presenter : dr.l.karthiyayini moderator: dr. abhishek v raut epidemiology of hepatitis

Presenter : Dr.L.Karthiyayini Moderator: Dr. Abhishek V Raut Epidemiology of hepatitis

Framework Introduction Hepatitis A,E,B,C,D&G Magnitude Natural history of the disease Epidemiological determinants Mode of transmission Clinical feature Sero epidemiology Prevention & control Hepatitis & HIV Global policy report on hepatitis-status of India WHO position of hepatitis vaccine

Introduction VIRAL HEPATITIS IS A MAJOR PUBLIC HEALTH PROBLEM Hepatitis A & E - 0.5-4 % mortality World wide 500 million people have chronic HBV & HCV infection In India, 45 million people with HBV 500,000 to 1,000,000 people die every year of HBV-related chronic Hepatitis, cirrhosis or liver cancer Out of nearly 22.6 million children born in India every year, over 9 million will acquire the infection in their lifetime.

Hepatitis is the inflammation of liver by any cause Viral hepatitis is mainly caused by Hepatitis A & E virus - Faeco-oral route - Acute & self limiting Hepatitis B,C & D virus- Parenteral route -Acute & chronic Other viruses- cytomegalovirus, rubella virus, epstein barr virus, yellow fever virus,herpes zoster virus,etc. Other hepatitis- Alcoholic hepatitis (50% of CLD)(mortality : M- 11/100000 & F-6/10000) Auto immune hepatitis, toxic & drug induced hepatitis,

Natural history of acute hepatits

HEPATITIS A

Source:CDC

MAGNITUDE GLOBAL: Prevalence of anti-HAV antibodies in general population -15%-100% Worldwide 1.5 million clinical cases yearly Outbreaks INDIA: seroprevalence of anti-HAV: 54.5%- high socio-economic status 85% in low socio-economic status

EPIDEMIOLOGICAL DETERMINANTS AGENT: Picarnovirus family 4 human genotypes 1 serophytype HOST: Low endemic area Adolescents & adults(homosexual, IV drug users) Travellers Intermediate endemic area Late childhood(faeco oral route) Early adult hood High endemic area Early childhood

ENVIRONMENTAL FACTORS: Water borne & food borne epidemics Sanitation & overcrowding MODE OF TRANSMISSION: Faeco-oral route Parentral route stage of viremia Sexual transmission- homosexual due to ano-oral contact Secondary attack rate among household contacts is 30% INCUBATION PERIOD 28 days

CLINICAL FEATURES Symptoms & signs Fever Anorexia Malaise Nausea Abdominal discomfort Dark urine Jaundice Complications: Relapsing hepatitis Cholestatic hepatitis Fulminant hepatitis(0.1%)

SERO EPIDEMIOLOGY IgM- Detectable from 5 days prior to onset of symptoms & declines to undetectable levels within 6 months. IgG-Detect previous infection, persists life long Elevated levels of serum bilirubin Elevated hepatic enzymes(AST,ALT)

HAV INFECTION-TYPICAL SEROLOGICAL COURSE Source: Yim, H. J., et al., (2006). Hepatology.

PREVENTION & CONTROL Control of reservoir: Complete bed rest Disinfection of faeces & fomites 0.5% sodium hypochlorite Control of transmission: promoting personnel & community hygiene Purification of community water supplies Proper sanitation & waste disposal During epidemics, boiling of water is preferred

Active immunization Inactivated vaccines & live attenuated vaccines Parenterally (IM), 2 dose,6-18 months apart. Combined vaccine(inactivated hepatitis A & recombinant hepatitis B) -0,1,6 mths. Passive immunization HAV IG Pre & Post exposure prophylaxis -single I.M dose,0.02 ml/kg within 2 weeks

HEPATITIS E

MAGNITUDE GLOBAL SEAR INDIA MAHARASHTRA Source:CDC

MAGNITUDE GLOBAL: Overall attack rates during hepatitis E outbreaks - 1% to 15%. The rates are highest among young adults (3%-30% Case-fatality rates - 0.5% to 4% During outbreaks mortality rates - 0.070.6% INDIA: Proportion- 10% Seroprevalence of anti-HEV antibodies-upto 50%

EPIDEMIOLOGICAL DETERMINANTS AGENT Hepatitis E like virus HOST 15-40yrs Pregnant mothers-20% fulminant(0.5% mortality) MODE OF TRANSMISSION: Faeco oral route Water borne disease Ingestion of raw or uncooked shell fish- sporodic cases Vertical transmission Secondary attack rates 0.7-2.2% INCUBATION PERIOD: 2-9 weeks

CLINICAL FEATURES Symptoms Abdominal pain Nausea Vomiting Anorexia Signs Jaundice Hepatomegaly

SERO EPIDEMIOLOGY Elevated antibody levels-RT-PCR

Symptoms ALT IgG anti-HEV IgM anti-HEV Virus in stool 012345678910101 1212 1313 Hepatitis E Virus Infection Typical Serologic Course Titer Weeks after Exposure Source: Yim, H. J., et al., (2006). Hepatology.

