PowerPoint Presentation · PDF fileTACE/TAE RFA Resection Liver Tx Overall Screened...

26/09/2014

1

The Hepatitis Foundation of New Zealand www.hepatitisfoundation.org.nz I 0800 33 20 10

HBV in New Zealand

Community HBV screening to long-term follow-up John Hornell, CEO, The Hepatitis Foundation of New Zealand

The Hepatitis Foundation of New Zealand


A registered charitable trust whose mission is:

To improve health outcomes for people living with hepatitis B and C in

New Zealand

Over 30 years experience in delivering community based services in a shared care

environment - facilitation, assessment, follow-up, education and support.

Work extensively with Māori, Pacific and Asian ethnic populations and communities


People Identifying as Māori

in New Zealand (5th March 2013)

• 598,602 Māori, 14.9% of the population

• 23.9 years median age (half are younger and half are

older than this age)

• 48.2% male (288,636 people)

• 51.8% female (309,966 people


Asia-Pacific Asia-Pacific


Milne A et al. NZ Med J 1980; 92: 87-91

1976: Identification of endemic HBV

Notified cases of acute HBV in Whakatane (population 35,000), NZ, from 1976 to 1978

0

20

40

60

80

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80

HB

sA

g+

icte

ric h

ep

atitis (

n)

Age (years)


1984: Kawerau community study

• Township built in 1953 around paper mill

– Population 10,000, predominantly Māori

– 98% of population screened

Milne A et al. I J Epidem 1987; 16: 84-80

0

10

20

30

40

50

60

70

80

90

100

0 5 10 15 20 25 30 35 40 45 50 55

Age (years)

% a

nti-H

bco

re+

Mode of HBV transmission is early horizontal,

not vertical

26/09/2014

2

The Hepatitis Foundation of New Zealand The Hepatitis Foundation of New Zealand


HBV vaccination: Beginnings

• 1983: Government decides to fund vaccines only for at-risk adults, health-care

workers

• 1985: Hepatitis Foundation initiates and funds own mass childhood vaccination

programme:

– Plasma-derived vaccine (MSD)

– IM low dose (2mg x3)

– Anti-HBs neg children <12 years

– >8000 vaccinated (>95% target)

– Subsequent followed for protective immunity


(i) Seroconversion (ii) Infection

Follow-up of low-dose vaccination

programme in Kawerau children

69%

5%

0%

20%

40%

60%

80%

1984 1992(vaccinated)

% a

nti-H

bco

re+

in 1

2 y

r o

lds

10%

0% 0%

10%

20%

30%

40%

50%

1984 1992(vaccinated)

% H

BsA

g+

in

12

yr

old

s

Lucas et al. NZ Med J 1994; 107:266-8


Roll out of HBV vaccination: Milestones

• 1985: International Vaccination Workshop

– Saul Krugman, Palmer Beazley, Ron Lucas, Mary Dimitrikakas, Brian

McMahon, Jim Maynard

• 1986: Vaccinate infants of HBsAg+ mothers

• 1987: Vaccinate all infants (80,000/year)

• 1988: Catch-up vaccination in all 12 yr olds

What about those already infected?


Impact of endemic HBV infection in NZ

Liver mortality

Weir,R, et al. J Gastro Hepatol 2002;17: 582–588

HBV 63%

HCV 8%

Alcohol 31%

Other 4%

200 cases per annum

Hepatoma Clinic

HBV 60%

HCV 21%

Alcohol 9%

NASH 7%

Other 3%

\

120 cases per annum

Fung J, et al. Hepatology 2005; 42:258A

26/09/2014

3


• 1991-1995: MoH HBV carrier workshops

• 1997: Ministry announce funding for screening pilot for Māori in South Auckland

• Hepatitis Foundation disputes that the pilot would be:

– unnecessary, given that reliable testing, vaccination, treatment, follow-up are available

– unethical as carriers living outside the pilot area would be an untreated “control” group

– too small to collect accurate data on complication rates (HCC, liver-related mortality)

– non-Māori high-risks groups must be included

National HBV screening takes shape


Who should be included in a National HBV

Screening Programme?

0%

5%

10%

15%

20%

25%

NZ

Maori

Co

ok

Isla

nd

s

Fiji

W. S

am

oa

Niu

e

To

ng

a

Ho

ng

Ko

ng

Ta

iwa

n

SE

Chin

a

Pre

vale

nce o

f H

BsA

g

Parkin D, et al. CA Cancer J Clin. 2005;55;74-108; Tuikitonga C, et al. NZMJ 1992. HCC Age Standardized Incidence per 100,000

28 13

8

0 10 20 30 40 50 10 20 30 40 50

Males

Females

China

Middle Africa

Japan

Eastern Africa

Southern Europe

Caribbean

Southern Africa

Western Europe

Eastern Europe

Northern America

Central America

Western Asia

Northern Africa

Australia

South America

Northern Europe

NZ Māori

NZ Asian

NZ Pacifican

Prevalence of HBV Incidence of HCC

The Hepatitis Foundation of New Zealand The Hepatitis Foundation of New Zealand http://www.stats.govt.nz/products-and-services/Articles/pop-proj-Jun04.htm

Projected ethnic populations 2001-2021

Māori Pacific Asian European


National HBV Screening Programme

June 1998: Pilot programme scrapped

National screening programme funded from

July 1999 until June 2002

Targeting “at-risk” adults

» Asian, Pacific Islander, Māori

» 15 years old (post vaccination)

