Epidemiology of Chronic Hepatitis B virus infection Dr Olufunmilayo Lesi Consultant Physician and Gastroenterologist College of Medicine, University of Lagos/LUTH July 2011

Management of Chronic Hepatitis B virus infection Lesi, Olufunmilayo MBBch, FWACP, FMCP Associate Professor,Department of Medicine, College of Medicine, University of Lagos Consultant Physician/Gastroenterologist, LUTH MARCH 2011

Learning Objectives What is Hepatitis Mode of transmission Burden of the disease

1. WHO. Hepatitis B Maynard JE, et al. In: Viral Hepatitis and Liver Disease. New York: Alan R. Liss, Inc CDC. Epidemiology & Prevention of Vaccine-Preventable Diseases. “The Pink Book.” 8th ed. 4. CDC. MMWR. 2001;50: RR-11. Global Impact of HBV A Significant Cause of Worldwide Morbidity and Mortality >2 billion have been infected 1 >2 billion have been infected 1 4 million acute cases per year 1 4 million acute cases per year 1 1 million deaths per year 1 1 million deaths per year million chronic carriers million chronic carriers 1 25% of carriers die from severe liver disease like chronic active hepatitis, cirrhosis, or liver cancer 1 25% of carriers die from severe liver disease like chronic active hepatitis, cirrhosis, or liver cancer 1 2nd most important carcinogen behind tobacco 3 2nd most important carcinogen behind tobacco 3 Causes 60% – 80% of all primary liver cancer 1 Causes 60% – 80% of all primary liver cancer 1

Breakdown of HBV-induced Deaths per Year (Total = 2m) Manifestation No. of Deaths Liver Cirrhosis 700, 000 Acute Hepatitis 500, 000 Chronic Hepatitis 400, 000 Hepatocellular Ca 300, 000 Fulminant Hepatitis 100, 000

HBV – a highly contagious virus 50–100 times more infectious than HIV Survives outside the body for at least 7 days HBV detectable 30–60 days after infection Virus remains in the body for variable periods of time. Chronic carriers have persistent infection and constitute : enormous reservoir of the virus source of infection for others HIV – human immunodeficiency virus WHO, 2008

HBV in Nigeria 7.3% -24% have evidence of CURRENT infection – (average 13.7%)-19 million Nigerians Chronic carriers may have Decreased life expectancy Reduced quality of life High lifetime costs associated with liver disease management and the consequences of HBV infection Healthcare costs increase with progression of CHB

HBV in NigeriaResearcher Place, year Population studied n Prevalence of HBsAg Anti-HBc Mutimer, Benin, 1994 general popn 15% Gasau Maiduguri, 1991 Gen.popn HCC cases 36%80%80%84.4% Olubuyide Ibadan, 1997 general popn 25% Otu 1987, Calabar HCC cases 20080% Ndububa, Ile-Ife, 2001 HCC cases 15461%

SOUTH WEST Ile-Ife: HBsAg Prevalence – Blood Donors (7.3%) – General Public (8.8%)(Durosinmi et al, 1991) – CLD Patients (70.8%), (Ojo et al, 1998) – HCC (61 %) (Ndububa et al, 2001 & 2005) Ibadan: HBsAg Prevalence – Healthy controls (24%) Lagos: – Hospital Staff (surgeons 25.7%, – Hospital administrators 15%)(Belo, 2000) –

SOUTH EAST Nsukka: HBsAg rate 9.1%, > 1 HBV marker (66%) > 1 HBV marker by age 40 (87%)  Rural population affected more than urban (Amazigo & Chime, 1990)

SOUTH-SOUTH HBsAg Prevalence Rate Benin City, 10.4% (Abiodun et al, 1994 Malnourished children, 27% Day Care children, 20% (Akenami et al, 1997) A & E patients, 29.3% (Halim et al, 2001)

NORTH CENTRAL Ilorin: HBsAg Prevalence Rate - General, 23.4% - Blood donors, 21.7% - ANC patients, 16% STD patients, 36% (Bada et al, 1996) Zaria: Under 5 years, 40% – Adults 30 yrs & above, 10% (Anti-HBs, 62.5%) HBsAg in HCC, 49% (Fakunle et al, 1977 & 1981)

NORTH EAST Maiduguri: HBsAg in – blood donors, 14.9% (Chikwem et al, 1999) – Anti-HBc in healthy controls, 84.4% (Gashau & Mohammed, 1991) Jos: HBsAg Prevalence – General, 10% - Students, 13% - Traders, 14% (Sirisena et al, 2002)

Who is number 12? A global disease awareness campaign slogan of the World Hepatitis alliance World Hepatitis Day-July 28

Who is number 8? Average prevalence rate about 13.7% 19 million Nigerians with current infections population 150,000,000

How do we get hepatitis infection? What social, economic and political factors contribute to driving this epidemic?

Infection mostly acquired in childhood in Nigeria! Unsafe injections in childhood Child to child transmission Mother to child Infants born to hepatitis B positive mothers Predominant mode of transmission in Nigeria and sub-Saharan Africa (over 70% of children have markers of infection by age 10yrs) 70-90% of these children will become chronic carriers

Unsafe injection Practices 8-12 billion injections are given in healthcare settings around the world annually – In developing countries over 50% of these are unsafe – Associated with 800,000 HIV infections/y – Associated with 10 million with hepatitis infection In Nigeria- native/cultural practices and scarification marks, uvulectomy, manicurs, acupuncture etc

Global annual incidence, deaths, years of life lost, and costs resulting from unsafe injection practices for hepatitis B, C and HIV infection using best case assumption (WHO 1999) Hepatitis BHepatitis CHIVTotal Annual incidence of infection from unsafe injections(x 10 6) Future deaths (x 10 6) No of years of life lost(x 10 6) Direct medical costs of disease (x 10 6) USD

Contact with blood from an infected person – Transfusion of infected blood – Paid/commercial blood donors – IV drug abuse – Contaminated needles/ sharps – Scarification marks – Ear piercing – Circumcision – manicures

Sexual contact with an infected person Predominant route of infection in low prevalence regions such as in Europe and America Affects mostly adolescents and adults Infection commonly clears and persists to chronic infections in <10%

Developed worldDeveloping world (USA, Canada &(SEA, China & sub- western Europe) Saharan Africa)  Sexual contactVertical & Horizontal & IV drug abuse transmission (80% of cases) Modes of Transmission

Lok ASF, et al. Hepatology. 2001;34:1225. Reprinted with permission of Wiley-Liss, Inc, a subsidiary of John Wiley & Sons, Inc. Prevalence of HBV Serologic Markers in Population Groups Who Should Be Tested for HBV Infection Prevalence of HBV Serologic Markers (%) PopulationHBsAgAny Marker Persons born in high endemic areas*1370–85 Men who have sex with men635–80 Injection drug users760–80 Dialysis patients3–1020–80 HIV infected patients8–1189–90 Pregnant females (USA)0.4–1.5 Family/household and sexual contacts3–630–60 *Africa; Southeast Asia, including China, Korea, Indonesia, and the Philippines; the Middle East, except Israel; South and Western Pacific Islands; the interior Amazon River basin; and certain parts of the Caribbean (Haiti and the Dominican Republic)

In Summary

Do you know your hepatitis B status? B Aware B Tested B treated Thank You