Policy on Prevention and Control of Viral Hepatitis of the National HIV, AIDS and STI Prevention and Control Program

July 5, 2017

DOH ADMINISTRATIVE ORDER NO. 2017-0011

 

I. RATIONALE

The United Nations 2030 Agenda for Sustainable Development has included the control of viral hepatitis as one of its goals, as stated, Goal 3.3: "By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water borne diseases and other communicable diseases." The initial strategies were outlined in the WHO Global Health Sector Strategy on Viral Hepatitis (GHSS), 2016-2021, and detailed plans were described in the Regional Action Plan for Viral Hepatitis in the Western Pacific (RAPVH). The GHSS and RAPVH encompass the control of hepatitis A, hepatitis B, hepatitis C, hepatitis D, and hepatitis E, with a focus on hepatitis B and hepatitis C due to the public health burden they represent. AScHCD

According to latest data from the National Nutrition and Health Survey (NNHS), an estimated 7.3 million adult Filipinos (16.7% of the adult population) are chronically infected with the hepatitis B virus (HBV). This prevalence is more than double the 8% average prevalence rate of HBV infection in the Western Pacific region. For hepatitis C virus (HCV) infection, small-scale studies suggest that up to 700,000 to 1 million Filipinos are infected. Furthermore, reports submitted to the Department of Health (DOH) from 2012-2015 showed a case fatality rate of 0.82% to 1.29% for hepatitis B, and 3.28% to 10.34% for hepatitis C. In addition, the hepatitis B prevalence in 2015 among men who have sex with men (MSM) and people who inject drugs (PWID) were 7.12% and 7.76%, respectively; and the hepatitis C prevalence among PWID was as high as 51.91%.

In response to the need for a comprehensive and multi-sectoral action to control hepatitis B and hepatitis C, a private-sector led National Viral Hepatitis Task Force (NVHTF) was convened in 2013. The NVHTF is a multi-sectoral coalition of stakeholders with a shared interest in viral hepatitis prevention and control. The coalition released a call to action to control viral hepatitis nationwide.

The DOH shall institutionalize all prior and current efforts, including that of the NVHTF, on viral hepatitis control with this Administrative Order, which hereby provides policies on the prevention and control of viral hepatitis under the NASPCP. This is in line with the first guarantee of the Philippine Health Agenda (PHA) to address the triple burden of disease in all life stages.

II. OBJECTIVES

A. General Objective:

To prescribe policies for Prevention and Control of Viral Hepatitis under the NASPCP

B. Specific Objectives:

(1) To identify the elements and components for Prevention and Control of Viral Hepatitis

(2) To describe the roles and responsibilities of agencies and offices involved

III. SCOPE

This issuance covers all health facilities, public and private, national and local government units and other health institutions providing hepatitis-related services. It shall also include other public and private associations such as the academe, media, professional associations, civil societies, non-government organizations and international development agencies. HESIcT

IV. DEFINITION OF TERMS

For the purpose of this Order, the following terms shall be defined as:

1. Viral hepatitis — inflammation of the liver due to a viral infection. There are five main hepatitis viruses, referred to as types A, B, C, D and E.

2. Hepatitis B — a viral infection (caused by the hepatitis B virus) that attacks the liver and can cause both acute and chronic disease.

3. Hepatitis C — a viral infection (caused by the hepatitis C virus) that attacks the liver and can cause both acute and chronic disease.

4. Mother-to-child transmission — transmission of infection from an infected mother to an uninfected child from exposure to maternal blood and body fluids during delivery.

5. Birth dose vaccination — administration of hepatitis B vaccine within 24 hours of birth.

6. Vulnerable populations needing hepatitis B vaccination — population groups given priority for vaccination due to a high risk of infection or vulnerability to the impact of infection. These include persons who received blood transfusions before 1995, persons on long-term hemodialysis, persons with a history of incarceration, persons with a history of unhygienic body modifications, children born to mothers with hepatitis B and hepatitis C, sexual partners and other close contacts of infected patients, men who have sex with men (MSM), male and female sex workers, those with a history of illicit drug use (i.e., intranasal use, or persons who inject drugs [PWID]), persons living with HIV, those with occupational exposure such as healthcare workers, newborns and infants, patients with hepatitis C, and patients with cirrhosis or persistently elevated liver enzymes due to any cause.

