Transcript Nessun titolo diapositiva

SEIEVA
Integrated Epidemiological System
for Acute Viral Hepatitis
Alfonso Mele
Catania, November 7-8 2002
SEIEVA
AIMS
• Monitor epidemiological trends
• Identify risk factors
• Formulate and monitor prevention strategies
SEIEVA
METHODOLOGY
• Notification
• Interview
• Ascertainment of markers
• Weekly line listing of cases and questionnaires
are forwarded to ISS
SEIEVA participating ASL 2001:
133/243 (56% Italian population)
1/5
1/1
1/44
2/6
22/22
11/22
13/13
5/5
12/12
2/5
2/6
1/5
12/12
13/13
2/5
5/22
1/11
2/9
Serological definition of types of viral hepatitis
SEIEVA
HBsAg
IgM anti-HBc
IgM antiHAV
Anti-HCV
Anti-Delta
Hepatitis
Type
+o-
+o-
+
+o-
+o-
A
+o-
+
-
+o-
+o-
B
+o-
-
-
+
+o-
C
+o-
+
+o-
+o-
+
D
-
-
-
-
-
nAnBnC
NA/M
NA/M
NA/M
NA/M
NA/M
Unknown
Incidence
Distribution of notified cases of viral hepatitis
SEIEVA
1987 - 1990
1997 - 2001
Hepatitis
C
7,8%
Hepatitis
A
19,9%
Hepatitis
nAnB
23,6%
nAnBnC
2,4%
Hepatitis
B
24,1%
Hepatitis
B
56,5%
Hepatitis
A
65,7%
Case fatality rate of viral hepatitis in Italy by type
1985 - 1994
Hepatitis type
No. Deaths/ No. Cases
%
95%CI
A
1/6,353
0.02
0.0 – 0.1
B
40/7,907
0.5
0.3 – 0.7
Delta
1/422
0.2
0.0 – 0.7
nAnB
19/4,120
0.5
0.2 – 0.7
1/909
0.1
0.0 – 0.3
9/1,842
0.5
0.2 – 0.8
71/21,553
0.3
0.2 – 0.4
No. Deaths/ No. Cases
%
95%CI
A
2/12148
0.02
0.0 – 0.1
B
18/4881
0.4
0.2 – 0.6
0/47
0.0
0.0 – 7.9
C
2/1722
0.1
0.0 – 0.4
Unspecified
5/1774
0.3
0.1 – 0.6
27/20572
0.1
0.1 – 0.2
C
Unspecified
Total
1995 - 2001
Hepatitis type
Delta
Total
Incidence rates (cases x 100,000) of viral hepatitis
in Italy by type, SEIEVA 2001
Type of
hepatitis 85
86
87
88
89
90
91
92
Years
93 94 95
96
97
98
99
2000
2001
A
10
4
2
2
2
2
4
6
5
6
3
7
19
6
3
3
3
B
12
12
10
7
6
5
5
4
4
3
3
3
3
3
2
2
2
nAnB
5
4
3
3
3
2
2
2
2
2
1
1
1
1
1
0.6
1
Unknown
3
3
2
2
1
1
1
2
1
1
0.3
0.2
0.3
0.3
0.2
0.3
0.2
Total
30
23
17
14
12
10
12
14
12
12 7.3 11.2 23.3
10.3
6.2
5.9
6.2
Incidence of notified case of hepatitis B in Italy
by age-groups. SEIEVA 1985-2001
01
20
00
20
99
19
98
19
97
19
96
19
95
19
94
0-14
15-24
25 e +
Total
19
19
93
Anti-hepatitis B
vaccination
92
19
91
19
90
19
89
19
88
19
87
19
86
19
19
85
45
40
35
30
25
20
15
10
5
0
Incidence of notified case of hepatitis nAnB in
Italy by age and year. SEIEVA 1985-2001
01
20
00
20
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
90
19
89
19
88
19
87
19
86
0-14
15-24
25 e +
Total
19
19
85
18
16
14
12
10
8
6
4
2
0
Incidence of notified case of hepatitis A in Italy
by age and year. SEIEVA 1985-2001
60
0-14
15-24
25 e +
Total
50
40
30
20
10
01
20
00
20
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
19
91
19
90
19
89
19
88
19
87
19
86
19
19
85
0
Incidence (cases per 100,000) of hepatitis A in Italy by
geographical area. SEIEVA 1985-2001
50
45
40
35
North-Center
South-Islands
30
25
20
15
10
5
0
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
Risk Factors
Risk factors of hepatitis B: adjusted* O.R.
