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US Disease Burden of Hepatitis B

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US Disease Burden of Hepatitis B

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  1. Hepatitis BEliminating TransmissionPreventing Disease*John W. Ward, M.D.Division of Viral HepatitisCenters for Disease Control and Prevention *The findings and conclusion n this presentation have not been formally disseminated by CDC and should not be construed to represent CDC determination or policy

  2. US Disease Burden of Hepatitis B Total HBV infection ~14 million (5%) Chronic HBV 1-1.4 million Other blood-borne infections Chronic HCV 3 million HIV 1 million

  3. Global Disease Burden of Hepatitis B Total HBV infection 2 billion Chronic HBV 370 million Other blood-borne infections Chronic HCV 130 million HIV 40 million

  4. HBsAg Prevalence 8% - High 2-7% - Intermediate <2% - Low Geographic Distribution of Chronic HBV Infection

  5. Immigrants Admitted For Permanent Residence, 1994-2003, by HBV Endemicity1 Estimated HBsAg-positive3 Immigrants2 1. Country of birth 2. Yearbook of Immigration Statistics, Dept. of Homeland Security 3. Based on country-specific HBsAg prevalence estimates

  6. Age-Adjusted HCC Mortality Rates Among Males, by Race and Year, 1990-2002; n=77,107

  7. Prevention of HBV Transmission

  8. Modes of HBV Transmission Perinatal • Blood exposure during birth • Transmission risk depends on status of mother • HBeAg positive – 70-90% risk • HBeAg negative – 5-20% risk Percutaneous and permucosal • Early childhood/horizontal • Injection drug use- >50% infected after 5 years • Health-care related (transfusion, unsafe injections) Sexual • 16-40% of contacts infected

  9. Advisory Committee on Immunization Practices US Strategies to Eliminate HBV Transmission • Prevent perinatal HBV transmission (1984-88) • Maternal screening • Newborn vaccination • Recommend universal birth dose (2005) • Universal infant vaccination (1991) • Catch –up vaccination • adolescents 11-12 years (1995) • all persons <19 years (1999) • Adults at high risk (1982)

  10. Hepatitis B Vaccine Coverage Among Children*United States, 1995-2003 Asian-Pacific Islander HP 2010 target Black White Hispanic *Aged 19-35 months Source: National Immunization Survey

  11. Effectiveness of Hepatitis B Immunization Among API Children, Hawaii and Georgia Hawaii Georgia Before vaccination Before vaccination HBsAg 11.7% 4.5% Anti-HBc 6.6% 99% vaccine coverage 98% vaccine coverage 1.6% 0.04% 0.2% 0.6% 0.6% 2001 (n=2470) 1989 (n=2701) 1986 (n=251) 2002 (n=157) Sources: Pediatrics 1993, N Engl J Med 1989, CDC, GA Health Dept, HI Health Dept.

  12. Hepatitis B Incidence Among Persons <19 Yrs By Race/Ethnicity, 1990-2004 Overall decline ~ 93% Decline among API ~ 95% Asian/Pacific Islander Cases/100,000 Black AI/AN Hispanic White Year

  13. Hepatitis B Incidence Among Persons ≥19 YrsBy Race/Ethnicity, 1990-2004 Black Overall decline ~ 75% Decline among API ~ 85% Asian/Pacific Islander AI/AN Hispanic White

  14. WHO Recommendation for Hepatitis B Vaccination • Recommendation made 1991 • Integrate Hepatitis B vaccine into national childhood vaccination programs • By 2004, 153 of 192 (80%) WHO Member States had introduced • 48% of the world's children less than 1 year of age had received 3 doses of HepB

  15. Global Status of Hepatitis B Immunization Programs (2005) Countries with hep B programs: ~80% Global HepB3 coverage: ~40%

  16. Adult Hepatitis B Vaccine Coverage, United States,2002 Vaccination of 0-18 yrs recommended 60 50 40 30 Vaccine coverage, % 20 10 0 19-20 21-25 26-30 31-40 41-50 51-65 65+ Age group, yrs National Health Interview Survey

  17. Reported Acute Hepatitis B Incidence, By Age and Sex, United States, 2004 <5 0.1 0.1 Female Male 0.0 5-9 0.0 0.1 0.1 10-14 15-19 1.1 0.7 20-24 3.1 3.9 4.2 6.2 25-29 30-34 4.0 6.3 Age group 35-39 4.4 6.0 40-44 3.6 6.2 45-49 2.7 5.1 50-54 2.0 3.8 1.3 2.6 55-59 60+ 0.8 1.7 Rate per 100,000 persons

  18. Reported Risk Factors for AcuteHepatitis B in the U.S. (2001-2004) No Identified Risk (25%) IDU (13%) Other1 (5%) Heterosexual – contact w/ confirmed or suspected case (10%) Heterosexual – > 1 opposite sex partner in past 6 months (22.3%) MSM (23%) 1 Other: Household contact, institutionalization, hemodialysis, blood transfusion, occupational exposure, admits to a risk factor but does not specify which one Source: Sentinel Counties Study of Acute Viral Hepatitis, CDC (n = 591)

  19. Estimated Hepatitis B Vaccine Coverage in Adults

  20. Revised ACIP Recommendations for Adult Hepatitis B Vaccination • Settings with high HBV prevalence • Conduct universal vaccination • Settings with high prevalence settings (e.g. STD/ HIV, corrections Routinely inform patients of the potential value of HBV vaccination • Vaccinate all persons seeking protection • To assure high risk persons receive vaccination • Offer to all patients in high prevalence settings () • In Primary care settings • Risk based • Age-based

  21. Chronic HBV Infection

  22. Burden of Chronic HBV Infection United States • 1.0-1.25 million have chronic HBV infection • ~45,000 new cases of chronic HBV infection • ~40,000 (90%) are foreign born • >50% are Asian-Americans • Limited studies suggest most are unaware of infection • Improved therapies for chronic hepatitis B increase potential benefit of counseling and testing programs

  23. FDA Approved Therapies for Chronic Hepatitis B • Interferon alpha-2b (Intron A) • Adefovir (Hepsera) • Epivir-HBV (Lamivudine) • Entecavir (Baraclude) • Others in clinical trials

  24. Selected Characteristics of Chronic Hepatitis B Registries at Four Health Departments

  25. Deaths from Hepatitis B Vital records • Reported Deaths are level by year • Year 2000 1458 deaths • Year 2001 1370 deaths • Year 2002 1350 deaths

  26. Vital Records Do Not Capture All HBV-related Deaths 27 121 215

  27. Purposes of Hepatitis B Screening • Prevent transmission • Transfusion/transplantation • Perinatal • Close contacts • Efficient delivery of vaccine • Begin medical management of chronic disease • Early diagnosis • Evaluation and treatment

  28. Screening Recommendations for Pregnant Woman • Shift focus to include needs of HBV infected mothers • Prevention case management model • Vaccination of contacts • Referral for care • Particular focus on foreign born persons from high endemic areas

  29. Public Health Programs for Chronic Hepatitis B • Represents a change in division orientation • New research questions • New surveillance practices • Chronic disease registries • Program indicators • New public health infrastructure

  30. Strategic Imperatives • Sustain child/adolescent immunization programs • Increase vaccine coverage among at risk adults • Develop chronic HBV infection programs • Screening programs for Asian and other populations • Build services for immigrants and refugees • Conduct prevention case management • Facilitate access to medical care • Vaccinate close contacts of infected persons • Assist prevention efforts in Asia countries • Obtain data for program planning/evaluation

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