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Epidemiology of HepB and Hib diseases in India Dr Pradeep Haldar AC(I) SEPIO meeting 18-20 May 2011
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Hepatitis B: Disease Burden * References: Batham et al. Ind Pediatrics 2007
Hepatitis B Virus – Modes of Transmission   From mother to baby (perinatal transmission)  From child to child during play or from an adult to child by contact of body fluids;  (Most common cause in India) Unscreened blood transfusions and organ transplant  Through unsafe needles and injections  Through unprotected sexual contact
HBV transmission.. ,[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],Chronic Hepatitis B infection
Hepatitis B infection: Age and outcome Infection during infancy – very high chance of becoming chronic
Why infant immunization with Hep B? ,[object Object],[object Object],[object Object]
HepB vaccine introduction framework ,[object Object]
Overview of Hepatitis B Expansion GAVI support areas where Hepatitis B vaccination Started Sno On going States Districts Covered Sno Added States Hepatitis B Vaccination 1 Andhra Pradesh Entire State 22 Uttarakhand States Proposed for Expansion 2 Himachal Pradesh 23 Arunachal Pradesh 3 Jammu & Kashmir  24 Bihar 4 Karnataka 25 Chandigarh 5 Kerala 26 Chattisgarh 6 Madhya Pradesh 27 D & N Haveli 7 Maharashtra 28 Daman & Diu 8 Punjab 29 Tripura 9 Tamil Nadu 30 Sikkim 10 West Bengal 31 Manipur 11 A & N Islands* 32 Meghalaya 12 Delhi* 33 Mizoram 13 Goa* 34 Nagaland 14 Lakshadweep* 35 Jharkhand 15 Puducherry* 16 Assam Selected Area(s) Jorhat, Sibsagar Remaining districts 17 Gujarat Ahmedabad, Surat, Vadodara 18 Haryana Panchkula, Ambala 19 Orissa Sundergarh 20 Rajasthan Jaipur 21 Uttar Pradesh Kanpur, Lucknow
Haemophilus influenzae b disease
Under 5 mortality in India ,[object Object],[object Object],[object Object],[object Object],Source: India’s Million Death Study, National Mortality Estimates, 2005
Causes of <5 mortality in India, 2005 Neonatal deaths 43% Bassani 2010, Million Death Study Total pneumonia 23%
Hib diseases in India ,[object Object],[object Object],[object Object],[object Object],[object Object],1  Deivanayagam 1993  2  Singhi 2002  3  Mani 2007  4  Chinchankar 2002  5  Steinhoff 1998
Hib - A difficult organism to study ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Role of Surveillance for Hib ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Undetected Disease  including meningitis and pneumonia Additional cases preventable with vaccination Can be identified by surveillance for invasive disease Surveillance underestimates the burden of Hib disease
Bacterial meningitis surveillance
Sentinel Hospital Based Surveillance for Bacterial Meningitis in India ,[object Object],[object Object],[object Object]
Objectives ,[object Object],[object Object],[object Object]
Objectives ,[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Sentinel Hospital Based Surveillance for Bacterial Meningitis in India
[object Object],[object Object],[object Object],Sentinel Hospital Based Surveillance for Bacterial Meningitis in India
Hib vaccine introduction in India ,[object Object],[object Object],[object Object],[object Object]
Thanks
Extra slides
Hospitalised/severe clinical pneumonia ,[object Object],[object Object],Study Incidence (per 100,000 cyo) ICMR Part A 2700-7900 Lombok, Indonesia 3906-4518 Vitamin A (India, Ghana, Peru) 2300 South Africa 1530
Bacterial Pneumonia Etiology ,[object Object],*Frequency weighted mean of available methodologically-sound studies Author Syndrome Location Age Study Size  % disease due to Hib  % isolation rate of any organism Bahl  1995 Pneumonia Delhi 0-5 years 190 19  55 Kumar 1984 Pneumonia Chandigarh < 11 years 64 13 42 Patwari 1996 Pneumonia Delhi < 13 years 132 15  12
Bacterial Meningitis Etiology ,[object Object],Author/Year Syndrome Age Study Size  % Hib  % isolation rate Deivanayagam 1993 Suspected meningitis 2 months to 11 years 114 24.6  48 Singhi 2002 Suspected meningitis 1 month to 12 years 107 35 23 Devi 1982 Acute meningitis <15 years 7 19 41 Mani 2007 Bacterial meningitis <5 years 51 14  76 Chinchankar 2002 Bacterial meningitis 1 month to  5 years 54 26 50 ICMR Part A Chandigarh Bacterial meningitis 1-23 months 90 16.7 22 ICMR Part A Kolkata Bacterial meningitis 1-23 months 98 20.7 43 ICMR Part A Vellore Bacterial meningitis 1-23 months 181 29 50
Outcomes: Case Fatality Author/Year Syndrome CFR (%) Kabra 1991 Hib meningitis 25 Steinhoff 1998 Hib meningitis 29 Thomas 2002 Hib meningitis 20 Chinchankar 2002 Hib meningitis 21 Thomas 2002 Any invasive Hib disease 16
Outcomes: Sequelae ,[object Object],[object Object],Study Site Hib meningitis survivors with neurological sequelae (n) Hib meningitis survivors with neurological sequelae (%) Chinchankar 2002 Pune 5 36% Singhi 2007 Chandigarh 4 31% Bose (unpublished) Vellore 1 6%
Problems in Detection ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Issues in Diagnosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Antibiotic Usage Prior to Admission ,[object Object],[object Object],[object Object]
Chronic Hepatitis B infection ,[object Object],[object Object],Chronic HBV infection:  Long term  and asymptomatic

