Transcription
Outline1.Introduction2.Focused risk-based HBV testing Who to test How to test Key benefits Interventions to promote uptake3.Situation in Hong Kong Local epidemiology Hong Kong Viral Hepatitis Action Plan 2020-2024 Enhancing testing in populations at risk of HBV infection2
IntroductionChronic HBV infectionDevelopment of chronic HBV infection is common in infants infectedfrom their mothers or before the age of 5 yearsIn endemic regions, the majority of people with CHB acquired HBVinfection through mother-to-child transmission (MTCT) at birth15 - 40% of untreated persons with CHB may develop cirrhosis, liverfailure or liver cancer in their lifetimeRisk of chronicity followingacute infectionneonates80 90%children 6 yrs30 50%healthy adults 5%Antiviral treatment can slow the progression of cirrhosis, reduceincidence of liver cancer and improve long term survivalHBVinfectionWHO Factsheet on hepatitis B -bHyams KC. Risks of chronicity following acute hepatitis B virus infection: a review. Clin InfectDis 1995; 20(4): 992-1000Lok AS. Chronic hepatitis B. N Engl J Med 2002; 346(22):1682-3.3
IntroductionWHO Global progress report on HIV, viral hepatitis and STI, 2021Global estimates as of 2019Prevalence of HBV infection in the general population: 3.8% 296 million people living with chronic HBV infection 1.5 million new infections in 2019 820 000 people died from hepatitis B in 2019, mostlyfrom cirrhosis and hepatocellular carcinomaThe burden of HBV infection is disproportionately high inWestern Pacific and African Regions, particularly in low- andmiddle-income countriesScaled-up hepatitis B vaccination had steeply reduced theglobal prevalence of HBV infection among children under 5to 0.94% in 2019, from 4.7% in the pre-vaccination era4
IntroductionWilson and Jungner’s principles of screening, WHO 1968DiseaseThe condition sought should be an importanthealth problem - common, seriousThere should be a recognizable latent or earlysymptomatic stageThe natural history of the condition, includingdevelopment from latent to declared disease,should be adequately understoodDiagnostic test and treatmentThere should be an accepted treatment forpatients with recognized diseaseScreening testThere should be a suitable test or examinationsafevalid (sensitive and specific)simplecheapreliableThe test should be acceptable to the populationScreening programmeThere should be an agreed policy on whom totreat as patientsThe cost of case-finding (including diagnosis andtreatment of patients diagnosed) should beeconomically balanced in relation to possibleexpenditure on medical care as a wholeFacilities for diagnosis and treatment should beavailableCase-finding should be a continuing process andnot a “once and for all” projectWhen combinedwith vaccination,HBV screeningonly requiresonce-a-lifetimetesting5
IntroductionWHO Global progress report on HIV, viral hepatitis and STI, 2021In 2019, 10% of estimated 296 million people with CHB globally were diagnosed6.6 million were receiving treatment22% of patients diagnosed with HBV2.2% coverage of people with CHBHuge gap indiagnosis andcascade of 00270776
Target Areas2025 Targets2030 Targets60% diagnosed50% treated60% diagnosed50% treated90% diagnosed80% treated90% diagnosed80% treatedPercentage of newborns who have benefitted from a timely birthdose of hepatitis vaccine and from other interventions toprevent MTCT of HBV70%90%Hepatitis B vaccine coverage among children (third dose)90%90%Number of needles and syringes distributed per PWID200300Proportion of blood units screened for bloodborne diseases100%100%Proportion of safe health-care injections100%100%0.5%0.1%850 000 new cases11 per 100 0001 million new cases13 per 100 000170 000 new cases2 per 100 000350 000 new cases5 per 100 0003 per 1002 per 100530 000 deaths7 per 100 000240 000 deaths3 per 100 000310 000 deaths4 per 100 000140 000 deaths2 per 100 000Coverage targetsPercentage of people living with hepatitis B diagnosed / treatedPercentage of people living with hepatitis C diagnosed / curedImpact targetsHBsAg prevalence among children younger than 5 years oldNumber of new hepatitis B infections per yearNumber of new hepatitis C infections per yearNumber of new hepatitis C infections per year among PWIDsNumber of people dying from hepatitis B per yearNumber of people dying from hepatitis C per yearWHO Global Health Sector Strategieson, respectively, HIV, viral hepatitis andsexually transmitted infections for theperiod 2022-2030 (GHSS)7
