Presenter : Dr.L.Karthiyayini Moderator: Dr. Abhishek V Raut
Epidemiology of hepatitis
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Framework Introduction Hepatitis A,E,B,C,D&G Magnitude
Natural history of the disease Epidemiological determinants Mode of
transmission Clinical feature Sero epidemiology Prevention &
control Hepatitis & HIV Global policy report on
hepatitis-status of India WHO position of hepatitis vaccine
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Introduction VIRAL HEPATITIS IS A MAJOR PUBLIC HEALTH PROBLEM
Hepatitis A & E - 0.5-4 % mortality World wide 500 million
people have chronic HBV & HCV infection In India, 45 million
people with HBV 500,000 to 1,000,000 people die every year of
HBV-related chronic Hepatitis, cirrhosis or liver cancer Out of
nearly 22.6 million children born in India every year, over 9
million will acquire the infection in their lifetime.
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Hepatitis is the inflammation of liver by any cause Viral
hepatitis is mainly caused by Hepatitis A & E virus -
Faeco-oral route - Acute & self limiting Hepatitis B,C & D
virus- Parenteral route -Acute & chronic Other viruses-
cytomegalovirus, rubella virus, epstein barr virus, yellow fever
virus,herpes zoster virus,etc. Other hepatitis- Alcoholic hepatitis
(50% of CLD)(mortality : M- 11/100000 & F-6/10000) Auto immune
hepatitis, toxic & drug induced hepatitis,
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Natural history of acute hepatits
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HEPATITIS A
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Source:CDC
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MAGNITUDE GLOBAL: Prevalence of anti-HAV antibodies in general
population -15%-100% Worldwide 1.5 million clinical cases yearly
Outbreaks INDIA: seroprevalence of anti-HAV: 54.5%- high
socio-economic status 85% in low socio-economic status
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EPIDEMIOLOGICAL DETERMINANTS AGENT: Picarnovirus family 4 human
genotypes 1 serophytype HOST: Low endemic area Adolescents &
adults(homosexual, IV drug users) Travellers Intermediate endemic
area Late childhood(faeco oral route) Early adult hood High endemic
area Early childhood
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ENVIRONMENTAL FACTORS: Water borne & food borne epidemics
Sanitation & overcrowding MODE OF TRANSMISSION: Faeco-oral
route Parentral route stage of viremia Sexual transmission-
homosexual due to ano-oral contact Secondary attack rate among
household contacts is 30% INCUBATION PERIOD 28 days
SERO EPIDEMIOLOGY IgM- Detectable from 5 days prior to onset of
symptoms & declines to undetectable levels within 6 months.
IgG-Detect previous infection, persists life long Elevated levels
of serum bilirubin Elevated hepatic enzymes(AST,ALT)
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HAV INFECTION-TYPICAL SEROLOGICAL COURSE Source: Yim, H. J., et
al., (2006). Hepatology.
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PREVENTION & CONTROL Control of reservoir: Complete bed
rest Disinfection of faeces & fomites 0.5% sodium hypochlorite
Control of transmission: promoting personnel & community
hygiene Purification of community water supplies Proper sanitation
& waste disposal During epidemics, boiling of water is
preferred
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Active immunization Inactivated vaccines & live attenuated
vaccines Parenterally (IM), 2 dose,6-18 months apart. Combined
vaccine(inactivated hepatitis A & recombinant hepatitis B)
-0,1,6 mths. Passive immunization HAV IG Pre & Post exposure
prophylaxis -single I.M dose,0.02 ml/kg within 2 weeks
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HEPATITIS E
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MAGNITUDE GLOBAL SEAR INDIA MAHARASHTRA Source:CDC
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MAGNITUDE GLOBAL: Overall attack rates during hepatitis E
outbreaks - 1% to 15%. The rates are highest among young adults
(3%-30% Case-fatality rates - 0.5% to 4% During outbreaks mortality
rates - 0.070.6% INDIA: Proportion- 10% Seroprevalence of anti-HEV
antibodies-upto 50%
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EPIDEMIOLOGICAL DETERMINANTS AGENT Hepatitis E like virus HOST
15-40yrs Pregnant mothers-20% fulminant(0.5% mortality) MODE OF
TRANSMISSION: Faeco oral route Water borne disease Ingestion of raw
or uncooked shell fish- sporodic cases Vertical transmission
Secondary attack rates 0.7-2.2% INCUBATION PERIOD: 2-9 weeks
Symptoms ALT IgG anti-HEV IgM anti-HEV Virus in stool
012345678910101 1212 1313 Hepatitis E Virus Infection Typical
Serologic Course Titer Weeks after Exposure Source: Yim, H. J., et
al., (2006). Hepatology.
