July 05, 2017
ADMINISTRATIVE ORDER
No. 2017 – 0011
POLICY ON THE PREVENTION AND CONTROL OF VIRAL HEPATITIS OF THE NATIONAL HIV, AIDS AND STI PREVENTION
AND CONTROL PROGRAM (NASPCP)
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 prescribed 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.
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 to 2015 showed a
case fatality rate or 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
Objectives
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.
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
type 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 infected 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:
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:
· R.A. 10152 – an
act providing mandatory Basic Immunization Services for Infants and Children,
repealing for the purpose of Presidential Decree No. 996, as amended.
· R.A. 10526 – an
act declaring the Month of January of Every year as “Liver Cancer and Viral
Hepatitis Awareness and Prevention Month” and for October 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.
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:
A. 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.
B. Robust
research and information system
1. 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 to viral hepatitis.
2. 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.
C. 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.
D. Access to
effective hepatitis treatment
The
program shall work with the Pharmaceutical Division, PhilHealth and other
partners to adopt and 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.
E. 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:
1. 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.
2. Seroprevalence
of hepatitis B and hepatitis C
3. Indicators
reflecting the infection control practices of health facilities
4. 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.
5. 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: (1) Definitions (2) Baseline (3)
Performance indicators (4) source of date (5) frequency of collection, and (6)
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:
(1)
Facilitate the
dissemination of the policy;
(2)
Oversee the
implementation of the NASPCP;
(3)
Establish
standards and package of services related to viral hepatitis and ensure their
quality, access and availability at all levels of the health system;
(4)
Provide technical
assistance and augmentation of funds to the Regional Health Offices, LGUs and other
partners on the implementation of these services;
(5)
Ensure capacity
building at all levels, including the private sector, for the implementation of
program policies and standards;
(6)
Develop a
monitoring and evaluation system on the implementation of strategies and
activities for viral hepatitis.
(7)
Ensure
participation of other DOH offices and bureaus and coordinate with partners
within and outside the health sector for the effective implementation;
(8)
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:
(1) 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;
(2) Develop technical products for the dissemination of up–to–date
epidemiologic data to stakeholders.
e. The Pharmaceutical Division of the DOH shall:
(1) Undertake policy reviews to provide evidence in
conceptualizing and implementing strategies that shall improve access to
essential medicines for viral hepatitis at all levels;
(2) Provide mechanisms to ensure access to quality
medicines for persons with viral hepatitis.
f. The Health Promotion and Communication Service
(HPCS) shall:
(1)
Provide
leadership in the development and implementation of an effective national
communications plan/campaign on viral hepatitis;
(2)
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:
(1) Provide leadership in the development and
implementation of effective infection control programs against viral hepatitis
in health facilities;
(2) Provide technical assistance to ensure the
implementation, monitoring and evaluation of infection control program 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:
(1)
Coordinate and
assist the NASPCP – DPCB, other DOH units, and private entities to generate
data through conduct of relevant research and disseminate these data;
(2)
Provide technical
assistance in maintaining a surveillance system for viral hepatitis
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 provisions of
quality promotive, preventive, curative, rehabilitative, and palliative care of
patients with viral hepatitis.
n. The Local Government Units (LGU) shall
(1) Integrate viral hepatitis agenda into existing health
communities and legislations that encourages the implementation of the
strategic plan on viral hepatitis at appropriate levels
(Provincial/City/Municipal/Barangay).
(2) Ensure development and sustainability of local
programs on viral hepatitis through accessing technical resources and funding
support or 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:
(1)
Be responsible
for the continuing education activities of health care providers on viral
hepatitis;
(2)
Support the
universal screening of pregnant mothers for Hepatitis B;
(3)
Assist the DOH in
the information dissemination on general vaccination strategies to ensure
compliance;
(4)
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 series 1997 and Administrative Order No. 2006 – 0015 which are
not affected by this order shall remain valid and in effect.
VIII. SEPARABILITY
CLAUSE
In
the even 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.
PAULYN JEAN B. ROSELL –
UBIAL, MD, MPH, CESO II
Secretary of Health
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