Country snapshots: A country approach to Eliminating Hepatitis C

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Responsibility for healthcare in Canada is devolved to the provincial level. Despite lobbying by stakeholders, there is no official written national plan for Hepatitis C (HCV) at the federal level, and there is no designated unit solely responsible for co-ordinating and carrying out responsibilities related to viral hepatitis. While the federal authorities would argue that the existing treatment guidelines amount to a de facto plan, to date, Hepatitis C has been a low political priority, in particular when compared with the proactive approach towards the management of HIV in the 1980s and 1990s. There is some expectation that the new health minister, Jane Philpott, who previously worked as an AIDS activist in Africa, will review the country’s existing policy stance.

In practice, Canada’s HCV policy is part of an integrated approach to Sexually Transmitted and Blood Borne Infections (STTBBIs) and is focused on high-risk groups. At the federal level, Health Canada and the Public Health Agency of Canada (PHAC) have an integrated budget dedicated to HCV, HIV and related transmittable diseases. The HIV and HCV Community Action Fund, a fund for community civil society

participants, provides C$26.4m in annual funding across provinces to support projects that increase knowledge of the diseases, improve access to health and social services and strengthen capacity. In addition to government funding and patient group-generated income, pharmaceutical companies provide an alternative funding source to aid community groups and coalitions in the effort to drive awareness, prevention, cure and control.

In principle, HCV treatment is comprehensive in Canada. The provinces reimburse for HCV treatment, but each has its own criteria, typically determined by provincial health authorities based on budgets and population need; eg British Columbia has a strategy to address viral hepatitis. Moreover, access to medication is bound by clinical criteria and patients typically have to present at a chronic stage. As of 2012/13, direct-acting antivirals (DAAs) —boceprevir and telaprevir—were on the national essential list of medicines or subsidised by the government. Quebec is considered one of the more progressive provinces in terms of treatment, with doctors there advocating a more holistic approach to address the disease itself and its associated side effects and complications, including mental health issues.

Over all, primary care involvement in

diagnosis and treatment remains limited in Canada. In general, HCV awareness among at-risk populations and the non-specialist personnel dealing with people who inject drugs (PWID) is high, but it remains low in the general population and awareness campaigns have limited reach. The disease still carries a high level of stigma in Canadian society. Nonetheless, numbers of gastroenterologists are sufficient or higher per head than in comparable countries such as the United States, with a variety of training programmes also available for non-specialists.

Screening is risk-based, with limited guidelines, focused primarily on high-risk groups. No strategy for early detection currently exists. The Canada Notifiable Disease Surveillance System (CNDSS) gathers data on HCV (and other diseases), but not comprehensively. Aggregate national data are available online from PHAC. Most provinces and territories confirm cases using HCV antibody testing and do not currently distinguish reported HCV cases by infection status. Therefore, acute and chronic HCV cases are combined for analytical purposes. Actual numbers of HCV sufferers may be as high as 350,000, compared with the federal government estimate of 250,000 in 2014. Prevalence in prisons is probably under-recorded and under-treated.

The country lacks a formal written national plan for Hepatitis C, or a single co-ordinating body, but a local approach directed at the provincial level allows for comprehensive treatment. Treatment guidelines typically fall under general plans for the management of Sexually Transmitted and Blood Borne Infections.

Country snapshot: Canada

PATH TO ZERO: FRESH THINKING ON THE ROAD TO ELIMINATING HEPATITIS C


The country’s national health plan—Plan Nacional de Saúde 2012-2015—was developed by the Ministry of Health and includes components on Hepatitis C (HCV). Recognised by the international community as a robust and comprehensive plan, it includes specific objectives around HCV screening and surveillance, access to drugs and treatment and an increase in the number of treatment centres. All drugs used in HCV treatment are acquired by the federal government and distributed to the states following protocols defined by the Ministry of Health. The Brazilian Department for STD/AIDS and Viral Hepatitis (DDAHV), a subsidiary of the Ministry of Health, has an annual budget of approximately US$400m, which encompasses the acquisition of drugs for HCV treatment.

However, due to a lack of resources in the states, which are at different stages of economic development and have

faced budget constraints due to the unfolding economic crisis, the plan is not yet fully implemented across all states. The Ministry of Health has had difficulties addressing these issues, as delivery is provided at state and municipal levels. In theory, primary care physicians must follow protocols for identification, testing and treatment of HCV, but in practice, this happens only in large urban medical facilities. It is estimated that Brazil has 4,375 gastroenterologists, though most are located in the richer south and southeast regions. The Ministry of Health, in partnership with civil society and state health secretaries, raises awareness among the general population, and NGOs and HCV patient representative organisations are active in addressing high-risk populations. For instance, through its successful campaign “Cê tem que saber” (You got to know) the Brazilian NGO, C Tem que Saber-C Tem que Curar, has raised awareness by encouraging people to post selfies on social media making the letter C with their hands. Brazil does not invest in research, but the federal government funds new therapies and launches new

laboratories. Training for primary care professionals is in the early stages, with specialist institutes leading these efforts, especially in more remote areas.

Brazil’s surveillance and monitoring system is weak. The universal public healthcare service monitors diseases via the web-based Sistema de Informação de Doenças de Notificação Compulsória (Compulsory Disease Notification Information System). However, poor internet connectivity throughout much of the country means many primary care facilities have to rely on paper-based systems to report incidences of diseases to local municipal health secretaries, which is both complex and time-consuming. Information about HCV infections is therefore often underreported. Since HCV care is most often linked to care for HIV/AIDS, the overlap between populations infected with HIV/AIDS and HCV in Brazil is high. HIV/AIDS tends to be well treated, and chances are that HCV co-infected populations will be detected at some point through HIV/AIDS treatment, though not necessarily at the early stages of infection.

Though exceptional at the planning level, Brazil lacks the resources needed for implementation and its surveillance and monitoring system is weak.

Country snapshot: Brazil



Low public awareness and a lack of collaboration between government and civil society hamper the country’s ability to tackle the disease.

While Poland has no national strategic plan for viral hepatitis or Hepatitis C (HCV), its “Prevention of HCV Infections” programme consists of five national projects aimed at dealing with the disease. The programme is run by the National Institute of Public Health–National Institute of Hygiene (NIPH-NIH) and supported by a grant from Switzerland through the Swiss Contribution to the enlarged European Union. The programme is scheduled to run from 2012 through 2016, with a budget of CHF4,669,907 (US$4.7m). Some 85% of the programme is covered by the Swiss grant, with the remaining 15% coming from national contributions. The five projects cover improvement of HCV diagnostics with estimation of HCV; developing an evidence-based HCV prevention programme for injecting drug users; HCV testing among pregnant women; evaluation of infection risk associated with medical procedures; and raising awareness about the

prevention of blood-borne infections among service providers and the general public—a particularly important element, given the current low levels of awareness across both groups.