V. GENERAL GUIDELINES

A. The prevention and control of Viral Hepatitis shall be an integral part of the NASPCP under the Disease Prevention and Control Bureau.

B. The Prevention and Control of Viral Hepatitis shall be guided by the following principles: AcICHD

1. Goals and values of the Philippine Health Agenda. The program and health services shall also be established utilizing the PHA strategies (ACHIEVE) as appropriate.

2. Human rights for all persons diagnosed with hepatitis B and hepatitis C shall be promoted and protected especially in the workplace.

C. This shall be implemented and aligned according to existing mandates:

• RA 10152 — An Act Providing for Mandatory Basic Immunization Services for Infants and Children, repealing for the Purpose of Presidential Decree No. 996, as Amended.

• RA 10526 — An Act Declaring the Month of January of Every Year as "Liver Cancer and Viral Hepatitis Awareness and Prevention Month" and for Other Purposes.

• DOLE Department Advisory No. 05, Series of 2010. Guidelines for the Implementation of a Workplace Policy and Program on Hepatitis B.

D. The NASPCP shall be supported by the Steering Committee, a Technical Working Group and Experts Panel, as stipulated in DPO number 2016-0604 and 2016-0604A (links: http://home2.doh.gov.ph/ais_public/dppdf/dpo2016-0604(1).pdf and http://home2.doh.gov.ph/ais_public/dppdf/dpo2016-0604-a.pdf)

E. The above Technical Working Group shall develop a national viral hepatitis prevention and control strategic plan for the implementation of policies and guidelines.

F. The activities of the strategic plan on viral hepatitis shall align with the Philippine Health Agenda 2016-2022 and Sustainable Development Goals.

VI. SPECIFIC GUIDELINES

The priority components for the prevention and control of Viral Hepatitis under NASPCP are the following:

1. Advocacy and awareness — The program in coordination with the Health Promotion and Communications Service (HPCS) shall intensify advocacy activities on viral hepatitis. This shall include, but not limited to, nationwide multimedia campaign, annual observance of World Hepatitis Day every July 28 and January as "Liver Cancer and Viral Hepatitis Awareness and Prevention Month," public and private health provider education, community organization of infected persons, and creation and strengthening of policies to address stigma and discrimination. caITAC

2. Robust research and information system

a. The NASPCP shall collaborate with the Epidemiology Bureau (EB) and other relevant stakeholders to develop a national investment case for action on hepatitis with a focus initially on chronic hepatitis B and hepatitis C, informed by the local epidemiological context; and to harmonize databases and surveillance systems related to viral hepatitis.

b. The strategic plan shall also include research agenda to address the identified needs and to guide future policy-making for the prevention and control of viral hepatitis.

3. Halting transmission — The NASPCP shall coordinate with Family Health Office to improve hepatitis B vaccination with emphasis on the timely administration of the birth dose to prevent mother-to-child transmission, as well as vaccination of vulnerable populations, infection control, and harm reduction. The strategies for viral hepatitis shall be integrated with other DOH programs, such as the HIV/STI program and cancer control program, among others.

4. Access to effective hepatitis treatment — The program shall work with the Pharmaceutical Division, PhilHealth and other partners to adopt an effective, accessible, public health approach for the treatment of patients with viral hepatitis, as appropriate.

Furthermore, it shall adopt the hepatitis B treatment guidelines of the WHO (Guidelines for the Prevention, Care and Treatment of Persons with Chronic Hepatitis B Infection, March 2015) that recommends the use of Tenofovir- and Entecavir-based treatment regimens.

5. Monitoring and Evaluation

Categories of indicators for monitoring and evaluation will include baseline information on incidence, prevalence, etc.; operational indicators; and target outcomes. These indicators will be the gauge of the program in terms of achieving its goal of preventing and controlling the spread of viral hepatitis. Such indicators will be obtained from the following:

a. Situational analysis including burden of disease

A SWOT analysis of the NASPCP interventions on viral hepatitis will be conducted at least once every 3 years.

b. Seroprevalence of hepatitis B and hepatitis C TAIaHE

c. Indicators reflecting the infection control practices of health facilities

d. Birth-dose coverage and 3-dose coverage of the hepatitis B vaccine

The strategic plan intends to strengthen routine immunization services to achieve and sustain at least 95% coverage with the three doses of Hepatitis B vaccine by 1 year of age in each birth cohort at the national level, and deliver a timely birth dose (within 24 hours of birth) with a target of reaching at least 95% of births at the national level.

e. Coverage of hepatitis B and hepatitis C treatment in the poorest families

As a strategy of NASPCP, key indicators to measure success across the viral hepatitis screening, care and treatment cascade shall be identified and monitored.

