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Chronic hepatitis C (HCV) infection is a major global public health threat and in 2019 there were an estimated 58 million infected globally and 290,000 deaths. Elimination of viral hepatitis B/C as a public health threat by 2030 is defined as a 90% incidence reduction and a 65% mortality reduction. The Western Pacific region is one of the most affected regions with 10 million people living with HCV, one-fifth of the global burden. We review progress towards HCV elimination in the Western Pacific region since 2015. Key developments in the region, which comprises of 37 high-and-middle-income countries, include the following: 20 countries have national hepatitis action plans, 19 have conducted recent disease burden and investment cases, 10 have scaled-up hepatitis services at primary health care level, and in 11 countries, domestic financing including social health insurance support DAA costs. We highlight six countries' experience in navigating the path towards HCV elimination: Cambodia, China, Malaysia, Mongolia, Philippines, and Viet Nam. Future initiatives to accelerate elimination are expanding access to community-based testing using HCV point-of-care tests among at-risk and general populations; adopting decentralized and integrated HCV one-stop services at harm reduction sites, detention settings and primary care; expanding treatment to include children and adolescents; address stigma and discrimination; and ensuring sustainable financing through domestic resources to scale-up testing, treatment and prevention. The COVID-19 pandemic has a significant impact on hepatitis response across the region on community and facility-based testing, treatment initiation, monitoring and cancer screening, which is projected to delay elimination goals.

IntroductionYoung people have played a pivotal role as part of the COVID-19 response, including developing health messages and social innovations. Social innovation in health engages multiple stakeholders in linking social change and health improvement. The study examined the feasibility of youth ideas and innovations to address the impacts of the COVID-19 pandemic using quantitative and qualitative descriptive analyses.MethodsIn partnership with the WHO, academic institutions, youth organisations and civil society groups, we conducted a crowdsourcing open call among Filipino youth (15–30 years old) using a structured Special Programme for Research and Training in Tropical Diseases/Social Innovation in Health Initiative process. The open call had three categories: youth voices to cocreate the post-COVID-19 world (entries were texts, images, videos and music), youth-led COVID-19 social innovations, and youth-led social innovations not related to COVID-19. Each submission was evaluated by three independent judges. Finalists were selected in each of the categories alongside four grand winners. All finalists were invited to attend a 1 day online civic hackathon.ResultsWe received a total of 113 entries (youth voices to cocreate the post-COVID world=76; youth-led COVID-19 social innovations=17; youth-led social innovations not related to COVID-19=20). Twelve entries focused on youth mental health during the pandemic. The online hackathon provided the participants mentorship for further development of their ideas. Finalists were able to produce draft health communication campaigns and improved social innovations.ConclusionMany Filipino youth created exceptional entries in response to the open call. This suggests the feasibility of including youth voices in strategic planning processes. A global youth social innovation call is recommended.

