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Current Initiatives in Viral Hepatitis

Jose Gerard B. Belimac, MD, MPH

Division Chief

Infectious Diseases and Adult Health Division

Disease Prevention and Control Bureau

Sectoral Strategy and Standards

August 18, 2022

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Integrated Primary Health Care Towards UHC

The current focus of the Department of Health is the enactment of RA 11223 and the strengthening of primary health care

Thus, programs and developing programs are being evaluated for possible integration at the operational, implementation, and service delivery levels

Viral hepatitis strategies , which was lodged under the National HIV, AIDS and STI Prevention and Control Program (NASPCP), have now been integrated in the Omnibus Health Guidelines for LGU implementation

Elimination of hepatitis B is in the priority through the multi-disease elimination plan being developed by the Disease Prevention and Control Bureau

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Burden of Disease

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Burden of Disease

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Summary of Hepatitis Interventions - IDD

Service Delivery Area	Activities	Status
Policies	Hepatitis provisions in the Omnibus Health Guidelines per Lifestage (screening, vaccination)	AO approved
	Thru AHEAD, DOH collaborated with DOST on the Development of CPG (2019)	Planned to review Clinical Practice Guidelines (CPG) by the Hepatology Society of the Philippines
Service Delivery	DPCB - led Pilot demonstration project at selected facilities in Region III, VII and NCR (screening, diagnosis and treatment) in 2019	Well-documented in Region III, with subsequent national roll-out Provision of commodities and medicines by DOH

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Viral hepatitis initiatives in the Department of Health

Disease Prevention and Control Bureau

Hepatitis B vaccination among newborns and children through the National Immunization Program
Inclusion of hepatitis interventions in the Omnibus Health Guidelines

hepatitis is part of the routine antenatal care screening test (DOH AO 2016-0035)

Collaboration with medical society on the development of Clinical Practice Guidelines on hepatitis
Augmentation of logistics: Hep B and C test kits and and medicines

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Viral hepatitis initiatives in the Department of Health

Disease Prevention and Control Bureau

HEPATITIS DRUGS

▪ Tenofovir 300 mg (30 tabs per bottle)

– available in all Regions with need

▪ Daclatasvir 60 mg (28 tabs per bottle)

– available in Region 3 (Central Luzon) and Region 7 (Central Visayas)

▪ Sofosbuvir 400 mg (28 tabs per bottle)

– available in Region 3 (Central Luzon) and Region 7 (Central Visayas)

LABORATORY SUPPLIES

▪ Hepatitis B surface antigen rapid diagnostic test

– allocation plan submitted to SCMS

– delivery to CHDs can be expected between April to May

▪ Hepatitis C surface antigen rapid diagnostic test

– delivered to regions

▪ Hepatitis B viral load reagents

– delivered to SACCL

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Viral hepatitis initiatives in the Department of Health

Disease Prevention and Control Bureau

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Hepatitis Services in the Lifestage Omnibus Health Guidelines

Lifestage	Service	Sub-population
Newborn	Hepatitis B vaccine	<24 Hours newborn
Child	Pentavalent vaccine (DPT, HepB, Hib) Hepatitis B vaccine Hepatitis A vaccine	All infants <1 year old; 13-23 months old infant in catch - up vaccination in facility Children with HIV All children equal to or more than 1 year old
Adolescent	Hepatitis B vaccine Screening test for Hepatitis B Screening test for Hepatitis C	All adolescents and pregnant adolescents living with HIV Adolescents Adolescents with history of drug injection
Adult	Hepatitis A vaccine Hepatitis B vaccine Screening test for Hepatitis B Screening test for Hepatitis C	All immunocompetent adults (18-64 years old) All immunocompetent adults (18-64 years old) and all PLHIV regardless of CD4 count with no previous vaccination or no evidence of immunity Pregnant on 1st trimester, Key Popualtions Pregnant on 1st trimester with history of drug injection, Key populations
Eldrely	Medical advice and access to screening, testing, and treatment Screening for viral hepatitis	All senior citizens Senior citizens belonging to key populations and vulnerable communities

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Omnibus Health Guidelines for Children (DOH Department Circular No. 2022-0344)

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Omnibus Health Guidelines for Children (DOH Department Circular No. 2022-0344)

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Omnibus Health Guidelines for Children (DOH Department Circular No. 2022-0344)

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Omnibus Health Guidelines for Adolescents (DOH Department Circular No. 2022-0344)

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Omnibus Health Guidelines for Adolescents and Pregnant (DOH Department Circular No. 2022-0344)

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Omnibus Health Guidelines for Pregnant (DOH Department Circular No. 2022-0344)

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Omnibus Health Guidelines for Adults (DOH Department Circular No. 2022-0344)

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Omnibus Health Guidelines for Adults (DOH Department Circular No. 2022-0344)

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Omnibus Health Guidelines for Adults (DOH Department Circular No. 2022-0344)

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Omnibus Health Guidelines for the Elderly (DOH Department Circular No. 2022-0344)

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Omnibus Health Guidelines for the Elderly (DOH Department Circular No. 2022-0344)

