Dr Mohammad Bilal

Hepatitis ‘B’ Infection in General Population MPH314-Communicable and NonCommunicable Diseases By; Dr. Muhammad Bilal Khan Roll No:16

Types of Viral Hepatitis A Source of virus

B

Chronic infection Prevention

D

Feces

Fecal-oral

No

E Feces

Blood/bloodderived body fluids Route of transmission

C Blood/bloodderived body fluids

Blood/bloodderived body fluids

Percutaneous Percutaneous Percutaneous permucosal permucosal permucosal Yes

Yes

Yes

Fecal-oral

No

Pre/postPre/postBlood donor Pre/postEnsure safe exposure exposure screening; risk exposure drinking water immunization immunization behavior immunization; modification risk behavior modification

Source: Center for Disease Control and Prevention (CDC)

HBV and HCV Pose an Even Greater Risk Then HIV

Source: Centers for Disease Control and Prevention, 1991

%age of Blood Borne Infection Due to Contaminated Inj. Contaminated Injections

%age of cases

50% 40%

40% 32%

30% 20% 10%

5%

0% HBV

HCV

HIV

Type of Infection

PMRC

Bloodborne Pathogens

Hepatitis B DEFINITION Hepatitis B is a potentially lifethreatening liver infection caused by the hepatitis B virus & causes both acute and chronic disease. It can cause chronic liver disease and put people at high risk of death from cirrhosis of liver and cancer

Introduction HBV 1st time Lurman described in 1885 AD DNA Virus (Double Shelled) Affects only man & Champanzee (primate).  Destroys if boiled at 1000 C for 1 minute.  Incubation Period = 2-5 months.  Can be prevented though vaccination.   

Source:Pakistan Research Repository, HEC,Gov. of Pakistan.

Hepatitis B Virus The virus is transmitted through blood and other body fluids of an infected personnot through casual contact

CTLT by CDC

Concentration of Hepatitis B Virus in Various Body Fluids High

Moderate

blood semen serum vaginal fluid wound exudates saliva

Low/Not Detectable urine feces sweat tears breastmilk CDC

Common Modes of Transmission in Developing Countries

 Perinatal (from mother to baby at birth)  Early childhood infections (inapparent infection through close interpersonal contact with infected household contacts)  Unsafe injections practices.  Blood transfusions  Sexual contact.

Key Determinants       

Age Gender Place Socio economic status Pregnancy Occupation Immunodeficiency

Natural History of Hepatitis B

CTLT-CDC

Geographic Distribution of Chronic HBV Infection

Hepatitis B virus infection is a major global health problem and the most serious type of viral hepatitis

HBsAg Prevalence ≥ 8% - High 2-7% - Intermediate <2% - Low

CDC

Global Patterns of Chronic HBV Infection  High (³8%): 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 CDC

Magnitude of the Problem  World wide an estimated two billion people have been infected with hepatitis B (HBV) virus  more than 350 million have chronic (longterm) liver infection  Hepatitis B is 50 – 100 times more infectious than HIV  250 million Hepatitis B cases reside in Asia  Hepatitis B is endemic in China and other parts of Asia. (Prevalence is 8%-10%)  Middle East and Indian sub-continent, an estimated 2% to 5% of the general population is chronically infected

Situation in Pakistan

        

Endemic Disease HBV prevalence is 2.5 % Age <10 Yrs is 10% of all hepatitis. WHO study showed Pakistan has 13.6 injection/person/year AKU and PMRC studies showed 13&14 inj WHO allows 3.5 injections/person/year Pakistan has the highest therapeutic use of injection world wide In Pakistan, the estimate is 4.5 million carriers with a carrier rate of 3-4%. The higher is the injection use the higher is chance of blood born infections WHO & PMRC

Prevalence of HBV in Pakistan I.

