The changing pattern of hepatitis A in Lebanese adults

Hepatitis A in the Eastern Mediterranean Region: a comprehensive review

INTRODUCTION

With 583 million inhabitants, the Eastern Mediterranean Region (EMR) is a worldwide hub for travel, migration, and food trade. However, there is a scarcity of data on the epidemiology of the hepatitis A virus (HAV).

METHODS

The MEDLINE and grey literature were systematically searched for HAV epidemiological data relevant to the EMR region published between 1980 and 2020 in English, French, or Arabic.

RESULTS

Overall, 123 publications were extracted. The proportion of HAV cases among acute viral hepatitis cases was high. HAV seroprevalence rate ranged from 5.7% to 100.0% and it was decreasing over time while the average age at infection increased.

CONCLUSION

In the EMR, HAV remains a significant cause of acute viral hepatitis. The observed endemicity shift will likely increase disease burden as the population ages. Vaccinating children and adopting sanitary measures are still essential to disease prevention; vaccinating at-risk groups might reduce disease burden even further.

Factors influencing the occurrence of infectious disease outbreaks in Lebanon since the Syrian crisis

Since the beginning of the Syrian crisis in 2011, the region has witnessed a major population displacement. Lebanon, a country with a population of 4.2 million, has welcomed around one million refugees. A rise in the incidence of Measles, Hepatitis A and Leishmaniosis was noted. This paper aims to document the incidence of outbreaks along with the factors that contributed to their emergence in Lebanon. A comprehensive literature review was conducted using electronic databases and (non) governmental reports, including studies reporting the state of Syrian refugees in Lebanon and those reporting on infectious outbreaks in Lebanon and Syria. Primary outcomes were defined as incidence or prevalence of Measles, Hepatitis A, and Leishmaniosis in both populations. Secondary outcomes were set to be the risk factors for the outbreaks. As of February 2016, Lebanon registered a total of 1.067.785 refugees. Infectious outbreaks were reported in Lebanon just after initiation of Syrian migration, with 1760 new measles cases, 1551 hepatitis A cases, and 1033 Leishmania cases in 2013. Local factors probably contributing to the emergence and dissemination of the outbreaks include living conditions, water and sanitation, nutritional state, and immunization. The outbreaks were not only reported in regions with higher refugee concentration, but also within other Lebanese regions. This was attributed to deficiencies in immunization of measles, low socioeconomic status and poor living conditions. The Syrian crisis has led to considerable impact on the demographic, economic, and political systems in Lebanon, next to an important burden on the healthcare system.

Accelerating Effects of Vitamin E Supplementation on Liver Enzyme Normalization in Children with Acute Hepatitis A Infection; a Single-Blinded Clinical Trial

Background: Hepatitis A virus (HAV) infection is a widespread disease with no specific treatment. Objectives: In the present study, we investigated the effects of vitamin E in the treatment of acute HAV infection in children. Methods: This clinical trial study was conducted on 142 patients with acute HAV infection referred to Amir-Al-Momenin Hospital of Zabol during February 2016-August 2017. The patients were randomly divided into two groups of intervention (Vit E, n = 71) and control (no medication, n = 71). Liver enzymes were monitored during a six-month period. Results: The mean ages of the patients were 8.4 ± 2.5 and 9 ± 4.3 years in the control and intervention groups, respectively. Male participants constituted 36 (50.7%) and 35 (49.3%) in the control and intervention groups, respectively. In both the treatment and control groups, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) significantly decreased over six months during the study (P < 0.001). AST level (IU/L) was significantly lower in the children who received vitamin E than controls at one-month (P = 0.01), two-month (P = 0.002), three-month (P = 0.005), four-month (P < 0.001), and six-month (P = 0.002) post-treatment periods. There was no significant difference comparing ALT between the intervention and control groups except for two months post-treatment (P = 0.01). Conclusions: Our study showed that the administration of vitamin E in children with acute hepatitis A can accelerate liver enzyme normalization.

Hepatitis A immunity in Yozgat, Turkey

BACKGROUND

Since routine immunization could change the epidemiological profile of hepatitis A virus (HAV) infection in the future, it is important to determine the baseline immunity to HAV across Turkey.

OBJECTIVE

The aim of this study was to determine the seroprevalence of hepatitis A among individuals 6 years of age and older in Yozgat, Turkey.

DESIGN

Cross-sectional.

SETTING

Community in central region of Turkey.

