Viral Hepatitis Viral Hepatitis in Reproductive Healthin Reproductive Health
JosJoséé BengoaBengoa
Training in Reproductive Health Training in Reproductive Health Research Research –– Geneva 2006Geneva 2006
15 march 200615 march 2006
Epidemiology of Hepatitis BEpidemiology of Hepatitis B Dr JosDr Joséé BengoaBengoaConsultant Geneva University HospitalConsultant Geneva University HospitalFranco Vietnamese Hospital, Ho Chi Franco Vietnamese Hospital, Ho Chi MinhMinh CityCity
Epidemiology of Hepatitis CEpidemiology of Hepatitis C Dr Pierre Jean Dr Pierre Jean MalMalèèConsultant Geneva University HospitalConsultant Geneva University HospitalFranco Vietnamese Hospital, Ho Chi Franco Vietnamese Hospital, Ho Chi MinhMinh CityCity
HB Vaccination ProgramsHB Vaccination Programs Dr Steven Dr Steven WiersmaWiersmaWHO, FCH Medical Officer/Hepatitis Focal PointWHO, FCH Medical Officer/Hepatitis Focal Point
New Interventions in Health Services New Interventions in Health Services Dr Rafael BengoaDr Rafael BengoaWHO, Director of Health Systems PoliciesWHO, Director of Health Systems Policies
Treatment of VHB and VHC Treatment of VHB and VHC Dr Pierre Jean Dr Pierre Jean MalMalèè
Honduras Hepatitis B project Honduras Hepatitis B project Dr Francesco AureliDr Francesco AureliDirector of Imagine Foundation, RomeDirector of Imagine Foundation, Rome
Vietnam Hepatitis B/C projectVietnam Hepatitis B/C project Dr JosDr Joséé BengoaBengoa
Epidemiology and Prevention Epidemiology and Prevention of Viral Hepatitisof Viral Hepatitis
Hepatitis BHepatitis B
Hepatitis CHepatitis C
Viral hepatitis Viral hepatitis
worldwideworldwide
VHBVHB 350350’’000000’’000000
VHCVHC 200200’’000000’’000000
Acute Viral Hepatitis A, B and C/NANB Acute Viral Hepatitis A, B and C/NANB by Year, United States, 1952by Year, United States, 1952--20002000
05
1015202530354045
1952 54 56 58
1960 62 64 66 68
1970 72 74 76 78
1980 82 84 86 88
1990 92 94 96 98
2000
Year
Repo
rted
case
s per
100
,000
pop
ulat
ion
Hepatitis A
Hepatitis C/ NANB
Hepatitis B
Total
CDC
Viral Hepatitis – Historical Perspective
AA““InfectiousInfectious””
““SerumSerum””
Viral Viral hepatitishepatitis
EntericallyEntericallytransmittedtransmitted
ParenterallyParenterallytransmittedtransmitted
otherother
EE
““NANBNANB””
BB DD
CC
CDC
Viral Hepatitis Overview
Source ofvirus
Route oftransmission
Chronicinfection
Prevention
modification
feces blood/blood-derived
body fluids
blood/blood-derived
body fluids
blood/blood-derived
body fluids
feces
fecal-oral percutaneouspermucosal
percutaneouspermucosal
percutaneouspermucosal
fecal-oral
no yes yes yes no
pre-exposure
immunization
pre/post-exposure
immunization
blood donorscreening;
risk behaviormodification
pre/post-exposure
immunization;risk behavior
ensure safedrinkingwater
Types of Viral Hepatitis
A B C D E
CDC
A, B, Cs of Viral Hepatitis• A
– fecal-oral spread: hygiene, drug use, men having sex with men, travelers, day care, food
– vaccine-preventable• B
– sexually transmitted – 100x more infectious than HIV– blood-borne (sex, injection drug use, mother-child,
and health care)– vaccine-preventable
• C– blood borne (injection drug use primarily)– 4-5 times more common than HIV– NOT vaccine-preventable!