Provincial Status

%ages

4.30%

2.50%

2.40% 1.30%

Balochistan

Sindh

NWFP

Punjab

Provinces

PMRC

Existing Policies and Organizational Capabilities  EPI: Vaccination against HBV in <1yr  Prime Minister’s Program for Prevention and control of Hepatitis: – Launched in August 2005 (Actually started January 2006) – –

Total cost 2594.00 Millions Duration 5 years

PM’sHP&CP ,NIH

Prime Minister’s Program for Prevention and control of Hepatitis

 Major Objective of the Program were:

– Hepatitis B vaccination for high risk groups – Strengthen of Routine EPI – Safe injection, Blood transfusion and other invasive medical devices with proper SWM. – Surveillance Diagnostic Lab services and Epidemic response for Hepatitis infection – Advocacy and BCC strategy PM’sHP&CP ,NIH development

Prime Minister’s Program for Prevention and control of Hepatitis

 Major Achievements till date

– 473640 against target of 425000 high risk persons vaccinated – 25000000 Disposal syringes provided to 151 sentinel sites (Additional 1143310 syringes also given) – Hospital Waste management system established in 48 Districts out of 120 target Districts. – 50 out of 150 target, autoclaves provided for effective sterlization – 151 Teaching and DHQ hospitals have been equipped with requisite laboratory equipments, kits & reagents, consumables, medicines/Biologicals, hepatitis B vaccine PM’sHP&CP ,NIH

What Else to do?? Protecting one self from estimated risks and preventing the future loss by working upstream

Aim & Objectives Aim

Elimination of HBV from Pakistan

Objectives:

 To vaccinate 99% of the high risk groups among the general population of Pakistan in 05 Years.  To give awareness in 95-98% of general population in 05 years regarding the vaccination against HBV.

Rationale of the Intervention  For HBV control more active vaccination program needs to be launched especially in the high prevalence districts.  95% of the HBV infections can be prevented through vaccination. (PMRC)

Interventions For the Prevention & Control of Hepatitis B In General Population

Two strategies  

Prevention Control

Strategies……  Preventive Strategy: – Strengthening of Routine EPI Program  To improve drop out coverage  Separate catch up activities to vaccinate drop out children

– Supporting existing PM’s prog. for HP&C by  Vaccination of high risk groups – Occupational Groups (Doctors, Nurses, Lab. Technicians etc) – Pregnant women – Sex worker & IDU users – Patients on Dialysis

Strategies……contd.. – Mass vaccination of the general population by  Mandatory vaccination of school and college students  Mandatory vaccination for employees – Public employees – Private employees – Army  Mandatory vaccination for pregnant women during ANC

Strategies……contd..  Control Strategies: – Vaccination promotion campaign using;  IECs  Mass Media  Community awareness sessions  Involvement of the pvt. Sector. – Hepatitis B vaccination would be mandatory for immigrants – Promoting safe necessary injection practices – Involvement of stakeholders

Evaluation of the Interventions  Process Evaluation – % of the stake-holders involved. – IEC material printed & distributed in time. – % of fixed centres received vaccine in time. – Staff Hired in time. – Equipments procured and distributed in time. – Were IEC material useful?

Outcome Evaluation           

Prevalence of Hepatitis B infection % of children covered for HBV Drop out rate for HBV % of High risk Group vaccinated % of School and college students vaccinated % of employees vaccinated % of pregnant women vaccinated Case Fatality rate due to HBV infection % of General population vaccinated % of immigrants with Hepatitis B infection Carrier rate for Hepatitis B vaccine

Impact Evaluation  % of Population aware about Hepatitis B infection and its vaccination  % of population coming for vaccination to the fixed centers

Budget Estimates Total Estimated Cost 30 Billions Vaccine Purchase 18 Billions Salaries 5 Billions Procurement 2 Billions Monitoring & Evaluation 3 Billions  Health Promotion campaign 2 Billions     

LIFEISNOWHERE Life is no where? OR Life is now here!!

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