccination. Vaccine, 2009, 27: Cui FQ et al. Progress in Hepatitis B Prevention Through Universal Infant Vaccination China, MMWR. 11 May 2007/56(18); Access on 27 July 2010.

13 Dr. Cui Fuiqiang from the National Immunization Programme at the China CDC provided an overview of the evaluation plans for the GAVI Project (GAVI Global Alliance for Vaccines and Immunization) in China, and catch-up vaccination in children. With a population of 1.3 billion and a birth rate of twelve percent, China has a birth cohort of 16 million annually. Many economic disparities exist within the population, especially in the western and central provinces; 699 million people live in rural areas with average per capita incomes of less than 2USD per day, and among them 346 million people have an average per capita income of less than 1USD per day. Dr. Cui noted that an estimated 263,000 people die each year due to the chronic complications of hepatitis B. Government Investment Evaluation plans for gavi projects in china & children s catch-up vaccination Cui Fuqiang In 1992, when the hepatitis B vaccine was introduced, 120 million people had chronic HBV infection, which accounted for 9.75 percent of the population. The hepatitis B vaccine was integrated into China s Expanded Program on Immunization (EPI) in 2002 in collaboration with GAVI. Four years later in 2006, 93 million people were chronically infected, which was determined by the prevalence of HBsAg at 7.2 percent. Dr. Cui discussed the GAVI Project that was started with the China Ministry of Health in Its objectives are to accelerate integration of the hepatitis B vaccine into EPI and ensure immunization injection safety. Goals of the GAVI project are to achieve 85% HepB3 coverage in all counties, 75% HepB1 on-time administration in all counties and provide all immunization injections with auto-disable syringes. This 5 year project was eventually extended to 7 years with an investment of $76 million evenly divided between the China government and GAVI, with additional financial assistance from provincial governments. The collaboration between the China MOH and GAVI reached 470 million people and 1,302 counties in the twelve Western Provinces and two of the poverty counties in the Central Provinces., GAVI funding provided for the purchase of hepatitis B vaccine for all infants and the purchase of auto-disable (AD) syringes for all immunization injections. Strategies in the GAVI Project included education, public awareness, training, surveillance, and monitoring, encouragement of women to deliver in hospitals, promotion of coordinated efforts between the MCH and EPI at local levels, and connection of new rural cooperation medical care reform and projects on the elimination of neonatal tetanus. The Central Government continues to enlarge EPI since 2007 by providing funds to vaccinate all 16 million eligible children nationwide. In 2009, a catch-up campaign was implemented for children born between 1994 and 2001, essentially for the estimated million unvaccinated children under 15 years of age. Evaluation of both these projects has been proposed. The GAVI project will be evaluated internally and externally, with a technical evaluation involving international and national organizations. Evaluation of the catch-up vaccination program will include measures of economic and sociologic benefits, as well as a literature review, field investigation and policy analysis. Though introduction of the hepatitis B vaccine into the national immunization program was successful, challenges in immunization, eliminating stigma, and access to affordable treatment of chronic HBV infection still remain in China. 1. Xiaofeng Liang, et al. Evaluation of the Impact of Hepatitis B Vaccination among Children Born during in China. Journal of Infectious Disease, 2009, 200 (1): Summary Report: GAVI Board Teleconference. Global Alliance for Vaccination and Immunization. 25 September Accessed 28 July Cui FQ et al. Progress in Hepatitis B Prevention Through Universal Infant Vaccination China, MMWR. 11 May 2007/56(18); mmwr/preview/mmwrhtml/mm5618a2.htm Access on 27 July GAVI and the Vaccine Fund provide a major boost to child vaccination in China. UNICEF. 31 May Accessed on July Chinese Government, GAVI Alliance Announce Dramatic Progress in Hepatitis B Immunisation in China. Global Alliance for Vaccination and Immunization. 25 July press_releases/2006_07_25_en_pr_chinagavihepb.php Accessed on 28 July

