The prevalence of HBV, HCV and HIV infection in Romania - a nationwide

screening program for surveillance of viral infections

Risk factors for HBV and HCV infection in two young cohorts in Romania

Dr. Oana Săndulescu, MD, PhDBucharest – Romania

October 2016

06 Oct 2016

Disclosures and acknowledgements

This study is part of the RO 19.02. Project “Strengthening the prevention and control of HIV/AIDS, HBV, HCV in Romania”, financed by the Norway Financial Mechanism 2009-2014, “Public Health Initiatives”.

License thesis “Hepatitis risk factors distribution in a young cohort” performed at the Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. Coordinator: Dr. Anca Streinu-Cercel, MD, PhD; Supervisor: Dr. Oana Săndulescu, MD, PhD.

No relevant conflicts of interestin relation to this presentation

HBV numbers and facts

1995: incidence of HBV in Romania is 25/100,000 population1

1996: Romania implements national vaccination against HBV in children (first dose at birth), healthcare workers

Subsequent catch-up immunization campaigns:o 1999: 9 y/oo 2004: 18 y/o

2015: Nationwide screening program for surveillance of viral infections

2015: incidence of HBV in Romania is 1.15/100,000 population2

1Pitigoi D, et al, Euro Surveill. 2008;13(2).pii:8012.2Romanian National Institute for Public Health 2015. http://www.cnscbt.ro/index.php/rapoarte-anuale/

Methods Nationwide screening program

o HBsAg, anti-HCV, anti-HIV

Confirmation and characterization of positive caseso HBV-DNA, HCV-RNA, HIV-RNA

Risk factor assessmento Standardized paper-based questionnaireo Romanian population vs. international students

Statistical analysis: IBM SPSS Statistics v.22 (Armonk, USA)

12000 persons screenedMedian age 46 (IQR: 36, 57) years

62.7% females

Results

Total number of tests

Number of positive tests

56

9

69

6

410

22 146

17

71

3

914

67

178

12

62

6

106

10

46

1033

5

105

2081

14 30

8

298

21

1209

104

129

13

385

29

1120

73

633

49

450

36

36

4

111

12

30 6

663

12445

9200

19

29

4

62

7

183

15199

15

734

3742

038

3

50

4

57

5

65

13

25

1

539

302166

70

190

6

HBV testing

● <2%

● 2-7%

● >=8%HBV hotspots

Positive HBV tests

7.7% positive tests 1 county in Romania was “HBV-free”

8% 7%10%

8%

4%

8%

12%

6%

11%

19%

9%10%

27%

5%7%

3%

20%22%

10%

17%

11%

8% 8%

20%

7%

40%

9% 9%

3%

8%

15%

20%

16%

0%

4%5%

19%

7%9% 8%

14%11%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

0

562

6926

410

14

146

6

71

3

42

0

38

28

914

5

178

6

62

3

1063

46

3

33 4

105

6

81

2

30

13

298

17

1209

36

1120

13

385

7

129

4

111

030

43

633

29

450

0

36

0

57

34

663

8

183

10

734

6

199

0

1901

50

3

2524

539

23

2166

2

62

0

29

9

200 1

45

0

65

HCV testing Total number of tests

Number of positive tests

HCV hotspots● <2%

● 2-7%

● >=8%

Positive HCV tests

3.3% positive anti-HCV tests

60.7% of the positive tests had negative HCV-RNA

9 counties in Romania were “HCV-free”

3% 3%

5%

6%

8%

0%

10%

4%4%

5%

0%

10%

7%

1%

4%

1%2%

7%5%

7%

3%2%

4%

0%

3%

0%

3% 3%

0%

7%

9%

0% 0%

7%

12%

6%

4%3%

1%

3%

0% 0%0%

2%

4%

6%

8%

10%

12%

14%

=> 1.9%

56 69410

146

71

914

178

62

106

46 33105 81

30 298

1209

129

385

1120

633

450

36

111

30

663

45

2002962

183

199

734

4238

50

5765

25539 2166

190

100

1

0

0

1

2

30

10

10

0

0

0

1

0 0

0

0

0

20 2 2

1

2

0

00

018

0

620

00

0

HIV testing Total number of tests

Number of positive tests

HIV hotspots● <2%

● 2-7%

● >=8%

Positive HIV tests

0.4% positive HIV tests 26 counties in Romania were “HIV-free”

0%0%

3%

0%0%0%

1%0%

0%

3%

0%0%0%0%

1%

0%0%0%

1%1%

0%0%

1%

0%0%0%

1%

0%0%0%

3%

0%0%0%0%0%0%0%0%0%

7%

0%0%

1%

2%

3%

4%

5%

6%

7%

8%

Risk factors

HB

V HIV infection OR: 13.2 (95%CI: 1.1, 157.1)

STIs – OR: 13 (95%CI: 1.1, 157.1)

Coagulopathy (p=0.030, χ(2)=6.999)H

CV Injected drug use

(p=0.003, χ(1)=305.000)

Needle sharing (p<0.001, χ(2)=305.000)

Coagulopathy (p<0.001, χ(2)=151.998)

Risk factors for viral hepatitis

Risk factors

Higher prevalence of risk factors in the male population:

o unprotected oral i/c OR: 5.5 (CI95%: 2.9, 10.2)

o history of STIs OR: 3.4 (CI95%: 1.3, 10.0)

o unprotected anal i/c OR: 2,6 (CI95%: 1.1, 6.0)

o unprotected vaginal i/c OR: 2.2 (CI95%: 1.5, 3.3)

o piercing/tattoos OR: 1.9 (CI95%: 1.4, 2.6)

Clustering of risk factors In patients with STIs:

o IDU OR: 372 (CI95%: 64, 2180)o Needle sharing OR: 124 (CI95%: 26, 598)

In patients with piercings/tattoos:o IDU OR: 69 (CI95%: 14, 346)o Needle sharing OR: 16 (CI95%: 4.5, 56.8)o Unprotected intercourse: oral OR: 34 (CI95%: 19, 61) anal OR: 25 (CI95%: 10, 64) vaginal OR: 13 (CI95%: 8, 23) homosexual OR: 10 (CI95%: 4.7, 21.2)

o Multiple sex partners OR: 10 (CI95%: 7, 14)

International students vs. general population

• Transfusion/transplantation (p=0.029)

• IDU (p=0.048)• Travel to endemic areas

(p<0.001)• Unprotected oral or

vaginal intercourse (p=0.004)

• Tattoos/piercing (p<0.001)

International students (n=77) General population (n=294)

Not seeking medical attention (p<0.001)

Median age: 25 years (IQR: 24, 26 years)

HBV

0%Study

4.4%Control

HCV

0%Study

0.4%Control

p=0.246 p=0.892

Prevalence of viral hepatitis

o International students had higher prevalence of risk factors

buto They were better informed on how to avoid riskand thereforeo They had a lower prevalence of HBV (0% vs. 4.4%) and

HCV (0% vs. 0.4%) infection.

Take home messages

Vaccination decreased the incidence of HBV infection 21-fold

12000 persons screenedo 7.7% positive HBsAgo 1.9% confirmed HCV infectiono 0.4% positive HIV tests

Targeted outreach programs in the identified hotspots