Primary care doctors are generally not involved in prevention and diagnosis of HCV, but there are government plans to improve the situation, including adding an HCV antibody test to the list of tests available free of charge through primary care. Through local programmes, general practitioners offer free HCV tests to patients with a history of exposure to HCV infection. No official specialisation in hepatology exists, though there are about 950 gastroenterologists and more than 1,100 specialists in infectious diseases. While Poland lacks training and accreditation programmes to bring non-specialists into HCV care, the Prevention of HCV Infections programme aims to raise awareness among general practitioners about diagnosis and management. It also attempts to increase awareness among employees of non-medical services that involve skin injury (such as tattoo salons and beauty parlours), which carry the risk of blood-

borne infections. Other public awareness campaigns include those run by groups such as Poland’s largest NGO for patients with HCV/HBV, Prometeusze, but these are not co-ordinated or conducted at a central level, which means that awareness among the general public and high-risk groups remains very low.

A national HCV surveillance system is maintained by the NIPH-NIH and integrated into the national health information system, the PZH register. While this covers only the incidence of the disease, it is regularly updated (annually, at minimum). Physicians are legally required to report diagnoses and laboratories are required to report positive test results. It is estimated that only 10–15% of cases are actually diagnosed, and therefore the prevalence in the population as a whole is thought to be much higher than official figures suggest. While steps have been taken towards establishing a national strategy (including the Swiss-sponsored programme), more needs to be done to co-ordinate public awareness campaigns.

Country snapshot: Poland



Russian HCV patients have arbitrary access to care and treatment, with incidence still a long way from being brought under control.

Policy shifts in recent years have generally been in a negative direction. Russia has no national strategic plan for viral hepatitis or Hepatitis C (HCV). Until 2011, the Priority National Health Programme, a national initiative launched in 2006 with the aim of raising the quality of medical care, included a sub-programme covering HCV and Hepatitis B (HBV). This programme was discontinued and national funding is now available only for treating patients co-infected with HIV. Some regional governments, such as the Khanty Mansi Autonomous Okrug—which launched a programme at the end of 2015 to fund 50% of the cost of HCV treatment—have initiated programmes to treat mono-infections, but lack of funding means that the number of patients who receive treatment is negligible. Several grassroots organisations campaign on behalf of patients, including the Andrey Rylkov Foundation, Together Against Hepatitis and the International Treatment Preparedness Coalition, but selective and discriminatory policies (such as excluding people who inject drugs from treatment

programmes) mean that most HCV sufferers lack access to proper care. The Global Fund to Fight AIDS, Tuberculosis and Malaria, an international funding organisation, once financed needle exchange programmes in the country. However, this was discontinued in 2010 when Russia withdrew from the fund.

There is no official consensus on the level of HCV care that should be provided. In some regions, it is considered a specialised treatment to be carried out by in-patient hepatology facilities; in others, it is an outpatient service provided by local polyclinics. Patients who are also infected with HIV are usually treated at HIV/AIDS centres. There is no official specialisation in hepatology, nor any state courses or certifications. Infectious disease specialists often lack proper training for dealing with HCV, and no training or accreditation programmes exist for non-specialists. Medication is expensive and not always covered by the mandatory health insurance system, meaning patients must often pay out of pocket (only about 5% of the population has private insurance). The government has made no attempt to lobby for reduced prices, something for which the Andrey Rylkov Foundation, Together

Against Hepatitis, and the International Treatment Preparedness Coalition are campaigning.

Surveillance of HCV is still at an embryonic stage. Until 2011, surveillance did not incorporate all laboratory data, so prevalence in the population as a whole was almost impossible to ascertain. Since then, a special Reference Centre for Monitoring Viral Hepatitis has been established as part of the consumer watchdog Rospotrebnadzor to deal with diagnostics, prevention, regional support and situational analysis based on an integrated computerised patient registry, the Register of People Suffering from HCV. However, this is still at the developmental stage, and currently covers only 60 of Russia’s 83 federal regions. Government-funded care is only available to patients who also have HIV, and patient selection criteria are often highly subjective. Though HCV is recognised as a socially significant disease, the government’s approach to addressing it leaves the vast majority of sufferers without proper treatment and incidence is still a long way from being brought under control.

Country snapshot: Russia



While more needs to be done to align reimbursement systems and to raise physician awareness, the country effectively manages HCV prevention and treatment.

Switzerland has long-established, model programmes that provide treatment and support for people who are HIV positive and for people who inject drugs (PWID). Within this context, the choice has been made not to single out HCV as a separate priority, on the basis that most people at high risk are already covered by existing HIV and PWID programmes. Switzerland has no specific national strategic plan for viral hepatitis or Hepatitis C (HCV). However, it covers these conditions within the scope of the National Programme on HIV and other STIs (NPHS) 2011–2017, published by the Federal Office of Public Health (FOPH), which is responsible for the surveillance and control of viral hepatitis through the Division for Communicable Diseases. The Swiss government manages HCV prevention and treatment by targeting high-risk populations through its well-developed programmes for PWID and HIV-positive patients. Clinical recommendations are updated regularly—most recently in January 2016—and take into account new types of treatment, such as direct-acting antivirals. These recommendations, which are prepared by the Swiss Association for the Study of the Liver (SASL) and Swiss Society for Infectious Diseases (SSID) and subsequently reviewed and approved by the FOPH, determine which treatments fall within mandatory basic health insurance and must be reimbursed by

law. In addition to the federal government, civil society organisations work to prevent HCV and raise awareness of the disease. Specifically, Swiss Experts in Viral Hepatitis (SEVHep) brings together more than 70 professionals to ensure close collaboration between the SASL, the Swiss Gastroenterology Society, the SSID and the FOPH, as well as international organisations.

HCV screening takes place in clinics for high-risk groups, such as those in HIV/AIDS treatment centres and clinics for PWID. Primary care physicians may also test patients presenting symptoms. However, awareness of HCV among primary care physicians is generally low, limiting the extent to which screening may occur. Moreover, treatment is reimbursed only once symptoms present, providing little incentive for primary care physicians to test for HCV before it becomes symptomatic. Treatment remains under the remit of specialists, with 357 gastroenterologists practising in Switzerland, of whom 30 to 40 specialise in hepatology. In addition, infectious diseases doctors specialise in (mainly HIV-co-infected) viral hepatitis and addiction medicine. This capacity is considered adequate for Switzerland’s identified disease burden. Beyond information sessions, no training or accreditation programmes exist for non-specialists to provide HCV services. Quality of treatment depends on individual physician awareness of HCV as a systemic disease. Once a corollary condition has been diagnosed, it will be treated. However, a hepatologist is likely to focus only on his or her area of

specialty (ie, the liver), and unlikely to recommend treatment for a field beyond his or her expertise. SEVHep developed the Swiss Hepatitis Strategy 2014–2030 to improve awareness and prevention of HCV (although the strategy is not backed by the FOPH).

