Prevention & Control of Viral Hepatitis Infection: A Strategy for Global Action © World Health Organization 2011. All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. 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Table of contents Disease burden 02 What is viral hepatitis? 05 Prevention & control: a tailored approach 06 Global Achievements 08 Remaining challenges 10 World Health Assembly: a mandate for comprehensive prevention & control 13 WHO goals and strategy for prevention & control of viral hepatitis 14 B C Hepatitis B Hepatitis C • About 2 000 million • Some 150 000 000 people have been infected people are chronically with HBV worldwide infected with HCV • More than 350 million • More than 350 000 worldwide are chronically people are estimated infected with HBV to die from HCV-related liver diseases each year • Between 500 000 and 700 000 people die annually as a result of HBV infection Disease burden The group of viruses (hepatitis A, B, C, D and E) that cause acute and/or chronic infection and inflammation of the liver gives rise to a major public health problem globally. Hepatitis B (HBV) and C viruses (HCV) are major causes of severe illness and death. Overall • Around 500 000 000 persons are chronically infected (HBV and HCV) • Approximately 1 000 000 persons die each year (~2.7% of all deaths) from viral hepatitis related causes, most commonly liver disease including liver cancer • An estimated 57% of cases of liver cirrhosis and 78% of cases of primary liver cancer result from HBV or HCV infection 02 A E Hepatitis A Hepatitis E • It is estimated that about • Infection in pregnancy is 1 400 000 new hepatitis associated with a high risk A virus (HAV) infections of obstetrical complications, occur globally each year poor fetal outcomes, and results in maternal death in one out of five cases. Need for action: 80% of countries identified hepatitis as an urgent public health problem Table 1. Hepatitis B and / or C considered an urgent public health issue Total countries % of region Africa 29 97% Americas 15 75% Eastern Mediterranean 11 92% Europe 28 65% South-East Asia 4 57% Western Pacific 19 90% Source: Viral Hepatitis: Global Policy, World World 106 80% Hepatitis Alliance, 2010 (N=133) 03 04 What is viral hepatitis? Viral hepatitis is an inflammation of the liver caused by one of the five hepatitis viruses, referred to as types A, B, C, D and E. While all hepatitis viruses cause liver disease, they vary in important ways. Hepatitis A virus (HAV) is present in the Hepatitis C virus (HCV) is mostly faeces of infected persons and is most also transmitted through exposure to often transmitted through consumption infectious blood. This may happen through of contaminated water or food. Certain sex transfusions of HCV-contaminated blood practices can also spread HAV. Infections and blood products, contaminated are in many cases mild, with most people injections during medical procedures, making a full recovery and remaining and through injection drug use. Sexual immune from further HAV infections. transmission is also possible, but is much However, HAV infections can also be severe less common. There is no vaccine for HCV. and life threatening. Most people in areas of the world with poor sanitation have been Hepatitis D virus (HDV) infections occur infected with this virus. Safe and effective exclusively in persons who are infected with vaccines are available to prevent HAV. HBV. The dual infection of HDV and HBV can result in a more serious disease and Hepatitis B virus (HBV) is transmitted worse outcome. Safe and effective hepatitis through exposure to infectious blood, B vaccines provide protection from HDV semen, and other body fluids. HBV can infection. be transmitted from infected mothers to infants at the time of birth or from family Hepatitis E virus (HEV), like HAV, is member to infant in early childhood. transmitted through consumption of Transmission may also occur through contaminated water or food. HEV is a transfusions of HBV-contaminated blood common cause of hepatitis outbreaks and blood products, contaminated in developing parts of the world and is injections during medical procedures, increasingly recognized as an important and through injection drug use. HBV also cause of disease in developed countries. poses a risk to healthcare workers who Safe and effective vaccines to prevent HEV sustain accidental needle stick injuries while infection have been developed but are not caring for infected-HBV patients. A safe and widely available. effective vaccine is available to prevent HBV. 05 Prevention & control: a tailored approach Because hepatitis A, B, C, D and E viruses differ in their global distribution and routes of transmission, prevention and control strategies need to be tailored. A comprehensive approach to the prevention of viral hepatitis includes a number of strategies. Primary Prevention • Standard precautions in health care and community settings can prevent • Safe and effective vaccines are widely transmission of viral hepatitis. available for the prevention of HAV and HBV infection and HEV vaccines are being • Safe injection practices can protect against developed. HBV and HCV transmission. • Screening blood used for transfusion and • Safer sex practices, including minimizing blood products can prevent transmission the number of partners and using barrier of HBV and HCV. (condom) protective measures has been shown to protect against HBV and HCV transmission. • Harm reduction practices for injecting drug users prevent HBV and HCV transmission. • Occupational safety prevents transmission to health care workers at high risk. • Safe food and water provide protections against HAV and HEV. 06 Secondary & Tertiary Currently, recommended antiviral Prevention agents used for treatment of human immunodeficiency virus (HIV) infection Early diagnosis provides the best do not adequately suppress HBV, which is opportunity for effective medical support. of great concern for the estimated 10% of It also allows those infected to take steps HIV-infected persons in Africa who are co- to prevent transmission of the disease to infected with HBV. others, for example through counselling and use of preventive services. It allows HCV is generally considered to be a precautions to be undertaken to protect the curable disease but for many persons this liver from additional harm, specifically, by is not a reality. Scientific advances and eliminating alcohol and certain drugs which intense research and development have are toxic to the liver. led to the development of many new oral antiviral drugs for HCV infection. A great Antiviral agents against HBV and HCV exist. number of HCV specific oral drugs are in Treatment of HBV infection has been shown the late stage of development; some have to reduce the risk of liver cancer and death. been recently registered. These are more It is estimated that 20–30% of persons with effective and better tolerated. Much still HBV infection could benefit from treatment. needs to be done to ensure that these However, drugs active against HBV are new treatment advances lead to greater not widely available or utilized in persons access and treatment responses in resource infected with HBV. constrained areas of the world. 07 Global Achievements • As of 2009 91% of WHO Member States • New global burden of disease studies by included the hepatitis B vaccine in their WHO have demonstrated the high burden infant immunization programs and over of disease from HAV and HEV globally 70% of infants received 3 doses of this vaccine which provides them with life- • WHO has developed tools to assess long protection from HBV. injection practices and assist countries develop evidence based injection safety • As of 2010, 178 countries have introduced strategies. By 2009, two thirds of the 96 the hepatitis B vaccine. This intervention low and middle income countries which has prevented approximately 1,307,000 underwent this process had implemented future deaths. safe injection programs. • WHO’s advice, guidance and technical • WHO has defined core components for support is assisting countries in ensuring infection prevention and control (IPC) the safety and quality of blood and blood programmes, providing systematic products, their availability, equitable approach to prevention of hepatitis access and effective use to meet the needs and other communicable diseases in of all patients requiring blood transfusion healthcare settings.