IntroductionTesting and diagnosis of HBV and HCV infection is the gateway foraccess to both prevention and treatment services link to interventions to reduce transmission counselling on risk behaviours hepatitis B vaccination provide prevention commodities e.g. sterile needles, syringes receive the necessary care and treatment to prevent or delayprogression of liver disease8
HBV testingWHO Guidelines on hepatitis B and C testing (2017)Who to test for HBV infection1.Focused risk-based testing in most affected population in all settingsAdults and adolescents from populations most affected by HBV infectionwho are part of the population with high HBV seroprevalence(e.g. mobile/migrant populations from high/intermediate endemic countries)who have a history of exposure and/or high-risk behaviors for HBV infection(PWID, people in prisons/other closed settings, MSM, sex workers, peoplewith HIV, family members and children of persons with HBV infection)2.Screening of blood donors in all settings *3.Routine testing in pregnant women insettings with intermediate ( 2%) or high( 5%) HBsAg prevalence in the generalpopulation (Strong recommendation)4.General population testing in settings withintermediate ( 2%) or high ( 5%) HBsAgprevalence in the general populationSexual partners, children and other family members, and close householdcontacts of those with HBV infectionHealthcare workersThose with a clinical suspicion of chronic viral hepatitis(Strong recommendation)(Conditional recommendation)* Adapted from 2010 WHO guidance on screeningdonated blood for transfusion transmissible infections9
HBV testingClinically guided HBV testingClinical suspicion of chronic viral hepatitisclinical symptoms or signsabnormal liver function tests or liver ultrasoundDisease management in some patients, e.g.persons with end-stage renal disease (including pre-dialysis,haemodialysis, peritoneal dialysis, and home dialysis patients)persons needing immunosuppressive therapy (including chemotherapy,immunosuppression related to organ transplantation), andimmunosuppression for rheumatological or gastroenterologic disordersWHO Guidelines on hepatitis B and C testing (2017)Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 updateUpdate on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance10
HBV testingWHO Guidelines on hepatitis B and C testing (2017)Consideration of evidence mainly from cost–effectiveness analyses, and data onHBsAg seroprevalence in different settings and populations, and in the generalpopulation with considerations of feasibility and costKey drivers of cost-effectiveness for considering testing approaches(a) Cost of antiviral drug and testing cost (to a lesser extent)(b) Linkage to care and adherence to treatmentIt is likely to be worthwhile performing screening and providing treatment, even ifparticipation in screening may be low, in part because testing costs are low relativeto the costs and health benefits of treatment for those who are infected.HBsAg prevalence had a relatively small influence on cost-effectiveness across awide range of prevalence levels examined.11
HBV testingSerological testsHepatitis B surface antigen (HBsAg)Antibody to HBsAg (anti-HBs) test for HBV infection immunity in response tolaboratory-based immunoassayHepatitis B vaccination, orrapid diagnostic test (RDT) insettings where there is limitedaccess to laboratory testingand/or in populations whereaccess to RDT would facilitatelinkage to care and treatmentRecovery from past HBVinfectionRDTs are immunoassays that detect antibodiesor antigens and can give a result in 30minutes. Most RDTs can be performed withcapillary whole blood collected by finger-sticksamplingNon-immune and uninfected hepatitis B vaccinationAntibody to HB core antigen(anti-HBc) prior exposure to HBVNOT routinely recommendedfor HBV screeningindicated in selected patientspeople living with HIVthose who are about to undergoHCV, anti-cancer or otherimmunosuppressive therapies orrenal dialysisscreening donated bloodWHO Guidelines on hepatitis B and C testing (2017)Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 updateUpdate on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance12
