World Hepatitis Day 2015: Hepatitis prevention

Hepatitis Prevention Know the Facts

Dr. Paba Palihawadana Chief Epidemiologist

MBBS, MSc (Com Med), MPH, MD (Com. Med)

Epidemiology Unit - Ministry of Health

Global Burden of Hepatitis

• 400 million people living with chronic viral hepatitis

• 1.4 million die every year from causes related to viral hepatitis

• Around 780 000 persons die annually from hepatitis B infection

• Over 500 000 people die each year from hepatitis C-related liver diseases

Global Burden of Hepatitis

Chronic hepatitis B high prevalence - East Asian and African countries Chronic hepatitis B Moderate prevalence- Middle East and the Indian subcontinent HCV high prevalence- Central and East Asia and North Africa

HCV Global Prevalence

HBV Global Prevalence

Burden of Hepatitis in Sri Lanka

Epidemiology of Viral Hepatitis in Sri Lanka

• Viral Hepatitis is a Group B Notifiable disease in Sri Lanka

• 7356 Viral hepatitis cases reported to Epidemiology Unit for the past 5 years

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1800

2010 2011 2012 2013 2014

Incidence

Source- Epidemiology Unit

Viral Hepatitis Trend In Sri Lanka 2010-2014

Source- Epidemiology Unit

Gender specific Incidence

2010-2014

Male

Female

(70%) (30%) (70%)

Age specific Incidence

2010-2014

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incidence

Source- Epidemiology Unit

Viral Hepatitis Incidence by District 2010-2014

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Mullaitivu

Kilinochchi

Mannar

Trincomalee

Kalmunai

Vavuniya

Batticaloa

Ampara

Puttalam

Galle

Nuwara-Eliya

Kalutara

Polonnaruwa

Jaffna

Anuradhapura

Hambantota

Colombo

Matale

Badulla

Kurunegala

Matara

Kandy

Moneragala

Ratnapura

Gampaha

Kegalle

Incidence

• More than half of these cases (57%) are from 4 districts (Kegalle, Gampaha, Ratnapura and Moneragala)

Sero-Prevalence of Hepatitis Infection

• overall sero-prevalence of HBV (<2%) and HCV (<1%) is low in Sri Lanka and increases with age (WHO SEARO-2010)

• A sero-surveillance study of 407 children aged 1 to 5 Years in Kalutara district tested negative for current Hepatitis B infection(Hepatitis B Sero-Survey-2014, Epidemiology Unit-MRI joint Study)

Disease Surveillance

Notification system for Viral Hepatitis

Hospitals MOH RE district

Epidemiology Unit (Central Level)

399 / H 411a Surveillance of Viral Hepatitis-case investigation form

E- Based System

Laboratory Data/ Blood Bank Data / NSACP Data

Challenges in Viral Hepatitis Disease Surveillance

• Prevalence is underreported in Sri Lanka due to Under reporting of Viral Hepatitis cases from

government and private sector hospitals

Chronic nature of the disease with an often asymptomatic acute Infection

Less request for Laboratory confirmation

Limitations in inter-institutional exchange of information

E.g. : National Blood Transfusion Service (NBTS), National STD/AIDS Control Programme, MRI and other laboratory data

2013 – 2014 Special Surveillance reporting – Epidemiology Unit • viral hepatitis cases - 3319 • Cases tested for HBV

infection - 82 (2.4%)

• Cases positive serologically - 65 (2%)

Strengthening the Surveillance System

• Strengthen the routine national viral hepatitis surveillance mechanism

• Establish a system linking up the hospitals including private hospitals, OPDs, NBTS, NSACP, MRI and other laboratories with the Central Unit to gather data for utilization in planning and implementing strategies

• Surveys among vulnerable groups for detection of chronic HBV and HCV infection

• Establish the national referral centre for laboratory diagnosis and improve resources for serological confirmation

• Develop national standardized protocols for testing samples for viral hepatitis

Surveillance System

Hospitals

OPD Private Sector

CENTRAL UNIT

(Epid. Unit) Laboratories

NSACP

NBTS

Prevention and Control

• H 399 / H 411a • Special Surveillance Data • E-based System

Surveys in Vulnerable

Groups

Analysis Planning Implementation

Transmission of HBV and HCV

Mode of Transmission

• Hepatitis B - through blood and other body fluids (saliva, menstrual, vaginal, and seminal fluids)

• Hepatitis C - mostly through blood

Globally identified Risk Groups for HBV and HCV transmission

• People who frequently require blood or blood products

• Dialysis patients

• Recipients of solid organ transplantations

• Household and sexual contacts of people with chronic HBV and HCV infection

• People with multiple sexual partners

• Men who have sex with men

Risk Groups Cont.

