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 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 -20 o 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 Percent in Study Groups

Age distributions by group Numbers Cases Group Mean Age = /-9.7 years (Median = 21) Comparison Group Mean Age = /-2.3 years (Median = 19)

Etiology of Viral Hepatitis in Non-epidemic Season (February – May, 1998) 10% 63.7% 0.3% 14% 8% 4% Number of Patients N=430

Combined Viral Hepatitis Risk Factors among HBV, HCV Patients and Comparison Group HBV-Control: OR= 10.8 (95% CI ) P < HCV-Control: OR= 12.9 (95% CI ) P <

Parenteral Exposure among HBV, HCV Patients and Comparison Group P < 0.001

Blood Transfusion among HBV, HCV Patients and Comparison Group P > 0.26

At Least One Night in the Hospital among HBV, HCV Patients and Comparison Group P to contn.<0.01 P to contn.> 0..6

At Least One Visit to Ambulatory with Parenteral Exposure among HBV, HCV Patients and Comparison Group P to contn.< P to contn.= 1.0

At Least One Visit to the Dentists with Parenteral Exposure among HBV, HCV Patients and Comparison Group P to contn.< P 1-2 > 0.1

Illicit Drug Use among HBV, HCV Patients and Comparison Group P < 0.001

Illicit Drug Use among HBV, HCV Patients and Comparison Group ( Blood transfusion, Hospitalization, Dentist and Ambulatory Treatment Excluded) P < 0.001

Illicit Drug Use History among HBV, HCV Patients and Comparison Group

Number of Sexual Partners (last 6 month) among HBV, HCV Patients and Comparison Group (other risk factors excluded) P > 0.8

Selected Risk Factors Population Attributable Risk for HBV/HCV patients in Moscow Russia, Risk FactorsHBV N=274 HCV N=62 Illicit Drug Abuse79%87% Outpatient treatment39%34% Dentists14%n.a.** Hospitalization12%8% Tattoo4%n.a. 10 and more sexual partners (last 6 month) 3%n.a. History of Syphilis12%n.a. * - mutual exclusion; ** - Not applicable *

Injections Associated Population Attributable Risk for Acute Hepatitis B Patients (Drug Use Excluded) StudyHBV Moldova, 1993 (Y. Hutin)48% Kazakhstan, 1998 (A. Kazdirbekov) 52% Moscow, %

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