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OVERVIEW of HBV:
INFECTIONSROUTE of TRANSMISSIONVACCINATION
byMERAL A ÇIBLAK
SELİM BADUR
İstanbul School of Medicine, İstanbul University,TR
1
TURKEY
POPULATION ~72 millionUrban Population 59,01 %Rural Population 40,99 %
Ages 0-14 29.7 %Ages 20-24 9.9 %Ages 25-45 29.3 %OVER 45 31.1%
2
TurkeyA Country of “Intermediate Endemicity”
for HBV Infections
3-8 % of population is (+) for HBsAg 1/3 of the population is (+) forAnti-HBs
Characteristics of HBV Infections inTurkey
HDV co/superinfectionPrecore MutantsGenotype D (>99 %)
3
Number of Hepatitis B Cases
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
1990 1992 1994 1996 1998 2000 2002 2004
Data from MoH, Turkey
4
AETIOLOGICAL CLASSIFICATION OF HOSPITALIZEDACUTE VIRAL HEPATITIS CASES IN TURKEY (ADULTS)
CITY STUDYGROUP
N HBV(%)
HAV(%)
HCVHCVHCV(%)(%)(%)
HEVHEVHEV(%)(%)(%)
ANKARA Kurt, 1995 1022 76.0 17.1 6.86.86.8 NANANA
BURSA Mıstık, 1998 135 55.2 42.3 2.22.22.2 NANANA
DİYARB. Geyik, 1998 148 61.1 22.9 2.02.02.0 14.814.814.8İSTANBUL Özgüneş, 1998 720 68 26 1.41.41.4 NANANA
İZMİR Okan, 2000 518 61.3 28.1 2.02.02.0 NANANATOTAL 4471 60.4 27.5 5.55.55.5 0.50.50.5
5
AETIOLOGICAL CLASSIFICATION OF HOSPITALIZED ACUTEVIRAL HEPATITIS CASES IN TURKEY (CHILDREN )
CITY STUDYGROUP
N HBV(%)
HAV(%)
HCVHCVHCV(%)(%)(%)
ADANA Şahin, 1998 338 35.8 38.6 0.50.50.5
ANKARA Uysal, 1998 364 7.7 87.9 0.30.30.3
İSTANBUL Sıdal, 1990 160 24.0 66.0 10.010.010.0
TOTAL 912 22.4 63.1 2.12.12.1
6
AETIOLOGICAL CLASSIFICATION OF CHRONIC HEPATITIS IN İSTANBUL (%)
YEAR HBV HCV HBVHBVHBV+++HDVHDVHDV
HBVHBVHBV+++HCVHCVHCV
OTOIOTOIOTOIMMM---
CRYPTOCRYPTOCRYPTO--- DRUG DRUG DRUG
1991-1994n=296
56 23 6.86.86.8 333 1.51.51.5 0.70.70.7 0.7 0.7 0.7
1994-1997n=527
46.5 35 4.54.54.5 333 1.51.51.5 0.20.20.2 0.20.20.2
1998-2001n=1104
56.9 38.1 2.92.92.9 0.70.70.7 1.91.91.9 000 000
Ökten A, 2005, İstanbul
7
AETIOLOICAL CLASSIFICATION of CIRRHOSIS IN İSTANBUL (%)
YEAR HBV HCV HDVHDVHDV HBV+ HBV+ HBV+ HCVHCVHCV
ALCOALCOALCO CRYPCRYPCRYP MISCMISCMISC
1990-1993n=436
56.5 25.2 14.614.614.6 3.73.73.7 12.612.612.6 22.722.722.7 888
1994-1997n=393
42.6 34.5 15.715.715.7 1.21.21.2 10.910.910.9 16.816.816.8 12.812.812.8
1998-2001n=573
45.9 31.3 19.619.619.6 3.23.23.2 12.412.412.4 16.416.416.4 12.112.112.1
Ökten A, İstanbul, 2005
8
COMPARISON of AETIOLOGICAL CLASSIFICATION OF HEPATOCELLULAR CARCINOMA
Low Risk Countries(America-Europe)
(%)
Turkey(%)
High Risk Countries
(Africa-Asia)(%)
HBV <15 56 60
HCV 60 21 <10
ALCOHOL <15 16 11-30
CRYP. - 13 -
Ökten A et al., İstanbul, 2005
7/34
8.8/44.4
8.9/41.2
4.5/17
6.7/27.5
6.9/50
4.6/21.3
4.9/34
7.9/28
3.7/21.6
4.4/16
3.5/19.8
Regional Differences in HBsAg/Anti-HBs Positivity (%)
10
WHY REGIONAL DIFFERENCES?
