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Viral Hepatitis

Hepatitis, the inflammation of the liver tissue, is most commonly caused

by hepatitis viruses. Overconsumption of toxic substances such as
alcohol and certain drugs, or even an autoimmune condition, can lead to
Hepatitis. The condition can be self-limiting but is also capable of
advancing to fibrosis (scarring), cirrhosis (later stage of fibrosis) as well
as liver cancer.
There are five main types hepatitis viruses, namely type A, B, C, D and
E. These five types raise the greatest concerns due to the burden of
illnesses and deaths they cause, and their potential for outbreaks and
epidemic spread.

Hepatitis A and E are typically caused by ingestion of contaminated

food or water. Hepatitis E Virus is a common cause of hepatitis
outbreaks in developing countries of the world.
Hepatitis B, C and D usually occur as the result of parenteral contact
with infected body fluids. Common modes of transmission of these
three viruses include: receiving contaminated blood or blood
products; using contaminated equipment for invasive medical
procedures; hepatitis B transmission occurs from mother to baby
during labor or from family member to child; and also through sexual
contact. Hepatitis B Virus also poses a risk to healthcare workers who
sustain accidental needle stick injuries while caring for infected-HBV
patients.

Acute infection may occur with limited or no symptoms or may include

symptoms such as jaundice (yellowing of the skin and eyes), dark urine,
extreme fatigue, nausea, vomiting and abdominal pain. Hepatitis B and
C, lead to the chronic form of the disease in hundreds of millions of
people; collectively they are the most common cause of liver cirrhosis
and cancer

A Public Health Concern

Globally, viral hepatitis is the only communicable disease for which

mortality is increasing. It is the seventh leading cause of death worldwide
and is a significant public health problem in South East Asia.
Viral hepatitis caused 1.34 million deaths in 2015, exceeding the number
of AIDS-related deaths (1 million) and approaching mortality associated
with tuberculosis (1.67 million). Around 90% of these are due to chronic
hepatitis B and C infections. Most viral hepatitis deaths in 2015 were due
to chronic liver disease (720 000 deaths due to cirrhosis) and primary
liver cancer (470 000 deaths due to hepatocellular carcinoma). Globally,
in 2015, an estimated 257 million people were living with chronic
Hepatitis B Virus (HBV) infection and 71 million people with chronic
Hepatitis C Virus (HCV) infection.

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Hepatitis is preventable and, in the case of Hepatitis C, curable. There

are safe and effective vaccines to prevent hepatitis A and B; an effective
treatment for hepatitis B; and now, a cure for hepatitis C in most cases.
In 2014, the World Health Assembly called on WHO to develop a global
strategy for viral hepatitis. Two years later, WHO Member States
unanimously endorsed the WHO Global Health Sector Strategy for Viral
Hepatitis 2016–2021. The global strategy aims to eliminate Hepatitis as a
public health threat by reducing new infections by 90% and mortality by
65% by 2030. The strategy outlines a series of concrete actions to fully
leverage effective methods to prevent all forms of viral Hepatitis and to
scale up testing and treatment for HBV and HCV infections. To apply
these strategic directions in the WHO region with the heaviest hepatitis
burden, South-East Asia is implementing its own regional action plan on
viral hepatitis. (See Eliminating viral hepatitis as a major public health
threat in the South-East Asia Region. )

Viral Hepatitis Control Program in Indonesia

Indonesia is an archipelago with more than 17,000 islands, one of 11

countries which carry almost 50% of the global burden of chronic
hepatitis. With a population of over 250 million people, Indonesia
accounts for a substantial share of the viral hepatitis epidemic in Asia. In
the general population, 7% of the population are living with HBV and 1%
is living with HCV (MOH Basic Health Serology Survey Report, 2013),
with a total estimated of 20 million people with chronic hepatitis B and C.
Chronic hepatitis accounts for 2.7% death (Source: Sample Registration
System, 2014), seventh caused after non-communicable diseases and
Tuberculosis (5.7%). Between 2014 and 2017 cirrhosis hepatis
categorized as a catastrophic illness and accounts as the seventh
highest expenditure in National Health Insurance (Source: BPJS, 2017).
The Ministry of Health Republic of Indonesia initiated Hepatitis Control
Program in 2011 which was just one year after the Hepatitis resolution
proposed by Indonesia, Brazil and Colombia was adopted by the World
Health Assembly (WHA 63.18). Series of advocacy, communication and
resource mobilization activities were conducted by MOH and partners
since then.

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The Hepatitis Control Program was stated in the Minister of Health

Regulation number 53 endorsed in 2015. The Hepatitis B prevention
program, Prevention of Mother-To-Child Transmission (PMTCT), includes
immunization and Hepatitis B, early detection, followed by provision of
immunoglobulin (HBIg) for newborns (less than 24 hours) from HBsAg
mothers. The Hepatitis B four doses and birth dose (less than 24 hours)
has become the National Immunization Program Policy (updated in April
2017). Screening for Transfusion Transmissible Infections (TTIs) for
blood donation has been routinely conducted in Blood Transfusion
Services (MOH Regulation 91, 2014). Infection Prevention and Control
policy has been updated in 2017 (MOH Regulation 27, 2017), including
prevention of HBV, HCV and HIV in healthcare settings. The hepatitis C
prevention (test and treat) program has started since 2017 in DKI Jakarta
province, supported by Clinton Health Access Initiative (CHAI), and
expanded to 13 other provinces in 2018-2019.

WHO Indonesia

Between 2014 and 2018, WHO provided technical support for:

Reviewing the situation related to Hepatitis in Indonesia in 2014, prior

to the MOH Action Plan on Hepatitis for 2015-2019 and Viral Hepatitis
Program guidelines were developed.
Updating Hepatitis C treatment guidelines and planning for initiation of
treatment using recommended Direct-Acting Antivirals (DAA).
Developing Hepatitis B national clinical guidelines.
Developing National guidelines for preventing HIV, Syphilis and
Hepatitis B Mother to Child transmission, together known as the Triple
Elimination.
Reviewing the 10 core indicators for Hepatitis for the country.
Analyzing treatment cost using Hep C and Hep B calculator (see
Eliminating hepatitis costs money, but saves even more.)
Organizing World Hepatitis Day commemoration event in Lampung
(2017) and Jakarta (2018).

More links to WHO website:

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WHO works in Indonesia (see Hepatitis Country Fact Sheet 2018 and
Eliminating hepatitis costs money, but saves even more)
WHO - Global Hepatitis Programme and Publications
WHO Guidelines
Guidelines for the prevention, care and treatment of persons
with chronic hepatitis B infection (2015)
Guidelines on hepatitis B and C testing (2017)
Guidelines for the care and treatment of persons diagnosed
with chronic hepatitis C virus infection (2018)

World Hepatitis Day

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