HBV testingTypical serologic course ofacute hepatitis B to recoveryTypical serologic course of theprogression to chronic hepatitis BFigures obtained from .htm.13
HBV testingWHO prequalified rapid diagnostic test kits for HBV and HCV screening (as of June 2022)Product nameManufacturer (site)SampleSensitivity(95% CI)Specificity(95% CI)WHOreportDetermine HBsAg 2Alere Medical Co. Ltd(Japan)50 μL of serum/ plasma / venous andcapillary whole blood100%(98.2 - 100%)100%(98.8 - 100%) Bioline HBsAg WBAbbott DiagnosticsKorea Inc (Korea)100 μL of serum/ plasma/ whole bloodspecimen100%(98.1 - 100%)99.0%(97.2 - 99.8%) STANDARD Q HCV AbTestSD Biosensor, Inc.(Korea)10μl of serum/plasma /20μl of venous / capillary whole blood100%(97.8 - 100%)100%(98.9 - 100%) Rapid Anti‐HCV TestInTec PRODUCTS, INC(China)10 μl serum/ plasma/ venous or fingerprickwhole blood100%(97.6 - 100%)99.7%(98.8 - 100%) OraQuick HCV RapidAntibody Test KitOraSure Technologies,Inc. (USA) 5μL serum/ plasma/ venous or capillarywhole blood/ oral fluid100%(97.8 - 100%)99.7%(98.3 - 100%) Bioline HCVAbbott DiagnosticsKorea Inc (Korea)10 μl of serum/ plasma/ whole bloodspecimen100%(97.76 - 100%)100%(98.85 - 100%) est-kits.html14
HBV testingKey benefits of focused risk-based testing approach make use of the existing opportunities andinfrastructure for health facility-based testing,as well as community-based testing increase uptake and facilitate referral to careand other services likely to be associated with higher rates ofcase-finding a more readily feasible approach if resourcesto undertake general population screening islackingHealth facilitiesprimary care clinicsinpatient wardsoutpatient clinics including specialist dedicatedclinics e.g. HIV, STI, TB clinicsprivate clinical servicesCommunity-based testing - outreach/mobile approachhome-based testing /door-to-door outreachworkplaceplaces of worship, parks, bars .schoolsthrough campaigns (screening alongside that forNCD e.g. DM, HT)15
HBV testingInterventions to promote uptake and linkage to care peer and lay health worker support in community-based settings clinician reminders to prompt provider-initiated, facility-based HBV testing insettings that have electronic records or analogous reminder systems provide hepatitis testing as part of integrated services within mental health orsubstance use servicesTo best reach those with undiagnosed infection and populations at high risk, it is important toidentify the most strategic mix of facility- and community-based testing opportunities, as well asthe use ofintegration with other health servicesdecentralization to primary care facilities and outside the health systemtask-sharing of testing responsibilities to other health workers, including trained lay providers16
Local situationHBsAg seroprevalence in Hong KongIn 2016, a territory-wide prevalence studygave an age- and sex-adjusted HBsAgprevalence in the general population:7.2% ( 540 000 HBV infection )Mother-to-child transmission (MTCT)accounts for the prevalence of HBVinfection in Hong KongUniversal childhood hepatitis B vaccinationprogramme since 1988Liu KS, Seto WK, Lau EH, et al. A Territorywide Prevalence Study onBlood-Borne and Enteric Viral Hepatitis in Hong Kong. J Infect Dis2019; 219(12): 1924-33.17
Local situationHBsAg seroprevalence in Hong KongHBsAg prevelance in populationswithout specific HBV risk19912020New blood donors8.0 %1.0 %Pre-marital screening9.6 %3.4 %Sources: HK Red Cross Blood TransfusionServices, Family Planning Association, DHFamily Health ServiceAntenatal women10.9 %3.4 %18
Local situationHBsAg seroprevalence in Hong KongBaseline screening among HIV/AIDS patientsattending Integrated Treatment Centre 320142015201620172018201920205%YearPeriod 2015 – 2020HBsAg-positive: 5.6% - 8.1%Anti-HCV-positive: 3.0% - 6.5%19
Local situationProgress towards WHO service coverage targets*Hep B vaccinebirth-dose coverageHep B vaccinethird-dose coverageHepatitis Bdiagnosis rateHepatitis Cdiagnosis rateHepatitis Btreatment coverage2020 Target2025 TargetHepatitis Ctreatment coverage2030 Target0102030405060708090Coverage (%)* Otherservice coverage targets applicable to Hong Kong include blood safety and safe injections10020
