1. SEIEVA Integrated Epidemiological System for Acute Viral Hepatitis Alfonso Mele Catania, November 7-8 2002

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

3. SEIEVAMETHODOLOGY Notification Interview Ascertainment of markers Weekly line listing of cases and questionnaires are forwarded to ISS

6. 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

7. Serological definition of types of viral hepatitis SEIEVA

8. Incidence

9. Distribution of notified cases of viral hepatitis SEIEVA 1987 - 1990 1997 - 2001

10. 1985 - 1994 1995 - 2001 Case fatality rate of viral hepatitis in Italy by type

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

12. Anti-hepatitis B vaccination Incidence of notified case of hepatitis B in Italy by age-groups. SEIEVA 1985-2001

13. Incidence of notified case of hepatitis nAnB in Italy by age and year. SEIEVA 1985-2001

14. Incidence of notified case of hepatitis A in Italy by age and year. SEIEVA 1985-2001

15. Incidence (cases per 100,000) of hepatitis A in Italy by geographical area. SEIEVA 1985-2001

16. Risk Factors

17. Risk factors of hepatitis B: adjusted* O.R. SEIEVA 1998-2000 Risk factors adjusted OR 95% CI Blood transfusion 2.35(0.56 - 9.92) Intravenous drug use 6.78 (3.32 - 13.9) Surgical intervention 2.44 (1.42 - 4.19) Dental therapy 1.35(0.99 - 1.84) Other parenteral exposures 1.67(1.26 - 2.33) > 1 sexual partner ** 1.75(1.31 - 2.33) Household of HBsAg+ 10.1(4.52 - 22.7) * Adjusted for sex, age, area of residence, educational level and the other variables of the table. ** Subjects > 14

18. Risk factors adjusted OR 95% CI Blood transfusion 2.43(0.63 - 9.42) Intravenous drug use 38.0(19.1 - 75.6) Surgical intervention 7.02(3.99 - 12.4) Dental therapy 1.53(1.00 - 2.33) Other parenteral exposures 1.65(1.11 - 2.46) > 1 sexual partner ** 0.76(0.49 - 1.19) *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 1998-2000

19. Adjusted OR and 95% CI for different types of invasive procedure among hepatitis B cases. SEIEVA 1996-2000. Intervention type Hepatitis B Hepatitis AOdds ratio* (2689 cases)(6701 cases) (95% CI) n % n % Minor surgery 44 1.6 37 0.6 1.98 (1.19- 3.29) Gynaecological** 21 0.8 18 0.3 3.69 (1.77 - 7.73) Orthopaedic 19 0.7 29 0.4 1.93 (0.96 - 3.28) Abdominal 41 1.5 30 0.4 3.75 (2.09 - 6.72) Cardiovascular 21 0.8 5 00.7 6.56 (2.20 - 19.5) Dermatological 31 1.1 15 0.2 3.00 (1.53 - 5.86) Oral surgery 63 2.3 40 0.6 3.14 (1.97 - 4.99) Ophtalmological 10 0.4 5 00.7 3.85 (1.17 - 12.8) Urological 13 0.5 6 00.9 4.88 (1.54 - 15.4) Other intervention 66 2.4 62 0.9 2.37 (1.57 - 3.57) Biopsy/endoscopy 80 2.9 55 0.8 2.03 (1.39 - 2.96) 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.

20. Intervention type Hepatitis C Hepatitis A Odds ratio* (709 cases)(6701 cases) (95% CI) n % n % Minor surgery 13 1.8 37 0.6 3.18 (1.58 - 6.39) Gynaecological ** 19 2.7 18 0.3 16.6 (7.40 - 37.2) Orthopaedic 17 2.4 29 0.4 5.70 (2.82 - 11.5) Abdominal 13 1.8 30 0.4 6.01 (2.90 - 12.4) Cardiovascular 19 2.7 5 00.7 34.9 (12.0 - 102) Dermatological 6 8.4 15 0.2 2.72 (0.98 - 7.51) Oral surgery 15 2.1 40 0.6 3.60 (1.87 - 6.93) Ophtalmological 14 2.0 5 00.7 30.4 (9.98 - 92.3) Urological 6 8.4 6 00.9 10.7 (8.88 - 39.7) Other intervention 30 4.2 62 0.9 4.46 (2.72 - 7.32) Biopsy/endoscopy 40 5.6 55 0.8 4.57 (2.91 - 7.18) 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 1996-2000.

