viral hepatitis prevention and control in russia · 2014-12-03 · viral hepatitis clinical...

Viral Hepatitis Prevention and Control in Russia

Vladimir Chulanov

Two Decades of the VHPB: Achievements, Impact and Remaining Challenges in Prevention and Control of Viral Hepatitis

Antwerp, 13-14 November 2014.

Central Research Institute of Epidemiology Reference Center for Viral Hepatitis

Moscow, Russia

• Hepatitis A

• Hepatitis B

• Hepatitis C

• Incidence and prevalence of hepatitis B and C in Russia;

• Prevention and screening strategies;

• Chronic hepatitis B and C treatment options;

Presentation Outlines

165,5

117,2 110,1 109,9

123,5

87,4

50,4

34 30,2

57,3

79,36

46,9

28,3 30 30,2

15,7 10,3 8,1 7,3 6,3 4,3 5,5

0

50

100

150

200

250

5.8

204.3

per 1

00 0

00 p

opul

atio

n Incidence of Acute Hepatitis A in Russia

1990-2013

Official Bulletin of the Federal Center for Hygiene and Epidemiology, Russia

30,2

79,4 63,2

183,5

112,4

0

100.000

200.000

300.000

400.000

500.000

600.000

0

50

100

150

200

250

300

Hepatitis A immunizationIncidence of HAV children under 14 yearsIncidence of HAV total population

Incidence of Acute Hepatitis A and immunization program in Russia, 1999-2013

per 1

00 0

00 p

opul

atio

n

abso

lute

num

ber

Total n = 660 301 1 924 1 728 975 850 6 438

Rate of anti-HAV IgG in Different Age Groups 2004-2009, Russia

Rat

e of

ant

i-HAV

IgG

, %

0

10

20

30

40

50

60

70

80

90

<15 15-19 20-29 30-39 40-49 >50

27 25

36

47

56

81

Age

0

10

20

30

40

50

60

70

All Age Groups <20 20-40 >40

62

40

49

69

44

24

38

65

20042009

Total n = 338 1984 86 217 168 1182 84 585 4730

Decrease in the Seroprevalence of HAV 2004-2009, Russia

Rat

e of

ant

i-HAV

IgG

, %

0

10

20

30

40

50

60

70

All Age Groups <20 20-40 >40

62

40

49

69

44

24

38

65

20042009

Total n = 338 1984 86 217 168 1182 84 585 4730

Decrease in the Seroprevalence of HAV 2004-2009, Russia

Rat

e of

ant

i-HAV

IgG

, %

Incidence of acute Hepatitis B in Russia 1999-2013 (per 100 000 population)

43,7

1,3 0,0

5,0

10,0

15,0

20,0

25,0

30,0

35,0

40,0

45,0

50,0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Incidence of acute Hep B in different age groups in Russia, 1997-2007 (per 100 000 population)

32,6

13,8 6,6 5,7 7,1

12,6

141,9

102,5

24,1

12,3 7,4 3,1 5,2 1,3 0,2 0,3 0,2 0,5

5,6 17,7

7,5 3,4 2,1 0,7 0

20

40

60

80

100

120

140

160

1997

2007

Age groups

Age

grou

ps

per 1

00 0

00 p

opul

atio

n

5,2 5,6

17,7

7,5

1,3 0,0 0,0 0,0 0,1 0,4

2,9 3,4

0

2

4

6

8

10

12

14

16

18

2007200820092010201120122013

Age groups

per 1

00 0

00 p

opul

atio

n Incidence of acute Hep B in different age groups

in Russia, 2007-2013 (per 100 000 population)

Proportion of IDUs among Acute Hepatitis B Cases in Russia, 1997-2013

10743

11248

16486

15233

9584

3515 2108

1489 1263 938 905 654 600 447 360 259 332

0

5

10

15

20

25

30

35

40

45

0

2.000

4.000

6.000

8.000

10.000

12.000

14.000

16.000

18.000

Proportion of IDU Absolute number of IDU

Abs

olut

e nu

mbe

rs

%

Reference Center for Viral Hepatitis, 2014

Hepatitis B immunization coverage, Newborns, 1999-2013, Russia

2,8 9,4

42,7

80,5

93,6 96,1 97,2 97,7 98 98,5 98,1 97,9 97,7 97,7 97,7

0102030405060708090

100

%

Hepatitis B immunization coverage, Teenagers, 1999-2013 Russia

1,7 6,5 8,2

24,1

36,5

49,1

60,1

92,7 97,8 98,6 99 99,2

99,3 99,3 99,5

0102030405060708090

100

%

0

10

20

30

40

50

60

70

80

90

0,1 0,8 2,0 4,5 7,5 10,6 13,9

24,9 27,9 30,0 31,7 33,4 35,1 36,8 38,5

0,04 0,1 0,4 0,7 1,8 3,5 6,5 10,0 13,6 17,3

29,1

39,0

52,1

64,2

71,3 74,5 80,2

84,4 mln

Children under 14 General Population

Cumulative Number of Hep B Vaccinated People in Russia, 1996-2013

Incidence of acute and chronic HBV infection in Russia 1999-2013 (per 100 000 population)

