World Hepatitis Day 2015: Hepatitis prevention
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Transcript of World Hepatitis Day 2015: Hepatitis prevention
Hepatitis Prevention Know the Facts
Dr. Paba Palihawadana Chief Epidemiologist
MBBS, MSc (Com Med), MPH, MD (Com. Med)
Epidemiology Unit - Ministry of Health
Global Burden of Hepatitis
• 400 million people living with chronic viral hepatitis
• 1.4 million die every year from causes related to viral hepatitis
• Around 780 000 persons die annually from hepatitis B infection
• Over 500 000 people die each year from hepatitis C-related liver diseases
Global Burden of Hepatitis
Chronic hepatitis B high prevalence - East Asian and African countries Chronic hepatitis B Moderate prevalence- Middle East and the Indian subcontinent HCV high prevalence- Central and East Asia and North Africa
HCV Global Prevalence
HBV Global Prevalence
Burden of Hepatitis in Sri Lanka
Epidemiology of Viral Hepatitis in Sri Lanka
• Viral Hepatitis is a Group B Notifiable disease in Sri Lanka
• 7356 Viral hepatitis cases reported to Epidemiology Unit for the past 5 years
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1800
2010 2011 2012 2013 2014
Incidence
Source- Epidemiology Unit
Viral Hepatitis Trend In Sri Lanka 2010-2014
Source- Epidemiology Unit
Gender specific Incidence
2010-2014
Male
Female
(70%) (30%) (70%)
Age specific Incidence
2010-2014
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1400
incidence
Source- Epidemiology Unit
Viral Hepatitis Incidence by District 2010-2014
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Mullaitivu
Kilinochchi
Mannar
Trincomalee
Kalmunai
Vavuniya
Batticaloa
Ampara
Puttalam
Galle
Nuwara-Eliya
Kalutara
Polonnaruwa
Jaffna
Anuradhapura
Hambantota
Colombo
Matale
Badulla
Kurunegala
Matara
Kandy
Moneragala
Ratnapura
Gampaha
Kegalle
Incidence
• More than half of these cases (57%) are from 4 districts (Kegalle, Gampaha, Ratnapura and Moneragala)
Sero-Prevalence of Hepatitis Infection
• overall sero-prevalence of HBV (<2%) and HCV (<1%) is low in Sri Lanka and increases with age (WHO SEARO-2010)
• A sero-surveillance study of 407 children aged 1 to 5 Years in Kalutara district tested negative for current Hepatitis B infection(Hepatitis B Sero-Survey-2014, Epidemiology Unit-MRI joint Study)
Disease Surveillance
Notification system for Viral Hepatitis
Hospitals MOH RE district
Epidemiology Unit (Central Level)
399 / H 411a Surveillance of Viral Hepatitis-case investigation form
E- Based System
Laboratory Data/ Blood Bank Data / NSACP Data
Challenges in Viral Hepatitis Disease Surveillance
• Prevalence is underreported in Sri Lanka due to Under reporting of Viral Hepatitis cases from
government and private sector hospitals
Chronic nature of the disease with an often asymptomatic acute Infection
Less request for Laboratory confirmation
Limitations in inter-institutional exchange of information
E.g. : National Blood Transfusion Service (NBTS), National STD/AIDS Control Programme, MRI and other laboratory data
2013 – 2014 Special Surveillance reporting – Epidemiology Unit • viral hepatitis cases - 3319 • Cases tested for HBV
infection - 82 (2.4%)
• Cases positive serologically - 65 (2%)
Strengthening the Surveillance System
• Strengthen the routine national viral hepatitis surveillance mechanism
• Establish a system linking up the hospitals including private hospitals, OPDs, NBTS, NSACP, MRI and other laboratories with the Central Unit to gather data for utilization in planning and implementing strategies
• Surveys among vulnerable groups for detection of chronic HBV and HCV infection
• Establish the national referral centre for laboratory diagnosis and improve resources for serological confirmation
• Develop national standardized protocols for testing samples for viral hepatitis
Surveillance System
Hospitals
OPD Private Sector
CENTRAL UNIT
(Epid. Unit) Laboratories
NSACP
NBTS
Prevention and Control
• H 399 / H 411a • Special Surveillance Data • E-based System
Surveys in Vulnerable
Groups
Analysis Planning Implementation
Transmission of HBV and HCV
Mode of Transmission
• Hepatitis B - through blood and other body fluids (saliva, menstrual, vaginal, and seminal fluids)
• Hepatitis C - mostly through blood
Globally identified Risk Groups for HBV and HCV transmission
• People who frequently require blood or blood products
• Dialysis patients
• Recipients of solid organ transplantations
• Household and sexual contacts of people with chronic HBV and HCV infection
• People with multiple sexual partners
• Men who have sex with men
Risk Groups Cont.