PATIENTS AND METHODS

Questionnaires and blood specimens were collected and the presence of hepatitis A IgG antibodies against hepatitis A virus was determined quantitatively by ELISA.

MAIN OUTCOME MEASURES

The rates of hepatitis A immunity by age group.

SAMPLE SIZE

1862.

RESULTS

Immunity to hepatitis A was 79.1% (n=1473). The mean (SD) age was 17.1 (14.7) years in the nonimmune group and 37.8 (19.5) years in the immune group (P less than .001), and immunity increased with age. No significant difference in immunity rate was detected between gen.ders in children and adults. The seropositivity rate for subjects ages 6-19 years was lower than in subjects aged 20-96 years (52.2% versus 93.9%; P less than .001).

CONCLUSION

A catch-up vaccination program is needed for persons aged 6-19 years in Yozgat.

LIMITATIONS

Single region data which can not be generalized. For this reason, a multi-centered study that can reflect the whole country is recommended.

CONFLICT OF INTEREST

None.

Infectious diseases in the era of refugees: Hepatitis A outbreak in Lebanon

BACKGROUND

The Syrian crisis has altered the epidemiology of infectious diseases in countries hosting large numbers of refugees. Lebanon witnessed several outbreaks linked to the presence of significant numbers of Syrian refugees, namely, Hepatitis A virus (HAV). We explore the epidemiology of HAV in Lebanon and the impact of the Syrian war during the 2014 outbreak and suggest solutions to prevent and minimize the HAV spread amid the current socioeconomic conditions.

METHODS

We reviewed all HAV cases reported to the Epidemiologic Surveillance Unit at the Ministry of Public Health between January 2001 and December 2017. Demographics and distribution of Syrian refugees in Lebanon were linked to reports of new HAV cases.

RESULTS

A sharp rise in the number of reported HAV cases was observed in Lebanon in 2013, concurrent with the Syrian crisis and influx of refugees. Most cases reported in 2013 and 2014 involved Syrian refugees and their relevant areas of settlement in the Beqaa and North governorates.

CONCLUSION

The influx of refugees strained overburdened sanitary infrastructure and overstretched existing public health services in Lebanon, which led to an increase in the incidence of reported HAV cases. The Lebanese health authorities and the international community need to intensify their efforts in surveillance and prevention of communicable diseases. Providing proper sanitation and free vaccination for affected communities are effective solutions to contain the HAV outbreak. Yet, financial constraints and the need to prioritize in the health budget put HAV-immunization at a lower priority. The Lebanese scenario could be reflective to other countries hosting sizeable numbers of refugees.

Age-period-cohort analysis of hepatitis A incidence rates in Korea from 2002 to 2012

OBJECTIVES

This study aimed to evaluate the epidemiology of hepatitis A in Korea from 2002 to 2012 using age-period-cohort analyses.

METHODS

We used claims data from the Korean National Health Insurance Corporation for the entire population. Census data from 2010 were used as the standard population. The incidence of hepatitis A was assumed to have a Poisson distribution, and the models and effects were evaluated using the intrinsic estimator method, the likelihood ratio, and the Akaike information criterion.

RESULTS

The incidence of hepatitis A gradually increased until 2007 (from 17.55 to 35.72 per 100,000 population) and peaked in 2009 (177.47 per 100,000 population). The highest incidence was observed among 27-29-year-old individuals when we omitted data from 2005 to 2007. From 2005 to 2007, the peak incidence was observed among 24-26-year-old individuals, followed by 27-29-year-olds. The best model fits were observed when the age-period-cohort variables were all considered at the same time for males, females, and the whole population.

CONCLUSIONS

The incidence of hepatitis A exhibited significant age-period-cohort effects; its incidence peaked in 2009 and was especially high among Koreans 20-39 years of age. These epidemiological patterns may help predict when high incidence rates of hepatitis A may occur in developing countries during their socioeconomic development.

Pre-travel advice, attitudes and hepatitis A and B vaccination rates among travellers from seven countries†

BACKGROUND

Knowledge about the travel-associated risks of hepatitis A and B, and the extent of pre-travel health-advice being sought may vary between countries.

