Title: USE OF ACUTE HEPATITIS SURVEILLANCE TO EVALUATE PROGRAM FOR VIRAL HEPATITIS PREVENTION AND CONTROL
1USE OF ACUTE HEPATITIS SURVEILLANCE TO EVALUATE
PROGRAM FOR VIRAL HEPATITIS PREVENTION AND CONTROL
- Central Asian Program, DIH, EPO, CDC
2Acute Hepatitis Incidence,Kyrgyzstan, 1990-2002
3Weaknesses of the Acute Hepatitis Surveillance
Used before 2000
- Acute hepatitis case definition was not applied
- Cases were not serologically tested for specific
markers of acute hepatitis A,B,C and D - Epidemiological data collection procedure and
analysis methodology were not standardized
4Sentinel Surveillance Introduction (goals)
- To provide reliable etiological diagnostics of
acute viral hepatitis on bases of representative
sample - To define risk groups and risk factors for acute
hepatitis - To use surveillance data for design, monitoring
and evaluation of programs for viral hepatitis
control and prevention - To provide database for epidemiological studies
5Sentinel Surveillance Introduction (stages 1)
- National Reference Laboratory was established
standard laboratory procedures and quality
assurance were provided - External Quality Assessment of the accuracy of
Reference laboratory results was conducted in
CDC, Atlanta - Corresponding Ministry of Health orders were
issued - Sentinel Sites were organized in three regions
Bishkek, Naryn and Jalal-Abad
6Sentinel Surveillance Introduction (stages 2)
- The structure and procedure of sentinel
surveillance were developed, including - sample size and sampling design
- acute hepatitis case definition
- algorism of laboratory testing
- acute hepatitis case classification
- standard questionnaire for epidemiological data
collection - blood samples collection and transportation
- 4 trainings have been conducted for the sentinel
sites personnel (laboratory workers, physicians,
epidemiologists, nurses) on sentinel surveillance
structure and operating, data quality assurance
7Acute Hepatitis Case
- Infectious Hospital
- (physician, nurse)
- - confirmation of correspondence to case
definition - - filling in and marking of the questionnaire
- - blood sample collection and marking
- - transportation of samples and questionnaires to
the State - Sanitation and Epidemiological Surveillance
Center
State Sanitary and Epidemiological Surveillance
Center (epidemiologist, laboratory worker) -
serum separation - transportation of samples and
questionnaires to the Reference Laboratory
8Reference Laboratory (epidemiologist, laboratory
worker) - laboratory testing - data entering -
data analysis and report preparation
report
report
report
Ministry of Health
State Department of Sanitation and
Epidemiological Surveillance
Regional health authorities and State
Sanitation and Epidemiological Surveillance
Centers
9Algorithm of Laboratory Testing
Blood sample
HBsAg
IgM anti-HBc
IgM anti-HAV
Total anti-HCV
Anti-HDV
10GNP/capita (USD) 1994-2000
Country/Years 1994 2000 (estimate for 2002) GNP increase
Kazakhstan 721 1230 70.6
Kyrgyzstan 275.3 286 4
Tajikistan 159.1 159,8 0.4
Turkmenistan 517 552,5 6.9
Uzbekistan 255.4 264,3 3.4
European Bank for Reconstruction and Development.
Transition Report Update, May 2002.
