SEIEVA Integrated Epidemiological System for Acute Viral Hepatitis

SEIEVA Integrated Epidemiological System for Acute Viral Hepatitis Alfonso Mele Catania, November 7 -8 2002

SEIEVA AIMS • Monitor epidemiological trends • Identify risk factors • Formulate and monitor prevention strategies

SEIEVA METHODOLOGY • Notification • Interview • Ascertainment of markers • Weekly line listing of cases and questionnaires are forwarded to ISS

SEIEVA participating ASL 2001: 133/243 (56% Italian population) 1/5 1/1 1/44 2/6 22/22 11/22 13/13 5/5 12/12 13/13 2/5 12/12 2/6 1/5 12/12 13/13 2/5 5/22 1/11 2/9

Serological definition of types of viral hepatitis SEIEVA

Incidence

Distribution of notified cases of viral hepatitis SEIEVA 1987 - 1990 1997 - 2001

1995 - 2001 1985 - 1994 Case fatality rate of viral hepatitis in Italy by type

Incidence rates (cases x 100, 000) of viral hepatitis in Italy by type, SEIEVA 2001

Anti-hepatitis B vaccination Incidence of notified case of hepatitis B in Italy by age-groups. SEIEVA 1985 -2001

Incidence of notified case of hepatitis n. An. B in Italy by age and year. SEIEVA 1985 -2001

Incidence of notified case of hepatitis A in Italy by age and year. SEIEVA 1985 -2001

Incidence (cases per 100, 000) of hepatitis A in Italy by geographical area. SEIEVA 1985 -2001

Risk Factors

Risk factors of hepatitis B: adjusted* O. R. SEIEVA 1998 -2000 Risk factors adjusted OR 95% CI Blood transfusion 2. 35 (0. 56 - 9. 92) Intravenous drug use 6. 78 (3. 32 - 13. 9) Surgical intervention 2. 44 (1. 42 - 4. 19) Dental therapy 1. 35 (0. 99 - 1. 84) Other parenteral exposures 1. 67 (1. 26 - 2. 33) > 1 sexual partner ** 1. 75 (1. 31 - 2. 33) Household of HBs. Ag+ 10. 1 (4. 52 - 22. 7) * Adjusted for sex, age, area of residence, educational level and the other variables of the table. ** Subjects > 14

Risk factors of hepatitis C: adjusted* O. R. SEIEVA 1998 -2000 Risk factors adjusted OR 95% CI Blood transfusion 2. 43 (0. 63 - 9. 42) Intravenous drug use 38. 0 (19. 1 - 75. 6) Surgical intervention 7. 02 (3. 99 - 12. 4) Dental therapy 1. 53 (1. 00 - 2. 33) Other parenteral exposures 1. 65 (1. 11 - 2. 46) > 1 sexual partner ** 0. 76 (0. 49 - 1. 19) * Adjusted for sex, age, area of residence, educational level and the other variables of the table. ** Subjects > 14

Adjusted OR and 95% CI for different types of invasive procedure among hepatitis B cases. SEIEVA 1996 -2000. Intervention type Minor surgery Gynaecological** Orthopaedic Abdominal Cardiovascular Dermatological Oral surgery Ophtalmological Urological Other intervention Biopsy/endoscopy Hepatitis B (2689 cases) n % 44 1. 6 21 0. 8 19 0. 7 41 1. 5 21 0. 8 31 1. 1 63 2. 3 10 0. 4 13 0. 5 66 2. 4 80 2. 9 Hepatitis A (6701 cases) n % 37 0. 6 18 0. 3 29 0. 4 30 0. 4 5 00. 7 15 0. 2 40 0. 6 5 00. 7 6 00. 9 62 0. 9 55 0. 8 Odds ratio* (95% CI) 1. 98 (1. 19 - 3. 29) 3. 69 (1. 77 - 7. 73) 1. 93 (0. 96 - 3. 28) 3. 75 (2. 09 - 6. 72) 6. 56 (2. 20 - 19. 5) 3. 00 (1. 53 - 5. 86) 3. 14 (1. 97 - 4. 99) 3. 85 (1. 17 - 12. 8) 4. 88 (1. 54 - 15. 4) 2. 37 (1. 57 - 3. 57) 2. 03 (1. 39 - 2. 96) Subjects < 14, intravenous drug users, and transfused patients were excluded from the analysis. * Adjusted for sex, age, instruction level and area of residence in multiple logistic regression analysis. ** For females.

Adjusted OR and 95% CI for different types of invasive procedure among hepatitis C cases. SEIEVA 1996 -2000. Intervention type Minor surgery Gynaecological ** Orthopaedic Abdominal Cardiovascular Dermatological Oral surgery Ophtalmological Urological Other intervention Biopsy/endoscopy Hepatitis C (709 cases) n % 13 1. 8 19 2. 7 17 2. 4 13 1. 8 19 2. 7 6 8. 4 15 2. 1 14 2. 0 6 8. 4 30 4. 2 40 5. 6 Hepatitis A (6701 cases) n % 37 0. 6 18 0. 3 29 0. 4 30 0. 4 5 00. 7 15 0. 2 40 0. 6 5 00. 7 6 00. 9 62 0. 9 55 0. 8 Odds ratio* (95% CI) 3. 18 (1. 58 - 6. 39) 16. 6 (7. 40 - 37. 2) 5. 70 (2. 82 - 11. 5) 6. 01 (2. 90 - 12. 4) 34. 9 (12. 0 - 102) 2. 72 (0. 98 - 7. 51) 3. 60 (1. 87 - 6. 93) 30. 4 (9. 98 - 92. 3) 10. 7 (8. 88 - 39. 7) 4. 46 (2. 72 - 7. 32) 4. 57 (2. 91 - 7. 18) Subjects < 14, intravenous drug users, and transfused patients were excluded from the analysis. * Adjusted for sex, age, instruction level and area of residence in multiple logistic regression analysis. ** For females.

