Integrated Surveillance Integrated Surveillance for HIV, Viral Hepatitis, for HIV, Viral Hepatitis,

and Sexually Transmitted Diseasesand Sexually Transmitted Diseasesin Central Asia Region in Central Asia Region

CDC Central Asia Program, DIH, EPO; CDC Central Asia Program, DIH, EPO; Division of Viral Hepatitis, NCID;Division of Viral Hepatitis, NCID;

Centers for Diseases Control and Prevention, AtlantaCenters for Diseases Control and Prevention, Atlanta

In Partnership with: USAID, USA Embassies,

and Ministries of Health of

Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan

MFavorov@cdc.gov

Surveillance Surveillance

The process of systematic collection, collation and analysis of data with

prompt dissemination to those who need to know, for relevant action to be

taken.

http://www.who.int/emc-documents/surveillance

Protocol for the Assessment of National Communicable Disease Surveillance and Response Systems. Guidelines for Assessment TeamsWHO/CDS/CSR/ISR/2001.2

Surveillance that identifies persons with

conditions, infections, diseases

that often have overlapping risk factors,

to achieve better public health interventions ‘Provisional Definition’

H.S. Margolis, MD - ‘Provisional Definition’, 2001

What is Integrated Surveillance ?What is Integrated Surveillance ?

Reasons to Combine Reasons to Combine Viral Hepatitis, HIV/AIDS and STD Viral Hepatitis, HIV/AIDS and STD

Surveillance, Control, and Prevention Surveillance, Control, and Prevention

• Major public health problems

• Routes of transmission overlap

• Effective prevention tools

– Immunization, treatment, risk reduction

• Lack of national programs for integrated prevention activities leads to transmission of viral hepatitis, HIV/AIDS and STD

Major public health Major public health problems problems

HeroinHeroin

KhankaKhanka HeroinHeroin HeroinHeroinKhankaKhanka

Bloodborn diseases transmission related activities in Central Asia

production, trafficking, dissemination and consumption of illicit drugs

HeroinHeroin

KhankaKhanka HeroinHeroinKhankaKhanka HeroinHeroin HeroinHeroinKhankaKhanka

Bloodborn diseases transmission related activities in Central Asia

production, trafficking, dissemination and consumption of illicit drugs

Routes of transmission Routes of transmission overlapoverlap

Risk Factors for Transmission of Hepatitis Risk Factors for Transmission of Hepatitis Viruses and HIV in the USViruses and HIV in the US

Transfusion

Unknown

Occupational

Heterosexual partners MSM

Injection drug use

Transfusion

Unknown

Occupational

Heterosexual partners MSM

Injection drug use

Heterosexual partners MSM

Injection drug use

Risk Factor

Rare

30

5-7(past)

40

15

14

HBV

Rare

30

5-7(past)

40

15

14

Rare

30

5-7(past)

40

15

14

HBV

Past7- 20

10

<<1

20

1

60

HCV

Past7- 20

10

<<1

20

1

60

HCV

9

Past2

<<1

10

47

31

HIV

9

Past2

<<1

10

47

31

HIV

Proportion of Infections (%)

Effective prevention tools -Effective prevention tools -ImmunizationImmunization

Missed Opportunities for Prevention of Hepatitis B Virus Infection

• Of persons with acute hepatitis B:

–36% previously treated for an STD

–25% previously incarcerated

–11% both incarcerated and treated for an STD

Lack of national programs for Lack of national programs for integrated prevention activities integrated prevention activities leads to transmission of viral leads to transmission of viral hepatitis, HIV/AIDS and STDhepatitis, HIV/AIDS and STD

HIV, STI, and HCV among IDUs in HIV, STI, and HCV among IDUs in Karaganda Oblast, Kazakhstan, 2002Karaganda Oblast, Kazakhstan, 2002

442\605

73.1%

58\890

6.5%

57\890

6.4%

116\890

13.0

21\890

2.4%Karaganda City

576\646

89.2%

52\899

5.8%

50\899

5.6%

103\899

11.5%

222\899

25%Temirtau City

HCV(two + by consec. tests; Abbott)

Other STI(symptoms and sign)

Chronic

syphilis(VDRL -;

TPPA +)

Acute

syphilis(VDRL +;

TPPA +)

HIV(anti-HIV +

EIA+IB)

Sites

Diseases

AntiAnti--HIVHIV among IDUs by lengths of drug among IDUs by lengths of drug useuse,, Karaganda Oblast, Kazakhstan, Karaganda Oblast, Kazakhstan, 2002 2002

0%

5%

10%

15%

20%

25%

30%

35%

<1 1-2 2-3 3-5 5-10 > 10

Temirtau

Karaganda

N = 1799

HIV, HCV, HBV, and Syphilis among IDUs HIV, HCV, HBV, and Syphilis among IDUs by lengths of drug useby lengths of drug use,, Kazakhstan, Kazakhstan, 2002 2002

0%10%20%30%40%50%60%70%80%90%

100%

<1 1-2 2-3 3-5 5-10 10+

Years

HIV HCV HBV Syphilis

p<0.001

p<0.001

p<0.001

p>0.1

N = 1799

Main principles for integrated sentinel Main principles for integrated sentinel surveillance buildingsurveillance building

• Populations under surveillance: IDUs, SW, Prisoners, Pregnant, Clients of STD clinics, MSM, Donors, Police.

