The hepatitis A vaccination in Turkey: targeted versus universal

The hepatitis A vaccination in Turkey: targeted versus universal

TURKEY
Hepatitis A vaccine
Mehmet Ceyhan, MD
2009
Hepatitis A
General opinion:
It is not a severe disease?
“Thank God!, I had hepatitis A”
Reason of wrong perception:
There is no chronic disease,
malignancy
Reality:
Most common viral hepatitis
Serious morbidity
Serious mortality
Hepatitis A – Disease burden in
Children
„
„
„
„
Mortality rate is generally low in children
However liver failures know no age boundaries
Children are the main source of infection
Infected children are a risk for susceptible adults, which may suffer
from a prolonged disease
[Source: Bell BP, 2002,
www.cdc.gov/ncidod/diseases/hepatitis/a/global_hepA_epi.pdf.]
Hepatitis A, rotavirus,
salmonella, enteral viruses
7749 cases with rotavirus gastroenteritis
Mayor of Malatya
Are we eating shit?
Media, 3.12.2006
Hepatitis A, rotavirus, salmonella,
enteral viruses
May 12, 2009, Aksaray
Mayor of Malatya
Are we eating shit?
Hepatitis A endemicity criteria (Hadler ve ark, 1997)
• Very high: < 5 years of age > 90 % HAV+
• High: < 10 years of age > 90 % HAV+
• İntermediate: < 20 years of age > 80 %
HAV+
• Low: < 15 years of age> 10 % HAV+ (< 50
years of age < 70 % HAV+)
• Very low: < 35-40 years of age < 10 % HAV+
Hepatitis A prevalence before
1990s
Percent HAVAB (+)
Hepatitis A, TURKEY
Morbidity rate
(1/100.000)
Mortality rate
(1/1.000.000)
60
0,9
0,8
50
0,7
40
0,6
0,5
30
0,4
20
0,3
0,2
10
0,1
0
0
1990
1992
1994
1996
1998
2000
2002
2004
Turkish Ministry of Health Database
SHIFT IN THE PREVALENCE OF HEPATITIS A
DEPENDS ON THE IMPROVEMENT IN HYGENIC
CONDITIONS
Seroprevalance
(anti‐HAV %)
100
80
60
Improvement in hygene
40
20
0
10 20 30 40 50
Age (years)
Van Damme, 1994
Hepatitis A – Anti-HAV prevalence in Turkey
Akbulut
Elazığ
Babacan
İstanbul
Taşyaran
Erzurum
Aldeniz
İstanbul
Baki
Trabzon
Aydoğan
İzmir
Age
%
0-1 years
0-18 years
adult
0-5 years
adult
3-6 years
7-10 years
0-4 years
5-9 years
10-14 years
adult
6 ay-3 years
4-7 years
8-12 years
13-18 years
0-4 years
5-8 years
9-12 years
13-16 years
12.1
72.5
100
39.7
75.6
33.3
78.6
15.2
36.1
57.7
95.1
13.4
32.1
63.4
88.6
7.8
38.5
40
68
HAV in Turkey
(Seroprevalence)
100
90
80
70
60
50
40
30
0
1-4 yaş
5-9 yaş
10-14 yaş
15-19 yaş
20-24 yaş
25-29 yaş
Bilinmeyen
Kanra G, et al. Turk J Pediatr 2002
HEPATITIS A VIRUS ANTIBODY
100
Prevalence (%)
90
80
Indonesia
Ethiopia (Hadler 1991)
(Sulaiman 1994)
USA
(Hadler 1991)
USA (Hadler 1991)
70
60
50
40
Turkey (Ceyhan
2008)
Ethiopia
(Hadler
1991)
30
20
10
0
0
20
40
Age (years)
60
Geographic Distribution of HAV
Anti-HAV Prevalence
High
Intermediate
Low
Very Low
Source: Centers for Disease Control
Hepatitis A incidence, Turkey 1/100,000, 2005
13,6
9,2
17,75
10,1
11,13
23,6
12,79
Turkish Ministry of Health Database
Why is this old disease of
growing importance?
