1. . In the name of God In the name of God

2. Epidemio logy

3. Acute viral hepatitis in Iran Acute viral hepatitis in Iran

4.  HAV – Most common cause in pediatric age group.  HBV – most common cause in adult.  HEV – mainly in endemic areas with poor sanitation.  HCV – Rarely present as acute hepatitis.  OTHERS – Still unidentified viruses. Acute Viral Hepatitis In Iran

5. HAV Prevention & control

6. sanitation- separate waste from water source sanitation- separate waste from water source and foods and foods Hand washing, avoidance of contaminated foods Hand washing, avoidance of contaminated foods inactivated virus vaccine is effective (1995) inactivated virus vaccine is effective (1995) human IgG given as passive immunization human IgG given as passive immunization vaccine to travelers or higher risk workers, healthcare or sewer workers, food handlers, vaccine to travelers or higher risk workers, healthcare or sewer workers, food handlers, those with chronic liver disease those with chronic liver disease

7. Vaccine

8. HAV Prevention HAV Prevention Prior to 1992. Prior to 1992. Promotion of hygiene to reduce fecal oral spread.Promotion of hygiene to reduce fecal oral spread. Short term passive immunization.Short term passive immunization. Pre exposure for travel to endemic areas. Pre exposure for travel to endemic areas. 1992 – 1 st available vaccine in Europe. 1992 – 1 st available vaccine in Europe. HAVRIX – introduced to the US in 1995.HAVRIX – introduced to the US in 1995.

9. Routine Immunization Goals of HAV immunization are Goals of HAV immunization are Protect persons from infectionProtect persons from infection Reduce disease incidence by preventing transmissionReduce disease incidence by preventing transmission Ultimately eliminate transmissionUltimately eliminate transmission Children have a high incidence of HAV Children have a high incidence of HAV This makes them a good target for immunization strategy.This makes them a good target for immunization strategy.

10. Vaccination Special situations Patients with HCV & HBV infection Patients with HCV & HBV infection Liver transplant patients Liver transplant patients Patients with cirrhosis Patients with cirrhosis

11. Epidemiology HBV Epidemiology HBV

12. Where Is the HBV Infection in Asia Pacific? Longterm Carriers Country Millions Longterm Carriers Country Millions China120.0 India48.0 Indonesia11.6 The Philippines7.6 Korea2.5 Japan1.3 Hong Kong0.7 Singapore0.03 Australia0.2 Taiwan3.0 Various local sources

13. Chronic hepatitis in Iran Hepatitis B Virus is The Most Common Cause of Chronic hepatitis (70%) In IRAN yet

14. Hepatitis B Virus The Most Common Cause of Chronic liver Disease In IRAN

15. cirrhosis Hepatitis B is the cause of more than 80% of cirrhosis in Iran yet Hepatitis B is the cause of more than 80% of cirrhosis in Iran yet

16. Hepatitis B transmission portal of entry and transmission- blood bourne portal of entry and transmission- blood bourne carried to liver by bloodstream carried to liver by bloodstream role of immune system in pathogenesis is important role of immune system in pathogenesis is important symptomatic and asymptomatic infection symptomatic and asymptomatic infection persistently infected "carriers ” persistently infected "carriers ” blood, blood products, semen, shared needles, unsterile body piercing or tatto equipment, sharing of toothbrushes, razors or towels, sexual intercourse, mother to child blood, blood products, semen, shared needles, unsterile body piercing or tatto equipment, sharing of toothbrushes, razors or towels, sexual intercourse, mother to child

17. In Iran vertical transmission ( from mother to child ) seem to be the most common route of transmission yet

18. HBV prevention and control highly protective vaccines highly protective vaccines - HBsAg from serum of carriers (1980’s) - HBsAg from serum of carriers (1980’s) - yeast recombinant HBsAg since 1986 - yeast recombinant HBsAg since 1986 - recommended for all, especially healthcare and high risk - recommended for all, especially healthcare and high risk treatment and control treatment and control - HBIG hepatitis B immune globulin is protective - HBIG hepatitis B immune globulin is protective - education of vaccine and avoiding contact with - education of vaccine and avoiding contact with transmitting agents transmitting agents - anti-viral : interferon &lamivudin - anti-viral : interferon &lamivudin