PREVENTION & CONTROL Good personnel hygiene High quality standards of public water supply Proper disposal of sanitary waste Vaccines undergoing clinical trails

HEPATITIS B

Source:CDC

MAGNITUDE GLOBAL: 2million 240 billion carriers 60-80% of all primary liver cancer High endemicity, intermediate endemicity & low endemicity INDIA: Point prevalence of hepatitis B is 2.1% chronic carrier rate 1.7% HCC 1.6% of all cancers High carrier state among health workers 11% & in general population 5%

High (>8%): 45% of global population lifetime risk of infection >60% early childhood infections common Intermediate (2%-7%): 43% of global population lifetime risk of infection 20%-60% infections occur in all age groups Low (

National immunization schedule: 3 dose schedule :At birth, along with 1 st & 3 rd dose of DPT 4 dose schedule: At birth, 6,10,& 14 weeks Monovalent or combined Minimum interval between the doses are 4 weeks If prevalence is > 8%- within 24 hrs of birth Duration of protection: 15 yrs Protective antibody levels-> 95% (infants, children & young adults) More than 40yrs protection

MAGNITUDE GLOBAL: Global pattern corresponds to prevalence of HBV Highest prevalence in Amazon basin & Romania(20% of chronic HBV & 90% of HBV-chronic liver disease) Moderate prevalence-Spain, northern Italy, Turkey & Egypt(asymptomatic HBVcarriers10-20% & 30-50% of HBV- chronic liver disease) Low prevalence-southeast Asia & china INDIA: Acute hepatitis-10.7- > 30% Chronic hepatitis-8-21% Cirrhosis-15-19%:

EPIDEMIOLOGICAL DETERMINANTS AGENT: RNA virus Satellite virus or sub viral agent HOST: high risk group MODE OF TRANSMISSION: Parenteral route Perinatal route Sexual transmission INCUBATION PERIOD: 30-180 days

CLINICAL FEATURES Co-infection: Simultaneous infcetion Acute form of HBV & HDV Self limiting Chronic form -< 5% Super infection: HDV infection of chronically infected HBV Severe acute hepatitis chronic hepatitis (80%) Associated fulminant acute hepatitis, severe chronic active hepatitis-cirrhosis

anti-HBs Symptoms ALT Elevated Total anti-HDV IgM anti-HDV HDV RNA HBsAg HBV - HDV Coinfection Typical Serologic Course Time after Exposure Titre

Jaundice Symptoms ALT Total anti-HDV IgM anti-HDV HDV RNA HBsAg HBV - HDV Superinfection Typical Serologic Course Time after Exposure Titre

Diagnosis: RT-PCR EIA Treatment: A-interferon (9million units, TDS weekly for 12 months or 5 million units daily for 12 months) Prevention & control: Pre & post exposure prophylaxis of HBV Health education to reduce risk behaviour

HEPATITIS G 1995-Flavivirus family GBV-A,GBV-B,GBV-C GBV-C affects man. Transmission : blood transfusion Sexual contact Vertical transmission Intravenous drug users Globally 1-3% in volunteer blood donors Incubation period-30-120 days HGV co-infection is observed in 6% of chronic HBV infections & in 10% of chronic HCV infections.

HEPATITIS & HIV About one-third of HIV-infected persons are coinfected with hepatitis B or hepatitis C, which can cause long-term (chronic) illness and death. 10% of 40 million people of HIV are co-infected with HBV Viral hepatitis progresses faster among persons with HIV infected persons HIV/HBV & HIV/HCV coinfection -leading cause of non-AIDS-related deaths

HEPATITIS & HIV Coinfection with hepatitis -complicate the management of HIV infection. To prevent coinfection with hepatitis B, universal hepatitis B vaccination of susceptible patients with HIV infection or AIDS & high risk groups is recommended All persons living with HIV should be tested for hepatitis B and hepatitis C Coinfected persons should be counseled about drug interacions and side efects of hepatitis and HIV treatments.