The exposure is changing due to:
… dining
out culture
… preference for exotic food, fast food, etc.
… growing trend to send young children to day
care (at an earlier age)
Î
if we are not travelling to hepatitis A,
hepatitis A is travelling to us!
Î
Î
Changing migration patterns
increasing number of people on the move
FAST FOOD
FAST FOOD (Doner kebab)
MIGRATION
(% )
Elazığ
100
90
80
70
60
50
40
30
20
10
1
20 9
-2
4
25
-2
9
30
-3
9
40
-6
60 0
us
tu
18
17
16
15
14
13
12
11
9
10
8
7
6
5
4
3
2
1
0
Years
Ceyhan M, Yildirim I, Kurt N, et al Journal of Viral Hepatitis 2008;15:69-72.
%
Diyarbakır
100
90
80
70
60
50
40
30
20
10
0
6
7
8
9
10
11
12
13
14
Year
Ceyhan M, Yildirim I, Kurt N, et al Journal of Viral Hepatitis 2008;15:69-72.
15
16
17
%
Ankara
100
90
80
70
60
50
40
30
20
10
Year
Ceyhan M, Yildirim I, Kurt N, et al Journal of Viral Hepatitis 2008;15:69-72.
4
30 9
-3
40 9
60 60
us
tu
-2
-2
25
19
20
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
İzmir
%
100
90
80
70
60
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9
10
11
12
13
Year
Ceyhan M, Yildirim I, Kurt N, et al Journal of Viral Hepatitis 2008;15:69-72.
14
15
16
17
18
Istanbul, HepA seroprevalance in pediatric age groups
60,00
50,00
40,00
30,00
20,00
10,00
0,00
0-1 year
2-6 year
7-15 year
Overall
Güven F, et al. Zeynep Kamil Tıp Bülteni 2004;35:41-44.
INTERMEDIATE ENDEMICITY
HIGH ENDEMICITY
Seroprevalence Turkey, summary
„
Overall; seroprevalence rate 71,3% under age of
30.
…
„
„
A steady incease from 1 year of age from 42,7 % to
91,1 % at 25-29 years of age*
High endemicity in Eastern and small cities
Intermediate endemicity in Western and bigger
cities
WHO RECOMMENDATIONS
„
„
„
High endemicity: No universal immunization
Intermediate immunicity: Universal immunization with
sanitation and health education
Low endemicity: Vaccination for risk groups:
…
…
…
…
…
…
…
…
…
Travelers to HAV endemic areas
Staff of schools and day care centers
Mentally retarded children and their care givers
Health personel
Cleaners and food handlers
Homosexual males
Patients using iv drugs and substances
Patients with chronic liver diseases
Hemophiliacs using factor concentrates
WHO/VSQ/GEN/96.02, Weekly Epidemiol Rec 2000
Government Policy / Strategy
Current
„ Improvement of hygene status
… Public
education for hygene practices
… Sanitation
… Infection control practices
Future
„ Vaccination
Vaccines
available in Turkey
National Immunization Program, Turkey, 2009
Birth
1m
2m
4m
6m
9m
12 m
16-24 m
BCG
I
DTaP
I
II
III
IV
OPV/IPV
I
II
III
IV
dT
Hep B
1st cl
V
I
I
II
III
MMR
I
II
III
Pneumo
X
X
X
II
IV
X
Additional vaccines on market
Varicella
X
Hep A
X
Rotavirus
X
X
X
II
I,II,III*
I
Hib
8th cl
?
X
UNIVERSAL OR REGIONAL
VACCINATION
„
Regional vaccination in big cities and Western
Turkey
Major Challenges
Today and future
„ Social and cultural obstacles
„ Economical problems
„ Educational level of the population
„ Other priorities of the health programmes
„ Other priorities in the vaccination programmes