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Integrated Surveillance Integrated Surveillance for HIV, Viral Hepatitis, for HIV, Viral Hepatitis,
and Sexually Transmitted Diseasesand Sexually Transmitted Diseasesin Central Asia Region in Central Asia Region
CDC Central Asia Program, DIH, EPO; CDC Central Asia Program, DIH, EPO; Division of Viral Hepatitis, NCID;Division of Viral Hepatitis, NCID;
Centers for Diseases Control and Prevention, AtlantaCenters for Diseases Control and Prevention, Atlanta
In Partnership with: USAID, USA Embassies,
and Ministries of Health of
Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan
Surveillance Surveillance
The process of systematic collection, collation and analysis of data with
prompt dissemination to those who need to know, for relevant action to be
taken.
http://www.who.int/emc-documents/surveillance
Protocol for the Assessment of National Communicable Disease Surveillance and Response Systems. Guidelines for Assessment TeamsWHO/CDS/CSR/ISR/2001.2
Surveillance that identifies persons with
conditions, infections, diseases
that often have overlapping risk factors,
to achieve better public health interventions ‘Provisional Definition’
H.S. Margolis, MD - ‘Provisional Definition’, 2001
What is Integrated Surveillance ?What is Integrated Surveillance ?
Reasons to Combine Reasons to Combine Viral Hepatitis, HIV/AIDS and STD Viral Hepatitis, HIV/AIDS and STD
Surveillance, Control, and Prevention Surveillance, Control, and Prevention
• Major public health problems
• Routes of transmission overlap
• Effective prevention tools
– Immunization, treatment, risk reduction
• Lack of national programs for integrated prevention activities leads to transmission of viral hepatitis, HIV/AIDS and STD
HeroinHeroin
KhankaKhanka HeroinHeroin HeroinHeroinKhankaKhanka
Bloodborn diseases transmission related activities in Central Asia
production, trafficking, dissemination and consumption of illicit drugs
HeroinHeroin
KhankaKhanka HeroinHeroinKhankaKhanka HeroinHeroin HeroinHeroinKhankaKhanka
Bloodborn diseases transmission related activities in Central Asia
production, trafficking, dissemination and consumption of illicit drugs
Risk Factors for Transmission of Hepatitis Risk Factors for Transmission of Hepatitis Viruses and HIV in the USViruses and HIV in the US
Transfusion
Unknown
Occupational
Heterosexual partners MSM
Injection drug use
Transfusion
Unknown
Occupational
Heterosexual partners MSM
Injection drug use
Heterosexual partners MSM
Injection drug use
Risk Factor
Rare
30
5-7(past)
40
15
14
HBV
Rare
30
5-7(past)
40
15
14
Rare
30
5-7(past)
40
15
14
HBV
Past7- 20
10
<<1
20
1
60
HCV
Past7- 20
10
<<1
20
1
60
HCV
9
Past2
<<1
10
47
31
HIV
9
Past2
<<1
10
47
31
HIV
Proportion of Infections (%)
Missed Opportunities for Prevention of Hepatitis B Virus Infection
• Of persons with acute hepatitis B:
–36% previously treated for an STD
–25% previously incarcerated
–11% both incarcerated and treated for an STD
Lack of national programs for Lack of national programs for integrated prevention activities integrated prevention activities leads to transmission of viral leads to transmission of viral hepatitis, HIV/AIDS and STDhepatitis, HIV/AIDS and STD
HIV, STI, and HCV among IDUs in HIV, STI, and HCV among IDUs in Karaganda Oblast, Kazakhstan, 2002Karaganda Oblast, Kazakhstan, 2002
442\605
73.1%
58\890
6.5%
57\890
6.4%
116\890
13.0
21\890
2.4%Karaganda City
576\646
89.2%
52\899
5.8%
50\899
5.6%
103\899
11.5%
222\899
25%Temirtau City
HCV(two + by consec. tests; Abbott)
Other STI(symptoms and sign)
Chronic
syphilis(VDRL -;
TPPA +)
Acute
syphilis(VDRL +;
TPPA +)
HIV(anti-HIV +
EIA+IB)
Sites
Diseases
AntiAnti--HIVHIV among IDUs by lengths of drug among IDUs by lengths of drug useuse,, Karaganda Oblast, Kazakhstan, Karaganda Oblast, Kazakhstan, 2002 2002
0%
5%
10%
15%
20%
25%
30%
35%
<1 1-2 2-3 3-5 5-10 > 10
Temirtau
Karaganda
N = 1799
HIV, HCV, HBV, and Syphilis among IDUs HIV, HCV, HBV, and Syphilis among IDUs by lengths of drug useby lengths of drug use,, Kazakhstan, Kazakhstan, 2002 2002
0%10%20%30%40%50%60%70%80%90%
100%
<1 1-2 2-3 3-5 5-10 10+
Years
HIV HCV HBV Syphilis
p<0.001
p<0.001
p<0.001
p>0.1
N = 1799
Main principles for integrated sentinel Main principles for integrated sentinel surveillance buildingsurveillance building
• Populations under surveillance: IDUs, SW, Prisoners, Pregnant, Clients of STD clinics, MSM, Donors, Police.
