Basic Information About Turkey

Basic Information About TurkeyBasic Information About Turkey

AREA 774.815 km2

POPULATION 63,510,000Urban Population 59,01 %Rural Population 40,99 %

0-14 ages 32,7%15-64 ages 62,8 %Over 65 4,7 %

Basic Information About TurkeyBasic Information About Turkey

LIFE EXPECTANCY AT BIRTH (years)Male 65.40Female 70.00Average 67.70

PER CAPITA INCOME 2.500 – 2.900 USD

BASIC LİTERACY RATE 82%

TURKEY TURKEY a country of “intermediate

endemicity”for HB infections:

5% HBsAg positive 25-30% Anti-HBs positive

Seroconversion in 1/3 of a 63 million population, and 3-3.5 million carriers!

0

5.000

10.000

15.000

20.000

25.000

30.000

35.000

AVH 12.403 25.379 33.282 28.351 19.518 16.671 31.344 28.235 16.724 19.762 19.003 18.685 14.550

HepA 0 0 30.662 25.896 16.967 14.395 28.245 25.812 14.289 15.419 14.000 14.323 10.435

HepB 0 0 2.620 2.455 2.551 2.276 3.099 2.423 2.435 4.343 5.003 4.362 4.115

1980 1985 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

At least 10x of annual numbers stated by MoH

HBsAg(+) rate if soldier rate (mass vaccinations, crowded living conditions; effect of

vaccination?)

0

10

20

30

40

50

60

70

80

2

3

4

5

6

7

% Civilian 25 24 32 46 40 44 48 53 56 53 55 57 55

% Soldier 75 76 68 54 60 56 52 47 44 47 45 43 45

HBsAg+ 6,7 6,5 5,7 5,3 4,9 4,9 5,2 5,4 5,1 5,0 4,7 3,4 4,3

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

Regional variations

Higher rate of HBsAg positivity in EASTERN regions of TURKEY

(crowded families, poor socioeconomic status, infrastructure, lack of access to “sufficient” health services, traditional life-styles...)

Regional Differences in HBsAg PositivityRegional Differences in HBsAg Positivity

3.7%

6.9%

8.8%4.6%

8.9%3.5%

4.9%

4.5%

6.7%

7.9%

4.4%

Age of infection: increased after 10 yrs, and peak btw 21-25 yrs of age

0

5

10

15

20

25

30

35

40

45

50

age group

%

HBsAg 1,4 1,7 4,3 9,9 10,6 8,6 7,1 8,1 2,5 6,5 10,3 0 2,1

anti-HBs 6,9 3,4 13 25,3 14 21,8 34,7 35,5 31,3 21,7 48,7 37,5 29,2

0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 60+

Risk groups?

• No difference btw health personnel and donors regarding HBsAg, but anti-HBs is significantly increased.

• Patients with chronic hepatitis, cirrhosis and HCC ...

Horizontal transmission!

No known risk factors

among 44.5% of AVH cases in Turkey

Viral Hepatitis Prevention Society

• A local NGO with 1,200 members

• Communication networks targetting health personnel all around the country

• Important contribution towards the implementation of universal newborn immunization in 1998.

Social Marketing of Hepatitis B Immunisation Project

Viral Hepatitis Prevention Society

In collaboration with Ministry of Health Dept. of Primary Care, opinion leaders from medical schools and PR experts.

A baseline KAP (Knowledge, Attitute and Practice) survey was conducted.

Regional training teams established.

Training materials, leaflets, brochures, posters and a reference guide book for medical doctors and nurses were prepared.

Viral Hepatitis Journal, a quarterly medical bulletin was published.

Comparison of hepatitis B immunization strategies taking into account cost-effectiveness issues

• 3 strategies for 1997 cohort of 1.500.000 newborns:

1) no vaccination

2) screen mothers and vaccinate newborns

3) vaccinate all newborns

Comparison of hepatitis B immunization strategies by cost-effectiveness

1997 cohort (1.500.000 newborns) No vaccine Vaccinate after

screeningVaccinate all

Number vaccinated 0 74.556 1.083.000

Prevented infections 0 47.346 616.490

Prevented carrier cases 0 14.341 70.150

Prevented deaths 0 4.572 18.603

Cost of program 0 42.619.000 USD 6.700.000 USD

Cost of strategy 171.000.000 USD 186.655.000 USD 54.000.000 USD

853.000 infected

97.000 carriers

25.000 deaths

MoH recommendations for HB immunization

1. alternative Dose 1 At birth

Dose 2 3rd month

Dose 3 9th month

2. alternative

(infants born outside health facilities)

Dose 1 3rd month

Dose 2 4th month

Dose 3 9th month

3. Alternative

(for infants >3 month)

Dose 1 anytime

Dose 2 1 month after the first dose

Dose 3 5 month after the 2nd dose

In Turkey, universal Hepatitis B immunization is part of EPI since 1998. Children are vaccinated at 3, 4 and 9 months of age for Hepatitis B.

MoH EPI schedule in Turkey*

Vaccines 2 mo 3 mo 4 mo 9 mo 15 mo 18 mo

BCG X          

DBT+polio X X X     X

HepB   X X X    

Measles       X X  

*Haemophilus influenzae type B, MMR, varicella and hepatitis A vaccines are recommended by health personnel, but can be used only upon purchase from private pharmacy by parents. They are not mentioned among EPI vaccines nor covered by any form of insurance.

The first year of universal immunization - MoH data

• Annual no of newborns: 1 360 000• Children vaccinated by 3 doses: ~66%• Annual no of children immunized: 890 000

National HB Immunization 1999-2001

65 6674

0

10

20

30

40

50

60

70

80

90

1999 2000 2001

Dose 1

Dose 2

Dose 3

* First 3 months

• At the beginning, for the RISK GROUPS, the vaccine required was to be purchased from private pharmacies, and then reimbursed by social security institutions.

• Since 2000, as a cost-saving measure, MoH started to provide vaccine for risk groups also.

Cost of vaccine Pediatric dose Adult dose

MoH 0,58 USD 1,16 USD

Private sector 14,8 USD 17 USD

After the introduction of universal HepB immunization,

public/private vaccine consumption in Turkey

doses purchased by MoH 5.000.000 3.750.000 11.000.000

doses imported by privatesector

2.650.000 1.150.000 900.000

1998 1999 2000

Two main problems of HB immunization program in Turkey

• 1st vaccine dose at 3rd month of life (babies of women that were not screened for HBsAg in pregnancy remain still not protected. However, starting vaccination at birth is problematic for practical reasons.)

• No program for adolescents