1. Prevention of Hepatitis B: the Foundation of Viral Hepatitis Prevention
Harold S. Margolis, M.D.
Division of Viral Hepatitis
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Atlanta, GA

2. Reasons to Combine Viral Hepatitis and HIV/AIDS Prevention
Major public health problems
Routes of transmission overlap
Effective prevention tools
immunization, blood screening, universal precautions, risk reduction, treatment
Well established programs for HIV/AIDS
Lack of integrated prevention activities leads to transmission of both diseases, especially viral hepatitis
Hepatitis C: the tipping point for a new direction in prevention

3. Estimated Number of Persons with Chronic Bloodborne Virus Infections 1998
Region
Population
(millions)
HIV
HCV
HBV
Africa
749
22.7
22.5
59.3
Asia
3,585
7.3
107.5
286.8
Latin America
504
1.7
15.1
10.3
Europe
729
0.8
21.8
10.9
Oceania 30
0.0
0.9
2.4
North America
305
9.1
1.9
Total
5,902
33.4
176.9
371.6
Chronic infections

4. Routes of Transmission and Opportunities for Prevention of Infection with Hepatitis Viruses and HIV Overlap Substantially

5. Risk Factors for Transmission of Hepatitis Viruses and HIV
Proportion of Infections (%)
Risk Factor
Rare 30
5-7
(past) 40 15 14
HBV
Past
7- 20 10
<<1 20 1 60
HCV 9
Past 2
<<1 10 47 31
HIV
Transfusion
Unknown
Occupational
Heterosexual partners
MSM
Injection drug use
These infections are transmitted by injection drug use, and sex
Relative importance differs somewhat for each agent, however, the prevention messages are the same for all three

6. Prevention and Control of Viral Hepatitis: its becoming more than HBV infection
HAV, HBV and HCV infection are endemic in most parts of the world, including the independent states of the former Soviet Union.
First priority = prevention of HBV infection in infants and young children = infant hepatitis B immunization
Routine disease surveillance will identify hepatitis B and hepatitis C in other age groups
1.    Although hepatitis C virus appears to be endemic in most areas of the world, temporal and geographic differences have been observed in the epidemiology of hepatitis C that are related to differences in the frequency and extent to which various risk factors contribute to the transmission of HCV. The two risk factors most frequently cited as being responsible for transmission of HCV infection are blood transfusion from unscreened donors and injecting drug use. However, the potential roles of other medical and dental procedures, cultural practices, and high-risk behaviors have not been appreciated.

7. Components of a Hepatitis B Immunization Program
Infant
Catch-up for older children – ages defined by local epidemiology
Health care workers
Other high-risk adults – groups defined by local epidemiology
Assessment of effectiveness of HepB immunization
Vaccination coverage (age-specific)
Population-based serologic assessment
Acute disease surveillance
Surveillance for Acute Viral Hepatitis
All age groups
Serologic conformation
Risk factor data - immunization status, source of infection
1.    Although hepatitis C virus appears to be endemic in most areas of the world, temporal and geographic differences have been observed in the epidemiology of hepatitis C that are related to differences in the frequency and extent to which various risk factors contribute to the transmission of HCV. The two risk factors most frequently cited as being responsible for transmission of HCV infection are blood transfusion from unscreened donors and injecting drug use. However, the potential roles of other medical and dental procedures, cultural practices, and high-risk behaviors have not been appreciated.

8. A Model Hepatitis B Prevention Program
Immunization
infant
catch-up for older children
health care workers
other high-risk adults
Prevent transfusion-transmitted infection - safe blood and blood products
screening of blood donors for HBsAg
good manufacturing practices for blood products
pooled products include virus inactivation
Safe injection practices in all settings
Infection control practices to prevent transmission of bloodborne infections
Surveillance to assess prevention effectiveness
1.    Although hepatitis C virus appears to be endemic in most areas of the world, temporal and geographic differences have been observed in the epidemiology of hepatitis C that are related to differences in the frequency and extent to which various risk factors contribute to the transmission of HCV. The two risk factors most frequently cited as being responsible for transmission of HCV infection are blood transfusion from unscreened donors and injecting drug use. However, the potential roles of other medical and dental procedures, cultural practices, and high-risk behaviors have not been appreciated.