14 impact of hep a use on disease incidence in china Cui Fuqiang Dr. Cui Fuiqiang from the China CDC provided an overview the impact of hepatitis A vaccine use on disease incidence in China. During the background section, Dr. Cui noted that hepatitis has been reportable to the National Notifiable Disease System since Hepatitis has been reported separately by virus type since The largest hepatitis A outbreak in the world occurred in Shanghai in 1988 when more than 310,000 persons were infected. While the reported incidence was 55/100,000 in 1990, this number has dramatically decreased to only 3/100,000 in The hepatitis A live attenuated vaccine became available in 1992 with the inactivated version becoming available in Hepatitis A vaccine was recommended and parents and users were charged for vaccination. Although 60 million doses have been administered in the last 15 years ( ), most have been to school age children. In 2007, through the World Health Organization s Expanded Program on Immunization, free vaccination was officially offered for children less than 18 months of age. While the vaccine was mostly given to children, there has been a decline in hepatitis A cases apparent in all age groups. 1 Recently, China has experienced an increase in safety and effectiveness of the vaccine. Several studies showed that both the live and inactivated forms of the vaccine are safe and effective, having rare adverse effects following immunization (AEFI s) and high rates of seroconversion (80 100%). 2,3,4 There is a clear association between vaccination and incidence with a clear decrease in hepatitis A associated with increasing vaccine use and distribution. In addition to vaccination improvements, the risk of having HAV in China has decreased due to changing life styles. 5 However, challenges remain in rural regions where risk factors are not well established, immunization coverage is unknown and hepatitis A diagnosis is not clearly defined. Better monitoring and definition of the at risk population for vaccination are next steps for improvement. After the presentation, suggestions were made to include some prevalence studies so that outbreaks can be isolated and studied to determine underlying causes. Concerns were raised about the overall true effectiveness of the vaccine in other age groups given that the incidence decreased most rapidly in younger age groups targeted by vaccination. Dr. Cui noted that vaccine effectiveness can be hard to discern from natural immunity. He went on to point out that China should be commended from its continued increase in vaccination coverage as standards of living rise. A lack of such coverage has been a problem in other countries. Finally, there was a concern raised about the lack of a World Health Organization Hepatitis A module, making it difficult to receive and confirm data on Chinese vaccines Fuqiang Cui et al, Zhang S et al. Seroconversion occurred at a mean time of 2 to 5 weeks after inoculation, and the positive rate of specific antibody was 95.6%. Zhonghua Yi Xue Za Zhi (12): p , Mao, J.S., et al. No seroconversion was found among nonvaccinees, who had a close contact with their vaccinated classmates nor was it found among administered the vaccine orally. Further evaluation of the safety and protective efficacy of live attenuated hepatitis A vaccine (H2 strain) in humans. Vaccine, (9): p Faridi M, Shah N, Ghosh T, et al. Live attenuated injectable hepatitis A vaccine was immunogenic and tolerable with minimal reactogenecity, in this study of single dose schedule. Safety profile was also satisfactory in the study population. Immunogenicity and safety of live attenuated hepatitis A vaccine: a multicentric study. Indian Pediatr, (1): p Xu, ZY Global Hepatitis A Meeting Xu ZY, Wang X, Li Y, and Wu W. Decline in Risk of HAV in China, a Country with Booming Economy and Changing Life Style. International Vaccine Institute, Seoul, Korea, Fudan University, Institute of Biomedical Sciences, and Centers for Disease Control, Shanghai China. Miami, 30 November vaccinating children targeting risk populations 14

15 china chronic hepatitis b education program medical coverage migrant workers patients with chronic hbv infection: access to care and antiviral treatment in china Jidong Jia Dr. Jidong Jia discussed how China has a predominantly government-run hospital-based medical service system with primary, secondary and tertiary hospital facilities. In most hospitals, infectious disease specialists are treating hepatitis patients, while gastroenterologists, hepatologists, traditional Chinese medicine or integrated medicine doctors treat in some hospitals. Types of medical care vary in the population. Government employees have access to free medical care while enterprise employees and city residents have basic social medical insurance. In rural areas, residents only have access to cooperative medical insurance. During discussion, a question was raised about migrant workers and their coverage. China acknowledges this as a critical problem since migrant workers have different needs, but since it is difficult to implement a universal policy, there is little being done for this population. The China Chronic Hepatitis B Education Program launched a nationwide campaign, sponsored by industries to educate providers about anti-viral treatment. This educational program included an appointed panel of speakers, a formulated set of slides and two rounds of lectures in more than 50 cities. Despite increased awareness, coverage of antiviral treatment remained low with only 20% of patients with chronic hepatitis B receiving therapy, based on a 2004 study by the Chinese Society of Hepatology and Chinese Society of Infectious Diseases. 