USE OF ACUTE HEPATITIS SURVEILLANCE TO EVALUATE PROGRAM FOR VIRAL HEPATITIS PREVENTION AND CONTROL - PowerPoint PPT Presentation


Title: USE OF ACUTE HEPATITIS SURVEILLANCE TO EVALUATE PROGRAM FOR VIRAL HEPATITIS PREVENTION AND CONTROL


1
USE OF ACUTE HEPATITIS SURVEILLANCE TO EVALUATE
PROGRAM FOR VIRAL HEPATITIS PREVENTION AND CONTROL
  • Central Asian Program, DIH, EPO, CDC

2
Acute Hepatitis Incidence,Kyrgyzstan, 1990-2002
3
Weaknesses 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

4
Sentinel 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

5
Sentinel 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

6
Sentinel 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

7
Acute 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
8
Reference 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
9
Algorithm of Laboratory Testing
Blood sample
HBsAg
IgM anti-HBc
IgM anti-HAV
Total anti-HCV

Anti-HDV
10
GNP/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.
11
Aims
  • To evaluate parenteral hepatitis risk factors
  • To assess an impact of universal newborn
    Hepatitis B immunization program

12
Materials 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

13
Risk 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

14
Risk 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
15
Risk 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
16
Conclusion
  • 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)

17
Hepatitis 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)
19
Materials 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

20
Acute 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
21
Incidence 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
22
Acute 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
23
Conclusions (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

24
Conclusions (2)
  • KAHSS provides
  • the ability to EVALUATE the impact of an
    immunization program
  • an advocacy tool to support the necessity of
    sustainable immunization programs

25
Study 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

26
Acknowledgements
  • 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
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USE OF ACUTE HEPATITIS SURVEILLANCE TO EVALUATE PROGRAM FOR VIRAL HEPATITIS PREVENTION AND CONTROL

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Title: USE OF ACUTE HEPATITIS SURVEILLANCE TO EVALUATE PROGRAM FOR VIRAL HEPATITIS PREVENTION AND CONTROL


1
USE OF ACUTE HEPATITIS SURVEILLANCE TO EVALUATE
PROGRAM FOR VIRAL HEPATITIS PREVENTION AND CONTROL
  • Central Asian Program, DIH, EPO, CDC

2
Acute Hepatitis Incidence,Kyrgyzstan, 1990-2002
3
Weaknesses 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

4
Sentinel 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

5
Sentinel 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

6
Sentinel 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

7
Acute 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
8
Reference 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
9
Algorithm of Laboratory Testing
Blood sample
HBsAg
IgM anti-HBc
IgM anti-HAV
Total anti-HCV

Anti-HDV
10
GNP/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.
11
Aims
  • To evaluate parenteral hepatitis risk factors
  • To assess an impact of universal newborn
    Hepatitis B immunization program

12
Materials 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

13
Risk 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

14
Risk 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
15
Risk 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
16
Conclusion
  • 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)

17
Hepatitis 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)
19
Materials 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

20
Acute 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
21
Incidence 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
22
Acute 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
23
Conclusions (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

24
Conclusions (2)
  • KAHSS provides
  • the ability to EVALUATE the impact of an
    immunization program
  • an advocacy tool to support the necessity of
    sustainable immunization programs

25
Study 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

26
Acknowledgements
  • 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
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