43,7

1,3

109,5

29,7

0,0

20,0

40,0

60,0

80,0

100,0

120,0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

acute HBV chronic HBV and HBV carriage

0

0,5

1

1,5

2

2,5

3

3,5

4

4,5

5

2004 2005 2006 2007 2008 2009

3,8

2,4 2,1 2,1

1,8 1,9

≈ 2.0%

Total n = 5 817 14 631 25 056 35 853 56 735 48 154 186 495

Prevalence of HBV Infection in Moscow, 2004-2009

Rat

e of

HB

sAg

dete

ctio

n, %

0

5

10

15

20

25

30

35

40

45

CHC AHC

Incidence of Acute and Chronic Нep С Russia, 1999-2013 (per 100 000 population)

21.1

1.5

39.2

12.9

Incidence of CHC in different age groups Russia, 2010

17,9

32,4

43,1

92,4

70,3

16,4

2,0

1,2

2,1

3,0

3,5

0,0 10,0 20,0 30,0 40,0 50,0 60,0 70,0 80,0 90,0 100,0

> 60 лет

50-59 лет

40-49 лет

30-39 лет

20-29 лет

15-19 лет

11-14 лет

7-10 лет

3-6 лет

1-2 года

до 1 года

Per 100 000 population

95,9%

4,1%

anti-HCV (-)anti-HCV (+)

n=43,866

Rate of anti-HCV detection in General Population in Moscow, 2005-2009

Viral Hepatitis Screening Programs in Russia

Screening groups Schedule - Blood donors At every donation

- Pregnant women During I and III trimester

- Newborns of women with CHB or CHC 0, 3,6 months; 1, 2, 3 years of age

- Health care workers At hiring, then every year

- In-patients At the point of admission

- Out-patients (Drug and alcohol abuse clinics, STI clinics)

At the first appointment; then every year

- Patients on hemodialysis At the first appointment; then on regular basis

- Orphanage At admission; then every year

- Households and contacts At index case identification; then every year

- Military personnel At hiring; then every year

Sanitary and Epidemiological Regulations СП 3.1.958-00

Nosocomial Acute Hepatitis B and C in Russia

0

200

400

600

800

1000

1200

1400

1600

1800

2000

2200

Acute Hep B Acute Hep C

Abs

olut

e nu

mbe

rs

Reference Center for Viral Hepatitis, 2014

Additional HCV Screening Programs in Russia (2014)

Screening groups Schedule - Risk groups As soon as risk factor identified

- IDUs and their sexual partners

- Sex workers and their sexual partners

- MSMs

- Prisoners At admission

Sanitary and Epidemiological Regulations СП 3.1.3112-13

HCV RNA + anti-HCV Screening Programs (2014)

Screening groups Schedule - Donors of blood, tissues and sperm At every donation

- Newborns of women with CHC or HIV 2, 6 and 12 months

- Immunocompromised patients

- Patients with liver disease of unknown etiology

As soon as the condition diagnosed

- Patients on hemodialysis At the first appointment; then on regular basis

- Households and contacts At index case identification; then every year

Sanitary and Epidemiological Regulations СП 3.1.3112-13

Treatment Options

Chronic Hepatitis B

• Nucleoside Analogues – Lamivudine – Telbivudine – Entecavir – Tenofovir

• IFNs – Standard – Pegylated

Chronic Hepatitis C

• IFNs – Standard – Pegylated

• Ribavirin • NS3 Protease Inhibitors

– Boceprevir – Telaprevir – Simeprevir

Viral Hepatitis Clinical Guidelines

• Guidelines for the diagnosis and treatment of adult patients with hepatitis C. Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2013; 23 (2): 41-70. [in Russian].

• Clinical guidelines of the Russian Gastroenterological Association and the Russian Society for the Study of liver for the diagnosis and treatment of adult patients with hepatitis B. Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2014; 3: 58-88. [in Russian].

Current Issues and Future Challenges

• Development of sound National Strategy on Viral Hepatitis;

• Improvement of Access to diagnostics and treatment;

• Improvement of viral hepatitis surveillance system;

• Increasing awareness;

• Decreasing stigmatization;

43

9 1,7 1,1

0

10

20

30

40

50

60

70

80

90

100

All HCV infected anti-HCV tested HCV care Treated Cured

Reference Center for Viral Hepatitis, 2012

Cascade «Screening-Care-Treatment» in Russia

Federal Service on Inf. Dis. Surveillance

Federal Ministry of Public Health

Regional MPH

Municipal Health Administration

Municipal clinic

Regional Service on IDS

Regional Center for H&E

Local Dep. of RS on

IDS

Local Branch of RC for H&E

Regional Hepatology

center

Federal Center for Hygiene and Epidemiology Federal Level

Regional Level

Municipal Level

Adm.

Officer

Tertiary center

Organogram of the Federal Viral Hepatitis Registry

Physician

Chief Physician

Administrator

Nurse

Pharmacist

Control of completeness of registration and quality of clinical supervision

Adm.

Officer

Adm.

Officer

Adm.

Officer

Adm.

Officer

Adm.

Officer

Adm.

Officer

Adm.

Officer

Reference Center for Viral Hepatitis

Adm.

Analyst

Tech. support

Conclusions • Over the last 10 years a steep decline in the

incidence of acute Hep A, B and C cases was observed. However the burden of chronic infection due to Hep B and C is still very significant.

• Universal vaccination against Hep B was implemented in 2002. By January 2014 more than 80 mln people had been vaccinated.

• An extensive range of obligatory screening programs for Hep B and C are in place, covering major risk groups;

• An access to treatment programs for chronic Hep B and C is very limited

• National strategy on Viral Hepatitis needs to be developed;