11Aims
- To evaluate parenteral hepatitis risk factors
- To assess an impact of universal newborn
Hepatitis B immunization program
12Materials and Methods (1)
- Study design matched case control study (1 case
2 controls matched by age, sex and place of
residence) - Cases acute hepatitis B, C and D cases
(parenteral hepatitis), 2000-2003 - Controls acute hepatitis A cases, 2000-2003
- N 214 case-control sets
- EPI INFO matched case-control analysis followed
by conditional logistic regression
13Risk Factors (6 months prior to the onset of
disease)
- Blood transfusion
- Surgery
- Injections in hospital
- Injections in polyclinic
- Blood samples collection in polyclinic
- Visit to surgeon, dentist, urologist,
gynecologist - Blood donation
- Multiple sexual partners
- STD
14Risk Factors of Parenteral Hepatitis (monovariate
analysis)
??????? ????? Frequency (N642) Frequency (N642) OR Confidence interval ?I0.95 P value
??????? ????? Cases Controls Cases Controls OR Confidence interval ?I0.95 P value
Blood transfusion 5.6 0.2 24.0 3.1 184.6 lt0.001
Injections in hospital 5.6 0.9 7.6 2.1 27.6 lt0.001
Injections in policlinic 22.0 7.2 3.5 2.1 5.8 lt0.001
Surgeon 7.0 1.6 4.8 1.9 12.6 lt0.001
Multiple sexual partners 4.7 1.4 8.7 1.8 41.9 lt0.05
15Risk Factors of Parenteral Hepatitis(2)
Risk factors ß? ORe Confidence interval ?I0.95 P value
Blood transfusion 11.4 1.3 99.7 lt0,05
Injections in hospital 3.2 2.0 5.9 lt0,001
Injections in policlinic 5.7 1.1 15.9 lt0,001
Surgeon 1.1 0.2 5.4 gt0,05
Multiple sexual partners 5.2 1.5 17.6 lt0,01
16Conclusion
- Risk of parenterally transmitted viral hepatitis
remains significant in health facilities. The
system of blood and injection safety should be
improved - The system of health communication and training
to improve understanding of natural Hep B
transmission mechanisms and prevention measures
should be strengthened (HIV)
17Hepatitis B Immunization Program in Kyrgyzstan
- Introduced in April 1999
- High immunization coverage gt 95
- 23 cases of acute HB among fully immunized
children registered by routine surveillance
18(No Transcript)
19Materials and Methods (2)
- Comparison of acute hepatitis B incidence rates
among vaccinated and unvaccinated children born
in sentinel sites between 2000 and 2003 - Analyses of acute hepatitis B incidence among
children under 5 years of age in sentinel sites
for the period 2000 to 2003 - Hepatitis B cases acute hepatitis sentinel
surveillance database - Vaccination status of acute hepatitis B cases
primary health facility immunization records - Number of children in age groups and vaccination
status of non-infected children official
statistical data of the Ministry of Health
20Acute Hepatitis B Cases Among Children Under
4,Sentinel Surveillance, 2000-2003
Sentinel sites Number of children under 4 Children born after April 1999 Children fully immunized
Bishkek 15 4 0
Dzalal-Abad 33 9 2
Naryn 5 1 0
Total 53 14 2
21Incidence rates among vaccinated and unvaccinated
children, Bishkek, Naryn, Jalalabat , 2000-2003
Number of children born in 2000-2003 37 784
Number of fully vaccinated children 37 112
Number unvaccinated children 672
Number of acute HB cases among vaccinated children 2
Number of acute HB cases among unvaccinated children 12
Incidence rate among vaccinated children 2.9 per 100,000 child-years
Incidence rate among unvaccinated children 760.0 per 100,000 child-years
22Acute Hepatitis Incidence Among children under 5,
2000-2003
50
100
47,4
45
90
86
40
80
35
70
66
30
60
25
50
46
20
40
18,8
Morbidity ratio 000
15
30
26
10
20
7
5,1
5
10
0
0
2000
2001
2002
2003
VHB morbidity rate
VHB immunization coverage
23Conclusions (1)
- AHSS allows effective MONITORING of immunization
program in sentinel sites, providing the ability
to - carry out epidemiological investigation of every
case of acute viral Hepatitis B - identify and quickly respond to immunization
program errors
24Conclusions (2)
- KAHSS provides
- the ability to EVALUATE the impact of an
immunization program - an advocacy tool to support the necessity of
sustainable immunization programs
25Study Limitations
- Evaluation of risk factors
- Use of acute hepatitis A cases as controls
- Aggregation of acute hepatitis B, C and D cases
into one group of parenteral hepatitis - Evaluation of Immunization program
- Use of official statistical data to define the
size of target age groups and vaccinated and
unvaccinated children
26Acknowledgements
- The Ministry of Health of the Kyrgyz Republic
- Republican Center for Viral Hepatitis Prevention
- State Department of Sanitation and
Epidemiological Surveillance - Republican Center for Immunization