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      Survey of programmatic experiences and challenges in delivery of hepatitis B and C testing in low- and middle-income countries

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          Abstract

          Background

          There have been few reports on programmatic experience of viral hepatitis testing and treatment in resource-limited settings. To inform the development of the 2017 World Health Organization (WHO) viral hepatitis testing guidance and in particular the feasibility of proposed recommendations, we undertook a survey across a range of organisations engaged with hepatitis testing in low- and middle-income countries (LMICs). Our objective was to describe current hepatitis B and C testing practices across a range of settings in different countries, as well as key barriers or challenges encountered and proposed solutions to promote testing scale-up.

          Methods

          Hepatitis testing programmes in predominantly LMICs were identified from the WHO Global Hepatitis Programme contacts database and through WHO regional offices, and invited to participate. The survey comprised a six-part structured questionnaire: general programme information, description of hepatitis testing, treatment and care services, budget and funding, data on programme outcomes, and perceptions on key barriers encountered and strategies to address these.

          Results

          We interviewed 22 viral hepatitis testing programmes from 19 different countries. Nine were from the African region; 6 from the Western Pacific; 4 from South-East Asia; and 3 from Eastern Europe. All but four of the programmes were based in LMICs, and 10 (45.5%) were supported by non-governmental or international organizations. All but two programmes undertook targeted testing of specific affected populations such as people living with HIV, people who inject drugs, sex workers, health care workers, and pregnant women. Only two programmes focussed on routine testing in the general population. The majority of programmes were testing in hospital-based or other health facilities, particularly HIV clinics, and community-based testing was limited. Nucleic acid testing (NAT) for confirmation of HCV and HBV viraemia was available in only 30% and 18% of programmes, respectively. Around a third of programmes required some patient co-payment for diagnosis. The most commonly identified challenges in scale-up of hepatitis testing were: limited community awareness about viral hepatitis; lack of facilities or services for hepatitis testing; no access to low cost treatment, particularly for HCV; absence of national guidance and policies; no dedicated budget for hepatitis; and lack of trained health care and laboratory workers.

          Conclusions

          At this early stage in the global scale-up of testing for viral hepatitis, there is a wide variation in testing practices and approaches across different programmes. There remains limited access to NAT to confirm viraemia, and patient self-payment for testing and treatment is common. There was consensus from implementing organizations that scale-up of testing will require increased community awareness, health care worker training, development of national strategies and guidelines, and improved access to low cost NAT virological testing.

          Electronic supplementary material

          The online version of this article (10.1186/s12879-017-2767-0) contains supplementary material, which is available to authorized users.

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          Most cited references64

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          Acceptability and feasibility of a screen-and-treat programme for hepatitis B virus infection in The Gambia: the Prevention of Liver Fibrosis and Cancer in Africa (PROLIFICA) study

          Despite the introduction of immunisation for hepatitis B virus (HBV) in the 1990s, HBV-related morbidity and mortality remain high in sub-Saharan Africa. Identification and treatment of asymptomatic people with chronic HBV infection should reduce the disease burden. We therefore assessed the feasibility of a screen-and-treat programme for HBV infection in The Gambia, west Africa, and estimated the proportion of HBV-infected people who had significant liver disease in need of treatment.
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            High prevalence of hepatitis B virus infection among pregnant women attending antenatal care: a cross-sectional study in two hospitals in northern Uganda

            Objective To determine the prevalence of the hepatitis B viral (HBV) infection and hepatitis B e antigen (HBeAg) positivity among pregnant women attending antenatal clinics in two referral hospitals in northern Uganda. Design Cross-sectional observational study. Setting Two tertiary hospitals in a postconflict region in a low-income country. Participants Randomly selected 402 pregnant women attending routine antenatal care in two referral hospitals. Five women withdrew consent for personal reasons. Data were analysed for 397 participants. Primary outcome Hepatitis B surface antigen (HBsAg) positivity. Results Of 397 pregnant women aged 13–43 years, 96.2% were married or cohabiting. 47 (11.8%) tested positive for HBsAg; of these, 7 (14.9%) were HBeAg positive. The highest HBsAg positivity rate was seen in women aged 20 years or less (20%) compared with those aged above 20 years (8.7%), aOR=2.54 (95% CI 1.31 to 4.90). However, there was no statistically significant difference between women with positive HBsAg and those with negative tests results with respect to median values of liver enzymes, haemoglobin level, absolute neutrophil counts and white cell counts. HIV positivity, scarification and number of sexual partners were not predictive of HBV positivity. Conclusions One in eight pregnant women attending antenatal care in the two study hospitals has evidence of hepatitis B infection. A significant number of these mothers are HBeAg positive and may be at increased risk of transmitting hepatitis B infection to their unborn babies. We suggest that all pregnant women attending antenatal care be tested for HBV infection; exposed babies need to receive HBV vaccines at birth.
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              Prevalence of hepatitis B virus infection among health care workers in a tertiary hospital in Tanzania

