1. Hepatitis- Epidemiology
Dr. Ameya
PG, Department of Community Medicine
MGIMS, Sevagram.

2. Introduction
Viral hepatitis is inflammation of liver caused by different viruses
Enterically
transmitted
Parenterally E C
“Infectious”
“Serum”
Viral hepatitis A
NANB B
F, G,
? Other *
* 10-20% of cases of presumed viral hepatitis are still not accounted for D
VIRAL HEPATITIS IS A MAJOR PUBLIC HEALTH PROBLEM IN NEED OF AN URGENT RESPONSE.1.34 million deaths in 2015
Non A Non B hepatitis.
Other viruses- cytomegalovirus, rubella virus, epstein barr virus, yellow fever virus ,herpes zoster virus,etc.
Other hepatitis-
Alcoholic hepatitis.
Auto immune hepatitis.
Toxic & drug induced hepatitis 2

4. Let me on focuses on hepatitis B and C, which are responsible for 96% of all hepatitis mortality

6. Hepatitis outbreaks- India - 2011–2013
804,782 hepatitis cases and 291 outbreaks.
Virus type was unspecified in 92% of cases.
Hepatitis A Positive 7.4% & Hepatitis E (10.4%)
Two-thirds of outbreaks were reported from rural areas(68%).
Outbreaks E(48%), A(33%), A& E(12%), B & C(07%)
Contaminated drinking water – major cause
3- Among 599,605 cases tested for hepatitis A, 44,663 (7.4%) were positive, and among 187,040 tested for hepatitis E, 19,508 (10.4%) were positive.
- The small proportion of jaundice cases tested for either hepatitis A or E that tested positive, 7% and 10%, respectively, needs further investigation.
Contaminated drinking water was the source of most outbreaks. Improvements in water quality and sanitation as well as inclusion of hepatitis A vaccine in childhood immunization programs should be considered to reduce the public health burden of hepatitis in India.
Source- National Centre for Disease Control (NCDC)

7. Blood-borne Viral Hepatitis
Hepatitis viruses B (HBV), D (HDV) and C (HCV) - serious “Silent epidemic” challenge to India
- 1 - Hepatitis viruses B (HBV), D (HDV) and C (HCV), which predominantly transmit through the parenteral route, pose a serious “silent epidemic” challenge to India,.
Infected persons are unaware of their chronic carrier status, and continue to infect others for decades and eventually burden the society with loss of productive workforce, and the health care system with expenses of treating liver failures, chronic liver diseases, and cancers.

8. HEPATITIS B
HBV is the second most common cause of acute viral hepatitis.
With a 3.7% point prevalence
India is considered to have an intermediate level of HBV endemicity.
Every year, one million Indians are at risk for HBV and about 100,000 die from HBV infection.
( ap 40 million HBV carriers)

9. Global Patterns of Chronic HBV Infection
High (>8%): 45% of global population
lifetime risk of infection >60%
early childhood infections common
Intermediate (2%-7%): 43% of global population
lifetime risk of infection 20%-60%
infections occur in all age groups
Low (<2%): 12% of global population
lifetime risk of infection <20%
most infections occur in adult risk groups

10. NATURAL HISTORY OF DISEASE
Fulminant hepatitis is a rare syndrome of massive necrosis of liver parenchyma and a decrease in liver size (acute yellow atrophy) that usually occurs after infection with certain hepatitis viruses, exposure to toxic agents, or drug-induced injury.

11. EPIDEMIOLOGICAL DETERMINANTS
AGENT:
DNA virus- hepadnaviridae family
Only reservoir - Man
Infective material-contaminated blood, saliva, vaginal secretions, semen
Resistance – stable for 7 days in environmental surface, destroyed by sodium hypochlorite & by heat sterilization mins
3 morphological forms-small spherical particles, tubules & Dane particle(infectious)