Risk factors associated to HAV: adjusted* O. R. (hepatitis B cases have been used by controls ) SEIEVA 1996 -2000 Risk factors Hepatitis A N. % Shellfish consumption 7085 (70. 6) 1325 (41. 9) 2. 41 (2. 17 -2. 68) Travel to high endemic areas 1519 (15. 5) 315 (10. 3) 4. 11 (3. 53 -4. 79) Household of day-care child 1227 (12. 0) 246 1. 51 (1. 26 -1. 82) Contact with an icteric cases 1021 (10. 7) ---- 10438 3620 N. of cases Controls N. % (6. 8) Adjusted O. R. 95% CI ---- * Adjusted for sex, age, area of residence, educational level and the other variables of the table.

Association between travel* and hepatitis A virus infection: adjusted** O. R. , SEIEVA 1996 -2000 Area of destination Adjusted O. R. 95% CI No travel 1. 00 -- Northern Europe, Northern America 1. 46 0. 92 -2. 34 Northern/Central Italy 0. 95 0. 78 -1. 15 Southern Italy 3. 03 2. 35 -3. 91 Mediterranean Area, Eastern Europe 3. 15 2. 42 -4. 11 Latin America, Asia, 9. 30 6. 71 -12. 9 Africa * Reported in the 6 weeks before the onset of the disease. ** Adjusted for age, gender, educational level, area of residence, shellfish consumption, contact with an icteric case and household of day-care child.

Association between travel* and hepatitis A virus infection: by area of residence. SEIEVA 1996 -2000 Area of residence adjusted** O. R. Northern and central Italy 95% CI Southern Italy/Islands Area of destination No travel 1. 00 -- Northern Europe, Northern America 1. 60 1. 00 -2. 57 0. 63 0. 07 -5. 34 Northern/Central Italy 1. 03 0. 84 -1. 26 0. 67 0. 37 -1. 20 Southern Italy 3. 70 2. 82 -4. 85 1. 25 0. 66 -2. 39 Mediterranean Area, Eastern Europe 3. 21 2. 47 -4. 19 1. 76 0. 19 -16. 3 Latin America, Asia, 9. 49 6. 83 -13. 2 0. 72 0. 15 -3. 52 Africa * Reported in the 6 weeks before the onset of the disease. ** Adjusted for age, gender, educational level, shellfish consumption, contact with an icteric case and household of day-care child.

SEIEVA FOR MONITORING PREVENTION PROGRAMS Vaccination of households of HBs. Ag carriers Vaccination of healthcare workers

SEIEVA FOR MONITORING PREVENTION PROGRAMS Hepatitis B cases among adolescents. SEIEVA 1992 -2001 Years Age 92 93 94 95 96 97 98 99 2000 2001 13 4 2 0 0 1 0 0 3 2 0 3 6 4 2 1 1 1 0 1 5 1 2 0 0 1 5 1 10 3 2 1 0 9 2 4 3 1 1 13 2 3 3 3 10 3 4 2 15 6 5 13 5 14 15 16 17 18 19 20 21 22 15

SEIEVA FOR MONITORING PREVENTION PROGRAMS Cases of n. An. B hepatitis associated with blood transfusion by year. SEIEVA 1987 -2001 Years Hepatitis (95% CI) non. A-non. B 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 4. 4 4. 5 4. 1 2. 9 1. 4* 0. 3** 0. 4 0. 1 0. 4 0. 2 0. 3 0. 5 0. 2 0. 3 (3. 2 -5. 6) (3. 5 -5. 6) (3. 1 -5. 1) (2. 1 -3. 7) (0. 8 -2. 0) (0. 1 -0. 6) (0. 2 -0. 7) (0. 0 -0. 3) (0. 1 -0. 6) (0. 2 -0. 4) (0. 2 -0. 5) (0. 2 -10. 5) (0. 05 -0. 4) (0. 1 -0. 4) (0. 2 -0. 6) * Compulsory of the ELISA-I test in the total blood bank ** Introduction of the ELISA-II test

Conclusions 1 Lessons from SEIEVA • SEIEVA is a useful tool for monitoring trends of acute viral hepatitis, for understanding the role played by each risk factor, and for establishing the priority and effectiveness of prevention programs.

Conclusions 2 Lessons from SEIEVA • Incidence of hepatitis B was decreasing in Italy before the vaccination campaign was launched. • Vaccination against hepatitis B has further contributed to the decline of HBV infection. • Invasive medical procedures represent an important mode of HBV and HCV transmission. • Intensive effort should be employed to increase vaccination coverage of specific risk groups. • Shellfish consumption and travels to endemic areas are major risk factors for hepatitis A.