1. Prevention and control of Hepatitis B In Central and Eastern Europe and Newly Independent States WHO/EURO

2. “Prevention and control of hepatitis B in CCEE and NIS” Siofok, Hungary, 1996, VHPB, WHO, CDC 4 first opportunity to raise awareness on hepatitis B 4 to discuss universal immunization with decision makers. The aim was : 4 to summarize available data, 4 to identify needs to implement effective programmes 4 to underline main constraints

3. Situation in 1996 –1  The WHO Regional Office estimated more than one million people acquire acute hepatitis B infection each year, most cases in NIS 4 Approximately 90 000 became chronic HBV carriers 4 In CCEE and NIS, levels of HBV endemicity were at intermediate or high endemic levels

5. Epidemiology in Europe, 1996 4 The level of endemicity increased from north to south and from west to east, with carrier rates; –northwestern Europe < 0.1% –midwestern Europe 0.1-0.5% –southwestern Europe, 1-5% –eastern Europe 2-7% –central Asian Republics > 7%

7. Hepatitis B Immunization schedules WHO/EORO, 1996 Uni INFANT Consideration Uni.ADOS Uni. INF + ADOS UNIVERSAL Selective Source WHO/EURO

8. only 5 of the 25 countries in Central and Eastern Europe and the Newly Independent States had implemented, mainly because of economic constraints. Hepatitis B Implementation

9. Recommendations to Countries 4 All countries should plan to integrate hepatitis B vaccination into their national immunization programmes as soon as possible.  All countries should develop a national plan for control of hepatitis B.

10. This plan should: 4 summarize current disease burden 4 include a strategy for routine vaccination of all infants and high-risk groups; 4 specify a time table and resources needed to implement the control programme

11. Recommendations to partners 4 The participants endorsed the UNICEF/ WHO strategy, calling for support of the neediest countries in obtaining hepatitis B vaccine. 4 Support should be targeted to countries with; –high disease burden, –well established EPI programmes, –a low per capita gross national product, –solid government commitment to hepatitis B prevention programmes.

12. R ecommendations to WHO 4 elaborate guidelines for national hepatitis B control plans, 4 provide assistance in developing and implementing these plans. 4 monitor effectiveness of hepatitis B prevention and control programmes 4 play coordinating role in working with other partners to support implementation of national plans

13. Progress since 1996...

14. Estimated baseline prevalence rates of hepatitis B surface antigen and routine hepatitis B immunization policy among Member States of WHO European Region, 2000 Estimated baseline prevalence rates of hepatitis B surface antigen and routine hepatitis B immunization policy among Member States of WHO European Region, 2000 <1% 1-5% >5% no data Hatching denotes routine Hep. B immunization in 2000 Prevalence

15. Incidence Rate of new hepatitis B cases, 1998/1999 (per 100,000 population)

16. Surveillance of Hepatitis B WHO/EURO 4 Most countries: –notification of acute hepatitis B is mandatory –not always well established –methods of surveillance can vary, however some countries have very complete data

17. Incidence Rate of new hepatitis B cases, 1999 (per 100,000 population) CCEE and Turkey * As of 1998; ** as of 1995;

18. Incidence Rate of new hepatitis B cases, 1999 (per 100,000 population) Newly Independent States and RF * As of 1998;

19. Incidence Rate of new hepatitis B cases, 1999 (per 100,000 population) EU countries * As of 1998; ** as of 1997;

20. Routine hepatitis B immunization policy among Member States of WHO European Region, 2000 Universal imm Universal+ screening Risk groups Children born HBs(+) mother Adolescent

21. Number of countries implementing universal Hepatitis B and immunization coverage, WHO/EURO, 1990-1999

22. Hepatitis B immunization Implementation in CCEE & NIS,2000 4 High endemicity (5) –Albania (GF) –Kazakhstan –Kyrgyzstan (GF) –Moldova (GF) –Uzbekistan (GF) –Intermediate (6) –Belarus –Bosnia & H. (F) –Bulgaria –(FYROMacedonia):Risk group –Lithuania –Romania 4 Low endemicity (9) –(Czech Republic) Risk group –(Croatia) Adolescents –Estonia:Born to HBsAg (+) mother –Latvia –Poland –Slovakia –Slovenia:Born to HBsAg (+) mother +Adolescents –Turkey –Ukraine:Born to HBsAg (+) mother

23. No Hepatitis B immunization programme, CCEE & NIS, 2000 4 High endemicity (5) –Armenia (GF) –Azerbaijan (GF) –Georgia (GF) –Tajikistan (GF) –Turkmenistan (GF) 4 Intermediate (1) –Russian Federation 4 Low endemicity (2) –Hungary –Yugoslavia

24. GAVI a great opportunity for introduction of Hepatitis B 4 Albania 4 Armenia 4 Azerbaijan 4 Bosnia & Herzegovina 4 Georgia 4 Moldova 4 Kyrgyzstan 4 Ukraine 4 Tajikistan 4 Turkmenistan 4 Uzbekistan

25. Hepatitis B Screening (survey + WHO/EURO database) 4 Screening of pregnant women: –universal screening recommended in 21 countries –4 countries, selective screening –7 countries no recommendation, because of birth dose –18 countries no information

26. Immunization Schedules, WHO/EURO, 2000 4 Neonatal: –0, 8, 24 (4) / 0, 8, 20 wks –0, 4, 24 (5)/ 0, 4, 20 wks –0, 4, 8, 52 wks 4 Infant: –12, 20, 40-48 wks –12, 16, 20, 96 wks –16, 20, 56 wks –8, 12, 24 wks –9, 13, 33 wks –8, 12, 16, 44 wks 4 Adolescent: –0, 1, 6 months (12/12)

27. Hepatitis B Risk group immunization (survey + WHO/EURO database) 4 Risk group programme: –information for 22/24 –15/19 in addition to a universal programme –6/19 risk group programme and no universal programme –no risk group programme

28. Hepatitis B immunization coverage, WHO/EURO, 1998-1999 81-100% < 80% < 50% Data not available No universal immunization

29. Hepatitis B immunization coverage, by Member States, WHO/EURO, 1999

30. Reported Hepatitis B cases, Russian Federation, 1980-2000

31. Hepatitis B vaccination coverage & new cases, Kazakhistan, 1991-2000

32. Hepatitis B vaccination coverage & new cases, Kyrgyzstan, 1991-2000

33. Hepatitis B vaccination coverage & new cases, Republic of Moldova, 1991-2000

34. Hepatitis B vaccination coverage & new cases, Turkey, 1991-2000

35. Key elements to help decision making 4 Feedback from the countries: –identification of prevalence, incidence of »carriers (age distribution) »cirrhotic cases (age distribution) »liver cancer (age distribution) »deaths (chronic / fulminant) (age distribution) –cost-effectiveness analysis –financing plan

36. Conclusion: HB recognized as a cause of significant disease burden 4 in all intermediate and high endemicity countries 4 put on the political agenda in 1996 –financial constrains 4 Several countries in the Region consider hepatitis B as the most significant infectious disease problem and the leading cause of death among vaccine preventable diseases. 4 Hepatitis B vaccination is regarded as one of the most cost-effective health interventions.

37. Conclusion 4 Main challenges –sustaining immunization services –increasing coverage –logistics and cold chain –safety of injections –monitoring performance –evaluation of impact