• Comprehensive Integrated sentinel surveillance sites selection
• Site specific samples size calculation
• Unified outreach (response driven sampling)
• Standardize Laboratory Methods
• Standard Reporting (Computerized)
• Unified timelines
OshYange Yul
Temirtau
Almaty
PavlodarKostanai
HIV, VH, Syphilis integrated sentinel surveillance sites in Central Asia
Functioning and proposed HIV surveillance sites
HIV, HCV regional integrated sentinel surveillance data from IDUs, 2003-2004
Anti-HCVAnti-HCV
Anti-HIVAnti-HIV
Prevalence of:Prevalence of:
Anti-HIV, anti-HCV among Sex Anti-HIV, anti-HCV among Sex Workers in Kazakhstan , sentinel Workers in Kazakhstan , sentinel
surveillance data, 2004surveillance data, 2004
8%
20%
30%
12%
6%
20%2%
Antibody to Syphilis among IDUs in Antibody to Syphilis among IDUs in Kazakhstan, sentinel surveillance data, 2004Kazakhstan, sentinel surveillance data, 2004
Karaganda Pavlodar Chimkent Uralsk Total
IDUs 12/270 (4.4%)
14/250 (5.6%)
1/270
(0.4%)
0/250
(0%)
27/1040
2.6%
SWs 20/150 (13.3%)
8/100 (8.0%)
3/221
(1.4%)
4/64
(6.3%)
35/535
6.5%
Prisoners 3/500
(0.6%)
9/440 (2.0%)
3/400
(0.8%)
3/200 (1.5%)
18/1540
1.2%
Pregnant 4/470
(0.9%)
1/600 (0.2%)
1/600
(0.2%)
1/500 (0.2%)
7/2170
0.05%
STD 28/270 (10.4%)
43/460 (9.3%)
71/339 (20.9%)
54/500 (10.8%)
9.1%/1569
MSM 0/100
(0%)
Challenges Challenges
• Funding and/or referral sources for: vaccines, lab tests, medical care
• Funding of prevention services flows through separate programs (hepatitis, HIV/AIDS, STD, immunization, corrections)
• Staff of other programs (HIV/AIDS, STD, drug treatment, corrections) may not see viral hepatitis and STI prevention as part of their job
• Incorporation of viral hepatitis and STI prevention messages into “client-centered” counseling
Integrating prevention services for viral hepatitis, HIV/AIDS,STDs and
drug abuse is
GOOD PUBLIC HEALTH
Acknowledgement -Tatiana Kalashnikova MD, Ph.D., D.Sc., Gulzhan Muratbayeva MD, Ph.D., Umid Sharapov MD,
Andrew Dadu MD, Baurzhan Zhussupov, Maureen Sinclair MHP, Ed Maes Ph.D.; Central Asia Program, Division of International Health, Epidemiology Program Office,Rachel Bronzan, MD, MPH, Shakarishvili, Anna, MD, MPH, Ryan, Caroline MD, MPH;
International Activities Unit, Division of STD Prevention, National Center for HIV, STD and TB Prevention,
Harold Margolis MD, Jan Drobeniuc MD, Ph.D.; Division of Viral Hepatitis,Centers for Disease Control and Prevention Atlanta, USA
Nikolay Kuznetsov MD, Valeriya Kryukova MD, Zoya Tukhtina MD, Karaganda HIV Control and Prevention Center,
Sholpan Baimursina MD, Temirtau HIV Control and Prevention Center,Isidora Erasilova MD, Nataliya Kovtunenko MD, Viktoriya Zeman MD;
Kazakhstan Republic HIV Control and Prevention Center,Kanat Ermekbaev MD; Karaganda Oblast Health Commissioner,
Anatoliy Belonog MD, Aigul Kairolapova; Ministry of Health,Svetlana Demenkova MD, Andrew Mikhailov, Ric Golubjatnikov Ph.D.,MPH,
John Doyle MD, Ph.D.; Almaty Sexual Transmitted Infection Diagnostic Laboratory in affiliation with Wisconsin State
Laboratory of Hygiene, Wisconsin, USANurali Amanzhelov, NGO “Shapagat”
Almaz Sharman MD, Ph.D., D.Sc., Jennifer Adams Ph.D., Kerry Pelzman Central Asia Office,
The United States Agency for International Development