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PREVENTION & CONTROL Good personnel hygiene High quality
standards of public water supply Proper disposal of sanitary waste
Vaccines undergoing clinical trails
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HEPATITIS B
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Source:CDC
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MAGNITUDE GLOBAL: 2million 240 billion carriers 60-80% of all
primary liver cancer High endemicity, intermediate endemicity &
low endemicity INDIA: Point prevalence of hepatitis B is 2.1%
chronic carrier rate 1.7% HCC 1.6% of all cancers High carrier
state among health workers 11% & in general population 5%
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High (>8%): 45% of global population lifetime risk of
infection >60% early childhood infections common Intermediate
(2%-7%): 43% of global population lifetime risk of infection
20%-60% infections occur in all age groups Low (
National immunization schedule: 3 dose schedule :At birth,
along with 1 st & 3 rd dose of DPT 4 dose schedule: At birth,
6,10,& 14 weeks Monovalent or combined Minimum interval between
the doses are 4 weeks If prevalence is > 8%- within 24 hrs of
birth Duration of protection: 15 yrs Protective antibody
levels-> 95% (infants, children & young adults) More than
40yrs protection
MAGNITUDE GLOBAL: Global pattern corresponds to prevalence of
HBV Highest prevalence in Amazon basin & Romania(20% of chronic
HBV & 90% of HBV-chronic liver disease) Moderate
prevalence-Spain, northern Italy, Turkey & Egypt(asymptomatic
HBVcarriers10-20% & 30-50% of HBV- chronic liver disease) Low
prevalence-southeast Asia & china INDIA: Acute hepatitis-10.7-
> 30% Chronic hepatitis-8-21% Cirrhosis-15-19%:
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EPIDEMIOLOGICAL DETERMINANTS AGENT: RNA virus Satellite virus
or sub viral agent HOST: high risk group MODE OF TRANSMISSION:
Parenteral route Perinatal route Sexual transmission INCUBATION
PERIOD: 30-180 days
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CLINICAL FEATURES Co-infection: Simultaneous infcetion Acute
form of HBV & HDV Self limiting Chronic form -< 5% Super
infection: HDV infection of chronically infected HBV Severe acute
hepatitis chronic hepatitis (80%) Associated fulminant acute
hepatitis, severe chronic active hepatitis-cirrhosis
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anti-HBs Symptoms ALT Elevated Total anti-HDV IgM anti-HDV HDV
RNA HBsAg HBV - HDV Coinfection Typical Serologic Course Time after
Exposure Titre
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Jaundice Symptoms ALT Total anti-HDV IgM anti-HDV HDV RNA HBsAg
HBV - HDV Superinfection Typical Serologic Course Time after
Exposure Titre
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Diagnosis: RT-PCR EIA Treatment: A-interferon (9million units,
TDS weekly for 12 months or 5 million units daily for 12 months)
Prevention & control: Pre & post exposure prophylaxis of
HBV Health education to reduce risk behaviour
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HEPATITIS G 1995-Flavivirus family GBV-A,GBV-B,GBV-C GBV-C
affects man. Transmission : blood transfusion Sexual contact
Vertical transmission Intravenous drug users Globally 1-3% in
volunteer blood donors Incubation period-30-120 days HGV
co-infection is observed in 6% of chronic HBV infections & in
10% of chronic HCV infections.
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HEPATITIS & HIV About one-third of HIV-infected persons are
coinfected with hepatitis B or hepatitis C, which can cause
long-term (chronic) illness and death. 10% of 40 million people of
HIV are co-infected with HBV Viral hepatitis progresses faster
among persons with HIV infected persons HIV/HBV & HIV/HCV
coinfection -leading cause of non-AIDS-related deaths
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HEPATITIS & HIV Coinfection with hepatitis -complicate the
management of HIV infection. To prevent coinfection with hepatitis
B, universal hepatitis B vaccination of susceptible patients with
HIV infection or AIDS & high risk groups is recommended All
persons living with HIV should be tested for hepatitis B and
hepatitis C Coinfected persons should be counseled about drug
interacions and side efects of hepatitis and HIV treatments.
