Epidemiology , Prevention and Control programs of Hepatitis C in Egypt
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Epidemiology , Prevention and Control programs of Hepatitis C in Egypt Mostafa K. Mohamed and El-Said A. Aoun Egyptian Ministry of Health and Population WHO informal Consultation with VHPB Geneva, Swittzerland 13-14 May 2002
description
Epidemiology , Prevention and Control programs of Hepatitis C in Egypt Mostafa K. Mohamed and El-Said A. Aoun Egyptian Ministry of Health and Population. WHO informal Consultation with VHPB Geneva, Swittzerland 13-14 May 2002. Prevalence of HCV infection - PowerPoint PPT Presentation
Transcript of Epidemiology , Prevention and Control programs of Hepatitis C in Egypt
Epidemiology , Prevention and Control programs of Hepatitis C
in Egypt
Mostafa K. Mohamed and El-Said A. Aoun Egyptian Ministry of Health and Population
WHO informal Consultation with VHPB
Geneva, Swittzerland
13-14 May 2002
Prevalence of HCV infection
Incidence of new Infections or Seroconversions
Notification Systems
Prevenetion Programs
Laboratory /Clinical Networks
Role of Authorities
Cost and Burden of disease WHO informal Consultation with VHPB Geneva, Swittzerland
13-14 May 2002
Rural life
1996 62 Mil. Population 60 % in Rural Areas
2002 Population 70 Mil. Population Life expectancy 66 y
The Role of Parenteral Antischistosomal Therapy in the
Spread of Hepatitis C Virus in EgyptChristina Frank1, Mostafa K. Mohamed1, G. Thomas Strickland1, Daniel Lavanchy2 ,
Ray R. Arthur2, Laurence S. Magder1, Taha El Khoby3 ,Yehia Abdel-Wahab3, El-Said A. Ohn3 ,
Wagida Anwar3, Ismail Sallam3
1 = HCP Project 2 = World Health Organization 3 = Egyptian Ministry of Health and PopulationTHE LANCET Vol 355 March 11, 2000� �
Comparison of Exposure Index and Prevalence
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Alexandria
69 8
10 10
18
27
35 34 34 3532
35 36
13 13
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46 47
55
47
41
27
<05 10 15 20 25 30 35 40 45 50 55 60 >600
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50
60
National Survey > 10000 Workers > 5000
Seroprevalence of Hepatitis C Among Egyptian Workers 1996 and in the National Survey 1997-1998
0.1 0.5 1 2 3 4 5 6 7 8 9 100
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Appar 98% Appar 95% Appar 90%
98 pred+ 95 Pred+ 90 pred+
10 15 20 25 30 35 40 45 500
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Appar 98% Appar 95% Appar 90%
98 pred+ 95 pred+ 90 pred+
Sigf Constant Slope SPEC98 .000 1.9912 .9289SPEC95 .000 4.9903 .9015SPEC90 .000 9.9860 .8554
Sigf Constant SlopeSPEC98 .000 2.0033 .9310SPEC95 .000 5.0000 .9000SPEC90 .000 10.000 .8500
Relationship between True prevalence and Predictive value of HCV ELISA in Mass Screening
Age Adjusted Rates/100
HCV*% HBVHBsAg
Total Egypt
14.522.54.5
Rural18.924.95.2
Urban9.119.53.7
Males16.423.95.0
Females12.7214.0
Prevalence of HCV HBV and HBsAg in Egypt 1996
*Adjusted for +ve predictive value of ELISA 98% specificity and 98% sensitivity).