To determine the projected burden of hepatitis B virus (HBV) in China, the intervention strategies that can eliminate mother-to-child transmission (MTCT) by 2030 or earlier and the measurable parameters that can be used to monitor progress towards this target.We developed a dynamic, sex- and age-stratified model of the HBV epidemic in China, calibrated using hepatitis B surface antigen (HBsAg) and e antigen (HBeAg) prevalence data from sequential national serosurveys (1979-2014) and the numbers of HBV-related cancer deaths (2012). We determined whether China can achieve elimination of MTCT of HBV by 2030 under current prevention interventions. We modelled various intervention scenarios to represent different coverage levels of birth-dose HBV vaccination, hepatitis B immunoglobulin to newborns of HBsAg-positive mothers and antiviral therapy (tenofovir) to HBeAg-positive pregnant women.We project that, if current levels of prevention interventions are maintained, China will achieve the elimination target by 2029. By modelling various intervention scenarios, we found that this can be brought forward to 2025 by increasing coverage of birth-dose vaccination, or to 2024 by the administration of tenofovir to HBeAg-positive pregnant women. We found that achievement of the target by 2025 would be predicted by a measurement of less than 2% MTCT in 2020.Our results highlight how high-quality national data can be combined with modelling in monitoring the elimination of MTCT of HBV. By demonstrating the impact of increased interventions on target achievement dates, we anticipate that other high-burden countries will be motivated to strengthen HBV prevention policies.Déterminer la charge exercée par le virus de l'hépatite B (VHB) en Chine, les stratégies d'intervention qui pourraient éliminer la transmission de la mère à l'enfant (TME) d'ici 2030 au plus tard, et les paramètres mesurables pouvant être utilisés pour suivre les progrès réalisés dans ce domaine.Nous avons développé, pour l'épidémie de VHB en Chine, un modèle dynamique stratifié selon l'âge et le sexe. Nous l'avons calibré à l'aide des données de prévalence de l'antigène de surface (HBsAg) et de l'antigène e (HBeAg) de l'hépatite B, issues des enquêtes sérologiques nationales de type séquentiel (1979–2014) et du nombre de décès par cancer associés au VHB (2012). Nous avons établi si les interventions de prévention actuelles permettraient à la Chine d'éliminer la TME du VHB d'ici 2030. Nous avons modélisé plusieurs scénarios d'intervention pour représenter différents niveaux de couverture de vaccination contre le VHB à la naissance, d'injection d'immunoglobuline aux enfants nés de mères HBsAg-positives, et de traitement antiviral (ténofovir) administré aux femmes enceintes HBeAg-positives.Nous estimons que si les interventions de prévention actuelles sont maintenues, la Chine atteindra l'objectif d'élimination prévu d'ici 2029. En modélisant divers scénarios d'intervention, nous avons découvert que cet objectif pourrait même être concrétisé pour 2025 en augmentant la couverture de vaccination à la naissance, voire 2024 en administrant du ténofovir aux femmes enceintes HBeAg-positives. Nous avons également constaté qu'un taux de TME inférieur à 2% en 2020 préfigurait la réalisation de l'objectif pour 2025.Nos résultats mettent en lumière la façon dont des données nationales de qualité peuvent être combinées à des modèles pour surveiller l'élimination de la TME du VHB. En démontrant l'impact de l'accroissement des interventions sur les échéances des objectifs, nous espérons motiver d'autres pays durement touchés à renforcer leurs politiques de prévention du VHB.Determinar la carga prevista del virus de la hepatitis B (VHB) en China, las estrategias de intervención que pueden eliminar la transmisión maternofilial (TMT) para 2030 o antes y los parámetros mensurables que se pueden aplicar para vigilar los avances logrados en la consecución de este objetivo.Se elaboró un modelo dinámico, estratificado por sexo y edad, de la epidemia del VHB en China, que se calibró mediante el uso de datos de prevalencia del antígeno HBs y del antígeno HBe obtenidos a partir de encuestas serológicas nacionales secuenciales (1979-2014) y de la cantidad de muertes por cáncer causadas por el VHB (2012). Se determinó si China puede lograr la eliminación de la TMT del VHB para 2030 con las actuales intervenciones de prevención. Se elaboraron varios escenarios de intervención para representar diferentes niveles de cobertura de la vacunación contra el VHB en dosis al nacer, de la inmunoglobulina de la hepatitis B a los recién nacidos de madres con pruebas positivas para el antígeno HBs y de la terapia antivírica (tenofovir) a las mujeres embarazadas con pruebas positivas para el antígeno HBe.Se prevé que, si se mantienen los niveles actuales de intervenciones de prevención, China logrará el objetivo de eliminación para 2029. Mediante la elaboración de modelos de varios escenarios de intervención, se descubrió que este objetivo se puede adelantar para 2025 al aumentar la cobertura de la vacunación de dosis al nacer o para 2024 al administrar tenofovir a las mujeres embarazadas que den positivo en la prueba del antígeno HBe. Además, se observó que el logro del objetivo para 2025 se podría predecir mediante la medición de menos del 2 % de la TMT en 2020.Los resultados de este análisis destacan cómo se pueden combinar los datos nacionales de alta calidad con la elaboración de modelos para vigilar la eliminación de la TMT del VHB. Al demostrar el impacto del aumento de las intervenciones en las fechas de cumplimiento de los objetivos, se prevé que otros países con una gran carga del VHB estarán motivados para reforzar las políticas de prevención de este virus.الغرض لتحديد العبء المتوقع لفيروس الالتهاب الكبدي "ب" (HBV) في الصين، واستراتيجيات التدخل التي يمكنها أن تقضي على انتقال العدوى من الأم إلى الطفل (MTCT) بحلول عام 2030 أو قبل ذلك، والمعايير القابلة للقياس التي يمكن استخدامها لرصد التقدم باتجاه هذا الهدف. الطريقة قمنا بتطوير نموذج ديناميكي وفقاً للجنس والعمر، لوباء فيروس الالتهاب الكبدي ب في الصين، تمت معايرته باستخدام مستضد الالتهاب الكبدي "ب" السطحي (HBsAg)، وبيانات انتشار المستضد الإلكتروني (HBeAg) من المسوح المصلية الوطنية المتسلسلة (الفترة من 1979 إلى 2014)، وأعداد وفيات مصابي السرطان المرتبطة بفيروس الالتهاب الكبدي "ب" (2012). لقد حددنا ما إذا كان بإمكان الصين تحقيق القضاء على انتقال عدوى فيروس الالتهاب الكبدي الوبائي "ب" بحلول عام 2030 بموجب تدخلات الوقاية الحالية. قمنا بوضع نماذج لسيناريوهات تدخل مختلفة لتمثيل مستويات تغطية مختلفة لجرعة التطعيم ضد فيروس الالتهاب الكبدي "ب" عند الولادة، والجلوبولين المناعي ضد الالتهاب الكبدي "ب" لحديثي الولادة من أمهات تم تشخيصهم بإيجابية HBsAg، والعلاج المضاد للفيروسات (تينوفوفير) لنساء حوامل تم تشخيصهم بإيجابية HBeAg. النتائج نحن نتوقع أنه في حالة الحفاظ على المستويات الحالية من التدخلات الوقائية، سوف تحقق الصين هدف القضاء بحلول عام 2029. وعن طريق وضع نماذج لسيناريوهات التدخل المختلفة، وجدنا أنه يمكن تقديم ذلك إلى عام 2025 عن طريق زيادة تغطية التطعيم بجرعة الولادة، أو إلى عام 2024 عن طريق إعطاء تينوفوفير (tenofovir) للنساء الحوامل تم تشخيصهم بإيجابية HBeAg. وجدنا أنه سيتم توقع تحقيق الهدف بحلول عام 2025 عن طريق قياس أقل من 2% من انتقال العدوى من الأم إلى الطفل في عام 2020. الاستنتاج تركز النتائج لدينا على كيفية الجمع بين البيانات الوطنية ذات الجودة العالية، مع وضع النماذج في مراقبة القضاء على انتقال عدوى فيروس الالتهاب الكبدي "ب" من الأم إلى الطفل. عن طريق إظهار تأثير التدخلات المتزايدة على تواريخ الإنجاز المستهدفة، نتوقع أن يكون لدى البلدان الأخرى ذات العبء الثقيل الحافز لدعم سياسات الوقاية من فيروس الالتهاب الكبدي ب.旨在确定中国预计的乙型肝炎病毒 (HBV) 负担、可在 2030 年或更早之前消除母婴传播 (MTCT) 的干预策略，以及可用于监测实现这一目标进展的可衡量参数。.我们针对中国的乙型肝炎病毒 (HBV) 流行情况，建立了按性别和年龄分层的动态模型，采用来自全国血清流行病学调查（1979 年至 2014 年）的乙型肝炎表面抗原 (HBsAg) 和乙型肝炎病毒 e 抗原 (HBeAg) 患病率数据以及乙型肝炎病毒 (HBV) 相关癌症死亡人数（2012 年）进行了校准。我们确定了中国通过目前的预防干预是否能够在 2030 年之前实现消除乙型肝炎病毒 (HBV) 的母婴传播 (MTCT)。我们对各种干预方案进行了建模，以体现不同出生接种剂量的乙型肝炎病毒 (HBV) 疫苗、对乙型肝炎表面抗原 (HBsAg) 阳性母亲的新生儿的乙型肝炎免疫球蛋白和对乙型肝炎病毒 e 抗原 (HBeAg) 阳性孕妇的抗病毒治疗（替诺福韦）的覆盖程度。.我们预计，如果维持目前的预防干预程度，中国将在 2029 年之前实现消除目标。通过对各种干预方案进行建模，我们发现可以通过扩大出生接种剂量疫苗的覆盖范围将这一目标提前到 2025 年实现，或者通过让乙型肝炎病毒 e 抗原 (HBeAg) 阳性孕妇服用替诺福韦将这一目标提前到 2024 年实现。我们发现，由于 2020 年母婴传播 (MTCT) 的衡量值低于 2％。，因此预计会在 2025 年之前实现目标。.我们的结果突显出如何将高质量的国家数据与建模相结合，以监测消除乙型肝炎病毒 (HBV) 母婴传播 (MTCT) 的进展。通过证明增加干预对目标实现日期的影响，我们预计其他负担沉重的国家将会有动力加强乙型肝炎病毒 (HBV) 预防政策。.Определить прогнозируемое бремя вируса гепатита В (HBV) в Китае, стратегии вмешательства, которые могут исключить его передачу от матери ребенку (ПМР) к 2030 году или раньше, а также измеряемые параметры, которые можно использовать для мониторинга прогресса в достижении этой цели.Авторы разработали динамическую, стратифицированную по полу и возрасту модель эпидемии HBV в Китае, откалиброванную с использованием данных о распространенности поверхностного антигена вируса гепатита В (HBsAg) и е-антигена вируса гепатита В (HBeAg), полученных в результате последовательных национальных серологических обследований (1979–2014 гг.), а также ряда связанных с HBV смертельных случаев среди больных раком (2012 г.). Авторы определили, сможет ли Китай добиться ликвидации передачи HBV от матери ребенку к 2030 году при соблюдении текущих профилактических мер. Были смоделированы различные сценарии вмешательства, представляющие разные уровни охвата: вакцинация против HBV при рождении, иммуноглобулин против гепатита B для новорожденных от HBsAg-положительных матерей и противовирусная терапия (тенофовир) для HBeAg-положительных беременных женщин.Авторы прогнозируют, что при сохранении текущего уровня профилактических мер Китай достигнет цели по ликвидации передачи HBV от матери ребенку к 2029 году. Моделируя различные сценарии вмешательства, авторы обнаружили, что поставленная цель может быть достигнута к 2025 году в случае увеличения охвата вакцинацией при рождении или к 2024 году в случае назначения тенофовира HBeAg-положительным беременным женщинам. Авторы определили, что достижение поставленной цели к 2025 году можно спрогнозировать, если в 2020 году показатель передачи вируса от матери ребенку составит менее 2%.Полученные результаты подчеркивают, как высококачественные общенациональные данные можно объединить с моделированием для мониторинга ликвидации передачи HBV от матери ребенку. Авторы надеются, что демонстрация влияния расширенных мер вмешательства на сроки достижения поставленных целей послужит стимулом для других стран с высоким бременем этой болезни усилить политику профилактики HBV.