• Infants born to infected mothers
Screening of pregnant women for HBs Ag is necessary to identify
those neonates at risk of transmission
However Sero-prevalence of HBV is very low among pregnant women in Sri Lanka (WHO SEARO-2010)
Routine HCV Testing Is Not Recommended for Pregnant women (CDC)
• Health care and public safety workers at risk for
occupational exposure to blood or blood-contaminated body fluids
Risk Groups Cont.
• people with HIV infection Risk of HIV co-infection with HBV and HCV due to shared routes of
transmission
Faster progression to liver cirrhosis, and higher rates of mortality with co-infection
Adult HIV prevalence (>15 years) - <0.1%
Prevalence of HBV and HCV among people living with HIV (PLHIV) is usually Underestimated
• people who have had tattoos or piercings
Risk Groups Cont.
• people who inject drugs
Globally, around 16 million people inject drugs
A study done with 250 drug users in the Colombo district in 2005 revealed
• 12.6% (CI 5.1-24.5) prevalence of ever injecting drug use • 7.6% Prevalence of HBV, but none were infective (HBsAg negative) • 0.4% Prevalence of anti-HCV • None tested positive for HIV
(Tissera H. A, 2005) WHO recommend harm reduction with needle and syringe
programmes and opioid substitution therapy
Risk Groups Cont.
• people interned in prisons A study among cohort of prison inmates(n=393) in Sri Lanka
revealed low prevalence of
• HBV (HBsAg-0.25%) • HCV (HCV RNA- 0.5%) • Injecting drug use (4.3%)
None of the injecting drug users were positive for HBV-DNA or
HCV-RNA
(Niriella M. A et al)
• Residents and staff of facilities for developmentally
disabled persons
Risk Groups Cont.
• Travelers leaving to countries with high prevalence of HBV and HCV infection Hepatitis B vaccination should be administered to all unvaccinated people traveling to areas with intermediate to high prevalence of chronic hepatitis B (HBVsAg prevalence ≥2%) (CDC)
Prevention
HBV Vaccination
• Mainstay of hepatitis B prevention
• Introduced to the Expanded Programme of Immunization (EPI) schedule in 2003 in Sri Lanka
The complete vaccine series induces protective antibody levels in more than 95% of infants, children and young adults
Protection lasts at least 20 years and is probably lifelong
Indications:
• All infants on completion of 2, 4 and 6 months
• Those at risk of contracting HBV infection- High Risk sexual behaviour, partners and household contacts of HBVsAg positive persons, injecting Drug Users, frequent blood recipients, recipients of solid organ transplantations
• Occupational risk of HBV infection- HCW
• International travelers visiting HBV endemic countries
• Babies born to mothers who have had HBV infection during pregnancy
• Post-exposure vaccination following needle stick injuries
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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Hepatitis B Coverage
Heb B Coverage
Hepatitis B vaccine Coverage 2003-2014
• The Hepatitis B Sero-survey of 407 children aged 1 to 5 years in Kalutara district also assessed the Immunity levels in the study population
• 100% HBV vaccination status among the study participants
• 76.2% of children had protective levels of humeral immunity against Hepatitis B infection
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1 - 2 yrs
2 - 3 yrs
3 - 4 yrs
4 - 5 yrs
protected
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Age 1-2 yrs Age 2-3 yrs Age 3-4 yrs Age 4-5yrs
Mean Median Protective level
mIU/ml
• Median HBsAb level is seen decreasing gradually with increase in age (comparable with global literature )
Hepatitis B Sero Survey 2014
• No vaccine available for hepatitis C
• Therefore primary prevention of HCV infection depends upon reducing the risk of exposure to the virus in health-care settings, in higher risk populations
Thank You