1 According to data from the China Medical Tribune, the main factor associated with patients not receiving antiviral treatment is cost. 2 Since more than 50% of patients have to pay out of pocket, this poses a major problem for those seeking treatment. Most patients will only pursue 2-3 years of treatment due to high costs and many need more. The medical pay system is beginning to change because reimbursements are beginning to include antiviral drugs. However, these are just recommendations and cities and provinces will determine the out of pocket costs of antiviral treatments or whether they are able to cover part or all the costs based on their budgets. Plans to address these issues include optimization of vaccination strategy, improving diagnostic tests, optimization of HBV therapy and optimization of treatment of liver failure. 1. Chen J and Jia JD. Treatment of viral hepatitis in China: better clinical research and improved practice. Chinese Medical Journal, 2009, Vol 122, No. 19: id=lw Accessed on 28 July Interview with Prof. Xishan Hao, President of the Chinese Anti- CancerAssociation and President of the 2010 UICC World Cancer Congress. Chinese Medical Tribune, 21 January World Cancer Congress August 2010, Shenzhen, China. Accessed on 28 July

16 WHO consultation on the management of viral hepatitis Yvan Hutin & Lisa Cairns limited information treatment costs surveillance policy intervention strategies pilot project RECENT PROGRESS ON THE HEPATITIS B AGENDA IN CHINA AGENDA Immunization almost eliminated HBV infection among younger age groups Progress in the area of the former policies of discrimination against HBV infected patients Prevalent burden of chronic infections remaining in older age groups 93 million chronically infected (HBsAg positive) million of those with chronic HBV often will benefit from antiviral treatment A FIRST PRODUCT: PROPOSED PILOT PROJECT IN A CHINESE PROVINCE Access diagnosis and surveillance practices Use of diagnosis tests by clinicians Laboratory practices Surveillance practices Plan of action Sort out acute diseases (identification risk factors) from chronic disease (referral for management) Evaluation for scaling up Follow up on two tracks Management of chronic cases CURRENT ISSUES IN HEPATITIS B MANAGEMENT IN CHINA Patients in need for management Substantial burden for the health system Limited information is available to describe Practices Cost, including out of pocket Outcomes 16 What role for World Health Organization? China has seen great advances in immunizing newborns and younger age groups and establishing standard surveillance practices. However, patients with chronic hepatitis create a substantial burden on the health system. Furthermore, limited information is available on practices and costs. China now has medicines available, evidence based guidelines for treatment, and clinical pathways along with early attempts at healthcare reform. However, problems remain, including availability and dissemination of those guidelines, under and over treatment, and financial access to healthcare. Quality and safety of medicines is also an issue that requires attention. The World Health Organization (WHO) could assist in an overall strategy for the management of HBV infection in China by exploring strategies for disease management, building on current strengths, addressing difficulties, providing policy frameworks, developing intervention strategies, reviewing current diagnosis and management/treatment guidelines, evaluating access to medicine, and assessing monitoring and evaluating clinical practices. 1,2 This was discussed in a WHO consultation in the management of viral hepatitis held in Beijing in Future steps include meeting with the Ministry of Health, identifying a department of the Ministry that could be the primary counterpart for the coordination of the multidisciplinary approach proposes, and developing a costing toolbox for economic analyses. WHO proposes a pilot project to assess diagnostic and surveillance practices in one province. This would allow the creation of an entry point to address management issues, with a natural bridge from the current focus on immunization. Questions concerning false advertising for antiviral medicines and addressing the fear and stigma associated with hepatitis were raised. Discussions centered around the conversation that these medicines were flagged and efforts with the government were being made to put a stop to false advertising. Follow up studies on the experiences of screened patients were underway. The use of antiviral medicines on pregnant women in the hopes of preventing transmission to infants was suggested, but Dr. Hutin responded that the current focus of the government efforts were on (1) increasing the coverage of birth dose and (2) providing more evidence to frame a clearer policy on the use of hepatitis B immune globulin in the prevention of mother to child 1. Meeting Report: WHO consultation on the management of viral hepatitis in China. Western Pacific Regional Office. World Health Organization. Beijing, China. 21 December Lu FM and Zhuang H. Management of hepatitis B in China. Chinese Medical Journal, 2009, Vol. 122 No. 1: 3-4.