CDC
Hepatitis B Virus
CDC
Geographic Distribution of Chronic HBV Infection
HBsAg Prevalence
≥8% - High 2-7% - Intermediate<2% - Low
CDC
Global Patterns of Chronic HBV Infection
High (>8%): 45% of global populationHigh (>8%): 45% of global population–– lifetime risk of infection >60%lifetime risk of infection >60%–– early childhood infections commonearly childhood infections common
Intermediate (2%Intermediate (2%--7%): 43% of global population7%): 43% of global population–– lifetime risk of infection 20%lifetime risk of infection 20%--60%60%–– infections occur in all age groupsinfections occur in all age groups
Low (<2%): 12% of global populationLow (<2%): 12% of global population–– lifetime risk of infection <20%lifetime risk of infection <20%–– most infections occur in adult risk groupsmost infections occur in adult risk groups
CDC
0
2
4
6
8
10
12
14
1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000
Year
Cas
es p
er 1
00,0
00 P
opul
atio
n
Source: NNDSS
Vaccine licensed
HBsAg screening of
pregnant women
recommended
OSHA Rule enactedAdolescent
Immunization recommended
Decline among MSM & HCWs
Decline amonginjecting
drug users
Infant Immunizationrecommended
CDC
Hepatitis B by Year (USA 1966-2000)
• Incubation period: Average 60-90 daysRange 45-180 days
• Clinical illness <5 yrs, <10%(jaundice): >5 yrs, 30%-50%
• Acute case-fatality rate: 0.5%-1%
• Chronic infection: <5 yrs, 30%-90%>5 yrs, 2%-10%
• Premature mortality fromchronic liver disease: 15%-25%
CDC
Hepatitis B – Clinical Features
Outcome of HBV InfectionOutcome of HBV Infection
Infection
Asymptomatic Symptomatic acute hepatitis B
ResolvedImmune Chronic infection
Asymptomatic CirrhosisLiver cancer
ResolvedImmune
Chronic infection
Asymptomatic CirrhosisLiver cancer
CDC
Outcome of Hepatitis B Virus Infectionby Age at Infection
Chr
onic
Infe
ctio
n (%
)
100100
Symptomatic Infection
Chronic Infection
Birth
1 -6
mos
7-12
mos
1 -4
yrs
Old
er C
hild
r en
and
Adul
ts
0
20
40
60
8080
60
40
20
0
Symptom
ati c In fec ti on (%)
CDC
Weeks after Exposure
Symptoms
HBeAg anti-HBe
Total anti-HBc
IgM anti-HBc
anti-HBsHBsAg
0 4 8 12 16 20 24 28 32 36 52 100
Tite
rTypical Serologic Course
CDC
Acute Hepatitis B Virus Infection with Recovery
Progression to Chronic Hepatitis B Virus InfectionTypical Serologic Course
IgM anti-HBc
Total anti-HBcHBsAg
Acute(6 months)
HBeAg
Chronic(Years)
anti-HBe
0 4 8 12 16 20 24 28 32 36 52
Weeks after Exposure
Tite
r
CDC
• Sexual
• Parenteral
• Perinatal
HBV Modes of Transmission
CDC
Low/NotHigh Moderate Detectable
semenserum vaginal fluidblood
wound exudates saliva
urinefecessweattears
breast milk
Concentration of HBV in Various Body Fluids
CDC
Blood transfusion 0%
Other* 15%
Unknown 32%
Hemodialysis 0%Multiple sex partners 17%
Injection drug use 14%
Men who have sex with men 6%
Sexual contact with hepatitis B patient 13%
Medical Employee 1%
Household contact of hepatitis B patient 2%
Risk Factors Associated with Reported Hepatitis B, 1990-2000, USA
*Other: Surgery, dental surgery, acupuncture, tattoo, other percutaneous injury
CDCSource: NNDSS/VHSP
Prevalence of VHBPrevalence of VHB
HBV serologic markers in USAHBV serologic markers in USA
Chinese/SEAChinese/SEA 13%13%drug usersdrug users 6%6%homosexual males 6%homosexual males 6%HIV infectedHIV infected 8%8%pregnant females 0.4 pregnant females 0.4 –– 1.5 %1.5 %
Phases of hepatitis B infectionPhases of hepatitis B infection
immunotoleranceimmunotolerance-- virus is non pathogenic for liver cellsvirus is non pathogenic for liver cells-- may last several yearsmay last several yearsimmunoeliminationimmunoelimination-- active hepatitis, high ALT, fibrosis, cirrhosisactive hepatitis, high ALT, fibrosis, cirrhosis-- HBeAgHBeAg positive chronic hepatitispositive chronic hepatitisinactive carrier of inactive carrier of HBsAgHBsAg-- low low viremiaviremia, , HBeAgHBeAg negativenegativereactivationreactivation-- viral mutation, viral mutation, HBeAgHBeAg negativenegative
Complications of viral hepatitisComplications of viral hepatitis
CirrhosisCirrhosisin in HBeAgHBeAg + 3% per year+ 3% per year
HCCHCC ((hepatocellularhepatocellular carcinoma)carcinoma)risk of 2 % per year risk of 2 % per year increased risk in VHB high increased risk in VHB high viremiaviremia
N N EnglEngl J Med September 15, 2005J Med September 15, 2005Major Causes of Death among Men Major Causes of Death among Men
and Women in Chinaand Women in ChinaJiangJiang He, M.D., Ph.D., He, M.D., Ph.D., DongfengDongfeng GuGu, M.D., , M.D., XiguiXigui Wu,etWu,et alal
Take home messagesTake home messages
hepatitis B is a world wide public health issuehepatitis B is a world wide public health issuemajor country differences in prevalence existmajor country differences in prevalence existtransmission: sexual, transmission: sexual, perinatalperinatal and and parenteralparenteralit is a vaccine preventable diseaseit is a vaccine preventable diseasecirrhosis and liver cancer will represent a cirrhosis and liver cancer will represent a major challenge in terms of health care costsmajor challenge in terms of health care costsbreakthroughs in therapy but very high costbreakthroughs in therapy but very high cost