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Prevention of Hepatitis B: the Foundation of Viral Hepatitis Prevention

Prevention of Hepatitis B: the Foundation of Viral Hepatitis Prevention. Harold S. Margolis, M.D. Division of Viral Hepatitis National Center for Infectious Diseases Centers for Disease Control and Prevention Atlanta, GA. Reasons to Combine Viral Hepatitis and HIV/AIDS Prevention.

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Prevention of Hepatitis B: the Foundation of Viral Hepatitis Prevention

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  1. Prevention of Hepatitis B: the Foundation of Viral Hepatitis Prevention Harold S. Margolis, M.D. Division of Viral Hepatitis National Center for Infectious Diseases Centers for Disease Control and Prevention Atlanta, GA

  2. Reasons to Combine Viral Hepatitis and HIV/AIDS Prevention • Major public health problems • Routes of transmission overlap • Effective prevention tools • immunization, blood screening, universal precautions, risk reduction, treatment • Well established programs for HIV/AIDS • Lack of integrated prevention activities leads to transmission of both diseases, especially viral hepatitis Hepatitis C: the tipping point for a new direction in prevention

  3. Chronic infections (millions) Region Population (millions) HIV HCV HBV Africa 749 22.7 22.5 59.3 Asia 3,585 7.3 107.5 286.8 Latin America 504 1.7 15.1 10.3 Europe 729 0.8 21.8 10.9 Oceania 30 0.0 0.9 2.4 North America 305 0.9 9.1 1.9 Total 5,902 33.4 176.9 371.6 Estimated Number of Persons with Chronic Bloodborne Virus Infections 1998

  4. Routes of Transmission andOpportunities for Prevention of Infection with Hepatitis Viruses and HIV Overlap Substantially

  5. HBV HCV HIV Injection drug use 14 60 31 MSM 15 1 47 Heterosexual partners 40 20 10 Transfusion Rare Past 7- 20 Past 2 Occupational 5-7 (past) <<1 <<1 Unknown 30 10 9 Risk Factors for Transmission of Hepatitis Viruses and HIV Proportion of Infections (%) Risk Factor

  6. Prevention and Control of Viral Hepatitis: its becoming more than HBV infection • HAV, HBV and HCV infection are endemic in most parts of the world, including the independent states of the former Soviet Union. • First priority = prevention of HBV infection in infants and young children= infant hepatitis B immunization • Routine disease surveillance will identify hepatitis B and hepatitis C in other age groups

  7. Components of a Hepatitis B Immunization Program • Immunization • Infant • Catch-up for older children – ages defined by local epidemiology • Health care workers • Other high-risk adults – groups defined by local epidemiology • Assessment of effectiveness of HepB immunization • Vaccination coverage (age-specific) • Population-based serologic assessment • Acute disease surveillance • Surveillance for Acute Viral Hepatitis • All age groups • Serologic conformation • Risk factor data - immunization status, source of infection

  8. A Model Hepatitis B Prevention Program • Immunization • infant • catch-up for older children • health care workers • other high-risk adults • Prevent transfusion-transmitted infection - safe blood and blood products • screening of blood donors for HBsAg • good manufacturing practices for blood products • pooled products include virus inactivation • Safe injection practices in all settings • Infection control practices to prevent transmission of bloodborne infections • Surveillance to assess prevention effectiveness

  9. Injections among Unvaccinated Children < 5 years of age with Acute Hepatitis, Romania1997-1998 Population attributable risk among unvaccinated = 32%

  10. * Anit-HCV Prevalence - High >5% 1.1-5% - Intermediate 0.2-1% - Low - Very Low < 0.1% Unknown Prevalence of HCV Infection in Blood Donors *Anti-HCV defined by EIA and supplemental testing

  11. Proportion of HCV Infections Attributable to Unsafe InjectionsCase-Control Studies Population Country Year Age Attributable % Taiwan (Ho) 1993 Children 84%* (Chen) 1990-94 Adults 20%* (Sun) 1990 Adults 57% Pakistan (Luby) 1994-95 All 51%* Egypt (El Sakka) 1996-97 All 88%* * Calculated from data provided by authors Source: SIGN, WHO