SEIEVA 1998-2000
Risk factors
adjusted OR
95% CI
Blood transfusion
2.35
(0.56 - 9.92)
Intravenous drug use
6.78
(3.32 - 13.9)
Surgical intervention
2.44
(1.42 - 4.19)
Dental therapy
1.35
(0.99 - 1.84)
Other parenteral exposures 1.67
(1.26 - 2.33)
> 1 sexual partner **
1.75
(1.31 - 2.33)
Household of HBsAg+
10.1
(4.52 - 22.7)
*
Adjusted for sex, age, area of residence, educational level and the
other variables of the table.
** Subjects > 14
Risk factors of hepatitis C: adjusted* O.R.
SEIEVA 1998-2000
Risk factors
adjusted OR
95% CI
Blood transfusion
2.43
(0.63 - 9.42)
Intravenous drug use
38.0
(19.1 - 75.6)
Surgical intervention
7.02
(3.99 - 12.4)
Dental therapy
1.53
(1.00 - 2.33)
Other parenteral exposures
1.65
(1.11 - 2.46)
> 1 sexual partner **
0.76
(0.49 - 1.19)
* Adjusted for sex, age, area of residence, educational level and the
other variables of the table.
** Subjects > 14
Adjusted OR and 95% CI for different types of invasive procedure among
hepatitis B cases. SEIEVA 1996-2000.
Intervention type
Minor surgery
Gynaecological**
Orthopaedic
Abdominal
Cardiovascular
Dermatological
Oral surgery
Ophtalmological
Urological
Other intervention
Biopsy/endoscopy
Hepatitis B
(2689 cases)
n
%
44
1.6
21
0.8
19
0.7
41
1.5
21
0.8
31
1.1
63
2.3
10
0.4
13
0.5
66
2.4
80
2.9
Hepatitis A
(6701 cases)
n
%
37
0.6
18
0.3
29
0.4
30
0.4
5
00.7
15
0.2
40
0.6
5
00.7
6
00.9
62
0.9
55
0.8
Odds ratio*
(95% CI)
1.98 (1.19- 3.29)
3.69 (1.77 - 7.73)
1.93 (0.96 - 3.28)
3.75 (2.09 - 6.72)
6.56 (2.20 - 19.5)
3.00 (1.53 - 5.86)
3.14 (1.97 - 4.99)
3.85 (1.17 - 12.8)
4.88 (1.54 - 15.4)
2.37 (1.57 - 3.57)
2.03 (1.39 - 2.96)
Subjects < 14, intravenous drug users, and transfused patients were excluded from the analysis.
* Adjusted for sex, age, instruction level and area of residence in multiple logistic regression analysis.
** For females.
Adjusted OR and 95% CI for different types of invasive procedure among
hepatitis C cases. SEIEVA 1996-2000.
Intervention type
Minor surgery
Gynaecological **
Orthopaedic
Abdominal
Cardiovascular
Dermatological
Oral surgery
Ophtalmological
Urological
Other intervention
Biopsy/endoscopy
Hepatitis C
(709 cases)
n
%
13
1.8
19
2.7
17
2.4
13
1.8
19
2.7
6
8.4
15
2.1
14
2.0
6
8.4
30
4.2
40
5.6
Hepatitis A
(6701 cases)
n
%
37
0.6
18
0.3
29
0.4
30
0.4
5
00.7
15
0.2
40
0.6
5
00.7
6
00.9
62
0.9
55
0.8
Odds ratio*
(95% CI)
3.18 (1.58 - 6.39)
16.6 (7.40 - 37.2)
5.70 (2.82 - 11.5)
6.01 (2.90 - 12.4)
34.9 (12.0 - 102)
2.72 (0.98 - 7.51)
3.60 (1.87 - 6.93)
30.4 (9.98 - 92.3)
10.7 (8.88 - 39.7)
4.46 (2.72 - 7.32)
4.57 (2.91 - 7.18)
Subjects < 14, intravenous drug users, and transfused patients were excluded from the analysis.
* Adjusted for sex, age, instruction level and area of residence in multiple logistic regression analysis.
** For females.
Risk factors associated to HAV: adjusted* O.R.
(hepatitis B cases have been used by controls )
SEIEVA 1996-2000
Risk
factors
Hepatitis A
N.