Local situationHong Kong Viral Hepatitis Action Plan 2020 - 2024Progressing towards the targets set by WHO to eliminate viralhepatitis as a public threat by 203090% infected people diagnosed80% eligible patients treated no. of new cases of chronic HBV and HCV by 90% no. of deaths from HBV and HCV by 65%4 strategic axesVision: to render HK free of chronic viral hepatitis3221
Local situationPrevention of mother-to-child transmission of HBVMaternalpathwayInfantpathwayImplemented in DH MCHCssince January 202222
Local situationGap in HBV diagnosis and treatment coverageGiven the large number of undiagnosed people in Hong Kong, the currentscreening practices in place are not sufficient to achieve the WHO target ofdiagnosis rate at 60% by 2025 and 90% by 2030The Steering Committee on Prevention and Control of Viral Hepatitis (SCVH)recommended that both diagnosis and treatment capacity for HBV infectionshould be built up in order to meet the substantial demand of population-basedHBV screening and subsequent long-term careSCVH considered that focused risk-based testing of populations at higher risk ofHBV infectiona pragmatic way to start scaling up HBV screening in Hong Kongan expedient and short-term strategy while expansion of treatment and carecapacity of HBV infection is being addressed in parallel23
Local situationEnhancing treatment capacity for HBV infectionTo augment the diagnosis and treatmentcapacity for HBV infection, enhancementshave been made in HA in four areasTo enhance the management capacity ofHBV infection, HA hepatologists and primarycare physicians are devising a framework ofHBV management with recommendationsfor management of HBV infection in theprimary care setting24
Local situationEnhancing testing in populations at risk of HBV infectionSix most affected and at-risk populations are identified aspriority groups for the planning of focused risk-based testingPeople who inject drugs (PWID)People in prisons and other closed settingsMen who have sex with men (MSM)Sex workersPeople with HIVFamily members (parents, siblings and offspring) andsexual partners of people with HBV infectionOffer preventive measures and advice, vaccinationProvide concomitant HCV screening for at-risk groups25
Local situationFamily members and sexual partners of CHB patientsIn 2016, a territory-wide prevalence study gave anage- and sex-adjusted HBsAg prevalence ingeneral population : 7.2%( 540 000 people with HBV infection )% respondents (all age groups) who had HBVcarriage inmother : 2.7% (276/10086)other family members : 9.3% (934/10086)Prevalence of HBsAg and anti-HBs among familymembers and spouses of CHB patients, by age groupAge ity rate(%) 267252.638.826 - 3510207.450.636 - 45147810.951.446 - 5522388.052.556 - 6530448.053.6 6517307.354.6Figures collated from Table 1 and Table 3 of the articleLiu KS, Seto WK, Lau EH, et al. A Territorywide Prevalence Study on Blood-Borne and Enteric Viral Hepatitis in Hong Kong. J Infect Dis 2019; 219(12): 1924-33.26
Local situationHBsAg positivity rate among family members and sexual partners of CHB patientsGupta S, et al., 20081Lok AS, et al., 19872265 household contacts of 91 indexpatients with HBV-related chronicliver disease, in India731 family members of 240 indexCHB patients, in Hong KongJan 2006 – July 2007Jan 1983 – July 19845.9%9.6%Overall 30.6% (81/265)Overall 28.3%Parents31.5%Mother 40.9%Father 20.7%Siblings48.3%53%Spouse9.7%10.8%Study participantsStudy periodHBsAg prevalence in general populationHBsAg prevalence among family membersand spouses of CHB patientsRelationship with theindex CHB patientOffspring27.5%32.9%24.8%offspring of female CHB pt 50.5%offspring of a male CHB pt 13.5%Gupta S, et al. Role of horizontal transmission in hepatitis B virus spread among household contacts in north India. Intervirology 2008;51(1):7–13.2 Lok AS,et al. Hepatitis B virus infection in Chinese families in Hong Kong. Am J Epidemiol 1987; 126(3):492-9.127
