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)

11/22

1/1

22/22

5/5

1/44

1/5 2/6

13/13

12/12 13/13

12/12

2/5

2/6

13/13

12/12

2/5

1/11

2/9

5/22

1/5

HBsAg IgM anti-HBc IgM anti-HAV

Anti-HCV Anti-Delta HepatitisType

+ o - + o - + + o - + o - A

+ o - + - + o - + o - B

+ o - - - + + o - C

+ o - + + o - + o - + D

- - - - - nAnBnC

NA/M NA/M NA/M NA/M NA/M Unknown

Serological definition of types of viral hepatitis

SEIEVA

Incidence

Distribution of notified cases of viral hepatitisSEIEVA

Hepatitis C

7,8%

Hepatitis B

24,1%

Hepatitis A

65,7%

nAnBnC2,4%

1987 - 1990 1997 - 2001

Hepatitis nAnB23,6%

Hepatitis B

56,5%

Hepatitis A

19,9%

1985

- 1

994

1995

- 2

001

Case fatality rate of viral hepatitis in Italy by type Hepatitis type No. Deaths/ No. Cases % 95%CI

A 1/6,353 0.02 0.0 – 0.1

B 40/7,907 0.5 0.3 – 0.7

Delta 1/422 0.2 0.0 – 0.7

nAnB 19/4,120 0.5 0.2 – 0.7

C 1/909 0.1 0.0 – 0.3

Unspecified 9/1,842 0.5 0.2 – 0.8

Total 71/21,553 0.3 0.2 – 0.4

Hepatitis type No. Deaths/ No. Cases % 95%CI

A 2/12148 0.02 0.0 – 0.1

B 18/4881 0.4 0.2 – 0.6

Delta 0/47 0.0 0.0 – 7.9

C 2/1722 0.1 0.0 – 0.4

Unspecified 5/1774 0.3 0.1 – 0.6

Total 27/20572 0.1 0.1 – 0.2

YearsType ofhepatitis 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 2000 2001

A 10 4 2 2 2 2 4 6 5 6 3 7 19 6 3 3 3

B 12 12 10 7 6 5 5 4 4 3 3 3 3 3 2 2 2

nAnB 5 4 3 3 3 2 2 2 2 2 1 1 1 1 1 0.6 1

Unknown 3 3 2 2 1 1 1 2 1 1 0.3 0.2 0.3 0.3 0.2 0.3 0.2

Total 30 23 17 14 12 10 12 14 12 12 7.3 11.2 23.3 10.3 6.2 5.9 6.2

Incidence rates (cases x 100,000) of viral hepatitis

in Italy by type, SEIEVA 2001

05

1015202530354045

0-1415-2425 e +Total

An

ti-h

epa

titi

s B

vac

cin

ati

on

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

02468

1012141618

0-1415-2425 e +Total

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

0

10

20

30

40

50

60

0-1415-2425 e +Total

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

0

5

10

15

20

25

30

35

40

45

50

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

North-Center

South-Islands

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 HBsAg+ 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 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

Risk factors of hepatitis C: adjusted* O.R. SEIEVA 1998-2000

Adjusted OR and 95% CI for different types of invasive procedure among hepatitis B cases. SEIEVA 1996-2000.

Intervention type Hepatitis B Hepatitis A Odds ratio*(2689 cases) (6701 cases) (95% CI) n % n %

Minor surgery 44 1.6 37 0.6 1.98 (1.19- 3.29)Gynaecological** 21 0.8 18 0.3 3.69 (1.77 - 7.73)Orthopaedic 19 0.7 29 0.4 1.93 (0.96 - 3.28)Abdominal 41 1.5 30 0.4 3.75 (2.09 - 6.72)Cardiovascular 21 0.8 5 00.7 6.56 (2.20 - 19.5)Dermatological 31 1.1 15 0.2 3.00 (1.53 - 5.86)Oral surgery 63 2.3 40 0.6 3.14 (1.97 - 4.99)Ophtalmological 10 0.4 5 00.7 3.85 (1.17 - 12.8)Urological 13 0.5 6 00.9 4.88 (1.54 - 15.4)Other intervention 66 2.4 62 0.9 2.37 (1.57 - 3.57)Biopsy/endoscopy 80 2.9 55 0.8 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.