• Infants born to infected mothers

Screening of pregnant women for HBs Ag is necessary to identify

those neonates at risk of transmission

However Sero-prevalence of HBV is very low among pregnant women in Sri Lanka (WHO SEARO-2010)

Routine HCV Testing Is Not Recommended for Pregnant women (CDC)

• Health care and public safety workers at risk for

occupational exposure to blood or blood-contaminated body fluids

Risk Groups Cont.

• people with HIV infection Risk of HIV co-infection with HBV and HCV due to shared routes of

transmission

Faster progression to liver cirrhosis, and higher rates of mortality with co-infection

Adult HIV prevalence (>15 years) - <0.1%

Prevalence of HBV and HCV among people living with HIV (PLHIV) is usually Underestimated

• people who have had tattoos or piercings

Risk Groups Cont.

• people who inject drugs

Globally, around 16 million people inject drugs

A study done with 250 drug users in the Colombo district in 2005 revealed

• 12.6% (CI 5.1-24.5) prevalence of ever injecting drug use • 7.6% Prevalence of HBV, but none were infective (HBsAg negative) • 0.4% Prevalence of anti-HCV • None tested positive for HIV

(Tissera H. A, 2005) WHO recommend harm reduction with needle and syringe

programmes and opioid substitution therapy

Risk Groups Cont.

• people interned in prisons A study among cohort of prison inmates(n=393) in Sri Lanka

revealed low prevalence of

• HBV (HBsAg-0.25%) • HCV (HCV RNA- 0.5%) • Injecting drug use (4.3%)

None of the injecting drug users were positive for HBV-DNA or

HCV-RNA

(Niriella M. A et al)

• Residents and staff of facilities for developmentally

disabled persons

Risk Groups Cont.

• Travelers leaving to countries with high prevalence of HBV and HCV infection Hepatitis B vaccination should be administered to all unvaccinated people traveling to areas with intermediate to high prevalence of chronic hepatitis B (HBVsAg prevalence ≥2%) (CDC)

Prevention

HBV Vaccination

• Mainstay of hepatitis B prevention

• Introduced to the Expanded Programme of Immunization (EPI) schedule in 2003 in Sri Lanka

The complete vaccine series induces protective antibody levels in more than 95% of infants, children and young adults

Protection lasts at least 20 years and is probably lifelong

Indications:

• All infants on completion of 2, 4 and 6 months

• Those at risk of contracting HBV infection- High Risk sexual behaviour, partners and household contacts of HBVsAg positive persons, injecting Drug Users, frequent blood recipients, recipients of solid organ transplantations

• Occupational risk of HBV infection- HCW

• International travelers visiting HBV endemic countries

• Babies born to mothers who have had HBV infection during pregnancy

• Post-exposure vaccination following needle stick injuries

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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Hepatitis B Coverage

Heb B Coverage

Hepatitis B vaccine Coverage 2003-2014

• The Hepatitis B Sero-survey of 407 children aged 1 to 5 years in Kalutara district also assessed the Immunity levels in the study population

• 100% HBV vaccination status among the study participants

• 76.2% of children had protective levels of humeral immunity against Hepatitis B infection

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1 - 2 yrs

2 - 3 yrs

3 - 4 yrs

4 - 5 yrs

protected

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Age 1-2 yrs Age 2-3 yrs Age 3-4 yrs Age 4-5yrs

Mean Median Protective level

mIU/ml

• Median HBsAb level is seen decreasing gradually with increase in age (comparable with global literature )

Hepatitis B Sero Survey 2014

• No vaccine available for hepatitis C

• Therefore primary prevention of HCV infection depends upon reducing the risk of exposure to the virus in health-care settings, in higher risk populations

Thank You