1 / 35

Is Viral Hepatitis Important? World Hepatitis Day

Is Viral Hepatitis Important? World Hepatitis Day. May 19, 2009 Austin, Texas Gary Heseltine MD MPH Epidemiologist - Infectious Disease Control Unit. Public Health Priorities. World Health Organization Infection control Cancer prevention Office of the Surgeon General Disease prevention

Jeffrey
Télécharger la présentation

Is Viral Hepatitis Important? World Hepatitis Day

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Is Viral Hepatitis Important?World Hepatitis Day May 19, 2009 Austin, Texas Gary Heseltine MD MPH Epidemiologist - Infectious Disease Control Unit

  2. Public Health Priorities • World Health Organization • Infection control • Cancer prevention • Office of the Surgeon General • Disease prevention • Eliminating health disparities • Association of Schools of Public Health • Access to healthcare • Eliminating health disparities • Disease prevention

  3. Hepatitis Surveillance: What and Where • Acute Hepatitis A (HAV), B (HBV) and C (HCV) • Reportable all states* • basic information - event date, source of report, demographic characteristics etc. • 40% reports to CDC include supplemental information - laboratory test results, clinical information, exposure history etc. • Chronic Hepatitis B and C • Reportable: HBV 44 states, HCV 42 states • Often limited basic information e.g. only a lab report • Perinatal Hepatitis B (surface antigen positive pregnant women) • Reportable all states (not necessarily separate law) • Detailed case management • Alaska does not have perinatal B program *New Hampshire does not report HCV MMWR March 21, 2008 / Vol. 57 / No. SS-2

  4. Prometheus

  5. Progression of Liver Disease Time frame: years to decades Fibrosis Cancer Cirrhosis BC Hepatitis Services, 2003

  6. HAV Prevalence and Genotype Distribution 3a Multiple 1a 1a 1a

  7. HEPATITIS A RATE, BY AGE AND GENDER UNITED STATES, 1990 Female Male Age <5 10.1 11.9 5-9 26.7 26.7 10-14 17.7 17.2 15-19 12.8 14.1 20-24 16.1 20.4 25-29 15.8 22.2 30-34 11.4 17.7 35-39 7.9 13.5 40-44 6.4 10.3 45-49 5.6 7.7 50-54 4.4 5.9 55-59 3.8 5.9 60+ 2.8 3.4 Rate

  8. HEPATITIS A RATE, BY AGE AND GENDER UNITED STATES, 2001 Female Male Age 2.2 2.5 <5 4.7 4.7 5-9 3.5 3.6 10-14 2.8 3.4 15-19 3.8 6.3 20-24 3.6 7.5 25-29 2.8 9.3 30-34 2.3 8.7 35-39 2.1 6.1 40-44 2.2 5.6 45-49 2.6 5.2 50-54 2.4 3.6 55-59 2.4 2.8 60+ Rate

  9. Hepatitis A Post Exposure Prophylaxis • Age 1-40 years, healthy – single dose vaccine • Age > 40 years – IG preferred, vaccine OK • Age <1 year, immunocompromised, liver disease, vaccine contraindicated - use IG MMWR Oct. 19, 2007

  10. HAV Vaccines EL.U - enzyme-linked immunosorbent assay units GMT – geometric mean titers

  11. Geographic Distribution of Hepatitis E Outbreaks of Confirmed Infection in >25% of Sporadic non-ABC Hepatitis

  12. HEV • 29,000 cases acute viral hepatitis, New Delhi India after sewage contamination drinking water 1955-56 • Believed to be HAV – retrospective analysis in 1980 yielded enteric NANB • 1990’s agent sequenced and called hepatitis E • Large outbreaks in tropical and sub-tropical regions • Katmandu Valley 1973-74 10,000 • Kashmir 1978-82 52,000 • Xinjiang 1986-88 120,000

  13. HEV Studies • Antibodies to swine HEV cross react with human HEV • Prevalence • Endemic regions 3 - 26% • Saudi Arabia 9.5%, Thailand 2.8%, Egypt 24% • Cows, sheep, goats, 40-70% seropositive • North America 1- 3% • Up to 26% in some studies • Unexpectedly high for a non-endemic area • Rats 60% seropositive in US • Swine HEV ubiquitous in herds, but no illness • Belief that HEV is primarily in developing counties - myth

  14. HBV Prevalence and Genotype Distribution 1998 F D A C A, C, B, D D B, C B F E D F A A, B,C,D 8% and above = High 2% - 8% = Intermediate G, H not determined Below 2% = Low

  15. Global Burden of Hepatitis B Disease 2 billion with markers of current or past infection 350 million chronic carriers 130 million Chinese (1 in 10) have chronic HBV 15%-25% will die from cirrhosis or liver cancer 10th leading cause of death 600,000 to 1 million preventable deaths / year Second only to tobacco in cause of cancer deaths Risk of dying from liver cancer 100 greater for carriers than non-carriers Lavanchy D., J Viral Hepat. 2004 Mar;11(2):97-107. WHO. www.who.int/csr/disease/hepatitis/en/

  16. Un homme enceinte s’accouche dans son tombeau* *A pregnant man delivers in his grave

  17. 2006 HBV: 4,700 Reported Cases46,000 estimated www.cdc.gov/hepatitis/statistics.htm MMWR March 21, 2008 / Vol. 57 / No. SS-2 Chronicity 5% adults