Background and Aims: The World Health Organization (WHO) Western Pacific Region set a target of eliminating mother-to-child transmission (MTCT) of hepatitis B virus (HBV) by 2030. To assess the feasibility of this target in China, we carried out an epidemiological study to investigate the status quo of MTCT in the real-world setting. Methods: One thousand and eight hepatitis B surface antigen-positive pregnant women were enrolled at 10 hospitals. Immunoprophylaxis was administered to infants. In addition, mothers with HBV DNA level >2,000,000 IU/mL were advised to initiate antiviral therapy during late pregnancy. A health application called SHIELD was used to manage the study. Results: Nine hundred and five of the enrolled mothers, with 924 infants, completed the follow-up. Birth-dose hepatitis B vaccine and hepatitis B immunoglobulin were received by 99.7% and 99.7% of infants, respectively, within 24 h after birth. There were 446 mothers who received antiviral therapy, including 72.3% of the mothers with HBV DNA level >2,000,000 IU/mL and 21.0% of the mothers with HBV DNA level

Background Without intervention, HIV, hepatitis B virus and syphilis can be transmitted from mother-to-child during pregnancy, birth and breastfeeding and these can cause adverse pregnancy and longer-term outcomes. The 22 Pacific Island countries and territories (PICTs) have among the highest global prevalence of syphilis and hepatitis B. Mother-to-child transmission remains a concern, particularly hepatitis B. Global and regional elimination targets have been set to eliminate mother-to-child transmission (EMTCT) however progress of PICTs towards meeting targets is unknown. Methods Data from 2000-2019 relating to EMTCT epidemiological, process and impact targets were extracted from peer reviewed literature, online data repositories and grey literature. Results 27 peer reviewed reports, data from online data repositories for 19 countries and twelve national demographic and/or health reports were collated. Existing online databases report data for only small number of EMTCT indicators and there are few peer-reviewed studies that report EMTCT coverage estimates for PICTs. Availability of data varied between countries and available data suggests that few countries are meeting EMTCT indicator targets. Conclusions Based on the current trach trajectory, PICTs will not reach triple elimination by 2030. Both interventions to improve EMTCT activity coverage and strengthened surveillance, monitoring and evaluation systems are required. Key messages Mother-to-child transmission of HIV, hepatitis B and syphilis is a major concern in the Pacific and increased efforts are required, including strengthened monitoring and evaluation systems.