HCV is a notifiable disease (required by law to be reported to health authorities) in Switzerland, with information made public as it becomes available. The FOPH collects data on newly diagnosed cases of HCV in the general population and reports these data weekly on its website, along with data on other infectious diseases. Data on HCV are integrated into the national health information system. However, data on the incidence, prevalence and the burden of disease are not routinely collected with respect to either the general population or high-risk groups, nor are population serological surveys conducted to monitor HCV trends and evaluate the impact of prevention efforts. Laboratories must report the results of tests that are positive and doctors must submit a form to the FOPH when a diagnosis of HCV has been made. Incidence is considered to be under control.

Although Switzerland has no specific official strategy for managing HCV, incidence is believed to be under control based on assessment of high-risk groups. The cost of testing and treatment means that it is unlikely that this will be extended to patients who do not present symptoms, given the additional burden this would place on the cost of general mandatory insurance (LAMal), unless treatment costs moderate.

Country snapshot: Switzerland



While screening practices in Italy are inconsistent, a new national plan means comprehensive change is on the horizon.

Due to the persistent efforts of local advocacy organisations for hepatitis sufferers, the development of a comprehensive policy for treatment of HCV in Italy has now been elevated to a cabinet-level priority. Italy’s national plan for Hepatitis B (HBV) and Hepatitis C (HCV) was approved on November 5th 2015. Known as the Piano nazionale per la prevenzione delle epatiti virali (PNEV), the plan is run by the Ministry of Health’s Working Group to Prevent Hepatitis, and embodies five strategies: epidemiology (determining HCV prevalence, improving surveillance and launching pilots to screen for HCV); prevention (harmonising measures nationally to prevent transmission among high-risk subjects); awareness, information and training (raising awareness among the general population and high-risk groups, as well training healthcare and other workers at risk of exposure); treatment and access to care (instituting a network of specialised centres guaranteeing a diagnostic and therapeutic standard, creating a national ID register for HCV cases at all stages of treatment, examining the impact of different HCV treatments on health expenditure over the short and long term, studying vertical transmission of HCV to reduce prenatal foetal infection and standardising follow-up care); and social impact

(developing home care models and proposing revision of laws to improve care of patients under treatment as well as adherence to therapeutic regimens).

HCV screening practices in Italy are inconsistent. The decision to screen is subjective, made by the physicians’ first contact with patients, and asymptomatic but chronically infected individuals are often not screened. Italy has an estimated 1,500 specialists and 20–30 hepatitis centres. Training for HCV treatment and care is available to primary care physicians but less so to specialists or prenatal care and sexual health service providers. Nurses may take a six-credit, one-year distance-learning course given by a health education consultancy collaborating with hospitals and universities. Primary care physicians provide initial care and diagnosis, pre- and post-test counselling and referrals to specialists. Sexual health services provide similar counselling and referrals. With universal care—the Servizio Sanitario Nazionale—most drug costs are borne by the state, raising questions about the cost of new therapies and programmes. After spending more than EUR850m on treating HCV infections with new drugs between 2013 and 2016, the government limited reimbursement of new drugs to six categories of the most severely ill patients. As of 2012/13 direct-acting antivirals (DAAs)—boceprevir and telaprevir—were on the national essential list of medicines or subsidised by the government. It is seeking cost-effective long-term solutions,

such as negotiating price caps with drug makers and promoting a preventive approach by prioritising better data on the number and status of HCV-afflicted individuals in its national plan (PNEV).

HCV surveillance in Italy is based on the Sistema Informativo delle Malattie Infettive (SIMI—Information System for Infectious Diseases), which requires physicians to report acute HCV cases to local health agencies. Screening for HCV is common but inconsistent, and linked to other care. Screening for high-risk groups—such as HIV-positive individuals, people who inject drugs (PWID) and sex workers—varies depending on the healthcare provider. Among general practitioners, only PWID are commonly screened for HCV, but screening for high-risk patients is frequent at sexual health clinics, as it is for primary care patients with suggestive clinical symptoms and for pregnant women. However, no uniform guidelines exist on surveillance and follow-up. It is difficult to determine whether the disease is under control, as comprehensive data are lacking.

In conclusion, Italy’s approach to treatment of HCV has been of a high standard, but inconsistently applied. The recent adoption of the PNEV is a decisive move forward that should enable the country to centrally administer HCV policy and at last tackle the problem of HCV infection in a comprehensive manner.

Country snapshot: Italy



A five-year viral hepatitis strategy will help South Africa combat the disease, but surveillance and funding remain challenging.

South Africa faces a quadruple burden of disease in the form of HIV/AIDS, tuberculosis, infant and maternal mortality, and injuries (often caused by violence). As a result, while the political will to specifically address HCV exists, it is extremely constrained by competing calls on very limited resources. Despite this, access to treatment for identified cases is guaranteed although there may be a waiting period. South Africa’s five-year strategic and surveillance plan for viral hepatitis is comprehensive and includes components for vaccination; general prevention; transmission prevention via injecting drug use; transmission prevention in healthcare settings; treatment and care; and co-infection with HIV. The National Department of Health is expected to publish the plan by the end of 2016. Clinical guidelines for treating Hepatitis C (HCV) are produced by medical professionals and academics at the University of Cape Town Medical School and approved by the Department of Health. Updated in 2010, these are now being revised to ensure their relevance for primary healthcare professionals. Upon release later this year, the new guidelines will take account of new therapies and treatments, notably direct-acting antivirals (DAAs). Major

healthcare reform, with the introduction of a National Health Insurance System, aims to ensure universal access to healthcare. With the federal health budget disbursed to each of the nine provincial health departments, treatment is available to people diagnosed with HCV, but they may need to wait until funds become available. Treatment using DAAs is not standard, but is approved on a case-by-case basis. Recently, private medical aid schemes, which cover 16% of the population, have covered treatment, including the use of DAAs.

In theory, any primary care physician can screen patients for HCV. However, awareness of the disease is low, even among gastroenterologists, and testing takes place only once symptoms are present. Treatment occurs exclusively under the mandate of specialists—and South Africa has only 115, of which 80 are in private practice and just three are practising hepatologists (hepatology has only recently been registered as a sub-specialty). Training for non-specialists is either focused on raising awareness or on developing the capacity of professionals from elsewhere in Sub-Saharan Africa. Once a patient has been diagnosed, the full continuum of care, including treatment of co-morbidities, is made available to them. However, because of the high burden of other diseases such as HIV, little government funding is earmarked for targeting HCV.

