Download HEV Infection Among People Who Work in Close Contact With

Overview of Hepatitis B, C, and
D Epidemiology in Eastern
Europe and the Newly
Independent States
Michael O. Favorov MD, Ph.D., D.Sc.
CDC Central Asia Program Director
Elena Klimova MD, Ph.D.
Moscow Medical and Dentistry School,
Infection Disease Department, Associate Professor
Background
• High risk among intravenous drug users for
Viral Hepatitis and HIV infection transmission
has been demonstrated worldwide.
• Limited studies suggest significant changes in
risk factors for viral hepatitis B, C, and Delta
transmission occurred in the region during the
last decade.
• Descriptive nature of epidemiological studies
of risk factors for parenterally transmitted
hepatitis in the region.
• Moldova study (Y. Hutin et al.,1993) –
nosocomial transitions main risk factor for
HBV infection.
Study Objective
To assess risk factors for Viral
Hepatitis in hospitalized adult
patients and in a reference group in
Moscow, Russia.
Methods
Study Population
• Cases – patients with jaundice and ALT elevation (> 5
times higher than normal) hospitalized at Infectious
Disease Hospital Number 1 in Moscow, February–
May,1998. N = 430.
• Assessment of patient risk factors by collection of
detailed information on: history of injection practices,
medical procedures, drug abuse, sexual behavior,
alcohol consumption; demographic and other
characteristics. N = 300.
• Reference group (Non-Sick) -- Volunteers from Medical
High School and Pre-recruitment medical examination
participants, with no history of jaundice. Collected April–
June 1998. N=311 .
Methods
Data and Specimen Collection
• Obtained informed consent .
• Questionnaire administered.
• Obtained blood specimens:
– blood samples (5cc) drawn using disposable sterile materials
(needles, syringes, tubes);
– Sera separated by centrifugation and storage at -20o C until
shipment to CDC.
• ID-linked questionnaire, blood and serum tubes.
Methods
• Specimens test site CDC Hepatitis Reference Laboratory
• EIA Abbott ( North Chicago)
–
–
–
–
–
–
IgM Anti HAV
HBsAg
IgM anti - HBc
Anti-HCV
Anti-HCV Confirmatory test.
Anti HDV (total)
• Mosaic protein test (CDC)
– Anti HEV (IgG and IgM)
Study Population: Demographics and Education
100
Patients
Comparison
80
60
40
20
Russians
Higher
Education
Female
0
Age distributions by group
Cases Group Mean Age = 23.9 +/-9.7 years (Median = 21)
Comparison Group Mean Age = 19.4 +/-2.3 years (Median = 19)
Numbers
250
Cases
Comparison
200
150
100
50
0
15-19
20-39
40&>
Etiology of Viral Hepatitis in Non-epidemic Season
(February – May, 1998)
Number of Patients
63.7%
300
274
250
200
150
Patients
100
14%
62
10%
50
42
0.3%
33
2
0
HAV
N=430
8%
HBV
HCV
HDV
HAV+HBV
4%
19
NANC
Combined Viral Hepatitis Risk Factors among
HBV, HCV Patients and Comparison Group
100
90
80
70
60
% 50
40
30
20
10
0
HBV
HCV
Control
Any VH related Exposure
HBV-Control: OR= 10.8 (95% CI 6.4-18.5) P < 0.0001
HCV-Control: OR= 12.9 (95% CI 3.7-54.0) P < 0.0001
Parenteral Exposure among HBV, HCV
Patients and Comparison Group
100
80
60
HBV
HCV
Control
%
40
20
0
Invasive manipulations during last 6 month
P < 0.001
Blood Transfusion among HBV, HCV
Patients and Comparison Group
3
2,5
2
HBV
HCV
Control
% 1,5
1
0,5
0
Blood Transfusion
P > 0.26
At Least One Night in the Hospital
among HBV, HCV Patients and
Comparison Group
14
12
P to contn.<0.01
10
8
%
6
P to contn.> 0..6
4
2
0
Hospitalization
HBV
HCV
Control
At Least One Visit to Ambulatory with
Parenteral Exposure among HBV, HCV
Patients and Comparison Group
25
20
15
P to contn.<0.0021
%
10
P to contn.= 1.0
5
0
Ambulatory treatments (Hospital excluded)
HBV
HCV
Control
At Least One Visit to the Dentists with
Parenteral Exposure among HBV, HCV
Patients and Comparison Group
30
25
1
2
P to contn.<0.05
20
HBV
HCV
Control
% 15
10
5
0
Dentist Visit
P 1-2 > 0.1
Dentist Visit (Hosp.
Excluded)
Illicit Drug Use among HBV, HCV
Patients and Comparison Group
90
80
70
60
HBV
HCV
Control
50
%
40
30
20
10
0
Drug Use
P < 0.001
Illicit Drug Use among HBV, HCV Patients
and Comparison Group
(Blood transfusion, Hospitalization, Dentist and
Ambulatory Treatment Excluded)
90
80
70
60
HBV
HCV
Control
50
%
40
30
20
10
0
Drug Use
P < 0.001
Illicit Drug Use History among HBV,
HCV Patients and Comparison Group
80
70
60
50
HBV
HCV
Control
% 40
30
20
10
0
More then one IV druguse more
Injection per day
then a year
Syringes
Shearing
Number of Sexual Partners (last 6 month)
among HBV, HCV Patients and
Comparison Group (other risk factors excluded)
100
90
80
70
60
% 50
40
30
20
10
0
HBV
HCV
Control
0-1
P > 0.8
2-5
6 - 10
> 10
Selected Risk Factors* Population Attributable Risk for
HBV/HCV patients in Moscow Russia, 1998.
Risk Factors
HBV
HCV
N=274
N=62
Illicit Drug Abuse
79%
87%
Outpatient treatment
39%
34%
Dentists
14%
n.a.**
Hospitalization
12%
8%
Tattoo
4%
n.a.
10 and more sexual partners (last 6 month)
3%
n.a.
History of Syphilis
12%
n.a.
* - mutual exclusion; ** - Not applicable
Injections Associated Population Attributable
Risk for Acute Hepatitis B Patients (Drug
Use Excluded)
Study
Moldova, 1993 (Y. Hutin)
Kazakhstan, 1998 (A.
Kazdirbekov)
Moscow, 1998
HBV
48%
52%
41%
Conclusions
• Injection drug use with unsafe injection practice
strongly associated with acquiring acute hepatitis
B and C in Moscow.
• Outpatients treatment remain highly associated
with acquiring acute hepatitis; attributable risk for
non-drug users HBV patients 39%, HCV 34%.
• Hospitalization, tattooing, multiple sexual contacts
demonstrated attributable risk for non-drug users
3 – 12%.
Recommendations
• Promote the use of single use syringes and
needles (auto-disable) in Moscow
• Promote infection control practices in drug
use communities in Moscow
• Educate drug use communities members
and health care workers about the risks
associated with re-use injection material
Limitations
• Control group selection
Acknowledgements
• Moscow Medical
and Dentistry
School
- N.D. Uschuk
- M.M. Gadzhikulieva
• CDC, Hepatitis Branch
- M. Purdy
- H. Margolis