17 Building Sustainable Private Public Partnerships Throughout the meeting, many examples of successful partnerships were demonstrated, as was the need for additional partnerships with multinational companies in China, academics and universities, and provincial health departments. The consensus was that building effective partnerships needs to be a done through a multi-prong strategy that leverages new support and creates sustainable synergies between organizations. The sheer scale of the global hepatitis B epidemic means that eradication must be done through a joint effort. 17

18 building partnerships with provincial health departments Yan Wang & Fengshen Ding Improve public health and healthcare providers knowledge and practice Drs. Yan Wang and Fengshen Ding from the Shandong Province Department of Health discussed how a provincial health department can be an influential partner in the regional fight against hepatitis B and liver cancer. Dr. Wang discussed a new collaboration between the Asian Liver Center at Stanford University (ALC) and the Shandong Province Department of Health that aims to reduce transmission of hepatitis B, train and educate health workers, promote vaccination for the unprotected, protect health workers from HBV, especially in rural areas where there are less resources, increase routine checkups of those chronically infected to prevent progression to liver cancer, and produce policy evidence by researching the impact and cost effectiveness of the interventions. According to data from a 1992 national seroepidemiology survey, Shandong Province had a prevalence of chronic HBV infection of 7.2%. This was slightly lower than the national prevalence (9.8%) at the time, but nearly equal to the national prevalence in 2006 (7.3%). 1 Surveillance: Currently, infectious disease registry data in China do not distinguish acute HBV infection from chronic HBV infection, making it difficult to interpret patterns in disease incidence, design targeted publichealth interventions, and evaluate the impact of such programs. In addition, because both acute and chronic infection are usually asymptomatic, reported results do not reflect true incidence. Improvement in the capacity and quality of the surveillance system will be essential in monitoring the progress of the province at closing existing gaps throughout this program and during future interventions. HBV Incidence: Data analysis in Shandong reveals that the reported incidence rate of HBV infection has been increasing dramatically each year from 1990 to Since most of the cases reported were of chronic (lifelong, as opposed to acute/short-term) infection, the data are indicative of when the infection was diagnosed, rather than when the infection occurred. 2 The overall incidence from was 5.4 times the rate during the period of This increasing incidence holds true for all age groups except for the 0-9 year old age group, which saw improvements likely as a result of the 1992 newborn HBV vaccination policy (Figure 1). Although reporting quality might mitigate this dramatic increase, the increasing trend in reported hepatitis B incidence is still clear. The annual incidence of acute and chronic hepatitis B between 1990 and 2007 was 27.3/100,000, with the incidence for males (38.4/100,000) significantly higher than that for females (15.8/100,000). 3 The year -old age group had the highest incidence (49.1/100,000), followed by the and year-old age groups (Figure 2). Low vaccination rates, unsafe injection practices at local clinics, and increased social activities, such as entering higher education, could be contributing toward the high incidence in these groups of young adults (aged 15-29). Although the incidence in those born after 1991 will drop in the future due to successful newborn and catch-up vaccination in Shandong, the fact that catch-up vaccination policies do not cover young people born before 1991 indicates a need to address the young adult population, aged 18-29, who are not covered by this policy. HBV Vaccination Practices: In 2008, the number of newborns in Shandong totaled 925,389, with 256,862 born in cities and 668,527 born in rural areas. In 2007, approximately 99% of the newborns were delivered in hospitals. 4 The province-wide coverage rate that year for administration of the first dose of the hepatitis B vaccine was 98.4%, with 96.9% of those doses administered within 24 hours of birth. 5 Shandong initiated its own province-wide hepatitis B catch-up vaccination program for children under the age of 15 in 2006 and has successfully increased three-dose vaccination coverage from 80% to 90% for children in this age group. Within 3 years, 2 million children received 4 million doses of hepatitis B vaccine. More children may have enrolled in the catch up program if it was free. A randomized sampling survey showed that the current prevalence of chronic HBV infection has dropped to 1.4% in children under the age of 15 and less than 1% in children under the age of 5 in Shandong Province. 6 Still an estimated 43% of young adults aged in China were not protected against HBV (via either vaccination or natural immunity following acute HBV infection), according to 2006 national sero-epidemiology data. 18