Hepatitis A, B and C are notifiable

conditions that must be reported when diagnosed. An HCV surveillance system exists within the context of national requirements for reporting such conditions, but it is not comprehensive and lends itself to underreporting. The frequency of updating the health information system is currently unknown, but the system is being upgraded and overhauled, and will become electronic and nationwide eventually. The National Institute for Communicable Diseases (NICD) is in the early stages of implementing the overhaul of the health information system. Cause for concern is that many new HCV cases occur in populations that are not conventionally considered to be high risk (ie individuals who are not HIV-positive, have never injected themselves with drugs and have never had a blood transfusion) and surveillance of the general population (other than routine tests at blood banks) is virtually non-existent. Although diagnosed cases receive treatment, lack of information on incidence, even among high-risk populations, makes it difficult to tell whether HCV is under control in South Africa.

Low levels of awareness of HCV amongst medical professionals may result in under-reporting of HCV. More research is needed to improve understanding of incidence in the general population, since high-risk groups in developing countries may not correlate precisely with those in developed nations.

Country snapshot: South Africa



Scotland leads the way in targeted action to counter HCV.

In the United Kingdom (UK), healthcare is devolved to the four countries (England, Scotland, Wales and Northern Ireland). Each has a national action plan for the treatment of the Hepatitis C virus (HCV), which is administered by the respective national health authorities. Differences exist in plans and budgets, and therefore provision of care varies by country. In Scotland, for example, the government and medical authorities launched an HCV action plan in 2006 that was considered one of the most progressive anywhere. Following the success of that plan, HCV now is included in the Sexual Health and Blood Borne Virus Framework 2011–2015.

Taking its cue (and advice) from Scotland, Wales has taken a broadly similar approach to HCV. National Health Service (NHS) Wales oversees the Blood Borne Viral Hepatitis Action Plan for Wales 2010–2015, and the Welsh government has provided new funding for the Liver Disease Delivery Plan until 2020. In June 2015, NHS England announced a budget increase for the provision of new virological cures for HCV; however, lobbyists have been critical of the imposition of treatment quotas under this expanded budget (to approximately

10,000 patients a year). The Hepatitis C Trust, a UK charity, is considering requesting a judicial review of that decision and points to the incongruity of the UK government’s recent May 2016 decision to adopt the Global Health Sector Strategy on Viral Hepatitis 2016–2021, which commits it to eliminating viral hepatitis as a public health threat by 2030.

All UK strategies aim primarily to treat chronic infections, and so concentrate on high-risk populations, namely people who inject drugs (PWID). Prevalence of HCV among PWID in England is particularly high, estimated at more than 50%.

Responsibility for detection, prevention and treatment of HCV lies with the national health authorities (NHS England, Wales, Northern Ireland and Scotland), which, in conjunction with local health authorities and clinical need-determined managed care networks, co-ordinate patient pathways between providers by geographical area to ensure access to specialist resources. In theory, all patients in the UK have access to the full continuum of care and should be treated in accordance with the latest guidelines from National Institute for Health and Care Excellence (NICE). In practice, provision of care varies by area, with NHS England operating under particularly difficult budget constraints, with the

English service under more pressure than its three counterparts due to rapid population growth in London and the South East in the past decade. Primary general practitioner care involvement in diagnosis and treatment of HCV is both insufficient and inefficient across regions. Patients may present several times, for example, with proper diagnoses often made in only emergency rooms. Primary care at drug treatment centres has improved, thanks to training and accreditation programmes for non-specialist staff. In general, HCV awareness among at-risk populations is high, but remains low amongst the general population and awareness campaigns have had limited reach. As of September 2015, there were 1,414 gastroenterology consultants in the UK.

The UK’s HCV surveillance system covers incidence and prevalence both for the general population and for high-risk population groups. The Hepatitis C National Register is held by Public Health England, which, along with the four national health authorities, produces an annual UK-wide report. While there are data on prevalence and burden of disease, data on incidence are relatively weak. Data are integrated into the national health information system although lobby groups consider the existing surveillance system and published data to be generally lacking.

Country snapshot: United Kingdom



While HCV diagnosis and treatment remain strong and funding is available for research, surveillance is a relative weak spot.

Given that diagnosis and treatment of Hepatitis C (HCV) is strong in France, and mortality rates from related complications of the disease are low, HCV is not regarded as a particularly pressing political priority compared with other diseases. Reflecting this, the government did not renew the national plan for HCV when it expired in 2012, although it remains committed to continuing with efforts to improve detection and prevention.

France has had several national plans for HCV over the past 20 years. The most recent—Plan National de Lutte contre les Hépatites B et C 2009–12 (National Plan for the Struggle against Hepatitis B and C 2009–12)—expired when the previous government left office, but the current administration of François Hollande continues to use the plan as a guideline on HCV policy. The plan aims to reduce HCV transmission and improve HCV diagnosis by stepping up screening and improving access to care, covering the general public but focusing on high-risk groups. The government has

supplemented the 2009–12 plan with new drugs and oral therapies such as direct-acting antivirals (DAAs). Several public agencies active in the HCV space have their own budgets, the most prominent being the Bureau des Infections par le VIH, IST et Hépatites (Government Office for HIV, Sexually-Transmitted Infections and Hepatitis) and the Agence de Recherche Nord & Sud Sida-HIV Hépatites (ANRS—North & South Research Agency for HIV/AIDS and Hepatitis).

HCV detection, prevention and treatment fall under the specialist care remit in France. More than 3,600 gastroenterologists and hepatologists practise in the country, and treatment rates are the highest in Europe. Although few official efforts have been made to train non-specialists to provide HCV services, the services provided by specialists are comprehensive and high quality, with the full continuum of hepatitis care reimbursed by both the national health insurance system and by private insurers. Notwithstanding pressures on public finances, fairly extensive funding is available for hepatitis research, including new therapies, mainly from the state. The government has not funded an official general public

awareness campaign since 2012, but it observes a national Hepatitis C Day and has an ongoing campaign to increase awareness among high-risk groups.

Although diagnosis and treatment of HCV is strong in France, surveillance systems are a relative weak spot. Surveillance is administered and co-ordinated by the Institut National de Veille Sanitaire (National Institute for Healthcare Monitoring), but sero-surveys are not conducted regularly, which makes it difficult to monitor broader trends and evaluate the impact of prevention efforts. Basic information on prevalence, numbers being screened and how cases are managed is not readily accessible. Despite the gaps in surveillance, HCV care remains robust and is linked with primary care and other infectious disease care. Mortality rates for HCV are low (and falling), with specialists indicating that the country appears to have incidence under control.

Mirroring France’s overall excellent healthcare standards, the country compares very favourably with international peers with regard to HCV prevention, detection, diagnosis and treatment. However, surveillance systems remain relatively weak.

Country snapshot: France



Despite better diagnosis and treatment and the involvement of a variety of stakeholders, there is significant room for improvement.

