Transcript HBV Transmission by Needlestick Injury

The Swiss Population In 2001
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Resident population: 7,258,500
Population density: 176 per Km2
Foreign nationals: 20.1% (~1,460,000)
Excess of births over deaths: 13,000 per year
[Immigration] – [emigration] = +41,500 per year
Registered Medical Laboratories
Cross-checking
for duplicates
Reporting of positive
anti-HCV and HCV RNA tests
(mandatory since 1988)
Swiss Federal Office
of Public Health (OFSP)
Identification
from test reporting
Further clinical
and epidemiological data
Primary Care Physicians
HCV infection in Switzerland
based on a mandatory reporting systm
 Total number of declarations received at OFSP:
 all patients = 24,068 (~2,500 per year)
 acute hepatitis C = ~600 (~60 per year)
 Estimated prevalence (general population, based
on a survey on pregnant women):
 0.7-1% (50,000 - 70,000)
 Estimated incidence: 5 - 15 new cases per
100,000 per year, mostly (70%) due to IVDU
OFSP, 2001
Acute Hepatitis C Declarations
Classes of Age
250
200
150
100
50
0
0-19
20-29
30-39
40-49
50-59
60-69
>70
Acute Hepatitis C in Switzerland
Risk Factors
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Intravenous drug use: 68.2%
Blood transfusion: 6.8%
Health care workers : 2.8%
Sexual contact: 2.8%
Contact with anti-HCV+ patients: 1.9%
Unknown: 15.7%
All Declarations, Classes of Age
6000
5000
4000
males
females
3000
2000
1000
0
<20
20-29 30-39 40-49 50-59 60-69
>70
The HCV Epidemics in Switzerland:
Population-based Studies
Study population
HCV+ / total
(%)
Year
Reference
Blood donors
50 / 5,424
(0.9)
1992/ Zucca et al, 2000
1997
Dentists
1 / 1,056
(0.095)
1999 Weber et al, 2001
Pregnant women
64 / 9,057
(0.7)
1990/
1991
OFSP,
unpublished
Indications to Screening for HCV - 1
Swiss Recommendations (OFSP, 2001)
 According to official estimates, about 50% of
infected patients have been declared to Federal
Authorities
 Mandatory reporting often concerns diagnoses
made well before the declaration
 It is likely that more then half of HCV infected
patients already know about their own status
Indications to Screening for HCV - 2
Swiss Recommendations (OFSP, 2001)
 A general screening policy would
be expensive, of limited usefulness,
and out of proportion with respect
to the expected results
Bull OFSP, 2001;46:877
Indications to Screening for HCV - 3
Swiss Recommendations (OFSP, 2001)
• Present or former IVDU
• Individuals transfused with blood before
1992 or with blood derivatives before 1987
• Patients under dialysis
• Children born to HCV-positive mothers
• HCW after accidental exposure to blood
• Patients with elevated transaminases
The HCV Epidemics in Switzerland
How Many Are Infected?
• Although the pregnant women study is
representative in terms of ethnicity:
– females account for only 40% of the HCV infected
population
– only 2.4% of pregnant women under survey (1.5%
of HCV+) were in the >40 y class of age (vs. 39%
of OFSP declarations)
• Official estimates may have underestimated
the HCV prevalence in Switzerland
Prevalence of HCV in Switzerland
• Model predictions (assuming a median
0.75% prevalence according to OFSP
estimates) were compared with observed
incidence of HCV related deaths and OLT
• A revised prevalence of 1.25 – 1.75%
provided the best fit to the assumed
complications
SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25
Predicting HCV Disease Burden
(by Prevalence)
• Future complications of a cohort of 77,595 HCV
RNA positive patients were evaluated (age
distribution was identical to that of the OFSP
declarations)
• In the next 15 to 25 years:
– Annual HCC incidence will increase by 70%
– HCV-related mortality will increase by 90%
– Incidence of HCV-related cirrhosis will decline
SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25
Trends in overall and truncated (35-64 y)
age-standardised HCC death rates in Switzerland
females
males
females, 35-64 y
females, all ages
LA VECCHIA et al, Eur J Cancer 2000;36:909
Future complications of HCV infection in Switzerland
500
450
400
350
300
250
200
150
100
50
0
HCC
dec-CIRRH
DLD
OLT
1998
2005
2010
2015
2020
2025
2030
SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25
Effect of Antiviral Therapy
• Antiviral therapy will reduce the annual
HCV-related mortality by a mere 5%,
since:
– According to new estimate, only a minority
of patients have been diagnosed (~15%)
– Antiviral treatment may cure only 40% of
patients
SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25
Future Costs of Hepatitis C in
Switzerland
• Annual direct costs for treating
complications of HCV will double by
2020 (~32.9 million US $ per year) (vs.