Etiology of Acute Viral Hepatitis in Egypt 1997-2000
All -ve
13
16 %
24 %
1 %
%
21 %
25%
HBV
HAV
HEVMixed
HCVMedian Age 26
Median Age 12
Median Age 44
Median Age 46
Median Age 34
Analysis of 1860 Acute hepatitis
cases
Hepatitis C Virus Infection in a Community in the Nile Delta
Seroincidence and Risk Factors
Center for Field and Applied Research
Mostafa K. Mohamed, Fatma Abdel-Aziz, Mohamed Abdel-Hamid, Nabiel N. Mikhail, Mostafa Habib , Wagida Anwar , G. Thomas Strickland, Laurence S. Magder, Alan D. Fix, Ismail Sallam
HCV Seroprevalence in Aghour El Soughra During 1997-1999
611
23
43
6258
52
42
10 20 30 40 50 60 70 800
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70
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12
25
46
61 6058
47
10 20 30 40 50 60 70 80
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13
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5963
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40
10 20 30 40 50 60 70 80
1997 1998 1999
Overall25.7 %
Overall27.0 %
Overall24.6 %
ALT among Village Residents and HCV 1999
3.1
7.4
15.4
1.33.5
13.4
0
5
10
15
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HCV- ve 1582 3.1 1.3
HCV +ve PCR -ve 376 7.4 3.5
HCV +ve PCR +ve 584 15.4 13.4
ALT> <1.5N AL> 1.5N
%
S1 EIA NegativeS2 EIA Positive
87
S1 IMX
S2 PCR
S3 EIA
S2 IMX
Seroconverter5
Seroconverter9
Seroconverter11
+ve
+ve
+ve
-ve Exclude
24
Exclude10
Exclude28
+ve
-ve -ve
None30
Over 2 years of follow-up,
2502/ 3394 seronegative (73.7%) followed-up
25 had valid anti-HCV seroconversion
11 had HCV RNA seroconversions
RNA Seroconversion Rate 2.7/1000 P.Y.
95% C.L. 1.1-4.3 /1000 P.Y.
Anti-HCV seroconversion Rate 6.2 /1000 P.Y.
95% C.L. 3.8 - 8.6 /1000 P.Y.
95% CI for OR
Variable OR Lower CI Upper CI Significance
Kids Seroconversion
MOTHER HCV
6.8 1.4 32.8 .0171
FATHER HCV
.64 .20 2.0 .4503
INVASIVE Procedures
3.94 1.02 15.1 .0468
Frequent INJECTNS
1.44 .17 12.4 .7431
RAZOR Sharing
1.8 .28 11.4 .5424
AGE .96 .87 1.1 .4334
SEX .72 .26 2.0 .5225
Notification for Acute Jaundice : National Surveillance
in 110 Fever hospitals and referral hospitals
A National Cancer Registry with HCC notification in 8
MOHP cancer centers and University Centers
Research on use of sentinel surveillance based on blood banks
for monitoring changes in community prevalence by
comparing ratios blood banks prevalence with the surrounding
communities in 6 geographical locations over 2 years.
1 -Blood Banks : Screening of blood/blood products
Central management , Reporting
Provision of Lab Equipment
Training, supplies, Monitoring
2 -Central and Peripheral Infection Control Comittees
3 -Development of Guidelines for Infection Control
Training of Health Care personnel on :
1 -Safe Injection Practices
2 -Destruction of disposable needles
3 -Proper Disposal of contaminated invasive materials
4 -Proper sterilization of reusable material
5 -Universal precautions and barrier techniques
6 -Proper Counseling of Patients and their families
Public Education :Use of Contaminated materials
Reduce public use of injections
Unsafe practices shaving/circumcision
NO Current Laboratory or Clinical Networks
Blood Bank Serology reporting is
The only network available
Several Liver Disease Societies now collaborate for exchange of experiences but no common
network
Role of Authorities
Cost and Burden of disease
There are many public calls on authorities
including Peoples Assembly to
Develop guidelines for patient management
Act for control of transmission
Provide Public support for provision of
treatment of infected individuals
Cost and Burden of disease
MOHP Authorities are
Supporting Research projects lead by the Ministry of
Health and Universities in collaboration with
International Agencies NIH CDC and WHO
Physicians Syndicate authorities
Organize meetings with national insurance authorities for
developing guidelines for patient management
News and Media Authorities
Raising Awareness for prevention of infection
Role of Authorities cont.