9. Injections among Unvaccinated Children < 5 years of age with Acute Hepatitis, Romania 1997-1998
Reported Cases
HBV HAV
Cases
Controls OR
95%CI
Received an injection 16 41
5.1
2.3-11
No injection 23
300
Ref
Population attributable risk among unvaccinated = 32%

10. Prevalence of HCV Infection in Blood Donors
<
0.1%
- Very Low
>5%
- High
1.1-5%
- Intermediate
0.2-1%
- Low
Unknown
Anit-HCV Prevalence *
*Anti-HCV defined by EIA and supplemental testing

11. Proportion of HCV Infections Attributable to Unsafe Injections Case-Control Studies
Population
Country Year Age Attributable %
Taiwan (Ho) Children 84%*
(Chen) Adults 20%*
(Sun) Adults 57%
Pakistan (Luby) All 51%*
Egypt (El Sakka) All 88%*
* Calculated from data provided by authors
Source: SIGN, WHO

12. Health-Care Procedures and HCV Infection Low/Moderate Endemic Countries
Surgery Dental
Country HCV Pos HCV Neg HCV Pos HCV Neg
Case-Control
USA 10% 12% 24% 24%
Italy 17%* 2% 22%* 11%
Cross-Sectional
Italy 56%* 36% 91%* 80%
77% 57% 90% 90%
Taiwan 13% 3% 24% 28%
Pakistan No data 33% 39%
Japan 32%* 10% No data
* P<.05, independent of other risk factors

13. Unsafe Injections and HCV Infection Moderate Endemic Countries
History Reused Needles/Syringes
Country HCV Pos HCV Neg OR (95% CI)
Italy 63% 31% 3.8 (2.7, 5.3)
89% 53% 7.0 (4.4, 11.2)
76% 72% 1.2 (0.6, 2.5)
Taiwan 26% 8% 4.2 (1.2, 14.5)
Pakistan (>5/yr) 36% 6% 8.2 (1.9, 41.4)

14. Geographic Patterns of Age-Specific Prevalence of HCV Infection10 20 30 40 50
0-9
10-19
20-29
30-39
40-49
50+
Age Group (Years)
Percent Anti-HCV Positive
Egypt
Japan, Italy
U.S., Australia

15. Burden of Disease Attributable to Unsafe Injections, Developing and Transitional Economy Countries, Preliminary Data
HCV
HBV
HIV
Total number of infections
4.8 m
64.7 m
5.5 m
Infections attributable to unsafe injection
2.1 m
23.0 m
0.1 m
Attributable fraction
44%
36% 2%
Source: Armstrong, Hauri, Hutin

16. Posttransfusion Hepatitis in Developing Countries
Inappropriate use of blood and blood products – single unit transfusions common
Lack of organized transfusion services
Most transfused units not tested for HBV or HCV
Related donors often used – perception that less likely to be infected
Paid donors continue to be used in many countries

17. Posttransfusion Hepatitis C
All volunteer donors
HBsAg
Donor Screening for HIV Risk Factors
Anti-HIV
ALT/Anti-HBc
Anti-HCV
Improved HCV Tests
Good afternoon-
Review CDC’s progress in implementation of prgrams to prevent hepatitis C
Integration into CDC’s existing public health programs
Adapted from HJ Alter , et al . Clin Chem 1997

18. Injecting Drug Use: HBV and HCV Infection
Highly efficient mode of transmission
Rapidly acquired after initiation
Four times more common than HIV
Prevalence 50-90% after 5 years
Predominant risk factor in low prevalence countries
Emerging risk factor in medium prevalence countries –acute hepatitis B and hepatitis C in adults are often the best indicator of injection drug use problem

19. Duration of Injecting (months)
Risk of Bloodborne Virus Infections Injection Drug Users Baltimore 1983–1988 20 40 60 80
100
HCV
HBV
Seroprevalence (%)
HIV 6 12 18 24 30 36 42 48 54 60 66 72
Duration of Injecting (months)
Garfein RS. Am J Public Health. 1996;86:655.

20. Injecting Drug Use and HCV Infection High/Moderate Endemic Countries
Minor role in the distant past
Highest incidence of hepatitis C now seen in young adults in some countries (e.g., Italy, Japan)
sentinel event for emergence of injecting drug use
History of injecting drug use becoming more common
50% of persons with acute hepatitis C (Italy, Russia)
40% of HCV-positive persons <40 yrs old vs. 0% >40 (Italy)
2/3 of HCV-positive commercial blood donors (Egypt)

21. Relative Importance of Risk Factors for Hepatitis C and Prevention Strategies by HCV Endemicity
High/Moderate Endemicity
Transfusion
Other
Nosocomial
Sexual
Other
Injection Drug Use
Low Endemicity
Safe blood supply
Safe injections
Infection control
Risk reduction services
Testing and counseling

22. Relative Importance of Risk Factors for Hepatitis B and Prevention Strategies by Endemicity
High/Moderate Endemicity
Nosocomial
Other
Perinatal/Horizonal
Other
Injection Drugs
Sex
Low Endemicity
Infant Immunization
Safe blood supply
Safe injections
Infection control
Infant, adolescent, adult immunization
Risk reduction services