Hepatitis B vaccinationHepatitis B vaccination for adultsWHO Vaccination of groups at highest risk of acquiring HBVinfection is recommendedpatients who frequently require blood or blood productsdialysis patients, diabetes patientsrecipients of solid organ transplantationpersons with chronic liver disease including those with hepatitis Cpersons with HIV infectionpersons interned in prisonsinjecting drug usershousehold and sexual contacts of persons with chronic HBV infectionmen who have sex with men (MSM)persons with multiple sexual partnershealthcare workers and others who may be exposed to blood, bloodproducts or other potentially infectious body fluids during their workWHO position paper on hepatitis B vaccines, 2017US CDC The Advisory Committeeon Immunization Practices (ACIP)recommends hepatitis Bvaccination amongall adults aged 19–59 yearsadults 60 yrs with risk factorsAdults 60 yrs without identifiedrisk factors but seeking protectionmay still receive hepatitis BvaccinationCDC guidelines on hepatitis Bvaccination of adults (April 2022)28
Hepatitis B vaccinationHepatitis B vaccinationWHO does not recommend routine booster dose(s) of hepatitis B vaccine after completion of theprimary vaccination series for persons with normal immune status.Routine post-vaccination testing for immunity is not necessaryPost-vaccination testing should be considered for high-risk individuals, whose subsequent clinicalmanagement depends on knowledge of their immune statuspersons at risk of occupational exposure to HBV infection, e.g. health-care workersinfants born to HBsAg-positive motherschronic haemodialysis patientsHIV-positive and other immunocompromised personssex partners or needle-sharing partners of persons who are HBsAg-positiveTesting should be carried out 1–2 months after administration of the last dose of the vaccine seriesusing a method that allows for a quantitative determination of the anti-HBs antibody level with adetection limit 10 mIU/mL.WHO position paper on hepatitis B vaccines, 2017 29
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Hong Kong Viral Hepatitis Action Plan ch?v WqeRtCNtDk031
Information for health professionalsTraining materials32
Health educational resourcesCHP ChannelCHP Facebookhttps://youtu.be/E7k-SSmXXfY33
Health educational resources34
Useful resourcesCategoryTitleVideoHong Kong Viral Hepatitis Action Plan2020-2024iContinuingEducationMicro-elimination of hepatitis C inpeople who inject www.hepatitis.gov.hk/english/health professionals/files/iCE HCV PWID paper.pdfSerologic testing after hepatitis cination for babies born to mothers h/health professionals/files/iCE PVEducationST.pdfinfected with hepatitis B virusiContinuingEducationPrevention of mother-to-childtransmission of hepatitis B virushttps://www.hepatitis.gov.hk/english/health professionals/files/iCE PMTCT of HBV.pdf35
Useful llance of Viral Hepatitis inHong Kong – 2020 Reporthttps://www.hepatitis.gov.hk/english/health professionals/files/hepsurv20.pdfPamphletHepatitis B vaccinationhttps://www.hepatitis.gov.hk/tc chi/resources/files/leaflet2020 2.pdfPosterHepatitis B vaccinationhttps://www.hepatitis.gov.hk/tc chi/resources/files/poster2020 2.pdfVideoStop mother-to-childtransmission to realise ahepatitis B-free generationCoverhttps://youtu.be/5 FFuOKVVb436
Useful resourcesCategoryTitleLinkHealthTalkPrevention of mother-to-childtransmission of hepatitis Bhttps://www.hepatitis.gov.hk/english/health professionals/files/Prevention of MTCT of HBV web.pdfHealthTalkStop mother-to-childtransmission of hepatitis Bhttps://www.hepatitis.gov.hk/tc chi/resources/files/stop MTCT.pdfPamphletPrevention of perinatal hepatitis Bhttps://www.hepatitis.gov.hk/tc chi/resources/files/leaflet2020 3.pdfPamphletCoverStop maternal transmission of hepatitis B https://www.hepatitis.gov.hk/tc chi/resources/files/stop-transmiss(languages of ethnic minorities are available) leaflet-w3c.pdf37
Useful resourcesCategoryTitleLinkPosterPrevention of perinatal hepatitis Bhttps://www.hepatitis.gov.hk/tc chi/resources/files/poster2020 3.pdfStop maternal transmission ofhepatitis Bhttps://www.hepatitis.gov.hk/tc chi/resources/files/poster2020 4.pdfFactsheetPost-vaccination serologic testing (PVST)https://www.hepatitis.gov.hk/doc/pdf/PVST tc chi/reWhat you need to know about hepatitis C sources/files/What you need to know about hep C.pdfPosterCover38