Causes of Death in Egypt 1996Causes of Death in Egypt 1996
Details of Liver Diseases in ColumnDetails of Liver Diseases in Column
Source: Ministry of Health Information System data for 5 Governorates (population 8.0 million Total deaths registered 44892 or 5.61/1000 )
Liver Diseases3266 9%
Renal failure1575 4%
Hypertension/CVA4070 11%
Heart Diseases13985 37%
Diarreha1210 3%Total cancers1820 5%
Other9390 25%
ARI/pneumonia2287 6% HCC
248 8%
Liver Cell Failure1032 32%
Liver Cirrhosis1986 61%
Trend of Chronic Liver Disease and Hepatocellular Carcinoma Mortality in Egypt 1973-1996
1.0 1.2 1.5
2.0 2.3 2.5 2.3 2.5
1.42.1 2.4
3.2 3.3 3.74.2 4.6
6.6 6.66.0
5.4 5.85.3 5.6
7.66.7
7.3 7.08.0
15.915.5 15.4
13.6
12.3
10.9 10.5
12.311.3
12.813.5
14.0
1973 1974 1975 1978 1981 1984 1987 1990 1992 1993 1995 19960.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
CLD Males CLD Females HCC Males HCC Females
Rate /100.000
Data are not available on HCC mortality before 1981
Trend of Cancer Mortality in Egypt 1973-1996
5.04.7
4.34.1
3.5 3.43.1 3.0
0.6 0.61.0
1.3 1.41.6 1.5
2.1
1.31.7
2.0
2.62.9
3.23.4
3.6
1973 1974 1975 1978 1981 1984 1987 1990 1992 1993 1995 19960.0
1.0
2.0
3.0
4.0
5.0
6.0Age Adjusted Rate/100.000
Cancer Breast Leukemia Lung Cancer Cancer Liver
Cancer Brain Cancer Bladder
Fatal in < 2 years In chronic HCV infection Patients Occurs annually in 4% of Cirrhotic patients
Liver Cell damage Portal Fibrosis, Portal Hypertension Variceal bleeding occurs in ~ 20% of HCV-infected individuals After 20 of Infection
Periportal Fibrosis, Portal Hypertension , variceal bleeding
occurs in ~ 80% of individuals After 15-20 of Infection
Changes of Liver Disease Spectrum in Egypt over 70 Years
At Age 30-40’s At Age 60-70’sAt Age 50-60’sDeath
1930-1980
Schistosomiasis 30 %
Hepato-Splenomegaly
1990-2000 HCV 14%
HCCLiver Cirrhosis
1990 HCV 13%
Trend of Registered Hepatocellular Carcinoma Mortality in Egypt 1981-1998
1.41.7
2.0
2.7 2.93.2 3.4 3.6 3.4
3.7
538
745
954
14111569
1777
1960
21252088
2339
1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 19980
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1000
1500
2000
2500
0.0
2.0
4.0
6.0
8.0
number of cases Rate/100000
Trend of National Mortality due to Hepatocellular Carcinoma in Egypt 1981-1996
12.5
16.2
23.722.0
26.9
32.3
25.8
32.2
9.311.0 11.5
20.6 20.522.5 23.3
25.2
8.4 9.011.4
16.0
19.8 19.7 19.4
22.7
6.2 6.1
9.0
13.215.0 16.0
14.415.9
1.1 1.2 1.5 2.0 2.3 2.5 2.3 2.5
1981 1984 1987 1990 1992 1993 1995 1996
Overall 51-55 56-60 61-65 66-70 71-75
>75
11.39.5
15.9
27.0
38.3 38.7
53.351.6
8.9
14.5
17.7
26.4
32.633.9 33.7
44.7
1.5 2.0 2.4 3.2 3.4 3.8 4.4 4.6
1981 1984 1987 1990 1992 1993 1995 19960.0
10.0
20.0
30.0
40.0
50.0
60.0Rate /100.000
FemalesMales
Age GroupsN. in thousands
Total casesCLD=70%cirrhosis 15% HCC 2%
0-13997.31390027805-198138.619800396010-11983.311900238015-179125.317900358020-166116.216600332025-428299.642800856030-908635.6908001816035-1095766.51095002190040-914639.8914001828045-874611.8874001748050-589412.3589001178055-469328.346900938060-403282.140300806065-711497.77110014220
Total7.192.0005.034.400719.200143.840