Mexico’s healthcare system is relatively underdeveloped and the government’s main policy priorities in this area are focused on how to best use scarce resources to improve the population’s health, particularly given that poverty rates are high. As such, the focus has been on extending a new public healthcare insurance programme to the whole country, rather than on tackling individual diseases. Hepatitis C (HCV) treatment is therefore not regarded as a particular political priority (although no less of a priority than other major diseases). General access to treatment is improving, but there are comparatively few public facilities that provide comprehensive treatment.

Despite calls from hepatologists in Mexico for a national plan to tackle HCV, no official strategic plan is in place, nor is a budget ring-fenced for HCV treatment, though recent efforts have helped to move the government towards making a commitment to addressing HCV. A variety of stakeholders are involved in dealing with and treating HCV: the Secretaría de Salud (Ministry of Health) published guidelines in 2009 on the diagnosis and treatment of the disease. The Direccion General de Epidemiologia

(Department for Epidemiology, part of the Ministry of Health) ensures these guidelines are followed. An independent organisation, Asociación Mexicana de Hepatología (Mexican Association of Hepatology), works to deepen research on HCV and improve patient care.

HCV detection, prevention and treatment fall under the remit of specialist care. However, there are comparatively few specialist care facilities relative to the incidence of HCV; only a small percentage of cases of acute HCV are diagnosed in the early stages of infection. Mexico has about 1,450 gastroenterologists and 144 hepatologists. No training or accreditation programmes exist to bring non-specialists into the HCV field, which limits treatment capacity. HCV care is linked with other infectious disease care, although links with primary care providers are weaker. Treatment for HCV is comprehensive and covers the full continuum of care. The cost is reimbursed by the national health insurance scheme, Seguro Popular, but only a few hospitals have the necessary accreditation to provide treatment, so access to care remains patchy. The government is doing little to invest in research or raise public awareness of HCV, reflecting the absence of a national plan, as well as an ongoing stigma towards people who inject drugs (PWID).

Mexico has a national surveillance

system, the Encuesta Nacional de Salud y Nutricion (National Health and Nutrition Survey), as well as the Sistema Nacional de Vigilancia Epimediologia—Sistema Unico de Información (National Epidemiological Surveillance System, a separate monitoring system for new infections) in place. These are integrated into the Sistema Nacional de Información en Salud (National Health Information System). Data are accessible and standardised, but not linked to other related illnesses. In addition, the databases are updated only once every six years. The Instituto Nacional de Salud Publica (National Institute for Public Health) manages surveillance, including carrying out irregular serological surveys (the last one dates from 2005). Surveillance is reasonable, but lacks the thoroughness of countries where national plans are in place. The absence of a national plan indicates that the government does not view HCV as an epidemic, although incidence rates have remained unchanged, at around 1.2% of the population, in recent years.

Mexico compares relatively poorly in terms of HCV prevention, detection, diagnosis and treatment, mainly reflecting the fact that its healthcare system is less developed. Nonetheless, the government’s commitment to improving healthcare means that standards are improving, albeit gradually.

Country snapshot: Mexico



With the world’s highest HCV prevalence, the response has been aggressive but poor infection control persists and the surveillance system remains fragmented.

Egypt has the highest prevalence rate of Hepatitis C (HCV), globally. A 2008 population survey suggested that around 10% of the population aged 15–59 had active infections and another 5% had HCV antibodies, with much higher levels in rural areas and among older populations. However, results from the Egypt Health Issues Survey 2015 suggest that the total number of infections is lower, albeit still high by global standards, with about 4.4% of the population aged 1–59 being HCV RNA positive (and a further 2% with antibodies), meaning that about 4m–5m people have chronic HCV (including those aged 60 and over). The epidemic is thought to be largely the result of a vaccination campaign against bilharzia in rural areas from 1962 to 1982, often using unsterilised syringes. However, continued incidence among younger people suggests that poor infection control remains a major transmission factor.

Since the epidemic began in 1992, the national response has been aggressive. The National Committee for Control of Viral Hepatitis (NCCVH) was established in 2006, and a national treatment

programme was launched in 2008. New oral drugs have been introduced at heavily discounted prices from both originator and generic manufacturers. However, prevention has received insufficient attention, partly because of cultural barriers to challenging poor infection control practices. Political turmoil since 2011 has hampered Ministry of Health initiatives and, in 2014, under a military government, a general launched two misleading devices, the “C-Fast” which claimed to detect HCV remotely, and the “Complete-Cure,” which claimed to cure HCV using electromagnetic waves, creating false hopes. These devices are no longer being publicised, and the government is heavily promoting treatment with direct-acting antivirals (DAAs).

HCV treatment is mainly implemented though a network of specialist centres run by the National Liver Institute, although it is also available privately. The number of centres increased from about 35 in 2014 to 114 in late 2015, with plans to reach 194 by the end of 2016. Those who are infected register on the NCCVH’s website and are referred to the centres for testing and treatment. Barriers to wider service provision include financial resources and low detection before chronic symptoms have

developed. Meanwhile, some worry that access to DAAs from private pharmacies without the oversight of a hepatologist is resulting in incorrect usage, harming the individuals and risking the development of drug-resistant strains.

The national Plan of Action noted that the surveillance system is “poorly funded and fragmented, resulting in incomplete coverage and inconsistent reporting”. With assistance from a US military facility, the Ministry of Health and Population’s Epidemiological Surveillance Unit conducts population surveys about every seven years, most recently in 2015, and has established about five sentinel surveillance sites (efforts are underway to expand this number). Many people become aware of their HCV infection through job-related testing, particularly if they seek work in the Gulf, where all immigrants are tested, and those with HCV infection are expelled. The National Committee for the Control of Viral Hepatitis runs an awareness campaign, as does the HCV Awareness Media Unit at Damanhour University. Once progress is made in treating the existing caseload, the NCCVH is expected to shift focus to population screening to identify other cases.

Country snapshot: Egypt



While Croatia is only now putting a national HCV plan in place, the country has a well-developed approach to dealing with the disease.

Addressing viral hepatitis generally, and Hepatitis C (HCV) in particular, is a relatively high political priority in Croatia, where access to treatment is good and a range of prevention programmes are ongoing, typically within the context of existing programmes that target high-risk populations. Although Croatia is only now about to embark on drafting a specific national plan to address viral hepatitis, it has a well-developed approach to HCV, with regularly updated clinical guidelines that take account of new types of treatment such as direct-acting antivirals (DAAs). Croatia has a publicly funded healthcare system and mandatory health insurance, through the Croatian National Insurance Fund (CNIF). HCV is included in the list of conditions covered by the basic insurance provided by CNIF. Under the Croatian National Programme for the Prevention of HIV and AIDS 2011–15, HIV/AIDS counselling centres provide anonymous and free counselling and HIV testing, as well as counselling and screening for viral hepatitis. Croatia also has an extensive harm reduction programme for people who inject drugs (PWID) and provides

counselling and free, anonymous screening for HCV at these centres. Non-government organisations also run clinics for high-risk populations (namely, PWID and HIV-infected patients).

