Italy: Impact of universal vaccination programmes on the

Impact of universal vaccination programmes on
the epidemiology of hepatitis B in Italy
(SEIEVA results)
Milano
November 17, 2011
Dr. Alfonso Mele
Istituto Superiore di Sanità
Main modes of HBV transmission
before vaccination era
• Vertical and horizontal transmission
• Sexual transmission
• Reused syringes/needles
Alfonso Mele
Istituto Superiore di Sanità
Prevalence of HBV markers in two samples of
7-12 yrs old children enrolled in Naples 8 yrs apart
1980
HBsAg
Any HBV marker
1988
Value
2.1%
0.8%
< 0.05
11.7%
6.8%
< 0.05
D’Argenio et al. Public Health. 1989
Alfonso Mele
Istituto Superiore di Sanità
Prevalence of HBV markers of hepatitis B in
two national samples of Italian recruits
enrolled 9 yrs apart.
Year
Total no.
tested
HBsAg*
positive
anti-HBc*
positive
%
%
1981
5,005
3.4
16.8
1990
4,993
1.6
5.8
* HBsAg, hepatitis B surface antigen; anti-HBc, hepatitis B core
antibodies.
D’Amelio, AJE 1992
Alfonso Mele
Istituto Superiore di Sanità
HBsAg Prevalence of pregnant women by region
1984-1986
0.5
2
3.5
(2.4%)
1.1
2.1
1.6
1
1.5
1.1
1.0
0.4
1.7
NA*
2.4
5.2
5.6
2.2
5.2
2.9
NA* Not Available
Mothers <14 e >55 yrs not included
4.4
Stroffolini T, I.J.G., 1988
Alfonso Mele
Istituto Superiore di Sanità
Summary
At the end of eighties Italy was a country at
medium endemicity of HBV with about 2 milion
of chronic carriers
Alfonso Mele
Istituto Superiore di Sanità
Vaccination in countries at intermediate
endemicity: Italy
1983: Vaccination of high risk groups
1991: Vaccination of infants and adolescents
Alfonso Mele
Istituto Superiore di Sanità
Italian strategy for hepatitis B vaccination
24
age
24
12
12
0
1991
years
2003
0
STOP
Vaccination of 12-years-old
Alfonso Mele
Istituto Superiore di Sanità
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
Incidence rates x 100.000
40
35
30
25
20
15
12
Universal HBV vaccination
Hepatitis B. Yearly trend in incidence rates
SEIEVA 1985-2010
45
0-14
15-24
≥25
Totale
10
5
0
0,9
Year
Alfonso Mele
Istituto Superiore di Sanità
Distribution of notified Hepatitis B cases by age
SEIEVA 2006-2010
60
53,62
50
% di casi
40
30
23,56
17,31
20
10
5,19
0,32
0
0-14
2 Italians
6 Foreign
15-24
29 Italians
99 Foreign
25-34
35-54
55+
Età
Alfonso Mele
Istituto Superiore di Sanità
Cases of notified acute hepatitis B by nazionality
SEIEVA 2006-2010
Altro
16%
Italia
84%
Africa 20,4%
Central and South America 8,9%
Asia 14,5%
East Europe 54,6%
Western Europe 1,3%
Alfonso Mele
Istituto Superiore di Sanità
11
Risk factors for acute hepatitis B
SEIEVA 2006 - 2010
Risk factors
O.R.
(C.I.)
P.A.R.
I.V. drug users
2,2
(1,3 - 3,9)
2,1%
Surgical Intervention
1,7
(1,3 - 2,4)
5,5%
Other nosocomial exposures
1,8
(1,2 - 2,8)
4,2%
Other parenteral exposures
2,4
(1,9 - 2,9)
20,1%
Dental Therapy
1,5
(1,2 - 1,8)
9,4%
Household of HBsAg+
6,4
(3,8 - 10,5)
10,1%
Never/occasional condom use
3,2
(2,5 - 4,1)
13,8%
Alfonso Mele
Istituto Superiore di Sanità
12
Frequency of reported risk factors by year
SEIEVA 1991-2010
40,0%
35,0%
30,0%
25,0%
20,0%
15,0%
10,0%
5,0%
Drug
TD
users
CHousehold
onv HB s A g+HBsAg+
10
20
09
20
08
20
07
20
06
20
05
20
04
20
03
20
02
20
01
20
00
20
99
19
98
19
97
19
96
19
95
19
94
19
93
19
92
19
19
91
0,0%
Parenteral
es p. parent.exposures
Surgical
interventointervention
c hirurgic o
Alfonso Mele
Istituto Superiore di Sanità
13
Prevalence of
HBsAg positive pregnant women* by region
N. 17.260
0.0
Years 2008-2009
(0,9%)
ND*
ND
*
0.8
0.9
1.4
0.8
ND*
0.6
1.4
0.6
ND*
1.1
ND*
ND*
0.7
1.0
0.5
ND*
1.0
ND* Not Determined
*women <14 and >55 years are excluded
Spada E et al, J. Infection, 2011
Alfonso Mele
Istituto Superiore di Sanità
14
Prevalence of
HBsAg positive pregnant women by nazionality
N°
14.307
% Immigrants
25,0%
% testated
97,6%
Prevalence (%) of HBsAg
0,9%
Prevalence (%) of HBsAg in
Italians women
0,4%
Prevalence (%) of HBsAg in
Immigrants women
2,7%
Prophylaxis (%) of newborns
from mothers HBsAg+
100%
Spada E et al., J. Infection, 2011
Alfonso Mele
Istituto Superiore di Sanità
15
Prevalence of HBV markers in Abbiategrasso (Mi)
2010-2011
Age
18-34
35-44
45-54
55-64
65+
All ages
N.
Anti-HBc
(%)
HBsAg
(%)
379
385
395
331
276
1766
7 (1.9)
24 (6.2)
58 (14.7)
75 (22.7)
91 (33.0)
255 (14.4)
4 (1.1)
3 (0.8)
3 (0.8)
7 (2.1)
5 (1.8)
22 (1.3)
M. Zuin, in preparation
Currently HBV burden of disease in Italy
HBV
Chronic carriers
600.000
Cirrhosis
100.000
Deaths/year
1.500
Alfonso Mele
Istituto Superiore di Sanità
Conclusion
The incidence of HBV infection in Italy drammatically
declined in the last few decades. At the end of the 1980’
there were about 2 milion chronic carriers in Italy.
Today the prevalence of chronic carriers is about
500,000.
Universal vaccination of infants and adolescents
combined with improved social and economic condition
contributed to this phenomen.
Alfonso Mele
Istituto Superiore di Sanità
Conclusion
The majority of newly reported cases are
unvaccinated adults.
The most important risk factors for newly aquired
infection are: sexual contacts with infected
indivuduals, beauty treatments (i.e. pedicures,
tattoos) iatrogenic exposure and intra-venous drug
use.
Immigrants represent 16% of newly reported cases.
Alfonso Mele
Istituto Superiore di Sanità