19 Thus, as of 2009 (three years later), an estimated 40% of the young-adult population aged years, totaling nearly 47 million individuals, currently needs vaccination. Figure 1. Hepatitis B incidence rate in whole population and age group 0-9 years in Shandong Province 4 Mortality Rates: Adjusted mortality rates due to hepatitis B and liver cirrhosis combined decreased from 17.6/100,000 in 1990 to 4.0/100,000 in Shandong province, most likely due to improved medical technology, while the annual adjusted mortality rate of liver cancer remains stable at around 21/100, Education of chronically infected individuals about the importance of routine monitoring and liver cancer screening, which has been shown to result in earlier diagnosis and reduced mortality, 8 will be fundamental to decreasing the long-term mortality rate of liver cancer. Discrimination: Discrimination against those with chronic hepatitis B is widespread in Shandong, as evidenced by a lawsuit against the discriminatory behavior of hospital staff in a Shandong hospital. Though a new national policy authorized the right of children with chronic hepatitis B to enter kindergarten, it was conditional upon normal liver function. A better policy option would be mandatory vaccination of all children entering kindergarten instead of excluding children with active HBV infection from formal education. Discrimination reduction would be a long-term gain benefitting the large chronically infected population in China. Summary: It is clear that the vaccination of newborns and children 15 years of age or younger has become a successful practice in Shandong. However, more data are needed to determine and, ultimately, improve vaccination practices for newborns of HBsAgpositive mothers. The reported high incidence of HBV infection among yearolds as of 2009 indicates gaps and needs for potential interventions among this target group. In addition to addressing this vulnerable population, the Shandong Province Project will target healthcare providers, per WHO recommendations, as the next priority for immunization. The education of pregnant women about screening and timely vaccination should be addressed to improve rates of HBV infection among future generations. Finally, discrimination policies and practices against those chronically infected with HBV should be adjusted by policy makers and all social sectors, including those in education and business. Therefore, project implementation to reach the target populations of the Shandong Province Project will be split into three phases. Phase 1 will directly focus on health care workers including physicians, nurses, registered health care workers, and students within schools of medicine, nursing, and public health to increase knowledge and awareness, reduce new transmission and improve patient education. Phase 2 will directly target pregnant women through a perinatal educational program to increase knowledge and awareness, improve the timeliness of birth dose and improve the screening of pregnant women. Phase 3 will target the general public to increase knowledge and awareness among Shandong residents at large. Indirectly, through the development and implementation of this program, policy and decision makers within Shandong Province will be reached. All of these target groups will be residents of Shandong Province. Education and Training: The education and training components of the Shandong Province Project will occur during all phases, and are described in further detail below. Throughout all three phases, this strategy will emphasize dissemination of accurate, easily understood information and encouragement of Shandong residents to receive hepatitis B vaccination. All educational information will be developed at acceptable low-literacy levels, adjusted for the direct audience targeted during each of the corresponding phases. Both processes will, in turn, aid in the elimination of discrimination against those chronically infected with hepatitis B by dispelling misconceptions, as well as reducing fear of infection. Activities within this strategy will include development of training and education programs for current and future health care providers, the main target audience in Phase 1. In addition to general hepatitis B and liver cancer awareness, these programs will focus on needle and injection safety as well as patient education techniques. This education will parallel efforts to improve the health care Figure 2. Trend of hepatitis B incidence by year interval ( ) in Shandong Province 4 system through capacity building of healthcare workers, improved community-based management, and establishment of information systems and infrastructure. Since the project is integrated within the Health Department, policy makers are both directly and indirectly engaged in the program. Topics to be pursued will include improving the affordability and access to vaccinations and medical treatment, equitable rights for school enrollment and employment, as well as protection of high-risk groups such as healthcare workers and pregnant women. Integrating questions that gather cost-effectiveness data in the overall research design will help to establish evidence -based analyses that validate the importance of a training and educational program for providers and pregnant women to policy makers. 