Predicted Chronic Liver Disease in Egypt 1996
3.1354.679
7.7398.030
5.902
3.8303.081
0.9562.640
10.811.2 11.7 11.1 11.312.4
14.4
17.3
19.4
1987 1991 1993 1995 2002 2012 20220.000
5.000
10.000
15.000
20.000
25.000
Thousands
total cancers Mortality from liver Cancer Predicted HCC
Predicted Hepatocellular carcinoma in Egypt 1996
Predicted HCV Infected Individuals in Egypt 1996-2008
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Years
0.0001.0002.0003.0004.0005.0006.0007.0008.0009.000
10.000
Millions
PCR+ALT1.5N PCR+ALT PCR EIA
PCR+ALT1.5N 0.844 0.864 0.885 0.906 0.926 0.947 0.968 0.989 1.009 1.030 1.051 1.071 1.092
PCR+ALT 1.392 1.426 1.460 1.495 1.529 1.563 1.597 1.631 1.665 1.700 1.734 1.768 1.802
PCR 4.218 4.322 4.425 4.529 4.632 4.736 4.840 4.943 5.047 5.150 5.254 5.357 5.461
EIA 6.489 6.727 6.965 7.203 7.441 7.679 7.917 8.154 8.392 8.630 8.868 9.106 9.344
Cost of Treatment and Complications in HCV in Egypt 1996-2008
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 total
Years
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0160320480640800960112012801440160017601920208022402400256027202880304032003360352036803840400041604320448046404800496051205280544056005760592060806240640065606720688070407200736075207680784080008160832084808640880089609120928094409600976099201008010240104001056010720108801104011200113601152011680118401200012160123201248012640128001296013120132801344013600137601392014080142401440014560147201488015040152001536015520156801584016000161601632016480166401680016960171201728017440176001776017920180801824018400185601872018880190401920019360195201968019840200002016020320204802064020800209602112021280214402160021760219202208022240224002256022720228802304023200233602352023680238402400024160243202448024640248002496025120252802544025600257602592026080262402640026560267202688027040272002736027520276802784028000281602832028480286402880028960291202928029440296002976029920300803024030400305603072030880310403120031360315203168031840320003216032320324803264032800329603312033280334403360033760339203408034240344003456034720348803504035200353603552035680358403600036160363203648036640368003696037120372803744037600377603792038080382403840038560387203888039040392003936039520396803984040000Millions
PCR+ALT1.5N 844 864 885 906 926 947 968 989 1009 1030 1051 1071 1092 1092
cost of STD. tttt 25309 25930 26552 27173 27794 28416 29037 29659 30280 30902 31523 32145 32766
cost of compl. 422 432 443 453 463 474 484 494 505 515 525 536 546 6291
Lost Productivity 253 259 266 272 278 284 290 297 303 309 315 321 328 3775
Cost of yll 506 519 531 543 556 568 581 593 606 618 630 643 655 7550
Cost of Alt TTT 1392 1426 1460 1495 1529 1563 1597 1631 1665 1700 1734 1768 1802 20762
Total Cost 2573 2636 2699 2763 2826 2889 2952 3015 3079 3142 3205 3268 3331 38378
Cost of STD. TTT = ALL ALT 1.5N X 30000Cost of complication = Annually 10/100 ALT1.5N X 5000Lost Productivity = Annually 20/100 ALT1.5N X 1500Cost of YLL = Annually 3/100 ALT1.5N X 20000Cost of Alternative TTT = Annually All ALT > N X 1000
TTT of All Cases with Viraemia will prevent infection of new cases