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Global policy 2010 World Health Assembly to generate reliable
information as a foundation for building prevention and control
measures that match the local epidemiological profile and health
system capacities. Survey conducted in mid-2012 by the World Health
Organization and the World Hepatitis Alliance. Aim : To gather
country-specific baseline data on hepatitis policies in WHO Member
States in all six regions. offers insight into conditions in
specific countries Gaps that need to be filled are identified
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Issues addressed National coordination Awareness raising &
partnerships Evidence based policy & data for action Prevention
of transmission Screening care & treatme nt
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National coordination Written national strategy plan-raising
awareness, surveillance, vaccination, prevention of transmission
via injecting drug use, in health-care settings, in general, and
treatment and care. There is a designated governmental department :
For coordinating and/or carrying out viral hepatitis related
activities Four staff members Not known how many people work
full-time in all government agencies/bodies. The government has a
viral hepatitis prevention and control programme: activities
targeting health-care workers, including health-care waste
handlers
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Awareness raising & partnerships Not known whether the
government held events for World Hepatitis Day 2012 Funding-other
viral hepatitis public awareness campaigns since January 2011. The
government does not collaborate with in-country civil society
groups to develop and implement its viral hepatitis prevention and
control programme
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Evidence based policy & data for action There is no routine
surveillance for viral hepatitis. There are standard case
definitions for hepatitis. Hepatitis deaths are not reported to a
central registry. No classification:undifferentiated or
unclassified hepatitis HCC & HIV/hepatitis coinfection cases
are registered The government does not publish hepatitis disease
reports. Hepatitis outbreaks are reported & investigated There
is inadequate laboratory capacity nationally to support
investigation of viral hepatitis outbreaks There is no national
public health research agenda Viral hepatitis serosurveys are not
conducted regularly
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Prevention of transmission There is a national policy that
specifically targets mother-to- child transmission of hepatitis B
There is no national policy on hepatitis A vaccination. The
government has not established the goal of eliminating hepatitis B.
It is not known what percentage of newborn infants nationally
received the 1 st dose of hepatitis B vaccine within 24 hours of
birth or what percentage of 1yr received 3 doses of hepatitis B
vaccine. It is not known whether there is a specific national
strategy for preventing hepatitis in health-care settings.
Health-care workers are vaccinated against hepatitis B prior to
starting work
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Contd.. There is a national policy on injection safety in
health-care settings-auto-disable syringes Single-use or
auto-disable syringes, needles and cannulas are always available in
all health-care facilities. Official government estimates of the
number and percentage of unnecessary injections administered
annually in health-care settings are not known. There is a national
infection control policy for blood banks. All donated blood
products nationwide are screened It is not known whether there is a
national policy relating to the prevention of viral hepatitis among
people who inject drugs. The government has guidelines that address
how hepatitis A and hepatitis E can be prevented through food and
water safety.
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Screening care & treatment Health professionals obtain the
skills and competencies through on the job training. Not known
-national clinical guidelines for the management The government
does not have national policies relating to screening and referral
to care for hepatitis B or hepatitis C. People testing are register
by name & are kept confidential Hepatitis testing are free of
charge for all individuals and are compulsory for blood donors.
Publicly funded treatment is not available for hepatitis The
following drug for treating hepatitis B & C is on the national
essential medicines list: lamivudine & ribavirin respectively
The GOI welcomes assistance from WHO in one or more areas of viral
hepatitis prevention and control
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Who position of hepatitis vaccine All infants should receive
their first dose preferably within 24 hrs Delivery of hepatitis B
vaccine within 24 hours of birth should be a performance measure
for all immunization programmes. To complete the primary series the
birth dose should be followed by 2 doses or, if convenient, by 3
doses Minimum interval between doses is 4 weeks. There is no
evidence to support the need for a booster dose Catch-up
vaccination of children should be considered for cohorts with low
coverage. The need for catch-up vaccination in older age groups,
including adolescents and adults, is determined by the baseline
epidemiology of HBV infection in the country.
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Contd The importance of vaccinating people with particular risk
factors for acquiring HBV infection is emphasized. Eliminating HBV
transmission must address- infections acquired perinatally and
during early childhood, by teenagers and adults. WHO strongly
recommends that all countries develop goals for hepatitis B control
Process indicators and the use of outcome measures are critical to
verifying achievement goals. Primary tool to measure the impact of
immunization- Serological surveys of HBsAg prevalence supplemented
by surveillance for acute disease Collection of mortality data
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REFERENCE 1. Park k., text book of preventive and social
medicine, 20 th edition; p186 -189 2. Mansons text book tropical
disease;697-713 3. Harrisons principles of internal
medicine.17(2);p1945-1960 4. Berger SA. Infectious Diseases of
India, 2012. 503 pages, 67 graphs, 4248 references. Gideon e-books,
http://www.gideononline.com/ebooks/country/infectious-diseases-of-india
http://www.gideononline.com/ebooks/country/infectious-diseases-of-india
5. Berger SA. Hepatitis D, E and G: Global Status, 2012. 99 pages,
36 graphs, 1116 references. Gideon e-books,
http://www.gideononline.com/ebooks/disease/hepatitis-d-e-and-g-global-
status/
http://www.gideononline.com/ebooks/disease/hepatitis-d-e-and-g-global-
status/
6.heahttp://www.who.int/immunization/topics/hepatitis_b/en/index.htmllth
7. Global policy report on the prevention and control of viral
hepatitis in WHO Member States. 8.
http://www.who.int/immunization/documents/positionpapers/en/index.html
9. The Global Prevalence of Hepatitis A Virus Infection and
Susceptibility:A Systematic Review 10. The Global Prevalence of
Hepatitis EVirus Infection and Susceptibility:A Systematic
Review