A comprehensive monitoring and evaluation plan for the strategic plan shall be developed to include the following: (i) definitions, (ii) baseline, (iii) performance indicators, (iv) source of data, (v) frequency of collection, and (vi) office responsible for collection.

6. Roles and Responsibilities

The following offices and institutions shall assume the following roles and responsibilities:

a. The Technical Working Group (TWG) shall provide technical support in the development of policies and plans pertaining to the prevention and control of viral hepatitis. It shall also provide the forum for coordinating all aspects of the implementation of the policies and strategies.

b. The Experts Panel shall provide appropriate advice to the DOH on issues and concerns related to viral hepatitis including guidelines on screening, diagnosis and treatment. They shall provide evidence-based recommendations.

c. The Disease Prevention and Control Bureau (DPCB) shall:

i. facilitate the dissemination of the policy;

ii. oversee the implementation of the NASPCP;

iii. establish standards and package of services related to viral hepatitis and ensure their quality, access, and availability at all levels of the health system; ICHDca

iv. provide technical assistance and augmentation of funds to the Regional Health Offices, LGUs and other partners on the implementation of these services;

v. ensure capacity building at all levels, including the private sector, for the implementation of program policies and standards;

vi. develop a monitoring and evaluation system on the implementation of strategies and activities for viral hepatitis;

vii. ensure participation of other DOH offices and bureaus and coordinate with partners within and outside the health sector for the effective implementation;

viii. coordinate with Philippine Health Insurance Corporation (PHIC or PhilHealth) to develop and implement health insurance packages in the prevention, diagnosis and treatment of viral hepatitis.

d. The Epidemiology Bureau (EB) shall:

i. provide leadership in the development and implementation of an effective national surveillance, and generation of treatment cascade data, monitoring and evaluation system for viral hepatitis;

ii. develop technical products for the dissemination of up-to-date epidemiologic data to stakeholders.

e. The Pharmaceutical Division of the DOH shall:

i. undertake policy reviews to provide evidence in conceptualizing and implementing strategies that shall improve access to essential medicines for viral hepatitis at all levels; cDHAES

ii. provide mechanisms to ensure access to quality medicines for persons with viral hepatitis.

f. The Health Promotion and Communication Service (HPCS) shall:

i. provide leadership in the development and implementation of an effective national communications plan/campaign on viral hepatitis;

ii. provide technical assistance to ensure the implementation, monitoring and evaluation of health promotion interventions against viral hepatitis.

g. The Family Health Office (FHO) shall ensure full implementation of the Expanded Program on Immunization (EPI), which includes the timely administration of the hepatitis B birth dose vaccination.

h. The Health Facility Development Bureau (HFDB) shall:

i. provide leadership in the development and implementation of effective infection control programs against viral hepatitis in health facilities;

ii. provide technical assistance to ensure the implementation, monitoring and evaluation of infection control programs against viral hepatitis.

i. Health Facilities and Services Regulatory Bureau (HFSRB) shall ensure that infection control policies in healthcare facilities are enforced.

j. The Research Institute for Tropical Medicine (RITM) shall:

i. coordinate and assist the NASPCP-DPCB, other DOH units, and private entities to generate data through conduct of relevant research and disseminate these data;

ii. provide technical assistance in maintaining a surveillance system for viral hepatitis. TCAScE

k. The STD AIDS Central Cooperative Laboratory (SACCL) shall provide technical expertise and quality assurance services on the diagnosis of viral hepatitis infections.

l. The DOH Regional Offices shall lead and provide technical assistance to the local government units to ensure implementation of the strategic plan of NASPCP on viral hepatitis.

m. DOH-retained hospitals shall ensure provision of quality promotive, preventive, curative, rehabilitative, and palliative care for patients with viral hepatitis.

n. The Local Government Units (LGU) shall:

i. integrate viral hepatitis agenda into existing health committees and legislations that encourages the implementation of the strategic plan on viral hepatitis at appropriate levels (Provincial/City/Municipal/Barangay).