Croatia encourages primary care professionals to screen at-risk patients for HCV. This extends to general practitioners as well as other professionals working in HIV and harm reduction clinics, such as nurses, psychologists and social care workers. General practitioners receive training for follow-up care and surveillance. A patient who has tested positive after preliminary screening is referred to a specialist centre for further testing and treatment. Viral hepatitis is typically treated by infectious disease specialists, with only about one third of cases treated by hepatologists or gastroenterologists. It is estimated that Croatia has between 60 and 70 specialists (including infectious diseases specialists), a capacity close to adequate for managing the country’s disease burden. The full continuum of hepatitis care services is available to patients in line with World Health Organization (WHO) guidelines and European Union (EU) directives. Croatia is also exploring innovative ways to fund awareness campaigns, such as using funds acquired through a national

lottery. Healthcare and related professionals receive formal training to raise their awareness of viral hepatitis and support early detection and treatment.

The Croatian Institute of Public Health, which falls under the Ministry of Health, collates health information. HCV is a notifiable disease (cases must be reported to health authorities) and surveys of high-risk populations take place regularly. Blood bank samples are used to run serological profiles of the general population, and pregnant women are routinely tested for HCV. HCV data are reported annually to the EU and an HCV registry is being established. Croatia has a well-developed approach to HIV and other STDs, including HCV, and established harm reduction programmes; HCV care is linked to both the national HIV and harm reduction programmes. For example, the number of reported PWID is falling, with indications that the same is true for HCV incidence. Croatia’s approach to managing HCV has proved effective but is constrained by the lack of resources available for raising awareness of the disease amongst medical practitioners and the general public, due to a period of ongoing economic difficulty.

Country snapshot: Croatia



While the country has well-established national HCV policies and practices, the focus of attention is treatment rather than prevention.

In Hungary, national policies and regulations addressing Hepatitis C (HCV) focus primarily on treatment. The National Public Health and Medical Officers’ Service and the Hepatitis Therapy Committee are the country’s major components in HCV; the latter, which includes experts from various professional groups, organises and controls the treatments. Patients registering for treatment receive a priority index score and are placed on a waiting list accordingly. This system was reorganised in 2013, following the registration of new treatment methods. The budget depends on the National Health Insurance Fund, so it is available universally, and previously uninsured patients can also register for treatment. HCV care is either connected with

infectious disease centres or with gastroenterology. Between 1,000 and 1,100 patients receive treatment per year. There are practically no waiting lists for interferon treatments, yet interferon-free treatment can be initiated only after interferon therapy is not successful. The government’s healthcare strategy includes treatment for HCV only together with HIV prevention for people who inject drugs (PWID), for those with very limited funds.

Specialists control HCV treatment, while primary care providers are only partly involved in detection. Hungary has 108 hepatitis specialists at 35 centres, which makes treatment accessible for most patients. Medical professionals are required to undergo various types of training, some of which focus on hepatology. Yet some staff members of non-specialised healthcare units lack even basic knowledge of HCV and its treatment possibilities. Patients applying

for treatment need to register with the Hepatitis Therapy Committee. However, infected people without symptoms often do not register because certain pre-existing medical conditions (such as drug addiction and certain renal and heart conditions) hamper interferon treatments. Some syringe services have been restricted and funding for such programmes is now limited, though some still function. Experts fear an HCV epidemic among PWID groups, where the rate of infected people is already high.

The reporting of HCV cases is required by law. HCV surveillance is organised by the National Centre of Epidemiology, which publishes weekly and monthly reports about infectious diseases, including HCV cases both nationally and regionally, online. Figures demonstrate that incidence among sex workers and PWID is not under control.

Country snapshot: Hungary



The country’s well-managed healthcare system has room for improvement when it comes to addressing HCV.

National strategic plans for viral hepatitis, including Hepatitis C (HCV), are available in Taiwan, targeting the general population and high-risk groups. The Ministry of Health and Welfare remains the foremost entity combatting HCV in the country, while the Centers for Disease Control and National Health Insurance Administration are responsible for implementing and overseeing the plans. Other stakeholders involved in addressing hepatitis are some NGOs, such as the Liver Disease Prevention and Treatment Research Foundation and Taiwan Liver Research Foundation.

The Centers for Disease Control released amended working rules in September 2004, which addressed HCV prevention policy planning and supervision issues. Budget funding for implementing the national plans is available; however, the exact amount is unknown. National plans are not current with the latest information. All plans were released in 2000s and have not been

updated since their release. Although Taiwan has put more emphasis on HCV than China has, HCV control and prevention are not political priorities yet compared with HIV/AIDS and tuberculosis (TB). However, general access to HCV treatment is not a problem.

Hepatitis care services include basic liver-related disease treatment as well as follow-up treatment and surveillance. Almost all treatments are at least partially covered by National Health Insurance. HCV detection, prevention and treatment in Taiwan are not managed under a primary care remit. Statistics on specialists in hepatology and gastroenterology show that the number stands at more than 1,660. Training programmes and accreditation for non-specialists to provide HCV services are in place to deal with the burden of HCV. In the National Health Insurance Plan to Strengthen Chronic Hepatitis B and C Treatment Pilot Project, doctors not specialised in HCV can participate in providing HCV services in regions lacking in medical resources for addressing hepatitis B and C after receiving training

provided by the Digestive Medical Association and obtaining qualified certificates. Taiwan is investing in research, new therapies, laboratories and awareness campaigns.

The incidence of HCV in Taiwan is currently under control, with a well-managed HCV-specific surveillance system that is integrated into the national health information system. Some of the data are accessible, standardised and linked to other related illnesses. The National Notifiable Disease Surveillance System manages surveillance by requiring reporting from local health institutes and organisations. Data are updated on a weekly basis. Currently, HCV care is not fully linked with other care, but efforts are being directed towards this approach.

Overall, Taiwan has a very well-managed healthcare system. All citizens have full access to healthcare services including those for HCV, and insurance covers almost all diseases, with part of HCV treatment covered by National Health Insurance. Policies on HCV control and prevention can be further optimised in the future.

Country snapshot: Taiwan



With an overarching strategic national plan, a focus on the prevention and control of viral hepatitis is helping the country advance HCV care.