  18. HBV: Burden of Disease United States 200,000 persons infected each year in early 90s 50-60,000 new cases/year (2005) 1 of 20 persons infected with HBV during their lifetime (about 12.5 million) 1 of 200 persons chronic infection with HBV (about 1.25 million), 60% are Asian 2-4,000 deaths each year from cirrhosis, liver cancer >95% of new infections among adults MMWR 57: RR-8 2008

  19. Estimated Births to HBsAg-Positive MothersUnited States, 2002

  20. Are Three Doses Needed? “Thus, protection against chronic carriage does not depend on the number of doses received as originally assumed…results from GHIS follow-up of vaccinated subjects, more than 95% of children that received at least one dose are protected against the acquisition of chronic carriage early in life.” Fortuin, M. et al Lancet 1993; 341:1129-31 Unapparent exposures as “boosters”?

  21. HCV Prevalence and Genotype Distribution 5 3 1b 1a,b 2 2 6 1a,b 3a 4 1b, 3 5a 2c

  22. HCV 2006: 800 Reported Cases19,000 Estimated www.cdc.gov/hepatitis/statistics.htm Chronicity 70-80% adults MMWR March 21, 2008 / Vol. 57 / No. SS-2

  23. Prevalence of HCV Infection by Age, Race, and Gender, United States, 1988-1994 Black females Black males White males White females Source: NHANES III

  24. Reported Risk Characteristics Among Adults HCV Recent (<15 yr ago) HBV Recent (<8 yr ago) Injection Drug Use Injection Drug Use Unknown Sexual Other* MSM Transfusion Unknown Other* Heterosexual With shared risk behaviors integrated testing and prevention makes sense. *Other: Household contact, institutionalization, hemodialysis, occupational exposure etc. Modified from Sentinel Counties Study of Viral Hepatitis, CDC

  25. Surveillance: Who is missing? • Persons with: • Lack of signs and symptoms; mild or vague • New infections have broad spectrum of presentation • Not in provider differential • Chronic hepatitis often asymptomatic for years • Lack of Access (barriers) • Transportation, language, no insurance • Marginalized social groups • Lack of Trust • Disclosure of personal risk factors – sex, drugs • Providers don’t ask • Legal and law enforcement issues Outreach is a needed component of a complete surveillance program.

  26. Chronic Hepatitis Burden • HBV estimated 1.2M persons • 50-70% of these persons born outside U.S. • 2,000-4,000 deaths per year • HCV estimated 3.2-3.7M persons • 70% of these persons age 35-54 years • 8,000-10,000 deaths per year • Elevated ALT, history IDU, and history blood transfusion identified 85% persons 20-59 years • Chronic liver disease and cirrhosis 12th leading cause of death nationally, 6th for Hispanics What proportion of these persons know their sero-status? Sorrell et al, Ann Int Med, 2009 150(2):104, Armstrong et al , Ann Int Med 2006;144(10):705, www.cdc.gov/hepatitis/

  27. Chronic Viral Hepatitis Disease Burden = 409,400 cases

  28. Other Hepatitis B NASH 10% Hepatitis C 57% Alcohol 25% Cause of Newly Diagnosed Chronic Liver Disease HBV 4.4% National Cancer Institute – Surveillance Epidemiology and End Results 2006. http://seer.cancer.gov/resources/ Bell et al 2001

  29. Liver and Intrahepatic Bile Duct Cancer Mortality Rates and Average Annual Deaths by Race and Ethnicity, Texas, 2001-2005 51 391 155 1,242 641 Rates are average annual rates per 100,000 population, age-adjusted to the2000 U.S. Standard Population. Average annual mortality counts are rounded to the nearest whole. Source: Texas Cancer Registry, 1995-2005 SeerStat mortality file.

  30. Safe Injection Global Network 16 billion injections/year / 12 billion syringes sold 33% unsafe in developing countries 12 million HBV infections 3 million HCV infections 120,000 HIV infections Estimated 1 billion injections for childhood immunizations Little change until Global Alliance for Vaccine and Immunizations and SIGN were formed Eligible countries get auto-disable syringes for 3 years Countries responsible for national plan, training, waste management Kane A, et al, Bulletin of WHO, 1999, 77:801-807

  31. Common Mode Transmission: Posttransfusion Hepatitis All volunteer donors HBsAg HCV Donor Screening for HIV Risk Factors Anti-HIV 3rd gen HBsAg ALT/Anti-HBc Anti-HCV HCV RNA HBV

  32. HIV, HBV, HCV: Chronic Infections IVDU HIV: 1 Million HCV: 3 million 15-30% STD 10% HBV: 1 million • HAV: acute infection • vaccine TB-opportunistic

  33. Common in U.S.* Cytomegalovirus Epstein-Barr Herpes simplex Varicella zoster Measles Rubella Coxsackie Exotic** Yellow fever Argentineanhemorrhagic fever Bolivian hemorrhagic fever Lassa fever Rift Valley fever Marburg Ebola Other Viruses Associated with Acute Hepatitis * Each causes less than 1% of acute hepatitis. ** Not usually seen in the U.S.

  34. Surveillance: A Better Picture Immunizations Regulatory Vital Statistics Surveys Providers Hospital Discharge Data Liver Disease Surveillance Outreach Workers Lab Reports Substance Abuse TB HIV STD Hepatitis Immigrant Health Perinatal Health

More Related