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Epidemiology of Viral Hepatitis
Ashry Gad Mohamed
Prof. of Epidemiology
Consultant Medical Epidemiologist
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Hepatitis A
• Abrupt onset.
• Fever
• Malaise
• Anorexia
• Abdominal discomfort
• Jaundice
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• More than 90% are asymptomatic
• Seroprevalence increases with age.
• At age 15, 95% are seropositive.
• Case fatality rate (CFR)= 0.3%.
• If age > 40 years CFR=2%.
• Studies in KSA:
1997 25%
1999 25% Taif
10-82% Jazan (1-12 years)
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• Agent: RNA virus
• Reservior : Human (Clinical & subclinical
cases)
• Incubation period: 15-35 days ( median
one month).
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• Period of communicability : Last two weeks of I.P. + one week of illness.
• Modes of transmission:
Fecal-oral route.
Common source outbreaks.
Blood transfusion (rare).
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Prevention and Control
• Good sanitation & personal hygiene. “Careful hand washing”• Day- Care centers Hand washing after every diaper change and before eating.• Shellfish heat 85-90C 4 minutes. steam 90 seconds.
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• Inactivated hepatitis A vaccine
0 -1 -6 months.
Protection after one month.
Lasting immunity at least 10 years.
• Hepatitis A patient:
Enteric precaution for the PC
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Hepatitis B
• Incidous onset.
• Anorexia.
• Abdominal discomfort.
• Nausia.
• Vomiting.
• Arthralgia.
• Jaundice.
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• Carriage rates: Sudan 13-19% Pakistan 10-16% Egypt 2.7-15% Saudi Arabia 8.5% Jordan 7-10. Syria 4-6% Iraq 4-5% Morocco 3-6% Yemen 5-6%
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2 billion people infected 360 million CHB
More than 500,000 death/year
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OVERALL PREVALENCE OF HBsAg AMONG SAUDIS IN THE 80’S ACCORDING TO REGIONS
5.5
8.99.6
8.3
0
2
4
6
8
10
Central(n=6649)
South-western(n=7235)
Eastern(n=8300)
Total (n=32183)
Pos
itiv
ity
(%)
Al-Faleh. Annals of Saudi Medicine, 1988
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COMPARISON OF PREVALENCE OF HBsAg AMONG SAUDI CHILDREN IN 1989 (n=4575) AND 1997 (n=5355) – ACCORDING TO
AGE
9.68
0 0
6.54
0.16
7.24
0.3
5.06
0
6.35
0
7.57
0.2
6.51
0.82
7.2
0.93
5.81
2.31
0
66.71
0.310
2
4
6
8
10
Per
cent
age
1 2 3 4 5 6 7 8 9 10 11 12
Tot
al
(Age in years)
1989 1997Al Faleh, J Infect 1999
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PREVALENCE OF HBsAg POSITIVITY AMONG BLOOD DONORS IN KKUH FROM 1987 TO 2000
4.7
3
1.4
1.971.7
1.21.7
0
1
2
3
4
5
1987 (n= 3565)
1991(n=1991)
1996(n=6885)
1997(n=6285)
1998(n=6031)
1999(n=6841)
2000(n=6394)
Pos
itiv
ity
(%)
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Natural History
Gow, BMJ 2001
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• Agent: Double strand DNA.
Serotypes adw, ayw, adr, ayr.
• Reservior: Human (case + carrier).
• I.P. 2-3 months.
• P.C. One week of I.P. + illness period + carriage.
• Carriage depends on age.
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Concentration of Hepatitis B Virus in Various Body Fluids
Concentration of Hepatitis B Virus in Various Body Fluids
High ModerateLow/Not
Detectable
blood semen urineserum vaginal fluid feces
wound exudates saliva sweat
tearsbreastmilk
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• Sexual
• Parenteral
• Perinatal
Hepatitis B Virus Modes of Transmission
Hepatitis B Virus Modes of Transmission
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Modes of transmission:
• Percutaneous and permucosal exposure to infective body fluids.
