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Is Viral Hepatitis Important? World Hepatitis Day

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

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  1. Is Viral Hepatitis Important?World Hepatitis Day May 19, 2009 Austin, Texas Gary Heseltine MD MPH Epidemiologist - Infectious Disease Control Unit

  2. 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

  3. 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

  4. Prometheus

  5. Progression of Liver Disease Time frame: years to decades Fibrosis Cancer Cirrhosis BC Hepatitis Services, 2003

  6. HAV Prevalence and Genotype Distribution 3a Multiple 1a 1a 1a

  7. 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

  8. 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

  9. 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

  10. HAV Vaccines EL.U - enzyme-linked immunosorbent assay units GMT – geometric mean titers

  11. Geographic Distribution of Hepatitis E Outbreaks of Confirmed Infection in >25% of Sporadic non-ABC Hepatitis

  12. 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

  13. 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

  14. 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

  15. 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/

  16. Un homme enceinte s’accouche dans son tombeau* *A pregnant man delivers in his grave

  17. 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

  18. 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

  19. Estimated Births to HBsAg-Positive MothersUnited States, 2002

  20. 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”?

  21. HCV Prevalence and Genotype Distribution 5 3 1b 1a,b 2 2 6 1a,b 3a 4 1b, 3 5a 2c

  22. 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

  23. Prevalence of HCV Infection by Age, Race, and Gender, United States, 1988-1994 Black females Black males White males White females Source: NHANES III

  24. Reported Risk Characteristics Among Adults 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

  25. Surveillance: Who is missing? • 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.

  26. Chronic Hepatitis Burden • 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/

  27. Chronic Viral Hepatitis Disease Burden = 409,400 cases

  28. Other 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

  29. 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.

  30. Safe Injection Global Network 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

  31. Common Mode Transmission: Posttransfusion Hepatitis All volunteer donors HBsAg HCV Donor Screening for HIV Risk Factors Anti-HIV 3rd gen HBsAg ALT/Anti-HBc Anti-HCV HCV RNA HBV

  32. HIV, HBV, HCV: Chronic Infections IVDU HIV: 1 Million HCV: 3 million 15-30% STD 10% HBV: 1 million • HAV: acute infection • vaccine TB-opportunistic

  33. Common in U.S.* 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.

  34. Surveillance: A Better Picture 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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