Global policy 2010 World Health Assembly to generate reliable information as a foundation for building prevention and control measures that match the local epidemiological profile and health system capacities. Survey conducted in mid-2012 by the World Health Organization and the World Hepatitis Alliance. Aim : To gather country-specific baseline data on hepatitis policies in WHO Member States in all six regions. offers insight into conditions in specific countries Gaps that need to be filled are identified

Issues addressed National coordination Awareness raising & partnerships Evidence based policy & data for action Prevention of transmission Screening care & treatme nt

National coordination Written national strategy plan-raising awareness, surveillance, vaccination, prevention of transmission via injecting drug use, in health-care settings, in general, and treatment and care. There is a designated governmental department : For coordinating and/or carrying out viral hepatitis related activities Four staff members Not known how many people work full-time in all government agencies/bodies. The government has a viral hepatitis prevention and control programme: activities targeting health-care workers, including health-care waste handlers

Awareness raising & partnerships Not known whether the government held events for World Hepatitis Day 2012 Funding-other viral hepatitis public awareness campaigns since January 2011. The government does not collaborate with in-country civil society groups to develop and implement its viral hepatitis prevention and control programme

Evidence based policy & data for action There is no routine surveillance for viral hepatitis. There are standard case definitions for hepatitis. Hepatitis deaths are not reported to a central registry. No classification:undifferentiated or unclassified hepatitis HCC & HIV/hepatitis coinfection cases are registered The government does not publish hepatitis disease reports. Hepatitis outbreaks are reported & investigated There is inadequate laboratory capacity nationally to support investigation of viral hepatitis outbreaks There is no national public health research agenda Viral hepatitis serosurveys are not conducted regularly

Prevention of transmission There is a national policy that specifically targets mother-to- child transmission of hepatitis B There is no national policy on hepatitis A vaccination. The government has not established the goal of eliminating hepatitis B. It is not known what percentage of newborn infants nationally received the 1 st dose of hepatitis B vaccine within 24 hours of birth or what percentage of 1yr received 3 doses of hepatitis B vaccine. It is not known whether there is a specific national strategy for preventing hepatitis in health-care settings. Health-care workers are vaccinated against hepatitis B prior to starting work

Contd.. There is a national policy on injection safety in health-care settings-auto-disable syringes Single-use or auto-disable syringes, needles and cannulas are always available in all health-care facilities. Official government estimates of the number and percentage of unnecessary injections administered annually in health-care settings are not known. There is a national infection control policy for blood banks. All donated blood products nationwide are screened It is not known whether there is a national policy relating to the prevention of viral hepatitis among people who inject drugs. The government has guidelines that address how hepatitis A and hepatitis E can be prevented through food and water safety.

Screening care & treatment Health professionals obtain the skills and competencies through on the job training. Not known -national clinical guidelines for the management The government does not have national policies relating to screening and referral to care for hepatitis B or hepatitis C. People testing are register by name & are kept confidential Hepatitis testing are free of charge for all individuals and are compulsory for blood donors. Publicly funded treatment is not available for hepatitis The following drug for treating hepatitis B & C is on the national essential medicines list: lamivudine & ribavirin respectively The GOI welcomes assistance from WHO in one or more areas of viral hepatitis prevention and control

Who position of hepatitis vaccine All infants should receive their first dose preferably within 24 hrs Delivery of hepatitis B vaccine within 24 hours of birth should be a performance measure for all immunization programmes. To complete the primary series the birth dose should be followed by 2 doses or, if convenient, by 3 doses Minimum interval between doses is 4 weeks. There is no evidence to support the need for a booster dose Catch-up vaccination of children should be considered for cohorts with low coverage. The need for catch-up vaccination in older age groups, including adolescents and adults, is determined by the baseline epidemiology of HBV infection in the country.

Contd The importance of vaccinating people with particular risk factors for acquiring HBV infection is emphasized. Eliminating HBV transmission must address- infections acquired perinatally and during early childhood, by teenagers and adults. WHO strongly recommends that all countries develop goals for hepatitis B control Process indicators and the use of outcome measures are critical to verifying achievement goals. Primary tool to measure the impact of immunization- Serological surveys of HBsAg prevalence supplemented by surveillance for acute disease Collection of mortality data

REFERENCE 1. Park k., text book of preventive and social medicine, 20 th edition; p186 -189 2. Mansons text book tropical disease;697-713 3. Harrisons principles of internal medicine.17(2);p1945-1960 4. Berger SA. Infectious Diseases of India, 2012. 503 pages, 67 graphs, 4248 references. Gideon e-books, http://www.gideononline.com/ebooks/country/infectious-diseases-of-india http://www.gideononline.com/ebooks/country/infectious-diseases-of-india 5. Berger SA. Hepatitis D, E and G: Global Status, 2012. 99 pages, 36 graphs, 1116 references. Gideon e-books, http://www.gideononline.com/ebooks/disease/hepatitis-d-e-and-g-global- status/ http://www.gideononline.com/ebooks/disease/hepatitis-d-e-and-g-global- status/ 6.heahttp://www.who.int/immunization/topics/hepatitis_b/en/index.htmllth 7. Global policy report on the prevention and control of viral hepatitis in WHO Member States. 8. http://www.who.int/immunization/documents/positionpapers/en/index.html 9. The Global Prevalence of Hepatitis A Virus Infection and Susceptibility:A Systematic Review 10. The Global Prevalence of Hepatitis EVirus Infection and Susceptibility:A Systematic Review

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presenter : dr.l.karthiyayini moderator: dr. abhishek v raut epidemiology of hepatitis

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