12. HOST:
Age:
Acute hepatitis - 1% of perinatal cases,10% of early childhood, 30% of late childhood.
Chronic hepatitis – 80-90% -perinatally, 30% in early childhood, 5% infected after 6 yrs
High risk groups:
Surgeons have 50% more chance
Others- recipients of blood transfusion, health care & laboratory care personnels, percutaneous IV drug abusers, homosexuals, infants of HBV carrier mothers, immunocompromised patients.
The outcomes of HBV infection are age-dependent. Acute hepatits B occurs in approximately 1 per cent of perinatal, 10 per cent of early childhood (1-5years of age), and 30 per cent of late (> 5 years age) HBV Infections. The development of chronic HBV infection is inversely related to age and occurs in approximately per cent of persons infected perinatally, in 30 per cent infected in early childhood (less than 6 years of age) and in 5 per cent infected after 6 years of age

13. Parenteral route -Blood borne disease
MODE OF TRANSMISSION
Parenteral route -Blood borne disease
Perinatal route- 10%(HBsAg) 90%(HBsAg & HBeA)
Sexual transmission
INCUBATION PERIOD
days(75 days)
10% if the mother is hepatitis B surface antigen (HBsAg) positive only
90% when the mother is positive for both HBsAg and hepatitis B e-antigen (HBeAg).

14. PREVENTION & CONTROL Hepatitis B vaccine Hepatitis B immunoglobulin
Passive active immunization
Other measures
Routine infant vaccination & catch-up immunization for adolescents and high risk populations.
Globally, 84% of children born in 2015 received the 3 recommended doses of hepatitis B vaccine
HBV vaccine also protects from HDV infection
1- Hepatitis B is an important occupational hazard for health workers.
2- WHO recommends
4- Screening and immunization of high-risk groups, such
as those with history of exposure, risky practices, and
occupational risk; specific measures for prevention of
mother-to-child transmission and promoting safe blood
supply, safe injections and safe sex are other
recommended preventive measures.

15. HEPATITIS C
HCV accounts for most of the post transfusion hepatitis cases.
1.75 million people were newly infected with HCV in 2015
20% of are chronic liver cases also associated with HCV infection.
Sero-prevalence among donors in India % – 1.85%
Chronic liver cases- chronic liver disease, cirrhosis and liver cancers

16. NATURAL HISTORY OF DISEASE

17. EPIDEMIOLOGICAL DETERMINANTS
AGENT:
Flaviviridae family
HOST:
High risk group - recipients of blood transfusion, health care personnel, homosexuals, drug abusers & infants of carriers
MODE OF TRANSMISSION:
Parenteral route
Perinatal route
Sexual transmission
INCUBATION PERIOD:
days
6 genotypes & 100 sub types

18. PREVENTION & CONTROL Screening blood donors
Virus inactivation in plasma derived products
Promotion of behavior change

19. HEPATITIS & HIV 1% of persons with HBV - infected with HIV.
Global prevalence of HBV infection in PLHIV is 7.4%.
Co infection - Complicate the management of HIV.
Universal hepatitis B vaccination of susceptible patients & high risk groups is recommended.
PLHIV should be tested for hepatitis B and hepatitis C.
Co infected persons should be counselled about drug interactions and side effects of hepatitis and HIV treatments
1 - 1% of persons living with HBV infection (2.7 million people) are also infected with HIV.
2- Global prevalence of HBV infection in HIV-infected persons is 7.4%.
3- Coinfection with hepatitis -complicate the management of HIV infection.
4- To prevent coinfection with hepatitis B, universal hepatitis B vaccination of susceptible patients with HIV infection or AIDS & high risk groups is recommended
5- All persons living with HIV should be tested for hepatitis B and hepatitis C
Co infected persons should be counselled about drug interactions and side effects of hepatitis and HIV treatments

20. Source- WHO

21. Global Health Sector Strategy (GHSS)
Elimination of viral hepatitis as a public health threat by 2030 (reducing new infections by 90% and mortality by 65%).
Key pillars of the GHSS - Strategic information, interventions, equity, financing and innovation .