801 million US $ of direct costs of CHD)
• Indirect costs (loss of productivity)
equals 25.9 million US $ per year (1998)
SAGMEISTER et al, Eur J Gastroenterol Hepatol 2002;14:25
Current recommendations may help to
identify only 50-60% of patients with
chronic hepatitis C
• Extend screening to other groups at risk?
• Propose anonymous testing/counseling?
The Swiss Population In 2001
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Resident population: 7,258,500
Population density: 176 per Km2
Foreign nationals: 20.1% (~1,460,000)
Excess of births over deaths: 13,000 per year
[Immigration] – [emigration] = +41,500 per year
Foreign Nationals Living in Switzerland
• The foreign population is relatively young:
– 8 persons of retirement age every 100 workers
(Swiss nationals: 30 every 100)
• More than half have been living in Switzerland for
>15 years
• Current net migration is positive, thanks to
immigration from non-EU European countries
• About 80% of foreigners (~1,100,000) are from
countries where HCV infection is moderately
prevalent and long-standing
Switzerland: origin of foreign nationals (1999)
other
countries
243,350
28,100 Austria
60,500 France
80,200 Turkey
87,200
Spain
104,100
Germany
former
Yugoslavia
337,600
136,400
Portugal
Italy 329,150
anti-HCV positive (%)
Global Patterns of HCV Infection
50
3 = Egypt
40
30
20
2 = Spain, Italy
10
1 = US, Australia
0
0--9
10--19
20--29
30--39
40--49
50+
age group (years)
WASLEY and ALTER, CDC, 2000
Risk factors for HCV transmission in Italy
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Blood transfusions
IV drug use
Non-disposable needles within the family
Non-disposable needles outside the family
Hospitalization before 1970
Hospitalization after 1970
Previous tuberculosis
Sexually transmitted diseases
Surgical intervention before 1970
Surgical intervention after 1970
2.9
112
1.6
3.8
2.1
0.9
3.4
1.1
0.8
0.5
CHIARAMONTE et al, 1996
HCV Infection in Geneva
Risk factors, acute vs. total (%)
acute
total
IVDU
79.4
48.7
Sexual contact
22.1
13.0
Contact with HCV-positive patient
8.8
8.4
Health care worker
2.9
2.2
Transfusions
1.5
9.6
Other
1.5
4.4
Unknown / no information
11.6
51.7
DELAPORTE, 2001
HCV Infection in Geneva
Risk Factors Vs. Geographic Origin
IVDU
Others
60.7
39.3
Europe
45
55
Africa
7.7
92.3
Americas
38.5
61.5
Asia
28.6
71.4
Unknown
29.8
70.2
Total
48.7
51.3
Switzerland
DELAPORTE, 2001
HCV Infection in Geneva
 Acute hepatitis C patients are more often
young IV drug users, born in Switzerland
 Chronic hepatitis C patients are more often
of older age, and migrated to Switzeland
from countries where the prevailing risk
factor for HCV in the past decades was
nosocomial / iatrogenic transmission
Indications to Screening for HCV
• Consider to extend screening to:
– individuals exposed to non medical, invasive
procedures?
– individuals exposed in the past to potentially
unsafe medical procedures / unsafe injections?
– patients with extra-hepatic manifestations
possibly linked to HCV?