Total to be screened= 566,000

● All HBsAg+ offered life-long follow-up


313,071 at risk » 41% Māori » 31% Pacific » 28% Asian • 90% urban

• via GPs

252,765 at risk » 75% Māori » 12% Pacific » 15% Asian • 75% rural

• mobile clinics

Target population for screening

26/09/2014

4



• July 1999 - July 2002

– 177,292 Screened

11,936 HBsAg+ identified

7.3%5.8% 6.2%6.5%1%

45%

59%59%54%

0%

25%

50%

75%

Overall Maori Pacifican Asian European

HB

V S

tatu

s

Column 3

anti-HBs(+) = immune to HBV

HBsAg+ = chronic HBV



prevalence according to ethnicity

5.8% 7.4%

9.1%

13.3%

0.6%

9.3% 9.4%

0%

5%

10%

15%

20%

Maori

Co

ok Is

Niu

ea

n

To

ng

an

India

n(5

0,0

00)

SE

Asia

n(2

0,0

00)

Ch

ine

se

(72,5

00)

% H

BsA

g+

Robinson T, et al. NZ Med J. 2005; 118: No. 1211


National HBV Screening Programme followed

by opportunistic screening in the community

0

5000

10000

15000

20000

25000

pre

-19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

To

tal en

rolled


Numbers exiting from the National HBV

Surveillance Programme

0

100

200

300

400

500

600

700

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Nu

mb

ers

lo

st

fro

m f

/u

sAg loss

Emigrated

Died

Refused

The Hepatitis Foundation of New Zealand The Hepatitis Foundation of New Zealand

Polynesians in Australia

0

25000

50000

75000

100000

125000

1980 Census 1986 Census 2001 Census 2006 Census

Cook Is Tonga Samoa Fijian Māori

Pa

cific

pe

op

le in

Au

str

alia

(n

)

26/09/2014

5

www.hepatitisfoundation.org.nz I 0800 33 20 10

What are the long-term

benefits of the national

HBV screening

programme?


Characteristic of Hepatoma:

Screened vs Non-screened tumours

26% 28

16

6 3

83

64

46

38

29

0

10

20

30

40

50

60

70

80

90

100

Larger than 5cm Multinodular Tumour Bilobar Tumour PV Thrombosis Metastasis

Screened (n=284) Non-screened (n=374)

Median tumour size: 3cm vs 8cm (p<0.001)


p<0.001 p<0.001

p<0.001

p<0.001

p<0.001

% o

f p

atie

nts


Characteristic of Hepatoma:

Screened vs Non-screened tumours

17

9

35

25

79

4 1

5 0

13

0

10

20

30

40

50

60

70

80

90

100

TACE/TAE RFA Resection Liver Tx Overall

Screened Non-screened


p<0.001 for all comparisons

% o

f p

atie

nts

tre

ate

d

Treatment modality


0 730 1460 2190 2920 3650 4380 5110

0

20

40

60

80

100

Survival in hepatocellular carcinoma:

Screened vs non-screened HBV tumours


Log-rank: P<0.0001

27%

5% 2%

81%

56% 50%

Survival (Days)

Screened group

Median survival = 2931 days

n = 284

Non-screened group

Median survival = 130 days

n = 374

100

80

60

40

20

0

0 730 1460 2190 2920 3650 4380 5110

Cu

mu

lative S

urv

ival


Conclusions

• In a country with endemic HBV infection, neonatal vaccination will prevent chronic infection, thereby reducing the risks of liver-related complications

• Adults with chronic infection should be identified through targeted screening and recruited into a low cost national community-based surveillance programmes


Unresolved issues

0

10

20

30

40

50

60

70

1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

Nu

mb

er

of

HB

V-H

CC

Not screen-detected Screen-detected

Need to increase recruitment into natioanl programme

Need to optimise current surveillance strategies

» identify predictors and tailor screening to risk profile?

26/09/2014

6



Kawerau cohort HRC study

• 1984: 572 HBsAg+ Māori children diagnosed with chronic HBV

• 2012: 511 original cohort alive. 497 traced and contacted, 384 /511 patients

reassessed (105 in Australia, Sydney, Brisbane, Perth & Melbourne)

– 4% HCC; 11% cirrhosis (Fibroscan)

• Age, HBeAg status and baseline HBV DNA strongest predictors of HCC*

• 2013-5: Further studies on 1984 and 2012 sera including whole genomic sequencing

– 1) Determine impact of HBV genotype (C/D)

– 2) Identify which HBV mutations/deletions predict long term risk of HCC and

cirrhosis

• Develop predictive model for liver-related complications based on baseline factors

* Lim T-H, et al. (in press)


Special thanks to:

• Trustees and Staff at the Hepatitis Foundation of New Zealand

• Professor Ed Gane (Auckland)

• Dr. Tien Huey Lim (Auckland)

• Helen Purcell

• Professor Chris Cunningham (Massey University)

• Dr. James Fung (QMH Hong Kong)

• Dr. Brian McMahon (Alaska)

• Health Research Council (NZ)

The Hepatitis Foundation of New Zealand www.hepatitisfoundation.org.nz I 0800 33 20 10

Thank you

PowerPoint Presentation · PDF fileTACE/TAE RFA Resection Liver Tx Overall Screened...

Documents

Transcript of PowerPoint Presentation · PDF fileTACE/TAE RFA Resection Liver Tx Overall Screened...