  12. Health-Care Procedures and HCV InfectionLow/Moderate Endemic Countries SurgeryDental CountryHCV PosHCV NegHCV PosHCV Neg Case-Control USA 10% 12% 24% 24% Italy 17%* 2% 22%* 11% Cross-Sectional Italy 56%* 36% 91%* 80% 77% 57% 90% 90% Taiwan 13% 3% 24% 28% Pakistan No data 33% 39% Japan 32%* 10% No data * P<.05, independent of other risk factors

  13. Unsafe Injections and HCV InfectionModerate Endemic Countries History Reused Needles/Syringes CountryHCV PosHCV NegOR (95% CI) Italy 63% 31% 3.8 (2.7, 5.3) 89% 53% 7.0 (4.4, 11.2) 76% 72% 1.2 (0.6, 2.5) Taiwan 26% 8% 4.2 (1.2, 14.5) Pakistan (>5/yr) 36% 6% 8.2 (1.9, 41.4)

  14. Egypt 50 40 30 Percent Anti-HCV Positive Japan, Italy 20 10 U.S., Australia 0 0-9 10-19 20-29 30-39 40-49 50+ Age Group (Years) Geographic Patterns of Age-Specific Prevalence of HCV Infection

  15. Burden of Disease Attributable to Unsafe Injections, Developing and Transitional Economy Countries, Preliminary Data Source: Armstrong, Hauri, Hutin

  16. Posttransfusion Hepatitis in Developing Countries • Inappropriate use of blood and blood products – single unit transfusions common • Lack of organized transfusion services • Most transfused units not tested for HBV or HCV • Related donors often used – perception that less likely to be infected • Paid donors continue to be used in many countries

  17. Posttransfusion Hepatitis C All volunteer donors HBsAg Donor Screening for HIV Risk Factors Anti-HIV ALT/Anti-HBc Anti-HCV Improved HCV Tests Adapted from HJ Alter , et al . Clin Chem 1997

  18. Injecting Drug Use: HBV and HCV Infection • Highly efficient mode of transmission • Rapidly acquired after initiation • Four times more common than HIV • Prevalence 50-90% after 5 years • Predominant risk factor in low prevalence countries • Emerging risk factor in medium prevalence countries –acute hepatitis B and hepatitis C in adults are often the best indicator of injection drug use problem

  19. 100 80 60 40 20 0 0 6 12 18 24 30 36 42 48 54 60 66 72 Risk of Bloodborne Virus Infections Injection Drug UsersBaltimore 1983–1988 HCV HBV Seroprevalence(%) HIV Duration of Injecting (months) Garfein RS. Am J Public Health. 1996;86:655.

  20. Injecting Drug Use and HCV InfectionHigh/Moderate Endemic Countries • Minor role in the distant past • Highest incidence of hepatitis C now seen in young adults in some countries (e.g., Italy, Japan) • sentinel event for emergence of injecting drug use • History of injecting drug use becoming more common • 50% of persons with acute hepatitis C (Italy, Russia) • 40% of HCV-positive persons <40 yrs old vs. 0% >40 (Italy) • 2/3 of HCV-positive commercial blood donors (Egypt)

  21. High/Moderate Endemicity Low Endemicity Nosocomial Injection Drug Use Other Other Sexual Transfusion Relative Importance of Risk Factors for Hepatitis C and Prevention Strategies by HCV Endemicity • Risk reduction services • Testing and counseling • Safe blood supply • Safe injections • Infection control

  22. High/Moderate Endemicity Low Endemicity Perinatal/Horizonal Sex Injection Drugs Other Other Nosocomial Relative Importance of Risk Factors for Hepatitis B and Prevention Strategies by Endemicity • Infant, adolescent, adult immunization • Risk reduction services • Infant Immunization • Safe blood supply • Safe injections • Infection control

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