Hepatitis E infections in Hungary, 2002-2014

Ágnes Fehér

National Centre for Epidemiology,

Hungary

1st ECDC Hepatitis E virus expert group meeting Stockholm, 09-10 December 2015

Introduction

• Viral hepatitis has been notifiable in Hungary since 1950. The basis of the reports was the clinical diagnosis.

• Serological tests for hepatitis diseases have been available since mid 1980’s.

• Before 2002, acute viral hepatitis E was rarely diagnosed in Hungary.

• Electronic surveillance system since 2003.

Background – hepatitis E surveillance in Hungary

Hepatitis E surveillanve is a part of the general communicable diseases reporting system in Hungary.

• Reporting is compulsory – based on law.

- hepatitis E is on the list of compulsory notifiable communicable diseases

• Reporters – laboratories / physicians

• Surveillance is aetiology-based

• Case-based: Physicians have to report data of each case within 24 hours of the diagnosis making

- on a paper-based standard case report form - until 2013

- on-line – since 2014.

• Comprehensive and nation-wide: all physicians (GPs, specialists working in outpatient clinics, physicians working in hospitals, at emergency service, pathologists, microbiologists) should report suspected, probable or confirmed cases.

• Passive:

- There is no search for cases, only in the environment of a known patient

• The EU case definition is used for classifying reported cases.

Main characteristics of hepatitis E surveillance in Hungary

Hepatitis E surveillance in Hungary

Information from cases

- Case report form – online from the physicians

- Case investigation form

- PH workers ask the patients

- 3 different form (not uniform in all counties)

- Questinaire – pilot version (used not widely)

Laboratory results - from regional and central PH laboratories

and occasionally from private and university labs

There is only one central national database.

- nationwide electronic system for registering and analysing the data of communicable diseases.

Analysis of hepatitis E surveillance data

Number of hepatitis E cases in Hungary, 2000-2014 (N=604)

0

20

40

60

80

100

120

140 cases cases

years

1 Jan 2000 – 5 Dec 2015

• 686 hepatitis E cases were reported

• Sporadic (6 cases to epidemics)

• Case classification:

– Possible : 3

– Probable: 7

– Confirmed: 641 (97,3%)

– No classification: 8

• 67,1% hospitalized

• 5 death (1-1 in 2003, 2008, 2010, 2011, 2012)

• Reported rates per million inhabitants increased from 1 in 2002 to 9 in 2014.

Analysis of hepatitis E surveillance data

Number of HEV cases and incidence/100000 inhabitants by age-group, 2004-2014 (N=548)

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2

4

6

8

10

12

14

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20

40

60

80

100

120

140

160

0-10 10-19 20-29 30-39 40-49 50-59 60-69 70-

cases rate/100000

mean age: 54 years, median: 57 years, range: 4-90 years

case

s

rate

/10

00

00

Hepatitis E cases by sex in Hungary, 2000-2014

62% was man, male/female = 1,39

0

10

20

30

40

50

60

70

80

2000. 2001. 2002. 2003. 2004. 2005. 2006. 2007. 2008. 2009. 2010. 2011. 2012. 2013. 2014.

Male Female

cases

The annual trend increased - incidence rate ratio=1.3; 95% confidence interval: 1.2-3.4 (Poisson regression).

Distribution of hepatitis E cases and twelf-month runing avarage,

Hungary, 01.01.2004-12.05.2015, N=659

0

2

4

6

8

10

12

14

16

18

20

Jan

Jun

No

v

Ap

r

Sep

Feb

Jul

Dec

May Oct

Mar

Au

g

Jan

Jun

No

v

Ap

r

Sep

Feb

Jul

Dec

May Oct

Mar

Au

g

Jan

Jun

No

v

Ap

r

Sep

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Cases

Month

Year

Study on trends of hepatitis E infections in Hungary, 2002-2013

• Retrospective descirtivetopic analysis - of hepatitis E infections

• Calculate incidence rates using census data and analyzed by time, place and person.

• Determine epidemiological features and trends of hepatitis E infections

• Examine the changes in the occurrence and characteristics of hepatitis E cases compaire data 2002-2007 and 2008-2013

• Case definition - persons with clinical diagnosis of acute hepatitis and anti-HEV IgM positivity.

2002-2007 2008-2013 2002-2013

Number of cases 85 378 463

Incidence rate /100.000 0,14 0,63 0,37

Hospitalization rate/% 96% 70% 83%

Death number 1 4 5

Letality rate/% 1,2 1,1 1,1

Male/% 60% 62% 62%

Male/Female 1,5 1,6 1,6

Avarage/Year 51 55 54

Mean/Year 56 57 57

Min-max/Year 9-84 5-89 5-89

2002-2013: 480 hepatitis E cases were reported, 7 imported cases excluded.

Result of retrospectiv study, 2002-2013

0

5

10

15

20

25

30

35

40

45

50

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2002-2007

2008-2013

Six-years cumulative number

of hepatitis E cases by month, 2002-2013 (N=463)

A second study was performed using new questionaires since 2012. This new reported form have been completted.

No significant relationships between the number of cases and

• food consumption/habits (sausage)

• comorbidity (liver cirrhosis, alcohol dis.)

• certain medical supply no

• possibility of zoonotic infections more data needed

• occupation more data needed

• education no

• distance to the lab no

Retrospectiv study II., 1 Jan 2012. – 30 Jun 2014.

Conclusions

• Last years the number of hepatitis E cases increased

continuously and significantly, although they were

unterreported.

• During 2003-2014 reported rates of hepatitis E cases

increased. The highest rates were among elderly.

• The epidemiological characteristics of hepatitis E cases has not

changed.

• We have to enhance the surveillance to collect information

on risk factors .

• Anti-HEV tests should be possible to use for each county

• Should be evaluate the laboratory capacity, know how many

lab can detect HEV and which method they use to diagnoses.

• Is this continously increase due to improving the diagnostic

capacity or is there any other cause?

Recommendations