Background Mother to child transmission of hepatitis B virus (HBV) remains the most common form of HBV infection in China. Prevention of HBV vertical transmission involves timely administration of the complete hepatitis B vaccine (HepB) series and hepatitis B immunoglobulin. Post-vaccination serological testing (PVST) is utilized to determine an infant’s outcome after HBV exposure and completion of HepB series. We aim to determine the frequency of compliance with a PVST testing cascade for HBV infected mothers and analyze factors associated with infant lost to follow up (LTFU). Methods We conducted a retrospective cohort review of previously collected data in Fujian, Jiangxi, Zhejiang and Chongqing provinces in China from 1 June 2016–31 December 2017. The study population included all HBV-exposed infants and their mothers. SAS software was used for statistical analyses. Bivariate and multivariate regression analyses (presented in odds ratio [OR] with 95% confidence intervals [CI]) were used to compare the proportional differences of factors associated with PVST not being completed. Results Among enrolled 8474 target infants, 40% of them transferred out of the study provinces without further information and 4988 were eligible for PVST. We found 20% (994) of infants were not compliant with the testing cascade: 55% of LTFU occurred because parents refused venous blood sample collection or failure of sample collection in the field, 16% transferred out after 6 months of age, and 10% of families chose to have independent, confidential PVST completed without reporting results. High PVST noncompliance rates were more likely to be from Fujian (aOR = 17.0, 95% CI: 9.7–29.9), Zhejiang (aOR = 5.7, 95% CI: 3.2–10.1) and Jiangxi (aOR = 1.9, 95% CI: 1.0–3.4), and from HBV e antigen positive mother (aOR = 1.2, 95% CI: 1.1–1.4). Conclusions This study found that the LTFU rate reached 20% in PVST program, which was a significant problem. We recommend implementing a national electronic information system for tracking HBV at risk mother-infant pairs; encourage further research in developing a less invasive means of completing PVST, and take effective measures nationally to reduce HBV stigma. Without reducing the loss to follow up rate among infants eligible for PVST, elimination of vertical HBV transmission will be impossible.

Background and aim: Chronic hepatitis C is a major global health challenge. China has the world’s largest burden of hepatitis C and related liver disease, with several groups having an increased risk of acquiring hepatitis C virus (HCV) infection. We undertook a systematic review in Chinese and English literature to determine the seroprevalence of anti-HCV among men who have sex with men (MSM), sex workers, people who use drugs (PWUD) and migrant workers in China. Methods: We searched three Chinese databases (CNKI, Wanfang and Chongqing VIP Information) and four English databases (Pubmed, EMBASE, Global Health and CINAHL) for studies published between 2010 and 2015. Included were 89 studies for MSM, 112 for sex workers, 11 for migrant workers, 94 for people who inject drugs (PWID) and 67 for non-injectors. Random-effect models pooled estimates of anti-HCV seroprevalence in each population and a meta-regression model examined the relationship between anti-HCV seroprevalence and injecting drug use. Results: The overall pooled seroprevalence of anti-HCV among MSM was 0.67% (CI 95 0.51–0.86); for sex workers 0.65% (CI 95 0.53–0.77); for migrant workers 0.48 (CI 95 0.20–0.85); for IDUs 72.41% (CI 95 68.71–75.97); among non-injectors 25.07% (CI 95 21.51%–28.80%). Our meta-regression model predicted that the seroprevalence of anti-HCV among PWID increased by 8.6% for each 10% increase seroprevalence of reporting ever having injected drugs. Conclusions: Overall, seroprevalence of HCV infection is high among PWUD, especially those who inject. Lower HCV seroprevalence (

Background The paradigm shift in hepatitis C virus (HCV) treatment options in the last five years has raised the prospect of eliminating the disease as a global health threat. This will require a step-change in the number being treated with the new direct-acting antivirals (DAAs). Given constrained budgets and competing priorities, policy makers need information on how to scale-up access to HCV treatment. To inform such decisions, we examined the cost effectiveness of screening and treatment interventions in Yunnan, China. Methods and findings We simulated the HCV epidemic using a previously published model of HCV transmission and disease progression, calibrated to Yunnan data, and implemented a range of treatment and screening interventions from 2019. We incorporated treatment, diagnosis, and medical costs (expressed in 2019 US Dollars, USD) to estimate the lifetime benefits and costs of interventions. Using this model, we asked: is introducing DAAs cost effective from a healthcare sector perspective; what is the optimal combination of screening interventions; and what is the societal return on investment of intervention? The incremental cost-effectiveness ratio (ICER) of switching to DAAs with a median cost of 7,400 USD (50,000 Chinese Yuan) per course is 500 USD/disability adjusted life year (DALY) averted; at a threshold of 50% of Yunnan gross domestic product (2,600 USD), switching to DAAs is cost effective 94% of the time. At this threshold, the optimal, cost-effective intervention comprises screening people who inject drugs, those in HIV care, men who have sex with men, and ensuring access to DAAs for all those newly diagnosed with HCV. For each USD invested in this intervention, there is an additional 0·80 USD (95% credible interval: 0·17–1·91) returned through reduced costs of disease or increased productivity. Returns on investment are lower (and potentially negative) if a sufficiently long-term horizon, encompassing the full stream of future benefits, is not adopted. The study had two key limitations: costing data were not always specific to Yunnan province but were taken from China-level studies; and modelled interventions may require more operational research to ensure they can be effectively and efficiently rolled-out to the entire province. Conclusions Introducing DAAs is cost effective, the optimal package of screening measures is focussed on higher risk groups, and there are likely to be positive returns from investing in such HCV interventions. Our analysis shows that targeted investment in HCV interventions will have net benefits to society; these benefits will only increase as DAA costs fall.