1. Viral Hepatitis in China: Seroepidemiological Survey in Chinese Population (part one) 1992~1995. Beijing, China: Scientific and Technical Documents Publishing House; China Ministry of Health. Seroepidemiology survey result of Hepatitis B for the all population of China, Qi WT, Zhang Li, Xu AQ. Epidemiological trend of hepatitis B in Shandong province of China, Chin Prev Med 2009; 110(13): Health Bureau of Shandong province. Annual statistics on Health of Shandong province Jinan, China: Scientific and Technology Publishing House; Song LZ, Zhang Li, Yan BY, et al. HBsAg screening among puerperants and first dose Hepatitis B vaccination of their newborns in Shandong Province in Prev Med Trib Dec 2008; 14(12): Shandong province took the lead to vaccine children under 15 years with Hepatitis B vaccine. Available at htm. Accessed 10September Qi WT, Sun JD, Xu AQ. Epidemiological trend of hepatitis B, liver cirrhosis and liver cancer during in Shandong province China. Chin J Public Health Apr 2009; 25(4): Zhang, B. H., Yang, B. H., Tang, Z. Y. Randomized controlled trial of screening for hepatocellular carcinoma. J Cancer Res Clin Oncol 2004;130(7):

20 building partnerships with multinational companies Jean Wu & Stephen Maloy employee testing stigmas vaccination awareness 20 Dr. Jean Wu and Mr. Stephen Maloy demonstrated an effective model at General Electric (GE) for engaging future corporate partners in APAVH. Hepatitis B infection among the working force is not just an issue of public health, but one that includes economic and social implications. In China where chronic infection rates are high, HBV carriers face significant discrimination at work and at school. Misunderstanding about how the disease can be spread has created widespread fear among the public. This trend has had a large negative effect on the economy as many carriers are removed from the workplace. In an effort to remedy the situation, a new law now prohibits companies from testing their employees or job applicants for hepatitis B and the government has launched audits to explore discrimination. Nevertheless, discrimination and stigma remain major barriers to public awareness and interest in screening and vaccination. GE s involvement in Chinese public health and hepatitis B goes back to the SARS epidemic when GE s concern for their workforce resulted in the mass vaccination of employees for flu. Although the flu vaccination was ineffective against SARS, fear among the workers dropped and employee reaction was very positive. GE reflected on this experience in designing a hepatitis B program in 2007 that benefitted both the employer and the employees. The campaign lowered potential health costs of employee sickness (Hep B treatment = 338 times prevention cost), lowered potential sick or work-related leave, lowered stress and fear over HBV, protected employees, and increased employee morale. GE s analysis of the program estimated that potential cases were prevented, $510,000 - $732,000 in healthcare costs was avoided and lives were saved. GE s campaign was a mutually beneficial program that not only raised awareness and ameliorated stigmatization, but also saved money and lives. GE feels that there are many effective strategies and partnerships that can include corporations in running a successful hepatitis B vaccination and awareness program. While businesses can organize vaccinations, the government can provide support, policy and vaccines. The media can provide public promotion and international organizations can provide additional support. The financial burden of a HBV program goes to employees and companies, but the cost, time and human resources are well worth the avoided health costs, health benefits, and raised employee morale. GE s model benefits employer, employee and the public sector. The company is eager to share its success with other corporations and non profits in implementing their own vaccination and education programs. A number of comments and concerns were raised. One concern was about those employees at GE that did not respond to vaccination and those that were positive. Mr. Maloy responded that the company provided repeated vaccination and coverage for chronic treatment. A comment was made about lobbying international companies in general to support antiviral treatment and vaccination. Comments were also made as to whether the Chinese government might subsidize vaccination as an incentive to bring in corporate involvement. The campaign was praised as a much needed adult specific intervention as opposed to the large number of infant and child specific strategies currently in use in China.

