Dr Yvan J-F Hutin, Global Hepatitis Programme, WHO

WHO plans to monitor progress towards hepatitis elimination with core indicators

7 December 2018

.

Entering patient cards in a database, Myanmar, November 2018

17 ADDITIONAL

indicators from other

programmes (A.11-A.27)

Baseline

Epidemic

C1. Prevalence

Inputs

System

C2. Testing facilities

Elimination

Elimination

C.9 Incidence

C.10 Mortality from HCC, cirrhosis

Core interventions

Cascade of care

Prevent Test Treat Heal

C3. Vaccine coverage

C4. Needle syringe for

PWID

C5. Injection safety

C.6 People diagnosed

C.7 Treatment coverage / initiation

C.8 Viral supression

(HBV) or cure (HCV)

Monitoring and evaluation (M&E) framework for HBV and HCV (2016)

Data systems for hepatitis elimination,2017

Programme dataa. Prevention indicators

b. Cascade of care and cure

Hepatitis surveillance1. Acute hepatitis that reflect new infections

2. Chronic infections

3. Sequelae

1. How well are we implementing prevention, testing and treatment?

2. How does this turn into progress towards elimination?

3. How do we help WHO Member States making use of data for decision-making?

Monitoring progress, 2018

How well are we implementing prevention, testing and treatment?

Prevention indicators are already collectedthrough existing systems• Three dose hepatitis B vaccine coverage

• WHO / UNICEF Joint reporting form

• Hepatitis B birth dose coverage• WHO / UNICEF Joint reporting form

• Blood safety• WHO Global Database on Blood Safety

• Injection safety• Demographic and Health Surveys (DHS)• Health care facility surveys (Service Availability and Readiness assessment, SARA)

• Harm reduction for persons who inject drugs• Global AIDS Monitoring (GAM)

Data systems that can provide informationon the cascade of care / cure

• Counts of persons receiving services

• Sourced in tally sheets / registers

• Efficient

• Easy to analyze

• No deduplication

• Don’t allow cross tabulations

• Individual records

• Sourced in real time medical records

• Heavy in data entry and management

• More complex to analyse

• Deduplication of unique identifiers

• Allow cross tabulations

Aggregated data: COUNTS Individual databases: RECORDS

Reporting requirements from health care facilitiesto international level: 20 data elements

Aggregated reporting form to monitor the cascade

Testing and diagnosis (C6) Treatment initiation and continuation

(C7)

Monitoring of

treatment

effectiveness (C8)

Mortality from

sequelae (C10)

# people

identified

before

# tested

with

serology

# people

newly

diagnosed

with

infection

# people

already

on Rx

# people newly

starting Rx

# people

comple-

ting Rx

# people

assessed

# people

with

effective

treatment

% people

dying

from

cirrhosis

who had

HBV/HCV

%people

dying from

HCC who

had HBV/

HCVTotal PWIDs

HBV N/A

HCV N/A

PWIDs: Persons Who Inject Drugs

How does this turn into progress towards elimination?

10

An hepatitis epidemic evolves over > 30 years

New infections

Chronic infections

Deaths from liver cancer and cirrhosis

The 3 legs of viral hepatitis surveillance:3 templates protocol for adaptation

1. Obtain a reliable population based estimate of the prevalence of infection, by age if possible

Surveillance for chronic infections

HCC: Hepatocellular carcinoma

2. Identify the incidence trends, and who gets infected

Surveillance for acute hepatitis

Impact monitoring Initial assessment

3. Capture mortality from vital statistics + attributable fraction and understand what the trend is

Surveillance for cirrhosis and HCC

Impact monitoring

WHO General Programme of Work 13 impact

indicator

How do we help WHO Member States making use of data for decision-making?