19. Universal Hepatitis B Vaccination The Strategy All infants to be immunised before the age of 18 months – regardless of country All infants to be immunised before the age of 18 months – regardless of country In 1998, 80 countries have achieved this goal In 1998, 80 countries have achieved this goal The Experienc Protection lasts >10 years and booster doses not required Protection lasts >10 years and booster doses not required Screening of pregnant women for HBV markers, ensuring immediate vaccination of infants borne to HBsAg+ve mothers Screening of pregnant women for HBV markers, ensuring immediate vaccination of infants borne to HBsAg+ve mothers

20. Hepatitis B Vaccines Engerix-B ® Recombivax ® Children10µg2.5µg Adults20µg10µg Each at 0, 1 and 6 months

21. Cost of Childhood Vaccines Vaccine Cost per dose $ Tetanus 0.16 Measles 0.26 DTP 0.19 Yellow fever 0.27-0.31 Meningitis 0.31-0.41 Hepatitis B 0.65-0.85 Based on WHO/UNICEF data, 1997

22. Vaccination Reduces the Incidence of Hepatocellular Carcinoma in 6-14 Yr Olds 0 0.5 1 1.5 2 HCC Brain tumours Incidence per 100,000 1981-82 1982-83 1983-841984-851985-861986-871987-881988-891989-901990-911991-921992-931993-94 Chang et al., 1997

23. Hepatitis B Vaccine Highly effective in preventing infection Highly effective in preventing infection Universal immunization Universal immunization All newbornsAll newborns All adolescentsAll adolescents Adults at riskAdults at risk

24. summery

25. HBV IN IRAN Anti HBV-C-Ab 36%(18000000) Age > 25 HBSAg) 2.5% (1500000) HBeAg in HBSAg+ 10%(150000) HBV-DNA in HBSAg+ 20%(300000)

26. Epidemiology HCV Epidemiology HCV

27. Epidemiology HCV Previously HCV infection was rare in Iran, but recently it s incidence is increasing gradually especially in IV drug users Previously HCV infection was rare in Iran, but recently it s incidence is increasing gradually especially in IV drug users

28. Hcv in IRAN intravenous drug abuse and needle-sharing in the country. On the other hand, an increase in number of centers providing hemodialysis and transfusion facilities for hemoglobinopathies generated new sources and susceptible populations in Iran. intravenous drug abuse and needle-sharing in the country. On the other hand, an increase in number of centers providing hemodialysis and transfusion facilities for hemoglobinopathies generated new sources and susceptible populations in Iran.

29. HCV in a research, on 5,976 blood donors in Rasht, northern part of Iran, showed that 0.5% of the cases were positive. Others on North-West reported a prevalence of 0.97% positive HCV antibody. In another study in Shiraz in southern part of Iran on 7,897 cases, anti-HCV antibodies were found in 0.59%. in a research, on 5,976 blood donors in Rasht, northern part of Iran, showed that 0.5% of the cases were positive. Others on North-West reported a prevalence of 0.97% positive HCV antibody. In another study in Shiraz in southern part of Iran on 7,897 cases, anti-HCV antibodies were found in 0.59%.

30. HCV in chronic liver disease In a study that was done in 1999 among 162 chronic hepatitis and cirrhotic patients, HBsAg, anti-HBc Ab, and anti-HCV Ab were positive in 56.2%, 70%, and 40.7% of cases, respectively. In a study that was done in 1999 among 162 chronic hepatitis and cirrhotic patients, HBsAg, anti-HBc Ab, and anti-HCV Ab were positive in 56.2%, 70%, and 40.7% of cases, respectively.

31. HCV prevention and control no vaccine available no vaccine available diagnosis is important diagnosis is important transmission means is not always obvious transmission means is not always obvious milder clinical symptoms than HBV milder clinical symptoms than HBV no effective treatment except Peg- interferon no effective treatment except Peg- interferon major area of study is biology of virus major area of study is biology of virus

32. Prediction of Iranian population older than 25 years old who are infected with viral hepatitis ( HAV, HBV, HCV, and HDV ) Percent of chronic carriers Percent of infected during life Type of viruses 0% 0%90A %3%40B <0.3%<1%C ?10% OF HBSAg+ 20% OF HBSAg+ D

33. Virus Seropositivity in Healthy adult IRANIAN Healthy adult IRANIAN IgG HAV-Ab Age > 25 year 90% Age > 35 year 99% Anti HBV-C-Ab Age > 25 36% HBSAg 2.5% (1500000) HBeAg in HBSAg positive subject 10% (150000) HBVDNA in HBSAg positive subjects ?!20%(300000) Anti HDV-Ab in HBSAg positive subject 3-10% Anti HCV-Ab 2 nd -generation 0.3% HEV Endemic in north & west of IRAN

34. Au revoir A bientot