              Background Sub-Saharan Africa has a high prevalence of hepatitis B virus (HBV) infections. Health care workers (HCWs) are at high risk of contracting HBV infection through their occupation. Vaccination of HCWs against HBV is standard practice in many countries, but is often not implemented in resource-poor settings. We aimed with this cross-sectional study to determine HBV prevalence, HCW vaccination status, and the risk factors for HCWs contracting HBV infection in Tanzania. Methods We enrolled 600 HCWs from a tertiary Tanzanian hospital. Their demographics, medical histories, HBV vaccination details and risk factors for contracting blood-borne infections were collected using a standardized questionnaire. Serum samples were tested for HBV and hepatitis C virus (HCV) markers by ELISA techniques, PCR and an anti-HBs rapid test. HCWs were divided in two subgroups: those at risk of contracting HBV (rHCW 79.2 %) via exposure to potentially infectious materials, and those considered not at risk of contracting HBV (nrHCW, 20.8 %). Results The overall prevalence of chronic HBV infection (HBsAg+, anti-HBc+, anti-HBs-) was 7.0 % (42/598). Chronic HBV infection was found in 7.4 % of rHCW versus 5.6 % of nrHCW (p-value = 0.484). HCWs susceptible to HBV (HBsAg-, anti-HBc-, anti-HBs-) comprised 31.3 %. HBV immunity achieved either by healed HBV infection (HBsAg-, anti-HBc+, anti-HBs+) or by vaccination (HBsAg-, anti-HBc-, anti-HBs+) comprised 36.5 % and 20.2 %, respectively. 4.8 % of participants had indeterminate results (HBsAg-, anti-HBc+, anti-HBc-IgM-, anti-HBs-). Only 77.1 % of HCWs who received a full vaccination course had an anti-HBs titer >10 ml/U. An anti-HBs point-of-care test was 80.7 % sensitive and 96.9 % specific. There was a significantly higher risk for contracting HBV (anti-HBc+) among those HCW at occupational risk (rHCW) of older age (odds ratios (OR) in rHCW 3.297, p < 0.0001 vs. nrHCW 1.385, p = 0.606) and among those HCW being employed more than 11 years (OR 2.51, p < 0.0001***). HCV prevalence was low (HCV antibodies 1.2 % and HCV-RNA 0.3 %). Conclusions Chronic HBV infection is common among Tanzanian HCWs. One third of HCWs were susceptible to HBV infection, highlighting the need for vaccination. Due to high prevalence of naturally acquired immunity against HBV pre-testing might be a useful tool to identify susceptible individuals.
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                Author and article information

                Contributors
                aishizak@staff.kanazawa-u.ac.jp
                julie.bouscaillou@medecinsdumonde.net
                niklas.luhmann@medecinsdumonde.net
                cherungliu@gmail.com
                raissa111@gmail.com
                walshnic@paho.org
                hesss@who.int
                Elena.Ivanova@finddx.org
                Teri.Roberts@finddx.org
                +41 22 7914548 , easterbrookp@who.int
                Journal
                BMC Infect Dis
                BMC Infect. Dis
                BMC Infectious Diseases
                BioMed Central (London )
                1471-2334
                1 November 2017
                1 November 2017
                2017
                : 17
                Issue : Suppl 1 Issue sponsor : Publication of this supplement was funded by the WHO. Information about the source of funding for specific projects can be found in the individual articles. The articles have undergone the journal's standard peer review process for supplements. PE is a WHO staff member and has no financial conflicts of interest. RC has received funding from the U.S. Agency for Healthcare Research and Quality to conduct systematic reviews on hepatitis C screening. MH receives funding from the NHMRC in Australia for a Principal Research Fellowship. The Burnet Institute receives funding from Gilead Science, Abbvie and BMS for investigator initiated research, for which MH is the lead investigator, and receives support from the Victorian Government through the Victorian Operational Infrastructure Support Program. PH is an employee of BioMed Central. The Supplement Editors declare that they were not involved in the peer review process for any paper on which they are an author.
                : 696
                Affiliations
                [1 ]ISNI 0000000121633745, GRID grid.3575.4, Global Hepatitis Programme, World Health Organization, ; 20 Avenue Appia, 1211, 27 Geneva, Switzerland
                [2 ]Médecins du Monde, 62 rue Marcadet, 75018 Paris, France
                [3 ]ISNI 0000 0004 0639 4522, GRID grid.417260.6, World Health Organization, Regional Office of the Western Pacific, ; United Nations Avenue, 1000 Manila, Philippines
                [4 ]ISNI 0000 0001 1507 3147, GRID grid.452485.a, Foundation for Innovative New Diagnostics, ; Campus Biotech, Building B2, Level 0, 9 Chemin des Mines, 1202 Geneva, Switzerland
                Article
                2767
                10.1186/s12879-017-2767-0
                5688462
                29143609
                37ab284c-f2d2-40ea-a5ef-7e187533724d
                © World Health Organization. 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution IGO License ( http://creativecommons.org/licenses/by/3.0/igo/legalcode), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. In any reproduction of this article there should not be any suggestion that WHO or this article endorse any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.

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                © The Author(s) 2017

                Infectious disease & Microbiology
                hepatitis testing,who guidelines on hepatitis b and c testing,programme experience,feasibility,low- and middle-income countries

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