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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

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Is viral hepatitis important world hepatitis day l.jpg

Is Viral Hepatitis Important?World Hepatitis Day

May 19, 2009

Austin, Texas

Gary Heseltine MD MPH

Epidemiologist - Infectious Disease Control Unit


Public health priorities l.jpg
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


Hepatitis surveillance what and where l.jpg
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



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Progression of Liver Disease

Time frame: years to decades

Fibrosis

Cancer

Cirrhosis

BC Hepatitis Services, 2003



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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


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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


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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


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HAV Vaccines

EL.U - enzyme-linked immunosorbent assay units

GMT – geometric mean titers


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Geographic Distribution of Hepatitis E

Outbreaks of Confirmed Infection in >25% of Sporadic non-ABC Hepatitis


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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


Hev studies l.jpg
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


Hbv prevalence and genotype distribution 1998 l.jpg
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


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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/


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Un homme enceinte s’accouche dans son tombeau*

*A pregnant man delivers in his grave


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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


Hbv burden of disease united states l.jpg
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



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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”?


Hcv prevalence and genotype distribution l.jpg
HCV Prevalence and Genotype Distribution

5

3

1b

1a,b

2

2

6

1a,b

3a

4

1b, 3

5a

2c


Hcv 2006 800 reported cases 19 000 estimated l.jpg
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


Prevalence of hcv infection by age race and gender united states 1988 1994 l.jpg
Prevalence of HCV Infection by Age, Race, and Gender, United States, 1988-1994

Black females

Black males

White males

White females

Source: NHANES III


Reported risk characteristics among adults l.jpg
Reported Risk Characteristics Among Adults United States, 1988-1994

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


Surveillance who is missing l.jpg
Surveillance: Who is missing? United States, 1988-1994

  • 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.


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Chronic Hepatitis Burden United States, 1988-1994

  • 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/



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Other United States, 1988-1994

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


Slide29 l.jpg
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.


Safe injection global network l.jpg
Safe Injection Global Network Average Annual Deaths by Race and Ethnicity, Texas, 2001-2005

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


Common mode transmission posttransfusion hepatitis l.jpg
Common Mode Transmission: Posttransfusion Hepatitis Average Annual Deaths by Race and Ethnicity, Texas, 2001-2005

All volunteer donors

HBsAg

HCV

Donor Screening for HIV Risk Factors

Anti-HIV

3rd gen HBsAg

ALT/Anti-HBc

Anti-HCV

HCV RNA

HBV


Hiv hbv hcv chronic infections l.jpg
HIV, HBV, HCV: Chronic Infections Average Annual Deaths by Race and Ethnicity, Texas, 2001-2005

IVDU

HIV:

1 Million

HCV: 3 million

15-30%

STD

10%

HBV: 1 million

  • HAV: acute infection

    • vaccine

TB-opportunistic


Other viruses associated with acute hepatitis l.jpg

Common in U.S. Average Annual Deaths by Race and Ethnicity, Texas, 2001-2005*

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.


Surveillance a better picture l.jpg
Surveillance: A Better Picture Average Annual Deaths by Race and Ethnicity, Texas, 2001-2005

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


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