Blood transfusion.
Organs transplants.
Sharing needles.
Haemodialysis.
Needlestick.
Tattooing.
Razors & toothbrushes.
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• Sexual transmission.
• Perinatal transmission.
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Prevention and control
• Wide scale immunization of infants.• Immunization of high risk persons. Haemodialysis patients. Bleeding disorders. Susceptible households. Health care personnels.• Blood banks: avoid donors from risky groups.
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Education & history taking.
Testing for HBs Ag.
• Discourage:
Tattooing, Drug abuse,
Extramarital sexual relations.
• Needle stick
Single dose of HBIG (24 hours).
Vaccine series.
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• Sexual exposure
Single dose of HBIG (14 days).
Vaccination.
• Infants to HBsAg +ve mothers.
0.5 ml HBIG im.
First dose of the vaccine.
2nd & 3rd doses at 1 & 6 months later.
• Health care personnel.
Universal precautions
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Hepatitis C
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USA 4 M
USA 4 M
SOUTH
AMERICA
10 M
SOUTH
AMERICA
10 M
AFRICA 32 MAFRICA 32 M
EASTERNMEDITERRANEAN
20M
EASTERNMEDITERRANEAN
20MSOUTH EAST
ASIA30 M
SOUTH EAST ASIA30 M
AUSTRALIA0.2 M
AUSTRALIA0.2 M
WHO, 1999
WESTERN EUROPE
9 M
WESTERN EUROPE
9 M
FAR EAST/ASIA60 M
FAR EAST/ASIA60 M
170 Million Hepatitis C virus (HCV) carriers
3-4 MM new cases / year
170 Million Hepatitis C virus (HCV) carriers
3-4 MM new cases / year
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AGE SPECIFIC PREVALENCE OF ANTIBODY TO HCV/ANTI-HCV AMONG HEALTHY SAUDIS
Age Group
(years)
Community Based Study
No. tested Anti-HCV Pos. (%)
Location
1 – 10 1214
490
677
1096
1019
0.6
0.0
0.4
0.9
1,9
Central Province
Eastern Province
North-Western Province
South-Western Province
Southern Province
10 – 19 504 6 (1.2) Gizan
20 – 29 361 4 (1.1) Gizan
30 - 39 290 6 (2.1) Gizan
40 – 49 183 6 (3.3) Gizan
> 50 144 5 (3.5) Gizan
Total 1482 27 (1.8) Gizan
Al-Faleh et al, Hepatology Vol. 14(2), 1991
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COMPARISON OF PREVALENCE OF ANTI-HCV IN SAUDI CHILDREN BETWEEN THE STUDIES
CARRIED OUT IN 1989 AND 1997
0.87
0.04
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
Per
cent
1989 (n=4496) 1997 (n=5350)
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PREVALENCE OF ANTIBODY TO HCV TO SAUDI HIGH RISK GROUPS
High Risk Group No. Tested
No. Pos.
% Location
Hemophiliacs 28 22 78.6 KKUH, Riyadh
Thalassaemia and sickle cell disease
78 26 33.3 KKUH, Riyadh
-thalassaemia major
20 14 70.0 KKUH, Riyadh*
Sickle cell anaemia 55 10 18.2 KKUH, Riyadh*
Patients with sexually transmitted diseases
220 35 15.9 KKUH, Riyadh*
2nd-generation anti-HCV tests and confirmation were only donein this study.
