Epidemiology of Viral Hepatitis in Afghanistan. The presentation is prepared by Dr. Islam Saeed, Director for Surveillance/DEWS at Afghan National Public Health Institute (ANPHI), MoPH

1. Epidemiologic Pattern of Viral Hepatitis in Afghanistan
December, 2014
Dr. Khwaja Mir Islam Saeed, MD-KMU, MSc-AKU
Director Surveillance/DEWS , Afghan National Public Health Institute (ANPHI), Ministry of Public Health (MoPH),
Kabul Afghanistan

2. Introduction
Global, regional and national burden
Genotypes pattern in the country
High risk groups
Risk factors
Last ten years by HMIS data
Cyclical trend of cases and deaths
Recent prevalence study in Jalalabad
Challenges
WHO four axes for control and prevention

3. Viral hepatitis is an inflammation of the liver caused by one of the five hepatitis viruses, referred to as types A, B, C, D and E .
All these viruses cause liver disease, but vary significantly in terms of epidemiology, natural history, prevention, diagnosis and treatment
Viral hepatitis is a global public health problem affecting millions of people every year, causing disability and death
Viral hepatitis places a heavy burden on the health care system because of the costs of treatment of liver failure and chronic liver disease
the problem has not been addressed in a serious way for many reasons, have resulted in “the silent epidemic” we are experiencing today.

4. Viral hepatitis is a global public health problem affecting millions of people every year, causing disability and death.
It was estimated that 119 million people were infected with hepatitis A virus (HAV) in 2005, with 31 million symptomatic illnesses and 34000 deaths.
It is estimated that more than 2 billion people have been infected with HBV and 400 million are chronically infected cause 500 000–700 000 deaths each year worldwide
Every year there are 20 million hepatitis E infections, over three million acute cases, and 70 000 hepatitis E-related deaths
Some 170 000 000 people are chronically infected with HCV and more than 350 000 people are estimated to die annualy

5. It is estimated that approximately 4.3 million people are infected with HBV and 800 000 people are infected with HCV annually.
The HCV prevalence is estimated to be 1-4.6%, with levels higher than 15% in Egypt.
Overall, an estimated 17 million people in the region suffer from chronic HCV infection
The risk of infection with HBV is high in five countries (Afghanistan, Pakistan, Yemen, Sudan and Somalia), accounting for more than 55% of the total population of the region, and moderate in the remaining 17 countries
The prevalence of HEV infection is high in Sudan, South Sudan, Pakistan and Somalia.

6. Kabul Blood Bank Data (2006)
Prevalence of HBsAg ( 3.9%)
Prevalence of Anti-HCD (1.9%)
Seroprevalence and correlates of HIV, syphilis, and hepatitis B and C virus among intrapartum patients in Kabul, Afghanistan in BMC infectious diseases
Prevalence of HBsAg ( 1.53%)
Prevalence of Anti-HBC ( 0.31%)
HBsAg was associated with husband's level of education (OR = 1.13, 95% CI: 1.01 – 1.26)

7. Prevalence of hepatitis B among Afghan refugees living in Baluchistan, Pakistan in Journal of infectious diseases(2006)
Prevalence of HBsAg (8.3%)
Prevalence of HBsAg in Children (5.6%)
Receiving more than ten injections during the previous year increased the risk of HBV infection (OR 3.5, 95% CI 1.8–6.7).
A child positive for HBsAg was more likely to have a positive parent compared to an HBsAg negative child (OR 5.7, 95% CI 2.0–16.5).

8. An aberrant high prevalence of hepatitis B infection among Afghans residing in one of the Bushehr refugee camps (Dalaki camp) in the southwest of Iran. In International Journal of Infectious diseases (2006)
Prevalence of HBsAg ( 60.9%)
Prevalence of Anti-HBC (85.1%)
Share of Afghanistan populace in hepatitis B and hepatitis C infection’s pool: is it worthwhile? Virology journal (2011)
Prevalence of HBsAg ( 1.9%)
Prevalence of Anti-HBC (1.1%)