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Viral hepatitis initiatives in the Department of Health

Epidemiology Bureau

Hepatitis Demonstration Project

Background:

In 2019, through the efforts of DOH and VH TWG, the Hepatitis Demonstration Project was piloted in

Region 3 and in NCR (Taguig) guided by the following objectives:

• Document acceptability of a Viral Hepatitis B Service Delivery and Referral Model

• Establish baseline information on Cascade of Care (screening, treatment eligibility, treatment

coverage) of Chronic Hepatitis B patients

• Evaluate Hepatitis B service delivery and referral model for planning, sustainability and expansion

In Q4 of the same year, using the data gathered from the Pilot Demo Project, the DM 2019-0465 was

signed as a guideline for the national expansion.

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Viral hepatitis initiatives in the Department of Health

Epidemiology Bureau

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Current Program Initiatives with Partners

Current Initiatives	Lead
Workshop on VH Epidemiology and Strategic Information Mapping*	WHO & DOH
-Data Dictionary (Terminology Standards) Project	Hepatology Society of the Philippines (HSP)
- Integration of VH in One HIV, AIDS and STI Information System (OHASIS) that would capture the cascade of care.	DOH-Epidemiology Bureau

Department of Health, Philippines

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Current Program Initiatives with Partners

Current Initiatives	Lead
Implementation of the demonstration project in selected regions Policy and guidelines issuances for the expansion of the initiative of VH to other areas Logistics and commodities support to selected areas with focus on the demonstration sites	DOH, WHO, HSP, LGU, and other partners
-Training cascade on the updated VH Case management and information system with planned expansion to other Regions	HSP, DOH and LGU
-Ongoing project in the development of the Clinical Practice Guidelines (CPG) for Viral Hepatitis	HSP

Department of Health, Philippines

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Current Program Initiatives with Partners

Current Initiatives	Lead
- Development of the Medium Term Plan (Strategic Plan) for VH in the Philippines 2021-2025	WHO, DOH and Partners
- Development on the Interim Guidelines on the Management of VH B and C	DOH and partners
-Ongoing advocacy and awareness initiatives	DOH, HSP, YWSP

Department of Health, Philippines

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Status of the demonstration project in Region 3 (August 2019 - December 2021)

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Demonstration project in Region 3 (August 2019 - December 2021)

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Status of the demonstration project in Region 3 (August 2019 - December 2021)

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PhilHealth Case Rates for Inpatient Diagnoses Associated with Hepatitis

Source: Annex A. Medical Case Rates, PhilHealth Circular No. 2017-0019, Updated List of ICD Codes for Selected Medical Case Rates

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Current implementation of Hepatitis B and C treatment

Treatment Hubs

In 2019, the DOH issued DM No. 2019-0465 Expansion of the Hepatitis B Demonstration Project in DOH Medical Centers, Hospitals, Sanitaria, Treatment and Rehabilitation Centers and HIV Treatment Hubs with Priority Screening for DOH Personnel which extends the guidelines from the hepatitis B demonstration project in Central Luzon to DOH facilities across the country. Among the facilities subject to this memorandum are DOH-designated HIV treatment hubs and primary HIV care facilities which are identified in DM No. 2019-0380.

Geographical distribution of DOH-designated HIV treatment hubs and primary HIV care facilities.

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Current implementation of Hepatitis B and C treatment

Specialists Workforce

DOH guidelines for managing hepatitis B and C state that healthcare providers in primary care must be trained to manage hepatitis B and C, especially in low-resource settings. As per the guidelines, specialists are only warranted in specific cases such as for patients with decompensated cirrhosis, signs of treatment failure, family history of HCC, and HIV co-infection.

Geographical distribution of participating gastroenterologists and hepatologists members identified by the Hepatology Society of the Philippines

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Summary

Based on laboratory reports, the reactivity rates of Hepatitis B is 3% - 4% and Hepatitis C at 1% - 3% among those screened.
The DOH - Disease Prevention and Control Bureau has recently issued the Omnibus Health Guidelines across life stages. This Omnibus Health Guidelines will become basis for the implementation of health services at the Primary Care Facilities under the Universal Health Care Act.
A range of screening and vaccination guidelines for different lifetages are enumerated in the Omnibus Health Guidelines.
Since 2019, facilities and Health Care Workers across all levels of care had been capacitated on the screening, prevention, diagnosis and clinical management of People with Hepatitis B and C.
Hepatitis B and C screening and treatment are included in the commodities for distribution by DOH in 2022.
The provisions in the Universal Health Care Act can sufficiently enable the health sector to deliver comprehensive health services to all.

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Insufficient local and national data on Viral Hepatitis
Low health system awareness on the management of chronic Viral Hepatitis
Inadequate and fragmented response of the health system to address Viral Hepatitis
High cost of medicines
Discrimination and Social Stigma
Implementation of VH services hampered by Covid-19 Pandemic

Challenges in Addressing Viral Hepatitis on the Philippines

Department of Health, Philippines

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End of Presentation