21 building partnerships with foundations Wangsheng Li Zeshan Foundation Clinton Global Initiative Mr. Wangsheng Li introduced the ZeShan Foundation as a family foundation focused on health, education and human and social services with an emphasis on sustainability, long-lasting impact, collaboration, innovation, and strong potential for replication. He went on to describe its dedication to utilizing a multi-prong strategy for the effective control and eventual elimination of hepatitis B. By leveraging and creating synergies, a partnership like the APAVH can work together with members and collaborators to address the sheer scale of this problem. The ZeShan Foundation recently asked for hepatitis B to be included on the Clinton Global Initiative s global agenda. The Commitment to Action from the ZeShan Foundation for the APAVH has also been endorsed by the Clinton Global Initiative Asia. The foundation s successful international partnerships include seed funding for the APAVH, project support for the Asian Liver Center, and co-funding with the US CDC for the WHO Medical Officer working on viral hepatitis in China. The ZeShan Foundation has forged many partnerships with the Chinese Ministry of Health, Wuhan University and Tsinghua University on hepatitis B-related work. Many questions were fielded addressing the scope of the foundation s work. Mr. Li stated that the ZeShan Foundation tries to be strategic and pick projects with the highest impact. Mr. Li said it would consider supporting some of the projects offered by conference members. Praise was given to the foundation as a local champion for the cause. 21

22 panel discussions discussion 1 chairpersons: Cui Fuqiang & Jidong Jia Drs. Cui and Jia opened the panel discussions to discuss the key challenges and opportunities for hepatitis B prevention and control activities in China. They acknowledged that China has made a lot of progress, but still faces many problems and challenges. Perinatal Transmission infant transmission, screening policies, physician education During the first panel discussion, the group noted that even with timely birth dose and HBIG, about 5% of infants may still get infected via vertical transmission. The suggestion was made to clinically test the safety, and efficacy of antiviral drugs on pregnant women, who are HBeAg positive or have hight HBV DNA loads during pregnancy. However the group agreed that the there may be safety issues with administering drugs to pregnant women and that research should proceed cautiously. HBV and HIV Discussion drew several comparisons to HIV, where perinatal transmission is almost eliminated with prophylactic antiviral therapy. Institutional barriers need to be broken across immunization efforts, family planning, the CDC, public health systems and donors in order to further combat HBV. Collaboration is an area for big improvement in China. There may be ways to streamline maternal screening policies between HIV and HBV. Health Workers A second key topic was the vaccination of healthcare workers as a high risk population. Chinese representatives noted that their initial goal was vaccination of children under age 15. The next goal would be to vaccinate the unprotected high risk populations including healthcare workers. This is especially important in China where public health workers, not pediatricians, administer vaccines. Lack of physician and healthcare worker education about the risks of HBV and mode of transmission itself is another concern. 22

23 discussion 2 chairpersons: Liang Xiaofeng & John Ward education publications home births hospitals Drs. Liang Xiaofeng and John Ward noted that HBV represents a huge burden in the region but it is still a neglected disease. There is a need for continued education of others in order to elicit additional global funds for a variety of sources. China s Success & Potential Barriers Discussion began with praise for China for its success with implementing timely birth doses. However, it was pointed out that little in the form of publications was available, making it difficult for other countries to replicate. Access was brought up as a key barrier for many other countries where much of the population lives in rural areas. China has an extensive and well established public health system supported by well trained staff. In many places, refrigeration and record keeping is less reliable. It was agreed that programs are needed to educate both mothers and providers in these areas where home births are more common. Programs that pay mothers to give birth in local hospitals have seen great success. Collaborations & Partnerships Strategies to reach rural infants and mothers were discussed including public/private partnerships to obtain funding, combining HBV vaccination with other health programs to more efficiently deliver health. A good example was the encouragement of hospital birth for maternal health reasons those infants could also immediately receive HBV vaccines. Certification for reaching goals in the fight against HBV was mentioned as an accomplishment to be recognized by other countries. 23