%
Shellfish
consumption
7085 (70.6)
1325 (41.9)
2.41
(2.17-2.68)
Travel to high
endemic areas
1519 (15.5)
315 (10.3)
4.11
(3.53-4.79)
Household of
day-care child
1227 (12.0)
246
1.51
(1.26-1.82)
Contact with an
icteric cases
1021 (10.7)
----
10438
3620
N. of cases
Controls
N.
%
(6.8)
Adjusted O.R.
95% CI
----
* Adjusted for sex, age, area of residence, educational level and the other variables of
the table.
Association between travel* and hepatitis A virus infection:
adjusted** O. R., SEIEVA 1996-2000
Area of
destination
Adjusted O.R.
95% CI
No travel
1.00
--
Northern Europe,
Northern America
1.46
0.92-2.34
Northern/Central Italy
0.95
0.78-1.15
Southern Italy
3.03
2.35-3.91
Mediterranean Area,
Eastern Europe
3.15
2.42-4.11
Latin America, Asia,
9.30
6.71-12.9
Africa
* Reported in the 6 weeks before the onset of the disease.
** Adjusted for age, gender, educational level, area of residence, shellfish
consumption, contact with an icteric case and household of day-care child.
Association between travel* and hepatitis A virus infection:
by area of residence. SEIEVA 1996-2000
Area of residence
Area of
destination
adjusted** O.R.
Northern and central Italy
95% CI
Southern Italy/Islands
No travel
1.00
--
1.00
--
Northern Europe,
Northern America
1.60
1.00-2.57
0.63
0.07-5.34
Northern/Central Italy
1.03
0.84-1.26
0.67
0.37-1.20
Southern Italy
3.70
2.82-4.85
1.25
0.66-2.39
Mediterranean Area,
Eastern Europe
3.21
2.47-4.19
1.76
0.19-16.3
Latin America, Asia,
9.49
6.83-13.2
0.72
0.15-3.52
Africa
* Reported in the 6 weeks before the onset of the disease.
** Adjusted for age, gender, educational level, shellfish consumption, contact with
an icteric case and household of day-care child.
SEIEVA FOR MONITORING
PREVENTION PROGRAMS
Vaccination of households of HBsAg carriers
Vaccination of healthcare workers
SEIEVA FOR MONITORING PREVENTION PROGRAMS
Hepatitis B cases among adolescents.
SEIEVA 1992-2001
Years
Age
92
93
94
95
96
97
98
99
2000
2001
13
4
2
0
0
1
0
0
3
2
0
3
6
4
2
1
1
1
0
1
5
1
2
0
0
1
0
1
5
1
10
3
2
1
0
9
2
4
3
1
1
13
2
3
3
3
10
3
4
2
15
6
5
13
5
14
15
16
17
18
19
20
21
22
15
SEIEVA FOR MONITORING PREVENTION PROGRAMS
Cases of nAnB hepatitis associated with blood transfusion by
year. SEIEVA 1987-2001
Years
Hepatitis (95% CI)
nonA-nonB
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
4.4
4.5
4.1
2.9
1.4*
0.3**
0.4
0.1
0.4
0.2
0.3
0.5
0.2
0.2
0.3
(3.2-5.6)
(3.5-5.6)
(3.1-5.1)
(2.1-3.7)
(0.8-2.0)
(0.1-0.6)
(0.2-0.7)
(0.0-0.3)
(0.1-0.6)
(0.2-0.4)
(0.2-0.5)
(0.2-10.5)
(0.05-0.4)
(0.1-0.4)
(0.2-0.6)
* Compulsory of the ELISA-I test in the total blood bank
** Introduction of the ELISA-II test
Conclusions
1
Lessons from SEIEVA
• SEIEVA is a useful tool for monitoring trends of
acute viral hepatitis, for understanding the role
played by each risk factor, and for establishing the
priority and effectiveness of prevention programs.
Conclusions
2
Lessons from SEIEVA
• Incidence of hepatitis B was decreasing in Italy before the
vaccination campaign was launched.
• Vaccination against hepatitis B has further contributed to the
decline of HBV infection.
• Invasive medical procedures represent an important mode of HBV
and HCV transmission.
• Intensive effort should be employed to increase vaccination
coverage of specific risk groups.
• Shellfish consumption and travels to endemic areas are major risk
factors for hepatitis A.