Poor socio-economic status
Traditional life-styles
Infrastructure
Lack of access to “sufficient” health services
11
Age Dis tribution of HBV Infections ,Turkey
0
10
20
30
40
50
60
Age groups
Hbs Ag 1.4 1.7 4.3 9.9 10.6 8.6 7.1 8.1 2.8 6.5 10.3 0 2.1
anti-HBs 6.9 3.4 19 25.3 14 21.8 34.7 35.5 31.3 21.7 48.7 37.5 29.2
0--5 6--10 11--15 16--20 21--25 26--30 31--35 36--40 41--45 46--50 51--55 55--60 60 +
Tansuğ, 1999, İzmirEmiroğlu, 2000, Şırnak
Şahin, 1998, AdanaYousefi, 1999, AnkaraPahsa, 1999, İstanbul
12
Anti-HBc Positivity in Various Age Groups
Age Group Number Anti-HBc Positivity (%)
0-1 57 1.8
2-5 132 0.8
6-10 178 1.7
11-14 147 6.8
15-19 203 11.8
Total Number 717 5.4
Oktun M et al., 2001, Edirne
13
HBV Seropositivity in Children at a Children’sShelter
Age Group Number HBV Seropositivity (%)
0-6 32 25
7-12 45 63
13-22 40 60
Mıkla Ş et al., 1995, İstanbul
14
Age Distribution of HBV Cases,Turkey
(1997-2005)
0
1000
2000
3000
4000
5000
6000
7000
8000
0 1-4 5-9 10-14 15-44 45-64 65+ Total
1997 1998 1999 2000 2001 2002 2003 2004 2005
15
Routes of Transmission for Acute HBV Cases
Probable Route USA(%)
FR(%)
TR1
(%)
TR2
(%)
Unknown 26 31.5 44.4 38.1
Sexual 55 34 9.2 1.03
IVDU 12 25 0.2 -
Close Contact 4 4 7.5 8.2
Surgical Intervention 2 2 22.1 38.1
Others 1 2.5 15.2 14.41 Mıstık, 19972 Birengel, 2003
16
HBsAg Positivity in Pregnant Woman in VariousRegions, Turkey, 1990s
City Study Group N HBsAg (+)%
Kayseri Abacı IM et al.,1995 400 3.8
İstanbul Çepni İ et al.,1996 4078 4.4
İzmir Erensoy S et.al, 1996 760 4.2 (HBeAg %15)
Denizli Kaleli İ et al.,1997 312 7.7 (HBeAg % 8.3)
Sivas Poyraz Ö et al., 1999 95 6.3 ( HBeAg % 1.1)
17
HBsAg Positivity in Pregnant Woman in VariousRegions, Turkey, 2000s
City Study Group N HBsAg (+)%
Ankara Biri et al., 2001 451 7
Diyarbakır Turhanoğlu M et al., 2001 260 12.3(HBeAg % 4.6)
İstanbul Karaca Ç et al., 2003 460 4.7
Şanlıurfa Harma M et al., 2003 136 7.3
Afyon Yılmazer M et al.,2004 244 2.9
Mersin Börekçi G et al., 2004 114 3.5
18
VACCINATION
EPI, 1991WORLD HEALTH ASSEMBLY, 1992WHO, 1994
THE GOAL?
19
Still a lot of high endemicregions to cover
168 countries in theworld have a universalhepatitis B programme
by the end of 2005
Fig 1. Global status of countries using HepB vaccine in theirnational immunization system, May 2002
Yes No
June 2002
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which theremay not yet be full agreement.
Routine HepB implementation status
MoH Recommendations for HBV Immunization (1998)
1. DOSE At birth
2. DOSE 3th month
1. DOSE 3rd month
1. DOSE Anytime
2. DOSE 1 mo.after the 1st 3. DOSE 5 mo. after the 2nd
3. Alternative( For infants >3 month)
2. DOSE 4th month2. Alternative(Infants born outsideHealth facilities)
3. DOSE 9th month
3. DOSE 9th month
1. Alternative( routine
immunisation)
MoH Recommendations for HBV Immunization (2003)
1. DOSE At birth
2. DOSE 3th month
1. DOSE 3rd month
1. DOSE Anytime
2. DOSE 1 mo.after the 1st 3. DOSE 5 mo. after the 2nd
3. Alternative( For infants >3 month)
2. DOSE 4th month2. Alternative(Infants born outsideHealth facilities)
3. DOSE 9th month
3. DOSE 9th month
1. Alternative( routine
immunisation)
22
Hep B Immunization PolicyWHO European Region, 2004
Universal infant
Universal newborn
Universal adolescentNo universal HepBimmunization
23
MoH Recommendations for HBVImmunization (2006)
1st Dose At birth2nd Dose At the end of 2nd month3rd Dose At the end of 9th month
andAll Three Doses For 8th Graders (15 years of age)
24
7267
64
7773
66
8380
72
7876
72
7874
68
88 87
77
0
10
20
30
40
50
60
70
80
90
100
Cov
erag
e ra
te (%
)
1999 2000 2001 2002 2003 2004Ye ar
Hepatitis B Vaccination Coverage, 0 Age Group,
Turkey, 1999-2004
HBV-1HBV-2HBV-3
25
0 Age Group Vaccination Rates 2001-2005, Turkey
( MoH Vaccination)
82 83
72
84
38
77 7872
82
37
76
68 68
75
37
7985
7781
41
8884
8084
47
%30
%40
%50
%60
%70
%80
%90
%100
BCG DPT-3 HBV-3 Measels TT-2+2001 2002 2003 2004 2005
26
Regional Rates for 3-dose-HBV Vaccination
% Coverage<50%50-79%80-89%
27
FUTURE DIRECTION