Summary Background & Aims It is estimated that 3.26 million children and adolescents worldwide have chronic HCV infection. To date, the global response has focused on the adult population, but direct-acting antiviral (DAA) regimens are now approved for children aged ≥3 years. This global review describes the current status of policies on HCV testing and treatment in children, adolescents, and pregnant women in WHO Member States. Methods We identified national strategic plans and/or clinical practice guidelines (CPGs) for HCV infection from a World Health Organization (WHO) database of national policies from Member States as of August 2019. A standardised proforma was used to abstract data on polices or recommendations on testing and treatment in children, adolescents and pregnant women. Analysis was stratified according to the country–income status and results were validated through WHO regional focal points through August 2020. Results National HCV policies were available for 122 of the 194 WHO Member States. Of these, the majority (n = 71/122, 58%) contained no policy recommendations for either testing or treatment in children or adolescents. Of the 51 countries with policies, 24 had specific policies for both testing and treatment, and were mainly from the European region; 18 countries for HCV testing only (12 from high- or upper-middle income); and 9 countries for treatment only (7 high- or upper-middle income). Twenty-one countries provided specific treatment recommendations: 13 recommended DAA-based regimens for adolescents ≥12 years and 6 still recommended interferon/ribavirin-based regimens. Conclusions There are significant gaps in policies for HCV-infected children and adolescents. Updated guidance on testing and treatment with newly approved DAA regimens for younger age groups is needed, especially in most affected countries. Lay summary To date, the predominant focus of the global response towards elimination of hepatitis C has been on the testing and treatment of adults. Much less attention has been paid to testing and treatment among children and adolescents, although in 2018 an estimated 3.26 million were infected with HCV. Our review shows that many countries have no national guidance on HCV testing and treatment in children and adolescents. It highlights the urgent need for advocacy and updated policies and guidelines specific for children and adolescents., Graphical abstract, Highlights • Most national HCV policies lack specific recommendations for HCV testing and treatment in children and adolescents. • Only 33 countries have specific recommendations for treatment of children and/or adolescents. • Updated guidance on testing and treatment is needed for younger age groups. • Efforts are particularly needed in countries with a high HCV burden in children.

Background In 2016, the first global viral hepatitis elimination targets were endorsed. An estimated one-third of the world’s population of individuals with chronic hepatitis B virus (HBV) infection live in China and liver cancer is the sixth leading cause of mortality, but coverage of first-line antiviral treatment was low. In 2015, China was one of the first countries to initiate a consultative process for a renewed approach to viral hepatitis. We present the investment case for the scale-up of a comprehensive package of HBV interventions. Methods A dynamic simulation model of HBV was developed and used to simulate the Chinese HBV epidemic. We evaluated the impact, costs, and return on investment of a comprehensive package of prevention and treatment interventions from a societal perspective, incorporating costs of management of end-stage liver disease and lost productivity costs. Results Despite the successes of historical vaccination scale-up since 1992, there will be a projected 60 million people still living with HBV in 2030 and 10 million HBV-related deaths, including 5.7 million HBV-related cancer deaths between 2015 and 2030. This could be reduced by 2.1 million by highly active case-finding and optimal antiviral treatment regimens. The package of interventions is likely to have a positive return on investment to society of US$1.57 per US dollar invested. Conclusions Increases in HBV-related deaths for the next few decades pose a major public health threat in China. Active case-finding and access to optimal antiviral treatment are required to mitigate this risk. This investment case approach provides a real-world example of how applied modeling can support national dialog and inform policy planning., Approximately one-third of the world’s population with chronic Hepatitis B Virus (HBV) live in China. A comprehensive package of interventions against HBV, including case-finding and antiviral treatment, could reduce HBV-related deaths by 2.1 million and is likely to have a positive return on investment to society over 15 years.

Multilingual abstracts in the five official working languages of the United Nations. (PDF 616 kb)

Multilingual abstracts in the five official working languages of the United Nations. (PDF 616 kb)

Hepatitis B virus (HBV) infection is a major cause of acute and chronic liver disease and associated morbidity and mortality worldwide. Vertical (mother-to-child) and horizontal early childhood transmission are the main routes of HBV transmission and are responsible for most chronic infections, including among adults who bear the greatest burden of morbidity and mortality. Universal hepatitis B immunisation at birth and in infancy is the key strategy for global elimination of HBV infection, and has been highly effective in reducing new vertical infections. However, global progress in scale-up of HBV testing and treatment has been slow in adults and children. In this Series paper, we summarise knowledge on the epidemiology, natural history, and treatment of chronic HBV infection in adolescents and children, and we highlight key differences from HBV infection in adults. The estimated global prevalence of HBV infection in children aged 5 years or younger is 1·3%. Most children are in the high-replication, low-inflammation phase of infection, with normal or only slightly raised aminotransferases; cirrhosis and hepatocellular carcinoma are rare. Although entecavir is approved and recommended for children aged 2-17 years, and tenofovir for those aged 12-18 years, a conservative approach to treatment initiation in children is recommended. Key actions to address current policy gaps include: validation of non-invasive tests for liver disease staging; additional immunopathogenesis studies in children with HBV infection; long-term follow-up of children on nucleoside or nucleotide analogue regimens to inform guidance on when to start treatment; evaluation of different treatment strategies for children with high rates of HBV replication; and establishment of paediatric treatment registries and international consortia to promote collaborative research.