21. Risk factors associated to HAV: adjusted* O.R. (hepatitis B cases have been used by controls ) SEIEVA 1996-2000 Risk Hepatitis A Controls Adjusted O.R. factors N. % N. % 95% CI Shellfish 7085 (70.6) 1325 (41.9) 2.41 consumption (2.17-2.68) Travel to high 1519 (15.5) 315 (10.3) 4.11 endemic areas (3.53-4.79) Household of 1227 (12.0) 246 (6.8) 1.51 day-care child (1.26-1.82) Contact with an 1021 (10.7) ---- ---- icteric cases N. of cases 10438 3620 * Adjusted for sex, age, area of residence, educational level and the other variables of the table.

22. Association between travel* and hepatitis A virus infection: adjusted** O. R., SEIEVA 1996-2000 Area of Adjusted O.R. 95% CI destination No travel1.00 -- Northern Europe,1.460.92-2.34 Northern America Northern/Central Italy0.950.78-1.15 Southern Italy3.032.35-3.91 Mediterranean Area,3.152.42-4.11 Eastern Europe Latin America, Asia,9.306.71-12.9 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.

23. Association between travel* and hepatitis A virus infection: by area of residence. SEIEVA 1996-2000 adjusted** O.R. 95% CI Area of residenceNorthern and central Italy Southern Italy/Islands Area of destination No travel 1.00 -- 1.00 -- Northern Europe, 1.60 1.00-2.57 0.63 0.07-5.34 Northern America Northern/Central Italy 1.03 0.84-1.26 0.67 0.37-1.20 Southern Italy3.70 2.82-4.85 1.25 0.66-2.39 Mediterranean Area, 3.21 2.47-4.19 1.76 0.19-16.3 Eastern Europe Latin America, Asia, 9.49 6.83-13.2 0.72 0.15-3.52 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.

24. SEIEVA FOR MONITORING PREVENTION PROGRAMS Vaccination of households of HBsAg carriers Vaccination of healthcare workers

25. Hepatitis B cases among adolescents. SEIEVA 1992-2001 Years Age929394959697989920002001 13 4 2 0 0 1 0 0 3 2 0 14 3 6 4 2 1 1 1 0 1 15 5 1 2 0 0 1 0 1 16 5 110 3 2 1 0 17 9 2 4 3 1 1 1813 2 3 3 3 1910 3 4 2 2015 6 5 21 13 5 22 15 SEIEVA FOR MONITORING PREVENTION PROGRAMS

26. Cases of nAnB hepatitis associated with blood transfusion by year. SEIEVA 1987-2001 Years Hepatitis (95% CI) nonA-nonB 19874.4 (3.2-5.6) 19884.5 (3.5-5.6) 19894.1 (3.1-5.1) 19902.9 (2.1-3.7) 19911.4* (0.8-2.0) 19920.3** (0.1-0.6) 19930.4 (0.2-0.7) 19940.1 (0.0-0.3) 19950.4 (0.1-0.6) 19960.2 (0.2-0.4) 19970.3 (0.2-0.5) 19980.5 (0.2-10.5) 19990.2 (0.05-0.4) 20000.2 (0.1-0.4) 20010.3 (0.2-0.6) * Compulsory of the ELISA-I test in the total blood bank ** Introduction of the ELISA-II test SEIEVA FOR MONITORING PREVENTION PROGRAMS

27. 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

28. 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