Israel is making strides in its approach to addressing Hepatitis C (HCV). Politically, HCV is a rising priority for the Israeli parliament (the Knesset): updates in late 2014 expanded the number of HCV medications available on the subsidised national medicines list, and the government is actively working with advocates to improve and implement the overarching Eradicate Hepatitis National Plan, which focuses on the prevention and control of viral hepatitis and integrates HCV care with other diseases. The plan targets the general public, as well as high-risk groups such as healthcare workers, healthcare waste handlers, people who inject drugs (PWID), patients with HIV and travellers. The government is in discussions with local experts to update and expand the plan to include a variety of initiatives, such as a programme focusing on eradicating HCV in prisons, and to establish a national chronic hepatitis registry. In general, Israelis have excellent access to the latest HCV therapies, which are covered by the national health

system and are paid for by the government. For example, medicines such as interferon alpha, pegylated interferon, ribavirin, boceprevir and telaprevir are covered, as well as, viral load assays and assessment tools for hepatic fibrosis and chronic HCV. Annually, the Health Administration Committee for the Health Basket (the government entity responsible for Israel’s subsidised medicines list) and other stakeholders meet to update the national registry of medicines. In December 2014, this list was updated to include new treatments for HCV, which were projected to consume almost 25% of the budget for subsidised medicines.

Typically, patients are diagnosed by their primary care physicians and referred to specialists. With about 700 specialists in hepatology and gastroenterology, Israel has an adequate network of trained doctors to manage the current population of patients with HCV. However, local experts have identified the need for the government to provide more training for nurses and primary care doctors regarding HCV. To raise awareness of the disease, Israel participated in World Hepatitis Day in 2014 and 2015. Activities included a full day of discussions in parliamentary

committees of the Knesset, as well as further talks during the legislative body’s plenum session. However, the government has not funded other viral hepatitis public awareness campaigns since 2011.

The Ministry of Health tracks acute cases of hepatitis A, B and C, but not cases of chronic hepatitis. Each week, the ministry collects data from district health offices regarding newly diagnosed cases of hepatitis. It also maintains an electronic national registry of childhood vaccinations, which is linked to the national population database. This allows the government to track the efficacy of its hepatitis A and B immunisation program. While the government lacks a national surveillance programme for chronic HCV, Clalit Health Services (CHS), the country’s largest healthcare provider, manages a database encompassing close to 60% of the total population. CHS is creating a publicly available HCV registry to further study the disease in Israel. At present, the incidence of HCV is under control, but experts urge the government to fully fund and implement all areas of the strategic plan to remain ahead of the disease.

Country snapshot: Israel



HCV screening is required for migrants, but is not widespread for Saudi nationals—and treatment is expensive.

Saudi Arabia has no published national strategic plan on Hepatitis C (HCV), and there are contradictory reports about whether one exists. However, the Ministry of Health does have a National Hepatitis Programme, led by a scientific advisory committee. The Saudi Association for the Study of Liver Diseases and Transplantation (SASLT) independently formed an HCV committee in 2011 and developed guidelines for treatment. The Association has been in discussions with the Ministry of Health about a strategy to scale up HCV detection and treatment, given the availability of the new oral drugs, which have been approved by the Saudi Food and Drug Authority. However, given their cost in Saudi Arabia (like the United States), and the fiscal

squeeze from low oil prices, it is unclear whether resources will be available to scale up national efforts (which cover only Saudi nationals), unless discounts can be negotiated. Only a small minority of expatriates, who represent about a third of the population, have insurance policies that cover HCV treatment; those at greatest risk of infection cannot afford to pay for the treatment directly.

HCV detection is included in the array of tests required for nationals before getting married and for entrance into the military; blood donations are also tested. Immigrants (many from high-prevalence countries such as Egypt and Pakistan) are screened for HCV and other infections, as part of their residency process, as is common throughout the Gulf region, and those found to be HCV positive are usually not granted residency. There have been suggestions that detection and treatment could be scaled up by

about five-fold from existing levels, of about 2,000 cases a year, focusing on older people who have higher prevalence, to aim at elimination within 15 years. However, given that there are only about 250 hepatologists and gastroenterologists in the country, more personnel would be needed.

The national HCV surveillance system is largely based on passive reporting rather than cross-sectional surveys. Teams in each region send monthly reports to the National Hepatitis Programme, with clinical and epidemiological data. A recent meta-study of 442 available prevalence measures concluded that the prevalence is around 1.6%, with similar levels for both Saudi nationals and expatriates, although this may be an overestimate. Considerably lower prevalence among young people suggests that incidence is largely under control.

Country snapshot: Saudi Arabia



Reducing hospital infections and raising awareness amongst the population have helped keep prevalence low, but gaps remain and questions centre on how to afford new treatments.

Turkey’s public health services have concentrated on reducing child mortality and combating communicable diseases through vaccination programmes. More recent priorities have included lowering tobacco use. Hepatitis has received lower status, and attention has focused mostly on Hepatitis B, which is much more prevalent than Hepatitis C (HCV), and for which a vaccine is available.

Turkey has yet to develop a national strategy and action plan for viral hepatitis, although the issue is currently on the agenda of the Turkey Public Health Institution (THSK), which is affiliated with the Ministry of Health. Given these circumstances, the country relies on its existing institutions, capacities, budgets and procedures for the diagnosis and treatment of HCV infections. Efforts made to reduce hospital infections, as well as to increase awareness around blood safety,

may have helped to keep prevalence relatively low. In addition, levels of injecting drug use and HIV/AIDS are low in Turkey. Blood tests are conducted regularly for blood donors and military recruits. For treatment and for the diagnosis of chronic HCV infections, well-trained medical specialists are available and adequate medical facilities and laboratories are in place. Most of the population has access to healthcare and medication through the General Health Insurance (GSS) system. Meanwhile, medical faculties, associations of doctors and others are involved in scientific, educational and awareness-raising efforts related to viral hepatitis.

Nevertheless, there are gaps to be filled. In particular, surveillance and early detection are weak. There are no special services for high-risk groups. Data are not collected and published regularly, which reflects and perpetuates the relatively low visibility of the disease, and also leads to knowledge gaps—for example,

concerning current trends or patterns of prevalence. The primary healthcare system plays little role in testing and treatment of HCV infections. Collaboration with civil society is still limited and there are no innovative funding mechanisms in place or being developed for addressing HCV.

More recently, meeting the costs of newly developed treatments has become a hot topic, globally and within Turkey. Although protease inhibitors have been licensed by the Ministry of Health, can be obtained via pharmacies and are paid for by private health insurers, their cost is not met through the GSS. This means that treatments remain largely unavailable to most eligible patients. This issue will dominate the HCV policy agenda until it is resolved. Thereafter the authorities will have an added incentive to redouble preventive measures to keep down treatment costs, but may still need to be persuaded of the benefits of early detection.

Country snapshot: Turkey



The country’s new national strategic plan will include guidelines on screening, treatment, surveillance and monitoring.