Useful is.gov.hk/tc chi/resPamphletGetting tested for hepatitis C can saveources/files/Pamphlet Getting%20Testeyour lifed%20for%20Hep%20C WCAG.pdfPosterGetting tested for hepatitis C can save ter2021 1.htmlyour life39
Supplementary slides40
SupplementaryWHO Global progress report on HIV, viral hepatitis and STI, 202120152019HBV & HCV incidence6-10 million3 millionHBV & HCV deaths1.34 million1.1 million1.3%0.94%HBV prevalence257 million(3.5%)296 million[3.8%]*HCV prevalence71 million(1%)58 million[0.8%]*HBV prevalence under 5Scaled-up hepatitis B vaccination had steeplyreduced the global prevalence of HBVinfection among children under 5 to0.94% in 2019,from 4.7% in the pre-vaccination era (which,WHO Global progress report on HIV, viral hepatitis and STI, 2021WHO Global Hepatitis Report 2017according to the year of introduction can range from1980s to the early 2000s in different countries)*Mid-2019 world population 7.7 billion41
SupplementaryWHO Global progress report on HIV, viral hepatitis and STI, 202110% of estimated 296 million people with21% of estimated 58 million people withchroninc HBV infection were diagnosedchronic HCV infection were diagnosed6.6 million were receiving treatment22% of patients diagnosed with HBV2.2% coverage of people with CHB9.4 million treated between 2015 to 201962% of patients diagnosed with HCV13% coverage of the people in 002707742
HCV testingWHO Guidelines on Hepatitis B and C Testing 2017Who to test for HCV infection1. Focused testingAdults and adolescents from populations most affected by HCV infectionwho are part of the population with high HCV seroprevalence(e.g. some migrant populations from endemic countries, some indigenous populations)who have a history of exposure and/or high-risk behaviors for HCV infection(PWID, people in prisons/other closed settings, MSM, sex workers, HIV-infected, tattoos, transfusions, children ofmothers with chronic HCV infection esp. if HIV-coinfected)Those with a clinical suspicion of chronic viral hepatitis2. General population testing in settings with 2% or 5% (intermediate / high) HCV Ab prevalence3. Birth cohort testing for specific identified birth cohorts of older persons at higher risk of infection and morbiditywithin populations that have an overall lower general prevalence(historical exposure to unscreened or inadequately screened blood products and/or poor injection safety)2143
HCV servicedelivery & testingWHO updated recommendations on simplified service delivery anddiagnostics for hepatitis C infection (June 2022)Simplified service deliveryExpansion of HCV testing and treatmentservices, ideally at the same site, throughdecentralization of care to lower-level facilities;integration with existing services, such as inprimary care, harm reduction programmes,prisons and HIV services; andpromotion of task sharing through delivery ofHCV testing, care and treatment byappropriately trained non-specialist doctorsand nursesHCV diagnosticsuse of point-of-care (POC) HCV RNA viral loadassays as an alternative approach tolaboratory-based RNA assays to diagnoseviraemic infection, esp. applicable tomarginalized populations (e.g. PWIDs), andhard-to-reach communities with limitedaccess to health care and high rates of loss tofollow-upReflex HCV RNA testing in those with apositive anti-HCV test to promote linkage tocare and fection44
HCV treatmentWHO updated recommendations on treatment of adolescentsand children with chronic HCV infection (June 2022)extend the 2018 treat all recommendation for adults with chronic HCVinfection to include adolescents and children down to 3 yearsalign the existing recommended pangenotypic direct-acting antiviral(DAA) regimens (SOF/DCV, SOF/VEL and G/P) for adults, to those foradolescents and children.This alignment is expected to simplify procurement, promote access totreatment among children in low- and middle-income countries andcontribute to global efforts to eliminate the ection45
Outline 1. Introduction 2. Focused risk-based HBV testing Who to test How to test Key benefits Interventions to promote uptake 3. Situation in Hong Kong Local epidemiology Hong Kong Viral Hepatitis Action Plan 2020-2024 Enhancing testing in populations at risk of HBV infection 2