Background: The World Health Organization (WHO) has set a goal of eliminating viral hepatitis as public health threat by 2030. To assess feasibility of this goal in China, we carried out a real-world study to determine whether WHO's goal could be achieved. Methods: One thousand and eight hepatitis B surface antigen (HBsAg) positive pregnant women were enrolled at ten hospitals. Immunoprophylaxis was routinely administered to infants. In addition, mothers with HBV DNA level > 2,000,000 IU per milliliter were advised to initiate antiviral therapy during late pregnancy. A health application called SHIELD was used to manage the study. Findings: Nine hundred and five of enrolled mothers with 924 infants completed the follow-up, including 561 hepatitis B e antigen (HBeAg) positive mothers and 499 mothers with HBV DNA level > 2,000,000 IU per milliliter. There were 446 mothers who received antiviral therapy, including 72·3% of the mothers with HBV DNA level > 2,000,000 IU per millilitre and 21·0% of the mothers with HBV DNA level of < 2,000,000 IU per millilitre. Birth-dose hepatitis B vaccine (HepB) and hepatitis B immunoglobulin (HBIG) were received by 99·9% and 99·8% of infants within 24 hours after birth, respectively. Eight infants became infected with HBV. The overall rate of mother-to-child transmission (MTCT) was 0·9% (95% confidence interval, 0·4% to 1·7%). Birth defects were rare (0·5% among infants with maternal antiviral exposure versus 0·7% among infants without exposure; P=1·00). Interpretation: In real-world practice, there was a low rate (

Hepatitis C virus (HCV) infection is a major cause of chronic liver disease and associated morbidity and mortality worldwide. Short-course, oral, curative, direct-acting antiviral regimens have transformed treatment for HCV infection. Since the 2016 launch of the first global strategy towards elimination of viral hepatitis as a public health threat by 2030, the predominant focus of the global response has been on the treatment of adults, who bear the greatest burden of morbidity and mortality of HCV-related chronic liver disease. Compared with adults, there has been little attention paid to addressing the response to HCV in children and adolescents, in part because of the scarcity of data to inform specific paediatric management practices and policy. In this Series paper, we summarise knowledge on the epidemiology, natural history, and treatment of chronic HCV infection in adolescents and children, and we highlight key differences from infection acquired in adulthood. The estimated global prevalence and burden of HCV infection in children aged 1-19 years is 0·15%, corresponding to 3·5 million people (95% CI 3·1-3·9 million). HCV infection is usually asymptomatic during childhood, and cirrhosis and hepatocellular carcinoma are rare. Sofosbuvir with ledipasvir and sofosbuvir with ribavirin have received regulatory approval and guidelines recommend their use in adolescents aged 12 years and older with HCV infection. In April, 2019, glecaprevir with pibrentasvir also received regulatory approval for adolescents aged 12-17 years. Key actions to address the current policy gaps and achieve treatment scale-up that is comparable to that in adults include: establishment of a campaign on access to testing and treatment that is targeted at children and adolescents; fast-track evaluation of pan-genotypic regimens; and accelerated approval of paediatric formulations. Research gaps that need to be addressed include: age-specific prevalence studies of HCV viraemia in priority countries; further validation of non-invasive tests for staging of liver disease in children; and establishment of paediatric treatment registries and international consortia to promote collaborative research agendas.

ObjectivesNation-wide hepatitis B vaccination coverage among healthcare workers (HCWs) is not well researched in China. This study aims to investigate the self-reported hepatitis B vaccination status among HCWs in China.MethodsWe conducted a cross-sectional survey of health_care workers' vaccination statuses in 120 hospitals in China by collecting demographic and vaccination data. Univariate and multivariate logistic regression analysis were used to assess factors associated with hepatitis B vaccination coverage.ResultsEighty-six percent (2,666/3,104) of respondents reported having received at least one dose of the hepatitis B vaccination and 60% (1,853/3,104) reported having completed ≥3 doses of the hepatitis B vaccination. Factors associated with completing ≥3 doses of the hepatitis B vaccination included workplaces offering free hepatitis B vaccination with vaccination management, age, medical occupation, hospital level, acceptable hepatitis B knowledge and having received training on hepatitis B. HCWs in workplaces offering a free hepatitis B vaccine with vaccination management were 1.4 times more likely (OR = 1.4, 95% CI: 1.1-1.8) to complete their hepatitis B vaccination compared to HCWs in workplaces that did not offer a free hepatitis B vaccine. Either the possession of acceptable hepatitis B knowledge or an age of 30-39 years increased the odds of complete hepatitis B vaccination by 1.3-fold (95% CIs: 1.1-1.5 and 1.1-1.7, respectively) over their referent category. The receipt of training on hepatitis B was also associated with a higher percentage of completing the hepatitis B vaccination (OR = 1.5, 95% CI: 1.2-1.8). The main self-reported reason for incomplete hepatitis B vaccination was "forgot to complete follow-up doses" among 43% (234/547) of respondents. Among those who never received any hepatitis B vaccination, only 30% (131/438) intended to be vaccinated. Obtaining immunity from work (40%) and hospitals that did not provide hepatitis B vaccination activities (40%) were the top reasons mentioned for refusing hepatitis B vaccination.ConclusionsThe complete hepatitis B vaccination rate among HCWs in China is low, and the desire of HCWs for vaccination is indifferent; therefore, education campaigns are needed. In addition, a free national hepatitis B vaccination policy for HCWs that includes vaccination management should be prioritized to improve hepatitis B coverage among HCWs who are at-risk for HBV infection.