• Comprehensive Integrated sentinel surveillance sites selection

• Site specific samples size calculation

• Unified outreach (response driven sampling)

• Standardize Laboratory Methods

• Standard Reporting (Computerized)

• Unified timelines

OshYange Yul

Temirtau

Almaty

PavlodarKostanai

HIV, VH, Syphilis integrated sentinel surveillance sites in Central Asia

Functioning and proposed HIV surveillance sites

HIV, HCV regional integrated sentinel surveillance data from IDUs, 2003-2004

Anti-HCVAnti-HCV

Anti-HIVAnti-HIV

Prevalence of:Prevalence of:

Anti-HIV, anti-HCV among Sex Anti-HIV, anti-HCV among Sex Workers in Kazakhstan , sentinel Workers in Kazakhstan , sentinel

surveillance data, 2004surveillance data, 2004

8%

20%

30%

12%

6%

20%2%

Antibody to Syphilis among IDUs in Antibody to Syphilis among IDUs in Kazakhstan, sentinel surveillance data, 2004Kazakhstan, sentinel surveillance data, 2004

Karaganda Pavlodar Chimkent Uralsk Total

IDUs 12/270 (4.4%)

14/250 (5.6%)

1/270

(0.4%)

0/250

(0%)

27/1040

2.6%

SWs 20/150 (13.3%)

8/100 (8.0%)

3/221

(1.4%)

4/64

(6.3%)

35/535

6.5%

Prisoners 3/500

(0.6%)

9/440 (2.0%)

3/400

(0.8%)

3/200 (1.5%)

18/1540

1.2%

Pregnant 4/470

(0.9%)

1/600 (0.2%)

1/600

(0.2%)

1/500 (0.2%)

7/2170

0.05%

STD 28/270 (10.4%)

43/460 (9.3%)

71/339 (20.9%)

54/500 (10.8%)

9.1%/1569

MSM 0/100

(0%)

Challenges Challenges

• Funding and/or referral sources for: vaccines, lab tests, medical care

• Funding of prevention services flows through separate programs (hepatitis, HIV/AIDS, STD, immunization, corrections)

• Staff of other programs (HIV/AIDS, STD, drug treatment, corrections) may not see viral hepatitis and STI prevention as part of their job

• Incorporation of viral hepatitis and STI prevention messages into “client-centered” counseling

Integrating prevention services for viral hepatitis, HIV/AIDS,STDs and

drug abuse is

GOOD PUBLIC HEALTH

Acknowledgement -Tatiana Kalashnikova MD, Ph.D., D.Sc., Gulzhan Muratbayeva MD, Ph.D., Umid Sharapov MD,

Andrew Dadu MD, Baurzhan Zhussupov, Maureen Sinclair MHP, Ed Maes Ph.D.; Central Asia Program, Division of International Health, Epidemiology Program Office,Rachel Bronzan, MD, MPH, Shakarishvili, Anna, MD, MPH, Ryan, Caroline MD, MPH;

International Activities Unit, Division of STD Prevention, National Center for HIV, STD and TB Prevention,

Harold Margolis MD, Jan Drobeniuc MD, Ph.D.; Division of Viral Hepatitis,Centers for Disease Control and Prevention Atlanta, USA

Nikolay Kuznetsov MD, Valeriya Kryukova MD, Zoya Tukhtina MD, Karaganda HIV Control and Prevention Center,

Sholpan Baimursina MD, Temirtau HIV Control and Prevention Center,Isidora Erasilova MD, Nataliya Kovtunenko MD, Viktoriya Zeman MD;

Kazakhstan Republic HIV Control and Prevention Center,Kanat Ermekbaev MD; Karaganda Oblast Health Commissioner,

Anatoliy Belonog MD, Aigul Kairolapova; Ministry of Health,Svetlana Demenkova MD, Andrew Mikhailov, Ric Golubjatnikov Ph.D.,MPH,

John Doyle MD, Ph.D.; Almaty Sexual Transmitted Infection Diagnostic Laboratory in affiliation with Wisconsin State

Laboratory of Hygiene, Wisconsin, USANurali Amanzhelov, NGO “Shapagat”

Almaz Sharman MD, Ph.D., D.Sc., Jennifer Adams Ph.D., Kerry Pelzman Central Asia Office,

The United States Agency for International Development