24 discussion 3 chairpersons: chairpersons: Samuel So & Hui Zhang The third panel discussion focused on the role that APAVH can play in the fight against hepatitis B transmission and prevention. Recommendations for APAVH s participation include: Vaccination Promote vaccination programs where they are not well established; increase honesty with reporting to alleviate these problems Treatment Help to facilitate access to antiviral treatment, insurance coverage, build bridge between pharmaceutical companies and country government, organize a coalition of pharmaceutical companies to provide low-cost and affordable treatment Resource Development Be involved after GAVI resources are gone; bring in additional sources of funding and advocate for new partners/donors; provide a setting to bring in partners and see where synergies can exist Communications Initiate dialogue with government to determine where status on hepatitis B; Increase awareness of APAVH to garner further support and power for the group. Advocacy Provide forum for advocacy at country levels, including encouragement for certification as a route to regional progress. Advocate as experts for attention from national governments, pharmaceutical companies and corporations. pharmaceutical companies government dialogue affordable treatment advocacy funding 24

25 conclusion improving management optimizing treatment eliminating discrimination Throughout the course of the meeting, many examples demonstrated the effectiveness of China s current policies and practices, which would allow China to serve as a model for the rest of the Western Pacific region. While great progress has been made, the meeting discussion centered on work that can still be done to address the remaining gaps and challenges towards elimination of new transmission of viral hepatitis and reduce the associated complications including liver cancer. Vaccination Between 1992 and 2005, birth dose and three-shot completion rates had been steadily increasing and young people (1-15 years of age) have low prevalence of hepatitis B surface antigen due to the vaccination efforts. While China has mounted a nationwide hepatitis B catch-up vaccination program to vaccinate unvaccinated children under 15 years of age, select populations still need to be addressed, including those who did not receive timely birth dose, reaching births at home, the floating population, rural areas and disadvantaged people. Next steps to achieving successful coverage in China include screening of HBsAg and HBIG for infants born to HBsAg positive mothers, assuring that hospital delivery is followed by timely birth dose, and vaccinating the high risk populations (university students, soldiers, families in urban areas living close together, among others). Treatment China employs a hospital-based medical service system with three levels: university/major city, county/district and community health centers. Medical care is provided for free to government employees; basic social medical insurance is available to enterprise employees and urban residents; and rural use cooperative medical insurance is available to rural residents. Hepatitis B antiviral medications have traditionally been difficult for patients to receive reimbursement. Major problems are that more than half of patients in China pay out of pocket for medical expenses and most patients only pursue treatment for two to three years even when they require additional treatment. While the medical payment system is beginning to change and reimbursements are beginning to include antiviral drugs, much remain just recommendations. Next steps include developing guidelines for management of chronically infected individuals, improving the diagnostic test, optimizing therapy and liver failure treatments, and developing new recommendations to prevent HBV discrimination and stigma. 25

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