Background The World Health Organization recommends all men who have sex with men (MSM) receive Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) testing. MSM in China are a high-risk group for HBV and HCV infection, but test uptake is low. Crowdsourcing invites a large group to solve a problem and then shares the solution with the public. This nationwide online randomized controlled trial will evaluate the effectiveness of a crowdsourced intervention to increase HBV and HCV testing among MSM in China. Methods Seven hundred MSM will be recruited through social media operated by MSM organizations in China. Eligible participants will be born biologically male, age 16 years or older, report previous anal sex with another man, and reside in China. After completing a baseline online survey, participants will be randomly assigned to intervention or control arms with a 1:1 allocation ratio. The intervention will include two components: (1) a multimedia component will deliver two videos and two images promoting HBV and HCV testing developed through a crowdsourcing contest in China; (2) a participatory component will invite men to submit suggestions for how to improve crowdsourced videos and images. The control arm will not view any images or videos and will not be invited to submit suggestions. All participants will be offered reimbursement for HBV and HCV testing costs. The primary outcome is HBV and HCV test uptake confirmed through electronic submission of test report photos within four weeks of enrolment. Secondary outcomes include self-reported HBV and HCV test uptake, HBV vaccination uptake, and change in stigma toward people living with HBV after four weeks. Primary and secondary outcomes will be calculated using intention to treat and as-exposed analyses and compared using two-sided 95% confidence intervals. Discussion Few previous studies have evaluated interventions to increase HBV and HCV testing in middle-income countries with a high burden of hepatitis. Delivering a crowdsourced intervention using social media is a novel approach to increasing hepatitis testing rates. HBV and HCV test uptake will be confirmed through test report photos, avoiding the limitations of self-reported testing outcomes. Trial registration NCT03482388 (29 March 2018). Electronic supplementary material The online version of this article (10.1186/s12879-018-3403-3) contains supplementary material, which is available to authorized users.

Objectives To assess chronic hepatitis B (CHB) patients' knowledge about hepatitis B and their experience of discrimination with regard to study, work, and daily life. Methods We administered a questionnaire to 797 CHB patients in four provinces of China and used one-way analysis of variance (ANOVA) and a generalized linear model (GLM) to identify factors associated with discrimination. Results CHB patients had low levels of knowledge about hepatitis B. Patients under 40 years of age with a junior college education or above knew more about hepatitis B than CHB patients over 40 years of age who had only a high school education. Three-fourths of patients had experienced discrimination because of their hepatitis B infection, with no differences in the proportion experiencing discrimination by sex or age. People with more education reported less discrimination. Patients in Beijing and Henan province perceived less discrimination than those in Shaanxi and Guangdong provinces. Discrimination was significantly associated with negative emotions. CHB patients had little awareness of China's anti-discrimination laws and policies. Among patients who had experienced discrimination, fewer than 10% knew organizations or institutions that could offer help. Over 60% of CHB patients who experienced discrimination chose not to respond. Conclusion CHB patients in China commonly experienced discrimination, which was associated with significant, negative emotional stress. To mitigate the damaging effects of discrimination, our study suggests raising general population knowledge about hepatitis B, raising awareness of the availability of legal protection and organizations that can fight discrimination, and providing psychological support for CHB patients.

ObjectiveTo assess the feasibility and acceptability of using WHO prequalified combined dual HIV/syphilis rapid diagnostic tests (RDT) for same-day results in antenatal care (ANC) clinics.MethodsThis is a pragmatic implementation study using quantitative approach to evaluate outcomes. Antenatal clinic attendees from 21 rural and urban township hospitals in two provinces of China were offered with free dual RDTs testing that included HIV and syphilis, in addition to the routine blood tests. Study outcomes included testing uptake before and during dual RDT use, test feasibility and acceptability among pregnant women. Regression model was used to assess acceptance of RDT testing.ResultsIn total, 1787 out of 1828 pregnant women attending ANC received the RDT testing. Testing uptake among pregnant women in their first and second trimester increased from 76.0% (2438/3269) using standard blood testing to 90.1% (1626/1787) with concurrent RDT use (χ2=197.1, pConclusionCombined dual HIV/syphilis RDT with same-day results increased uptake of HIV and syphilis testing among pregnant women at primary healthcare facilities. Given the diversity of testing capacities among health services especially in rural areas in China, the dual RDT kit is feasible tool to improve testing uptake among pregnant women.