ii. ensure development and sustainability of local programs on viral hepatitis through accessing technical resources and funding support of other relevant programs such as HIV, STI, safe motherhood and reproductive health programs.

o. The Civil Society Organizations (CSOs), developmental partners and other relevant government agencies shall assist the DOH and other stakeholders in the implementation and advocacy for the prevention and control of viral hepatitis.

p. The Hepatology Society of the Philippines (HSP) along with other medical/professional societies shall:

i. be responsible for the continuing education activities of health care providers on viral hepatitis;

ii. support the universal screening of pregnant mothers for Hepatitis B; ASEcHI

iii. assist the DOH in the information dissemination on general vaccination strategies to ensure compliance;

iv. actively participate in the development of the treatment strategies for viral hepatitis.

7. Funding

The Department of Health through the National AIDS and STI Prevention and Control Program (NASPCP) and other concerned bureaus/offices of the Department shall provide funds to support the implementation of the activities for the prevention and control of viral hepatitis.

VII. REPEALING CLAUSE

Other related issuances inconsistent with the provisions of this Administrative Order are hereby revised, modified or rescinded accordingly. All other provisions of Administrative Order No. 2 s. 1997 dated February 20, 1997 and Administrative Order No. 2006-0015 dated June 23, 2006 which are not affected by this order shall remain valid and in effect.

VIII. SEPARABILITY CLAUSE

In the event that any provision of this Order is held invalid, the validity of the remaining provisions shall not be affected.

IX. EFFECTIVITY

This Order shall take effect immediately.

(SGD.) PAULYN JEAN B. ROSELL-UBIAL, MD, MPH, CESO IISecretary of Health

ANNEX A

Summary of "Prevention and Control of Hepatitis B and Hepatitis C in the Philippines: A Call to Action" by the National Viral Hepatitis Task Force 2013

In response to the call for a comprehensive and multi-sectoral action to control hepatitis B and hepatitis C, the National Viral Hepatitis Task Force (NVHTF) was convened. The NVHTF is a public-private partnership; it is a multi-sectoral coalition of stakeholders with a shared interest in viral hepatitis prevention and control. The member organizations of the task force are: cTDaEH

• Hepatology Society of the Philippines (HSP) as Convenor;

• Department of Health (DOH);

• Occupational Safety and Health Center (OSHC);

• Philippine Health Insurance Corporation (PhilHealth);

• Philippine College of Physicians (PCP);

• Philippine Cancer Society (PCS);

• Philippine Pediatric Society (PPS);

• Philippine Society of Gastroenterology (PSG);

• Philippine Society of Microbiology and Infectious Diseases (PSMID);

• World Health Organization (WHO); and International partners include the Coalition for the Eradication of Viral Hepatitis in Asia Pacific (CEVHAP), Viral Hepatitis Foundation (VHF), and the World Hepatitis Alliance.

The mission of the NVHTF is to develop and maintain a national strategy to eliminate or significantly decrease the prevalence of hepatitis B and hepatitis C in the Philippines. It aims to:

1. Increase knowledge and awareness of hepatitis B and hepatitis C among the public, health policy makers, and health care providers;

2. Promote appropriate hepatitis B and hepatitis C testing, and hepatitis B vaccination according to local practice guidelines;

3. Create a framework for comprehensive services for hepatitis B and hepatitis C, including screening, counseling, treatment, and surveillance of infected persons;

4. Create a framework for public health surveillance systems for acute and chronic hepatitis B and hepatitis C infection and for complications of acute and chronic hepatitis B and hepatitis C infection (i.e., fulminant liver failure, cirrhosis, and liver cancer); and,

5. Create a framework to minimize the social and economic impact of hepatitis B and hepatitis C on the country, on patient groups, and on the individual.

To align the efforts of NVHTF with those of the World Health Assembly Resolution 63.18, the NVHTF resolved to adapt the comprehensive health system approach of the WHO's Prevention and Control of Viral Hepatitis Infection: Framework for Global Action, and the four axes outlined. These axes are:

Axis 1: Raising awareness, promoting partnerships, mobilizing resources;

Axis 2: Evidence-based policy and data for action;

Axis 3: Prevention of transmission; and,

Axis 4: Screening, care and treatment. ITAaHc

Targetting viral hepatitis using this four-prong approach ensures that all sectors cooperate in unison, and that the problem is addressed in its entire spectrum.