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ANTI-HCV IN HAEMODYLYSIS PATIENTS IN SAUDI POPULATION
Author No. of Persons Type of Test %
Fakunle et al 895 ELISA I 53.7
Al-Mugeriren et al 20 Children ELISA I 45.0
Ayoola et al 74 ELISA I 41.9
Huraib et al 22 HD Centre
1147 Persons
ELISA II 68.8
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• 11( 6 major) with many subtypes and quasispecies
• The predominate genotype in Saudi is Genotype 4 (62.9% )
• Europe & America Genotype 1 75 (24.8) % severe disease
• Genotype 2 = 10.8 (7.4) %
• Genotype 3 = 5.8 (5.9) %
• Genotype 1 & 4 Poor response to therapy
Hepatitis C Virus Genotypes
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Natural History of HCV Infection
Exposure(Acute phase)
ResolvedResolved Chronic
CirrhosisStableStable
SlowlySlowlyProgressiveProgressive
HCCTransplant
Death
20% (17)
15% (15) 85% (85)
25% (4)
80% (68)
75% (13)
HIV and HIV and AlcoholAlcohol
MJ Semin Liver Dis 1995; 15: Management of Hepatitis C NIH Consensus Statement 1997; March 24-26:15(3).
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Blood transfusio
n
Blood transfusio
nIV drug abuseIV drug abuse
Important HCV Transmission Modes
Important HCV Transmission Modes
1:100,000 in US80% infected in first year
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Vertical transmission mother - Child
Vertical transmission mother - Child
Uncommon HCV Transmission Modes
Uncommon HCV Transmission Modes
Household transmission
1-5%
?
Needle stick injury
3%
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Other Transmission Issues
HCV not spread by kissing, hugging, sneezing, coughing, food or water, sharing eating utensils or drinking glasses, or casual contact
Do not exclude from work, school, play, child-care or other settings based on HCV infection status
HCV Counseling
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Features of Hepatitis C Virus InfectionFeatures of Hepatitis C Virus Infection
Incubation periodIncubation periodAverage 6-7 weeksAverage 6-7 weeks Range 2-26 weeksRange 2-26 weeks
Acute illness (jaundice)Acute illness (jaundice) Mild (Mild (<<20%)20%)
Case fatality rateCase fatality rate LowLow
Chronic infectionChronic infection 60%-85%60%-85%
Chronic hepatitisChronic hepatitis 10%-70%10%-70%
CirrhosisCirrhosis <5%-20%<5%-20%
Mortality from CLDMortality from CLD 1%-5%1%-5%
Age-related
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Chronic Hepatitis C Factors Promoting Progression or Severity
• Increased alcohol intake
• Age > 40 years at time of infection
• HIV co-infection
• Other– Male gender– Chronic HBV co-infection
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Serologic Pattern of Acute HCV Infection with Progression to Chronic Infection
Symptoms +/-
Time after Exposure
Tit
eranti-HCV
ALT
Normal
0 1 2 3 4 5 6 1 2 3 4YearsMonths
HCV RNA
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Exposures Known to Be Associated With
HCV Infection in the United States
• Injecting drug use• Transfusion, transplant from infected donor • Occupational exposure to blood
– Mostly needle sticks
• Iatrogenic (unsafe injections)• Birth to HCV-infected mother• Sex with infected partner
– Multiple sex partners
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Injecting Drug Use and HCV Transmission
• Highly efficient– Contamination of drug paraphernalia, not just
needles and syringes
• Rapidly acquired after initiation– 30% prevalence after 3 years– >50% after 5 years
• Four times more common than HIV
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Occupational Transmission of HCV
• Average incidence 1.8% following needle stick from HCV-positive source – Associated with hollow-bore needles
• Prevalence 1-2% among health care workers – Lower than adults in the general population– 10 times lower than for HBV infection
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HCV Related to Health Care Procedures
• Recognized primarily in context of outbreaks– Chronic hemodialysis– Hospital inpatient setting– Private practice setting– Home therapy
• Unsafe injection practices– Reuse of syringes and needles– Contaminated multiple dose medication vials
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HCW to Patient Transmission of HCV
• Rare– In U.S., none related to performing invasive
procedures
• Most appear related to HCW substance abuse– Reuse of needles or sharing narcotics used for
self-injection
• No restrictions routinely recommended for HCV-infected HCWs
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Perinatal Transmission of HCV