Intervention type Hepatitis C Hepatitis A Odds ratio* (709 cases) (6701 cases) (95% CI) n % n %

Minor surgery 13 1.8 37 0.6 3.18 (1.58 - 6.39)Gynaecological ** 19 2.7 18 0.3 16.6 (7.40 - 37.2)Orthopaedic 17 2.4 29 0.4 5.70 (2.82 - 11.5)Abdominal 13 1.8 30 0.4 6.01 (2.90 - 12.4)Cardiovascular 19 2.7 5 00.7 34.9 (12.0 - 102)Dermatological 6 8.4 15 0.2 2.72 (0.98 - 7.51)Oral surgery 15 2.1 40 0.6 3.60 (1.87 - 6.93)Ophtalmological 14 2.0 5 00.7 30.4 (9.98 - 92.3)Urological 6 8.4 6 00.9 10.7 (8.88 - 39.7)Other intervention 30 4.2 62 0.9 4.46 (2.72 - 7.32)Biopsy/endoscopy 40 5.6 55 0.8 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.

Adjusted OR and 95% CI for different types of invasive procedure among hepatitis C cases. SEIEVA 1996-2000.

Risk factors associated to HAV: adjusted* O.R. (hepatitis B cases have been used by controls )

SEIEVA 1996-2000Risk Hepatitis A Controls Adjusted O.R.factors N. % N. % 95% CI

Shellfish 7085 (70.6) 1325 (41.9) 2.41consumption (2.17-2.68)

Travel to high 1519 (15.5) 315 (10.3) 4.11endemic areas (3.53-4.79) Household of 1227 (12.0) 246 (6.8) 1.51day-care child (1.26-1.82)

Contact with an 1021 (10.7) ---- ----icteric cases

N. of cases 10438 3620

* 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 Adjusted O.R. 95% CIdestination

No travel 1.00 --

Northern Europe, 1.46 0.92-2.34Northern America

Northern/Central Italy 0.95 0.78-1.15

Southern Italy 3.03 2.35-3.91

Mediterranean Area, 3.15 2.42-4.11Eastern Europe

Latin America, Asia, 9.30 6.71-12.9Africa

* 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

adjusted** O.R. 95% CIArea of residence Northern and central Italy Southern Italy/Islands

Area of destination

No travel 1.00 -- 1.00 --

Northern Europe, 1.60 1.00-2.57 0.63 0.07-5.34 Northern America

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, 3.21 2.47-4.19 1.76 0.19-16.3 Eastern Europe

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 HBsAg carriers

Vaccination of healthcare workers

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

14 3 6 4 2 1 1 1 0 1

15 5 1 2 0 0 1 0 1

16 5 1 10 3 2 1 0

17 9 2 4 3 1 1

18 13 2 3 3 3

19 10 3 4 2

20 15 6 5

21 13 5

22 15

SEIEVA FOR MONITORING PREVENTION PROGRAMS

Cases of nAnB hepatitis associated with blood transfusion by year. SEIEVA 1987-2001

Years Hepatitis (95% CI) nonA-nonB1987 4.4 (3.2-5.6)1988 4.5 (3.5-5.6)1989 4.1 (3.1-5.1)1990 2.9 (2.1-3.7)1991 1.4* (0.8-2.0)1992 0.3** (0.1-0.6)1993 0.4 (0.2-0.7)1994 0.1 (0.0-0.3)1995 0.4 (0.1-0.6)1996 0.2 (0.2-0.4)1997 0.3 (0.2-0.5)1998 0.5 (0.2-10.5)1999 0.2 (0.05-0.4)2000 0.2 (0.1-0.4)2001 0.3 (0.2-0.6)

* Compulsory of the ELISA-I test in the total blood bank** Introduction of the ELISA-II test

SEIEVA FOR MONITORING PREVENTION PROGRAMS

• 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.

Conclusions1

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.

Conclusions2Lessons from SEIEVA