9. The structural and functional differences between hepatitis B virus (HBV) genotypes are the mainstay to severity, complications, treatment and possibly vaccination against the virus
Prevalence of Hepatitis B virus genotypes in HBsAg positive individuals of Afghanistan. In Virology Journal (2011)
Genotype D (35.67%) is the predominant genotype circulating in Afghani’s population.
Genotype C was observed in 32.16% followed by
Genotype A (19.30%), and
Genotype B (7.02%)
While 6.07% of the individuals were not typed

10. Injecting drug users ( HBV: 6.15% and HCV:36%)
Intrapartum patterns ( HBV: 1.53% and HCV:0.3%)
Sex Workers ( HBV: 6.54% and HCV:1.92%)
Blood donors ( HBV: 1.76% and HCV:0.63%)
Healthcare workers( HBV: 23% and HCV:36%)
Refugees
▪In US ( HBV: 4-5%)
▪In Iran (HBV: 60.8%)
▪In Pakistan (HBV: 8.3%)

11. Unsafe water, sanitation and poor waste management
Socioeconomic status
Drug abuse and needle sharing
Sexual activities and unsafe sex
Occupational exposure in healthcare settings
Unsafe healthcare practices
Other traditional exposures with blood
Knowledge and awareness

12. 0
5000
10000
15000
20000
25000
30000
35000
0
5000000
10000000
15000000
20000000
25000000
30000000
35000000
40000000
45000000
50000000
1383
1384
1385
1386
1387
1388
1389
1390
1391
1392
1393
AVH
Total Clients

24. 200
300
400
500
600
700
800
900
1000
1100
1200
0
2
4
6
8
10
12
Jan
Mar
May
Jul
Sep
Nov
Jan
Mar
May
Jul
Sep
Nov
Jan
Mar
May
Jul
Sep
Nov
Jan
Mar
May
Jul
Sep
Nov
Jan
Mar
May
Jul
Sep
Nov
Jan
Mar
May
Jul
Sep
Nov
Jan
Mar
May
Jul
Sep
Nov
2008
2009
2010
2011
2012
2013
2014(Jan-Nov
Number of Deaths Number of Cases Acute Viral Hepatitis cases and deaths by Provinces and by Months 2008-2014(Jan-Nov)
Cases
Deaths

25. 0.0%
0.0%
0.0%
0.1%
0.1%
0.1%
0.1%
0.1%
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
Jan
May
Sep
2008
2009
2010
2011
2012
2013
2014(Jan-
Nov)
Cyclic trend of AVH as a percentages of total clients from 2008-2014 by months

26. Study Design: Cross sectional (WHO STEP wise approach)
Study Population: Jalalabad adult citizens
Sampling: Cluster sampling of 1200 subjects
Study Period: March-December 2013
Data Collection: Structured Questionnaire via face to face interview with anthropometries measurements and blood sample biochemical and rapid hepatitis tests
Ethical Consideration: IRB approval and informed consent taken
Data Management: Epi Info and SPSS
Plan of analysis: Descriptive and proportions
Study Support: MoPH, WHO

27. A total of 1200 subjects (60.9% females 39.1% males) with a mean age of 38.78 (SD 11.05) years were enrolled in the study
The prevalence of HBsAg-positive was (3.8%) by rapid test and (3.4%) by ELIZA
Prevalence of anti-HCV-positive was (0.9%) in this study.
No mutual infection detected
By multivariate logistic regression analysis, independent predictors for HBsAg infection were being male (p value <0.01) traditional practice of tattooing (p value <0.05) and history of jaundice (p value <0.001)

28. Inadequate coordination and leadership
Lack of adequate knowledge and awareness among the general population as well as health professionals
Adequate surveillance systems and researches to enable them to take evidence based policy decisions
Transmission ways are poorly focused and prevented
Screening programs, care and treatment

29. Axis 1. Raising awareness, promoting partnerships and mobilizing resources
policy-makers, health professionals, and the public
Axis 2. Evidence-based policy and data for action
Surveillance, research, surveys, burdens, interventions assessment
Axis 3. Prevention of transmission
Vaccinations, Safer sex, safe and rational use of injections and safe blood transfusion, safe food and water for countries and on proper disposal of sanitary waste.
Axis 4. Screening, care and treatment
Guidelines for screening, for increasing access to care, for treatment of patients

30. Thanks
kmislamsaeed@gmail.com
Phone: 0093(0)202301366, cell: 0093700290955