Background New international guidelines, local experts, and the WHO China Office recommend a standardised package of treatment for hepatitis C virus, using sofosbuvir as the direct-acting antiviral drug due to its high efficacy and ease of use. Unlike currently available injection-based treatments (interferon or peginterferon-based therapy), sofosbuvir is taken orally, with improved treatment adherence expected. However, sofosbuvir is currently not in the market in China, and would be unaffordable to many patients. We aimed to assess the average cost of care for chronic hepatitis C virus in China with current injection-based therapies compared with the cost of sofosbuvir-based treatment, and the budget impact of introducing new guidelines for treatment of chronic hepatitis C virus with sofosbuvir. Methods A micro-costing multilevel and multicentric study collecting data on all care activities for chronic hepatitis C virus was designed and sent to a random sample of tertiary provincial hospitals in the east, central, west, and northwest regions of China. Snowball sampling was utilised to contact tertiary city hospitals, secondary city hospitals, and secondary county hospitals. 16 hospitals filled out the survey of 16 invited to take part. Average cost per patient per year was assessed; because large standard deviation in costs indicated large variations in the sample, we weighted costs by the number of patients with chronic hepatitis C virus (as a proportion of all patients in the country). Because there is no current price for sofosbuvir, we used a cost-effective price compared with the current regimen of peginterferon in China, the price of sofosbuvir in India, and the price of sofosbuvir in Brazil. We conducted a one-way sensitivity analysis on weights and treatment drug cost, and a computer-based budget impact analysis. Findings The average yearly cost for each patient (weighted by patient load per hospital) was ¥45 700. The cost of the standard package regimen (using the cost-effective sofosbuvir price) was ¥31 700 per patient, although this fell to ¥11 400 using the current price of sofosbuvir in India and rose to ¥75 000 using the price of sofosbuvir in Brazil. Pre-assessment and monitoring costs were much higher than the standard package (more than four times). Patients paying all costs of care paid ¥45 700 per year under the current practice, ¥31 748 under the standardised care using the cost-effective sofosbuvir price, and ¥11 360 using the Indian sofosbuvir price. These costs compared with the threshold for catastrophic health expenditure of ¥20 167 for average households, ¥28 844 for urban households, and ¥9892 for rural households, suggesting that rural patients cannot afford full chronic hepatitis C care. If a public payer were to cover all care costs for patients with hepatitis C virus in China (100 000 individuals), it would cost ¥4·6 billion for current care practices (including ¥4·1 billion for currently used antiviral treatments only) and ¥1·1 billion for standardised care (¥1·0 billion for standard-package antiviral treatments only), equivalent to 0·48% of the Ministry of Finance health expenditure for 2013 for the current package and 0·12% for the standard package. The total cost after 5 years would be ¥22·9 billion for the current package (including ¥20·4 billion for antiviral drugs) and ¥5·7 billion for the standard package (including ¥5·1 billion standard package for antiviral drugs). Based on the one-way sensitivity analysis, the sofosbuvir regimen price was the biggest cost-driver, followed by the target population. Interpretation At present, care for chronic hepatitis C virus is unaffordable for Chinese patients. Considering that current treatment costs are unaffordable for patients, and that better and curative therapies are available that could save lives and resources in the long run, it is reasonable for China to consider funding or reimbursing standardised care for hepatitis C virus with evidence-based therapies. Funding World Health Organization China.

Background The identification and management of first-line antiretroviral therapy (ART) failure is a key challenge for HIV programs in resource-limited settings. In 2008, the National AIDS Control Organisation, India piloted a national strategy to provide second-line ART. We assessed the National AIDS Control Organisation second-line ART evaluation algorithm. Methods Adult patients who had received 6 months or more of standard first-line ART were referred for second-line ART evaluation if they demonstrated CD4 decline to pre-ART values, CD4 drop to less than 50% of peak on-treatment value, failure to achieve CD4 greater than 100 c/mm(3), or development of a new World Health Organization Stage 3 or 4 AIDS-defining illness. Patients received HIV RNA testing, and those with HIV RNA 10,000 c/mL or greater qualified to switch to second-line ART. World Health Organization-defined clinical and CD4 criteria for ART failure were compared against virologic failure criteria. Results Between January and June 2008, 154 patients met criteria for evaluation. Of 122 (79%) patients who had HIV RNA testing, 87 (71%) had viral load 10,000 c/mL or greater and were recommended to start second-line ART, 29 (24%) had viral load less than 400 c/mL, and six (5%) had viral load between 400 and 10,000 c/mL. The positive predictive value of World Health Organization clinical/immunologic criteria to detect virologic failure was 71% (95% confidence interval, 63% to 79%). Conclusions Second-line ART was initiated in the public sector in India using an approach combining clinical and immunologic evaluation with confirmation of virologic failure. Almost 25% of patients who met clinical/immunologic failure criteria demonstrated virologic suppression. Inclusion of targeted HIV RNA testing in the evaluation of treatment failure can prevent unnecessary switches to second-line ART.

With the rapid scale-up in use of antiretroviral therapy (ART), monitoring the quality of care and factors that may lead to emergence of HIV drug resistance (HIVDR) is an important focus point for programme managers. The National AIDS Control Organisation of India embarked on strengthening the ART programme for continuous quality improvement (CQI), using defined quality-of-care indicators (QCIs), including World Health Organization (WHO) early-warning indicators (EWIs) for HIVDR. In this feasibility study, done during July 2014, an integrated QCI and EWI tool developed by WHO India was pilot tested across 18 purposively selected ART centres. At seven ART centres, the EWI 1 target of90% on-time pill pick-up was achieved for adult patients, while among the paediatric age group (15 years old) it was not achieved by any centre. EWI 2 (retention of patients in ART care at 12 months after initiation) showed that two centres had retention of both adult and paediatric patients of85% at 12 months of ART, while 11 centres had retention between 75% and 85%. EWI 3 (pharmacy stock-out) for adult and paediatric patients showed that 11 ART centres reported a minimum of one stock-out for the first-line ART drugs in the reporting period, while EWI 4 targets (pharmacy dispensing practices) were achieved by all the centres, for both adults and children. Average retention in care at 6, 12 and 24 months after ART initiation was 82%, 77% and 71%, respectively. This feasibility study showed that EWI analyses were much simpler to conduct if information was sought only for patients receiving ART, for whom the quality of record-keeping is better and more consistent. The activity has highlighted the need for improved quality of record-keeping at the facilities and implementation of specific interventions to ensure better patient follow-up. After modifications, use of the tool will be phased in across all the ART centres in India.

Follow-up survey. (DOCX 42 kb)

Pilot study results summary. (DOCX 109 kb)

Pilot study results summary. (DOCX 109 kb)

Baseline survey. (DOCX 49 kb)

Baseline survey. (DOCX 49 kb)

Follow-up survey. (DOCX 42 kb)