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HiBand Hep B

  • 1. Epidemiology of HepB and Hib diseases in India Dr Pradeep Haldar AC(I) SEPIO meeting 18-20 May 2011
  • 2.
  • 3. Hepatitis B Virus – Modes of Transmission From mother to baby (perinatal transmission) From child to child during play or from an adult to child by contact of body fluids; (Most common cause in India) Unscreened blood transfusions and organ transplant Through unsafe needles and injections Through unprotected sexual contact
  • 4.
  • 5.
  • 6. Hepatitis B infection: Age and outcome Infection during infancy – very high chance of becoming chronic
  • 7.
  • 8.
  • 9. Overview of Hepatitis B Expansion GAVI support areas where Hepatitis B vaccination Started Sno On going States Districts Covered Sno Added States Hepatitis B Vaccination 1 Andhra Pradesh Entire State 22 Uttarakhand States Proposed for Expansion 2 Himachal Pradesh 23 Arunachal Pradesh 3 Jammu & Kashmir 24 Bihar 4 Karnataka 25 Chandigarh 5 Kerala 26 Chattisgarh 6 Madhya Pradesh 27 D & N Haveli 7 Maharashtra 28 Daman & Diu 8 Punjab 29 Tripura 9 Tamil Nadu 30 Sikkim 10 West Bengal 31 Manipur 11 A & N Islands* 32 Meghalaya 12 Delhi* 33 Mizoram 13 Goa* 34 Nagaland 14 Lakshadweep* 35 Jharkhand 15 Puducherry* 16 Assam Selected Area(s) Jorhat, Sibsagar Remaining districts 17 Gujarat Ahmedabad, Surat, Vadodara 18 Haryana Panchkula, Ambala 19 Orissa Sundergarh 20 Rajasthan Jaipur 21 Uttar Pradesh Kanpur, Lucknow
  • 11.
  • 12. Causes of <5 mortality in India, 2005 Neonatal deaths 43% Bassani 2010, Million Death Study Total pneumonia 23%
  • 13.
  • 14.
  • 15.
  • 16. Undetected Disease including meningitis and pneumonia Additional cases preventable with vaccination Can be identified by surveillance for invasive disease Surveillance underestimates the burden of Hib disease
  • 18.
  • 19.
  • 20.
  • 21.
  • 22.
  • 23.
  • 26.
  • 27.
  • 28.
  • 29. Outcomes: Case Fatality Author/Year Syndrome CFR (%) Kabra 1991 Hib meningitis 25 Steinhoff 1998 Hib meningitis 29 Thomas 2002 Hib meningitis 20 Chinchankar 2002 Hib meningitis 21 Thomas 2002 Any invasive Hib disease 16
  • 30.
  • 31.
  • 32.
  • 33.
  • 34.

Hinweis der Redaktion

  1. We can do very little to help all those who are already infected. It is possible to protect the future generations by vaccinating infants. Hepatitis B vaccine in India’s UIP could help prevent about 10 lakh chronic infections and 1.5 lakh deaths in each year’s birth cohort.
  2. To stimulate interest put the choices to voting. Most people are unlikely to select the second choice. And they are surprised to know it when you show the last line creating interest. Child to Child (including Adult to child) also known as horizontal transmission accounts for most HBV infections. It is supported by the fact that there is familial clustering of HBsAg positivity among small children is frequently noticed in families where adults (usually a male adult) are HBsAg positive and there is no contact through blood/ sex.
  3. Infections in first year of life almost always (90%) end up in becoming chronic
  4. Please note the Age of Infection on the x-axis—the major epidemiological change occurs after the 1 st to 4 th year of life.
  5. Immunization provided to infants has the highest impact on reducing the chronic infections in the community.
  6. Etiology study locations: Deivanayagam, 1993, Chennai; Singhi, 2002, Chandigarh; Mani, 2007, Banglalore; Chinchankar, 2002, Pune; Steinhoff, 1998, New Delhi, Lucknow, Madras, Nagpur, Trivandrum and Vellore
  7. Remember you’ll need to say Haemophilus influenzae type b (“or Hib”) first time you use the terms
  8. Undetected disease Example: False Negative (C ulture Negative)
  9. In persons with cirrhosis, the liver tissue is found replaced with fibrous and fatty tissue. The liver appears nodular. Hepatocellular carcinoma (HCC or liver cancer) may also develop in the chornically infected liver tissue.