Due to their low prevalence in the Netherlands, viral hepatitis and Hepatitis C (HCV) do not currently feature as policy priorities for the Dutch government. Needle use has been on the decline since the 1980s and only several hundred new infections are reported each year.

This helps to explain why the Netherlands does not currently have a national strategic plan for viral hepatitis or HCV though a plan is forthcoming. The drop in the cost of medication has been one of the main triggers for the public health authorities—Rijksinstituut voor Volksgezondheid en Milieu (RIVM—the National Institute for Public Health and the Environment)—to start developing a plan, in cooperation with professional

agencies, health insurers and patient associations. This plan, due to be finalised towards the end of 2016, includes comprehensive guidelines on screening, treatment, surveillance, monitoring and the role of different health professionals in addressing HCV. The plan is financed primarily by public funds.

Detection, identification and prevention of HCV in the Netherlands are primarily in the hands of family doctors and local primary health service providers—the GGDs (community health services) and the Council’s Public Health Services. Treatment and follow-up care fall under a specialist care remit. The country has a total of 512 hepatologists and gastroenterologists, of which approximately 100 focus on liver patients. In addition, non-specialists and particularly family doctors are offered courses to provide HCV services. Hepatitis care services are comprehensive,

including care of extra hepatic manifestations and follow-up services, which vary from three months (in mild cases) to life-long check-ups (in severe cases). Since a drop in treatment costs in 2015, the Netherlands has expanded the group of patients who qualify for treatment to near-universal access and is investing heavily in policy and awareness campaigns.

The Netherlands currently registers only acute cases of HCV and does not track chronic cases, but this is set to change with the introduction of the national strategic plan by the end of 2016. Surveillance will include both acute and chronic cases, and will register mono- and co-infections (integrated with the national HIV monitoring system). This system will provide information on morbidity and mortality in the country, and will help to demonstrate the effectiveness of treatment.

Country snapshot: The Netherlands



National strategies and a new collaboration with the WHO are part of China’s efforts to monitor, manage and eliminate HCV.

In accordance with the China-World Health Organization (WHO) Country Cooperation Strategy 2016–2020, China will collaborate with the WHO to implement specific approaches to address communicable diseases, including hepatitis. In 2014, the Chinese Centre for Disease Control and Prevention (China CDC) conducted a national seroepidemiologic study of hepatitis B virus (HBV) infections in China. Several national strategic plans address viral hepatitis, including the People’s Republic of China Communicable Disease Prevention Act, China’s Chronic Disease Prevention Work Plan (2012–2015) and the Notice on 2010 Major Diseases Prevention and Control Management Program. Most are current with the latest plan launched in 2015. The National Health and Family Planning Commission of the People’s Republic of China (NHFPC) and the China CDC are the major players developing, implementing and overseeing the plans. The budget for addressing hepatitis is limited, with a small proportion being allocated to Hepatitis C (HCV) specifically. New drugs and oral

therapies are not included in the plans—in 2012/13, ribavirin was on the national essential medicines list or subsidised by government. Specific testing technologies for HCV are not mentioned in the plans either, although testing work was emphasised in the Notice on 2010 Major Diseases Prevention and Control Management Program. Both the general public and high-risk groups are targeted in the national strategic plans for control and prevention of the spread of HIV and HCV. In general, HCV is not a political priority compared with HIV/AIDS and HBV; HCV is given less attention and treatment is also more limited.

HCV detection, prevention and treatment do not fall under a primary care or specialist care remit. HCV care is not linked with other care in China unless requested by patients. China has at least 10,100 specialists in hepatology and gastroenterology—about 1,500 and 8,589, respectively. Training programs offered by the China Foundation for Hepatitis Prevention and Control are available for non-specialists to provide HCV services. Only basic hepatitis care services, namely treatment of hepatitis and related liver diseases, are available in China. Awareness campaigns include observing the National Protect Liver Day

on March 18, and annual participation in the WHO World Hepatitis Day since 2011. China invests in research and funds new therapies and laboratories, but does not currently offer expanded and innovative services such as Extension for Community Healthcare Outcomes (ECHO), a model to increase access to specialty treatment.

The China Information System for Disease Control and Prevention covers hepatitis, is national in scope and is integrated into the national health information system. The data are accessible and standardised under the surveillance of the China CDC. However, it is not an HCV/hepatitis-specific surveillance system and there is room for improvement in data accuracy and categorisation. With the control and prevention efforts by NHFPC and the China CDC, incidence of HCV is under control.

Over all, China is still in the early stages of addressing HCV, given that the country has been spending more time and effort on HBV prevention and control. But the government and some social institutions have been working on driving more attention and resources into managing and eliminating HCV within the country.

Country snapshot: China



Combating liver cancer, improving primary care detection and applying measures to address chronic hepatitis are on the agenda for Japan.

Japan has one of the highest rates of Hepatitis C (HCV) and also liver cancer (largely attributed to HCV) among industrialised nations. In order to address the virus, its complications and its persistence, the Ministry of Health, Labour and Welfare (MHLW) published a national strategy, the Basic Act on Hepatitis Measures, which focused specifically on the prevention and control of Hepatitis B and C in 2009. It includes components for awareness, vaccination and treatment. The MHLW has a specially designated Office for the Promotion of Hepatitis Measures, and the Ministry of Finance has dedicated funding to combat the disease. Japan has several active NGOs dedicated to HCV awareness and

prevention, including Japan Hepatitis Council and the Viral Hepatitis Research Foundation of Japan. In 2012/13 direct-acting antivirals (DAAs)—boceprevir and telaprevir—were on the national essential list of medicines or subsidised by the government.

Japan has more than 4,500 gastroenterologists dedicated to the treatment of hepatitis and more than 6,000 hepatologists. Although general guidelines for screening and treatment exist at the primary care level, of the 26% of respondents to a 2015 survey who had HCV symptoms at the time of diagnosis, very few were offered an HCV test upon reporting symptoms to their primary care physician. The MHLW has recognised the need to improve early detection by primary care, proposing in 2011 improvements for detection and co-ordination among primary care

physicians, specialists and regional institutions.

Japan has had nationwide screening and surveillance practices for the general population in place since at least 2008. Japan has sufficiently well-trained physicians and quality healthcare facilities to address HCV and related conditions. While surveillance and immediate measures for acute hepatitis are well established, measures for chronic hepatitis are insufficient and a policy focusing on long-term treatment of patients is currently lacking. The persistence of HCV and hepatocellular carcinoma is currently being addressed by way of awareness campaigns to urge the public to seek testing and treatment. In addition, in 2015, the MHLW approved a new regimen for the treatment of chronic HCV genotype 1 infection in adults.

Country snapshot: Japan


Country snapshots: A country approach to Eliminating Hepatitis C

Health & Medicine

Transcript of Country snapshots: A country approach to Eliminating Hepatitis C