METHODS

An online survey was undertaken to assess the awareness, advice-seeking behaviour, rates of vaccination against hepatitis A and B and adherence rates in Australia, Finland, Germany, Norway, Sweden, the UK and Canada between August and October 2014. Individuals aged 18-65 years were screened for eligibility based on: travel to hepatitis A and B endemic countries within the past 3 years, awareness of hepatitis A, and/or combined hepatitis A&B vaccines; awareness of their self-reported vaccination status and if vaccinated, vaccination within the last 3 years. Awareness and receipt of the vaccines, sources of advice, reasons for non-vaccination, adherence to recommended doses and the value of immunization reminders were analysed.

RESULTS

Of 27 386 screened travellers, 19 817 (72%) were aware of monovalent hepatitis A or combined A&B vaccines. Of these 13 857 (70%) had sought advice from a healthcare provider (HCP) regarding combined hepatitis A&B or monovalent hepatitis A vaccination, and 9328 (67%) were vaccinated. Of 5225 individuals eligible for the main survey (recently vaccinated = 3576; unvaccinated = 1649), 27% (841/3111) and 37% (174/465) of vaccinated travellers had adhered to the 3-dose combined hepatitis A&B or 2-dose monovalent hepatitis A vaccination schedules, respectively. Of travellers partially vaccinated against combined hepatitis A&B or hepatitis A, 84% and 61%, respectively, believed that they had received the recommended number of doses.

CONCLUSIONS

HCPs remain the main source of pre-travel health advice. The majority of travellers who received monovalent hepatitis A or combined hepatitis A&B vaccines did not complete the recommended course. These findings highlight the need for further training of HCPs and the provision of reminder services to improve traveller awareness and adherence to vaccination schedules.

Hepatitis A: epidemiology in resource-poor countries

PURPOSE OF REVIEW

Transmission of hepatitis A virus (HAV) infection is primarily fecal-oral. Symptomatic hepatitis, severe disease, and death are more likely to occur when infection occurs at an older age. Improvements in socioeconomic and hygienic conditions have led to a change in its epidemiology worldwide.

RECENT FINDINGS

In the last two decades, improved hygiene in several resource-poor countries has led to reduced transmission of HAV, an increase in average age at infection, and, consequently, a paradoxical increase in morbidity and mortality because of hepatitis A. In Argentina, introduction of one dose (instead of the conventional two doses, to reduce costs) of inactivated HAV vaccine at 12-month age in a universal childhood immunization program during such 'epidemiologic transition' has markedly reduced the incidence of symptomatic hepatitis A, and of fulminant hepatitis and liver transplantation caused by HAV infection. The monetary value of medical and nonmedical benefits of this strategy outweighed the expenditure on vaccination. These excellent results were possibly contingent upon a high vaccination coverage.

SUMMARY

Resource-poor countries should closely monitor the epidemiology of HAV infection and periodically undertake cost-effectiveness analyses of HAV immunization strategies. This should allow timely identification of epidemiologic transition and introduction of preventive strategies before HAV infection becomes a public health problem.

Migration pattern of hepatitis A virus genotype IA in North-Central Tunisia

Background

Hepatitis A virus (HAV) epidemiology in Tunisia has changed from high to intermediate endemicity in the last decades. However, several outbreaks continue to occur. The last reported sequences from Tunisian HAV strains date back to 2006. In order to provide an updated overview of the strains currently circulating in Tunisia, a large-scale molecular analysis of samples from hepatitis A cases was performed, the first in Tunisia.

Results

Biological samples were collected from patients with laboratory confirmed hepatitis A: 145 sera samples in Tunis, Monastir, Sousse and Kairouan from 2008 to 2013 and 45 stool samples in Mahdia in 2009. HAV isolates were characterised by nested RT-PCR (VP1/2A region) and sequencing. The sequences finally obtained from 81 samples showed 78 genotype IA and 3 genotype IB isolates.

A Tunisian genotype IA sequence dataset, including both the 78 newly obtained IA sequences and 51 sequences retrieved from GenBank, was used for phylogenetic investigation, including analysis of migration pattern among six towns. Virus gene flow from Sfax and Monastir was directed to all other towns; in contrast, the gene flows from Sousse, Tunis, Mahdia and Kairouan were directed to three, two, one and no towns, respectively.

Conclusions

Several different HAV strains co-circulate in Tunisia, but the predominant genotype still continues to be IA (78/81, 96% isolates). A complex gene flow (migration) of HAV genotype IA was observed, with Sfax and Monastir showing gene flows to all other investigated towns. This approach coupled to a wider sampling can prove useful to investigate the factors underlying the spread of HAV in Tunisia and, thus, to implement appropriate preventing measures.