1. Assessing the capacity of the health information system to

generate the data needed for elimination

2. Extracting baseline information on the 10 core indicators

3. Coordinating reporting of data on the cascade of care / cure

4. Organizing international reporting to WHO

Type of

information

Domain Components Status

Other provinces Pilot province

Surveillance Acute All types Sentinel surveillance for acute hepatitis with risk factors. IgM diagnosis but

case definition for HCV needs adjustment through updated analysis

Chronic HBV Information from population based

biomarker survey by age groups

Serial biomarker surveys

HCV

Sequelae Mortality envelope Need to examine the vital registration / mortality system

Etiologic fraction Expert opinion

Programme Prevention Hepatitis B vaccine WHO / UNICEF Joint Reporting form

Birth dose WHO / UNICEF Joint Reporting form

Harm reduction Reports from harm reduction programmes

Injection safety Demographic and health survey (2012-2013)

Care and

treatment

Cascade of care Aggregated reporting from

provinces

Individual patients’ database

Score card for hepatitis information systems in a country of the Eastern Mediterranean region, 2018

131. Assessing the capacity of the health information system to generate the data needed for elimination

Traffic light colour coding reflects data quality

HBV HCV

Prevalence 1.1% 1.2%

Testing (serology) 40 sites 40 sites

Prevention 3-dose vaccine coverage 94.4%

Birth dose / PMTCT 100%

Injection safety 98.8%

Harm reduction (NSP) 19 / PWID/ Year

Care and treatment Proportion diagnosed 10.5% 6.1%

Treatment coverage 22.4% 1.4%

Treatment effectiveness -

Impact Incidence 0.3% 2.51/ 100,000

Mortality 2,500 600

Baseline estimates for the 10 core indicators in a country of the Western Pacific Region, 2018

11/12/2018 | Title of the presentation 142. Extracting baseline information on the 10 core indicators

Traffic light colour coding reflects data quality

Making sure that data from different sources find their way to a national cascade dashboard

153. Coordinating reporting of data on the cascade of care / cure

Different

providers

using different

data systems

Aggregated

reporting to

the national

level

National level

dashboard

using DHIS2

software

Visual cascades of

care / cure

Number tested,

treated, and

controlled

Provider A using

individual records

Provider B using

individual records

Provider C using

individual records

Number tested,

treated, and

controlled

Number tested,

treated, and

controlled

Having a subset of the national database managed on an individual basis can address specific clinical

care issues, but aggregated data is an efficient way to monitor progress

DHIS: District Health Information System

The Global Reporting System on Hepatitis (GRSH)

Data collected

▪ Policy uptake indicators

▪ Cascade of care

▪ Sequelae

Country-specific dashboards (to visualize the data) with data entry screens

16

Web-based DHIS2 platform located on WHO’s integrated data platform

4. Organizing international reporting to WHO

Challenges

• Following the national health information system governance to

integrate the national blueprint

• Deliver use-friendly information technology tools that will help

programme managers

• Generate a feedback loop of information that with provides an

incentive to reporting

Conclusions

M&E framework• Accepted foundation to review progress

Surveillance• Epidemiology in terms of incidence, prevalence and mortality

• Mortality key for impact monitoring

Prevention indicators• Systems in place

Cascade of care and cure• Efficient, integrated national data systems that guide the

national programme

• A global system centralizing data from all Member States

Immediate next steps

• Integrate national DHIS2 packages with HIV, tuberculosis and

malaria, within national health information systems

• HCV treatment as Universal Health Coverage tracer indicator

• Provide a functioning national model that can be replicated

• Generate the incentive and momentum for global reporting

• GRSH 2.0 in 2019 for 2018 data

• Understand better pre- and post treatment mortality trends

US CDC

Government of Japan

Government of Korea

Zeshan Foundation

UNITAID

World Hepatitis Alliance

London School of Hygiene

and Tropical Medicine

Center for Disease Analyses

Thank you

www.who.int/hepatitis hepatitis@who.int

Help us by reaching out to your national focal point

to help her/ him to report in the Global Reporting System for Hepatitis!