Need for Chronic Viral Hepatitis Monitoring System

Transcription

1 Need for Chronic Viral Hepatitis Monitoring System Harry L.A. Janssen Dept. of Gastroenterology & Hepatology Erasmus University Medical Center Rotterdam The Netherlands Rotterdam November 2008

2 National Strategy on HBV and HCV Main targets: Monitoring Prevention Early Diagnosis Access to Care Should involve: National Leadership Public Health Networks Advocacy Groups Prioritized HBV, HCV Research

3 HBV/HCV Involves Several Policy Areas HBV policy

4 Why is management of Viral Hepatitis Suboptimal? POOR MANAGEMENT OF PREVENTION, DIAGNOSIS, TREATMENT OF HEP B /C Physicians LOW AWARENESS OF BURDEN AND INFECTIOUSNESS OF DISEASE Citizens, patients FUNDING CONSTRAINTS LEAD TO LACK OF RESOURCES FOR MANAGEMENT OF HEP B/C Budget holders Policy makers LOW PRIORITY FOR MOST POLICY MAKERS AND GOVERNMENTS

5 Why do we need viral hepatitis monitoring in The Netherlands? To assess the magnitude of the problem of viral hepatitis To clarify mortality statistics To assess the effect of immigration and travel To monitor the effect of treatment. Because there is effective treatment nowadays.

6 Why do we need viral hepatitis monitoring in The Netherlands? To assess the magnitude of the problem of viral hepatitis To clarify mortality statistics To assess the effect of immigration and travel To monitor the effect of treatment. Because there is effective treatment nowadays.

7 Transmission Mother to Child Sexual Contact Blood HBV HBV (HCV) HBV HCV

8 Death Death HBV/HCV Disease Continuum Resolution Stabilization Compensated Acute infection Chronic Hepatitis Cirrhosis HCC Asymptomatic carrier years Decompensation Transplantation Death

9 HBsAg prevalence in Europe Chronic HBV: 14 millions 36,000 deaths/yr

10 Epidemiology of hepatitis B in EU 7000 to 8000 newly diagnosed cases per year in EU Most affected age group: year, followed by year Men 1.8 times more affected than women Clustered to sub-populations Injecting drug users Sex workers Men who have sex with men HIV patients Prisoners Immigrants from high endemic regions HBsAg prevalence varies widely in Europe

11 Anti-HCV prevalence in Europe Chronic HCV: 9 million 86,000 deaths/yr

12 Epidemiology of hepatitis C in EU 27,000 to 29,000 newly diagnosed cases per year in EU Most affected age group: year, followed by yr Men 1.9 times more affected than women Clustered to sub-populations no sexual transmission Injected drug users HIV patients Prisoners Immigrants from high endemic regions HCV prevalence: high variability across MS Low: 0.5% in Scandinavian countries, Austria, The Netherlands High: 3% in Bulgaria, Greece, Italy, Romania

13 Why do we need viral hepatitis monitoring in The Netherlands? To assess the magnitude of the problem of viral hepatitis To clarify mortality statistics To assess the effect of immigration and travel To monitor the effect of treatment. Because there is effective treatment nowadays.

14

15 Worldwide Mortality WHO Regio Hepatitis B & C Original Recalculation HIV/AIDS TBC Malaria Africa 29,078 90,822 2,203, ,087 1,087,758 America 12,941 74, ,751 43,989 1,470 East Mediterrane 14,289 76,584 50, ,014 56,967 Europa 9, ,184 42,923 74, ZO Azie 50, , , ,527 64,462 West Pacific 40, ,360 46, ,693 10,531 World 156,079 1,380,796 2,819,227 1,603,814 1,221,330 Number of Death due to HCC and Cirrhosis caused by viral hepatitis. World Health Report 2003, Perz et al, J.Hepatol 2006

16 Why do we need viral hepatitis monitoring in The Netherlands? To assess the magnitude of the problem of viral hepatitis To clarify mortality statistics To assess the effect of immigration and travel To monitor the effect of treatment. Because there is effective treatment nowadays.

17 De prevalence of Hepatitis B China Nederland 8-10% %

18 Universal Hepatitis B Vaccination program Fig 1. Global status of countries using HepB vaccine in their national immunization system, May 2002 Routine HepB implementation status Yes No 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 there may not yet be full agreement. June 2002

19 Migrant population and migration rates in Europe Esteban et al. 2008

20 Impact of Migration Low national prevalence can mask the areas of high endemicity within the country K v in e s d a l B B ( ) G reece Panagopoulos et al (2004) D alekos et al (1995) Roudot-Thorval et al France (1989) C azal et al (1976) B e lg iu m Beutels et al (1997) Im m igrant population Indigenous population S p a in Vall M ayans, M et al (2002) Ita ly S tro ffo lin i T ( ) Baldo et al (2000) 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% Prevalence of HBsAg in host vs. immigrant populations

21 Why do we need viral hepatitis monitoring in The Netherlands? To assess the magnitude of the problem of viral hepatitis To clarify mortality statistics To assess the effect of immigration and travel To monitor the effect of treatment. Because there is effective treatment nowadays.

22 Advances in HBV Treatment 1957 Interferon discovered 1990 PMEA anti-hbv activity discovered TC anti-hbv and anti-hiv activity discovered 1998 Entecavir anti-hbv activity discovered 2001 Telbivudine anti-hbv activity discovered 2008 Tenofovir approved for HBV 1991 Interferon alfa-2b approved for HBV 1998 Lamivudine (3TC) approved as first nucleoside analogue for HBV 2002 Adefovir dipivoxil (PMEA prodrug) approved for HBV 2005 Entecavir and peginterferon alfa-2a approved for HBV 2006 Telbivudine approved for HBV Clinical Care Options (clinicaloptions.com/hep)

23 Resuls of Antiviral Therapy Chronic Hepatitis B Chronic Hepatitis C No response 10% Cure (%) % Cure Virus suppression 60% IFN 24 wk IFN 48 wk 1996 IFN Ribavirine 1998 PEG-IFN 2000 PEG-IFN Ribavirine Anno 2008

24 Viral hepatitis monitoring in The Netherlands What should be done?

25 Hepatitis Monitoring Mission statement To strengthen surveillance in order to reinforce detection, prevention and control of HBV and HCV in The Netherlands. Financial support for a national monitoring system for chronic HBV/HCV, as well as for treatment monitoring Monitoring/ data acquisition overlapping with HIV but in part separate organisational structure Disseminate the results to stakeholders for timely public health actions at national and EU level