22. 2030 elimination goal – dream?
GAPS In CARE
Achieving the 2030 elimination goal is not a dream; reports from 28 high-burden countries give cause for optimism despite remaining challenges.
Source- WHO

23. World Hepatitis Day 2017: Eliminate hepatitis
Activities and awareness around world hepatitis :
Political engagement
National responses to hepatitis in heavy burden countries.
Encourage actions and engagement by individuals, partners and the public
Highlight the need for a greater global response
World Hepatitis Day 2017: Eliminate hepatitis

24. Key messages for World Hepatitis Day 2017
A major global health problem and needs an urgent response.
Very few of those infected accessed testing and treatment, especially in low- and middle-income countries.
Viral hepatitis caused 1.34 million deaths in 2015 = TB deaths and exceeding deaths from HIV.
Hepatitis deaths are increasing.
New hepatitis infections continue to occur, mostly hepatitis C.
Viral hepatitis is a major global health problem and needs an urgent response.
There were approximately 325 million people living with chronic hepatitis at the end of 2015.
Globally, an estimated 257 million people were living with hepatitis B (HBV) infection, and 71 million people were living with hepatitis C (HCV) infection in 2015.
2. Very few of those infected accessed testing and treatment, especially in low- and middle-income countries.
By the end of 2015, only 9% of HBV-infected people and 20% of HCV-infected people had been tested and diagnosed. Of those diagnosed with HBV infection, 8% (or 1.7 million people) were on treatment, while 7% of those diagnosed with HCV infection (or 1.1 million people) had started treatment in 2015.
The global targets for 2030 are: 90% of people with HBV and HCV infections tested and 80% of eligible patients are reached with treatment.
3. Viral hepatitis caused 1.34 million deaths in comparable with TB deaths and exceeding deaths from HIV. Hepatitis deaths are increasing.
4. New hepatitis infections continue to occur, mostly hepatitis C.
The number of children under five living with chronic HBV infection was reduced to 1.3% in 2015 (from 4.7% before vaccines were introduced).
Hepatitis B vaccine is preventing approximately 4.5 million infections per year in children.
However, 1.75 million adults were newly infected with HCV in 2015, largely due to injecting drug use and due to unsafe injections in health care settings in certain countries.
5. Achieving the 2030 elimination goal is not overly ambitious; reports from 28 high-burden countries give cause for optimism.
On World Hepatitis Day 2017, WHO is publishing 28 country profiles which show that, despite many challenges, the global effort to eliminate hepatitis is gaining ground. However, major obstacles still remain.

25. What can you do for World Hepatitis Day?
Initiate discussions
Hold an event
Engage health professionals and national stakeholders
Engage media
Organize a public event on hepatitis testing/treatment
Share the communication materials
Join the social media campaigns – “Show your face”
Promote WHO's injection safety campaign
Use the country profiles to highlight progress and create momentum to "eliminate hepatitis"
1- Initiate discussions with the focal point and other counterparts in the different sectors including ministry of health.
Encourage commemorating World Hepatitis Day 2017 under the theme: “Eliminate hepatitis”.
2- A high-profile event (e.g. sports activity, fun run/walk, concert, fundraiser)
7- Joint the polaroid campaign "I am" by learning more from World Hepatitis Alliance #ShowYourFace. Tag #NoHep hashtag or twitter which is an overall grassroots movement to support the global elimination of hepatitis.

26. Messages for patients and communities
Eliminate hepatitis. Prevent hepatitis.
Eliminate hepatitis. Get tested.
Eliminate hepatitis. Make injection safe.
Eliminate hepatitis. Demand treatment.
1- hepatitis infections are higher among certain population groups, including people who inject drugs; children and partners of people living with hepatitis; men who have sex with men; and people coinfected with HIV.
  Know your risks and prevent hepatitis!
2- 9 out of 10 people with hepatitis B are unaware of their infection.
  8 out of 10 people with hepatitis C are unaware of their infection.
3- The risk of getting hepatitis B from a contaminated syringe or needle is 30%, 3% for hepatitis C.
4- only 8% of people with hepatitis B are treated.
  Only 7% of people with hepatitis C accessed treatment – which will fully cure the infection.

27. WHO
Source- WHO

28. THANK YOU World Hepatitis Summit 2017
1 - 3 November 2017, São Paulo, Brazil
THANK YOU