SEIEVA Integrated Epidemiological System for Acute Viral Hepatitis Alfonso Mele Catania, November

SEIEVAAIMS Monitor epidemiological trends Identify risk factors Formulate and monitor prevention strategies

SEIEVAMETHODOLOGY 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

Serological definition of types of viral hepatitis SEIEVA

Incidence

Distribution of notified cases of viral hepatitis SEIEVA

Case fatality rate of viral hepatitis in Italy by type

Incidence rates (cases x 100,000) of viral hepatitis in Italy by type, SEIEVA 2001

Anti-hepatitis B vaccination Incidence of notified case of hepatitis B in Italy by age-groups. SEIEVA

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

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

Incidence (cases per 100,000) of hepatitis A in Italy by geographical area. SEIEVA

Risk Factors

Risk factors of hepatitis B: adjusted* O.R. SEIEVA Risk factors adjusted OR 95% CI Blood transfusion 2.35( ) Intravenous drug use 6.78 ( ) Surgical intervention 2.44 ( ) Dental therapy 1.35( ) Other parenteral exposures 1.67( ) > 1 sexual partner ** 1.75( ) Household of HBsAg+ 10.1( ) * 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( ) Intravenous drug use 38.0( ) Surgical intervention 7.02( ) Dental therapy 1.53( ) Other parenteral exposures 1.65( ) > 1 sexual partner ** 0.76( ) *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

Adjusted OR and 95% CI for different types of invasive procedure among hepatitis B cases. SEIEVA Intervention type Hepatitis B Hepatitis AOdds ratio* (2689 cases)(6701 cases) (95% CI) n % n % Minor surgery ( ) Gynaecological** ( ) Orthopaedic ( ) Abdominal ( ) Cardiovascular ( ) Dermatological ( ) Oral surgery ( ) Ophtalmological ( ) Urological ( ) Other intervention ( ) Biopsy/endoscopy ( ) 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 ( ) Gynaecological ** ( ) Orthopaedic ( ) Abdominal ( ) Cardiovascular ( ) Dermatological ( ) Oral surgery ( ) Ophtalmological ( ) Urological ( ) Other intervention ( ) Biopsy/endoscopy ( ) 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

Risk factors associated to HAV: adjusted* O.R. (hepatitis B cases have been used by controls ) SEIEVA Risk Hepatitis A Controls Adjusted O.R. factors N. % N. % 95% CI Shellfish 7085 (70.6) 1325 (41.9) 2.41 consumption ( ) Travel to high 1519 (15.5) 315 (10.3) 4.11 endemic areas ( ) Household of 1227 (12.0) 246 (6.8) 1.51 day-care child ( ) Contact with an 1021 (10.7) icteric cases N. of cases * 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 Area of Adjusted O.R. 95% CI destination No travel Northern Europe, Northern America Northern/Central Italy Southern Italy Mediterranean Area, Eastern Europe Latin America, Asia, Africa * 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 adjusted** O.R. 95% CI Area of residenceNorthern and central Italy Southern Italy/Islands Area of destination No travel Northern Europe, Northern America Northern/Central Italy Southern Italy Mediterranean Area, Eastern Europe Latin America, Asia, 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 Years Age SEIEVA FOR MONITORING PREVENTION PROGRAMS

Cases of nAnB hepatitis associated with blood transfusion by year. SEIEVA Years Hepatitis (95% CI) nonA-nonB ( ) ( ) ( ) ( ) * ( ) ** ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) * 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. Conclusions2 Lessons from SEIEVA