• Transmission only from women HCV-RNA positive at delivery– Average rate of infection 6%– Higher (17%) if woman co-infected with HIV– Role of viral titer unclear
• No association with– Delivery method– Breastfeeding
• Infected infants do well– Severe hepatitis is rare
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Sexual Transmission of HCV
• Case-control, cross sectional studies– Infected partner, multiple partners, early sex, non-
use of condoms, other STDs, sex with trauma, Partner studies
– Low prevalence (1.5%) among long-term partners• infections might be due to common percutaneous
exposures (e.g., drug use), BUT
– Male to female transmission more efficient• more indicative of sexual transmission
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Household Transmission of HCV
• Rare but not absent• Could occur through percutaneous/mucosal
exposures to blood– Contaminated equipment used for home
therapies• IV therapy, injections
– Theoretically through sharing of contaminated personal articles (razors, toothbrushes)
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Reduce or Eliminate Risks for Acquiring HCV Infection
• Screen and test donors• Virus inactivation of plasma-derived products• Risk-reduction counseling and services
– Obtain history of high-risk drug and sex behaviors
– Provide information on minimizing risky behavior, including referral to other services
– Vaccinate against hepatitis A and/or hepatitis B• Safe injection and infection control practices
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Reduce Risks for Disease Progressionand Further Transmission
• Identify persons at risk for HCV and test to determine infection status– Routinely identify at risk persons
through history, record review
• Provide HCV-positive persons– Medical evaluation and management– Counseling
• Prevent further liver damage• Prevent transmission to others
MMWR 1998;47 (No. RR-19)
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HCV Prevalence by Selected GroupsUnited States
0 10 20 30 40 50 60 70 80 90
Hemophilia
Injecting drug users
Surgeons, PSWs
Hemodialysis
Average Percent Anti-HCV Positive
Gen population adults
Military personnel
STD clients
Pregnant women
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HCV Testing Routinely Recommended
• Ever injected illegal drugs• Received clotting factors made before 1987• Received blood/organs before July 1992 • Ever on chronic hemodialysis• Evidence of liver disease
• Healthcare, emergency, public safety workers after needle stick/mucosal exposures to HCV-positive blood
• Children born to HCV-positive women
Based on increased risk for infection
Based on need for exposure management
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Postexposure Management for HCV
• IG, antivirals not recommended for prophylaxis
• Follow-up after needlesticks, sharps, or mucosal exposures to HCV-positive blood– Test source for anti-HCV – Test worker if source anti-HCV positive
• Anti-HCV and ALT at baseline and 4-6 months later
• For earlier diagnosis, HCV RNA at 4-6 weeks– Confirm all anti-HCV results with RIBA
• Refer infected worker to specialist for medical evaluation and management
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Hepatitis E - Clinical
FeaturesHepatitis E - Clinical
Features
• Incubation period: Average 40 daysRange 15-60 days
• Case-fatality rate: Overall, 1%-3%Pregnant women,
15%-25%
• Illness severity: Increased with age
• Chronic sequelae: None identified
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•Most outbreaks associated withfecally contaminated drinking water
•Minimal person-to-person transmission
Hepatitis E -
Epidemiologic FeaturesHepatitis E -
Epidemiologic Features
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Geographic Distribution of Hepatitis E
Geographic Distribution of Hepatitis EOutbreaks or Confirmed Infection in >25% of Sporadic Non-ABC Hepatitis
Outbreaks or Confirmed Infection in >25% of Sporadic Non-ABC Hepatitis
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Viral Hepatitis - OverviewViral Hepatitis - Overview
AA BB CC DD EESource ofvirus
feces blood/blood-derived
body fluids
blood/blood-derived
body fluids
blood/blood-derived
body fluids
feces
Route oftransmission
fecal-oral percutaneouspermucosal
percutaneouspermucosal
percutaneouspermucosal
fecal-oral
Chronicinfection
no yes yes yes no
Prevention pre/post-exposure
immunization
pre/post-exposure
immunization
blood donorscreening;
risk behaviormodification
pre/post-exposure
immunization;risk behaviormodification
ensure safedrinkingwater
Type of HepatitisType of Hepatitis