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Koga M, Saito M, Kubota M, Senkoji T, Adachi E, Ikeuchi K, Kikuchi T, Otani A, Takahashi K, Tsutsumi T, Yotsuyanagi H. Attenuation of hepatitis A antibody after immunization with hepatitis A vaccine (Aimmugen) in people living with HIV. Hepatol Res 2024; 54:487-494. [PMID: 38263905 DOI: 10.1111/hepr.14012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/11/2023] [Accepted: 12/28/2023] [Indexed: 01/25/2024]
Abstract
AIM Hepatitis A (HA) is a vaccine-preventable disease. In regions with good sanitation, men who have sex with men (MSM) are the key affected populations. During the 2018-2019 HA outbreak among MSM in Japan, we actively vaccinated MSM living with HIV (MSM-LWHIV) with Aimmugen. As previously reported, their antibody seroconversion rate due to vaccination was lower than that of healthy individuals. However, the durability of Aimmugen in people living with HIV has not yet been reported. We evaluated attenuation after the one-series vaccination (comprising three inoculations) and the factors associated with attenuation. METHODS We retrospectively examined anti-HA immunoglobulin G (anti-HA-IgG) titers and other clinical data from our hospital's medical records. Patients with no history of vaccination or HA infection (i.e., negative HA-IgG titers) who received one series of Aimmugen, achieved seropositivity, and anti-HA-IgG antibodies were tested ≥2 years after three doses were included. Fisher's exact test and the Mann-Whitney U-test were performed. p < 0.05 was considered statistically significant. RESULTS Fifty-one MSM-LWHIV were included. All were seropositive after the third dose with a median HA-IgG titer of 10.1 (interquartile range, 7.2-12.2) (sample/cut-off values [s/co]). In 45 (40-49) months, seropositivity decreased to 90% (46/51) and was attenuated to a median of 4.4 (2.3-6.5) s/co. Lower baseline B cell counts (p = 0.049), lower anti-HA-IgG levels after the second dose (p = 0.002), and lower anti-HA-IgG levels after the third dose (p = 0.003) were associated with seronegativity. CONCLUSIONS Anti-HA-IgG titers of vaccinated MSM-LWHIV may be attenuated; thus, additional immunizations should be considered.
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Affiliation(s)
- Michiko Koga
- Division of Infectious Diseases, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Makoto Saito
- Division of Infectious Diseases, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Megumi Kubota
- Division of Infectious Diseases, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Tomoe Senkoji
- Division of Infectious Diseases, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Eisuke Adachi
- Department of Infectious Diseases and Applied Immunology, Hospital of the Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Ikeuchi
- Department of Infectious Diseases and Applied Immunology, Hospital of the Institute of Medical Science, The University of Tokyo, Tokyo, Japan
- Department of Infection Control and Prevention, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tadashi Kikuchi
- Department of Infectious Diseases and Applied Immunology, Hospital of the Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Amato Otani
- Department of Infectious Diseases and Applied Immunology, Hospital of the Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Kazuaki Takahashi
- Division of Infectious Diseases, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Takeya Tsutsumi
- Division of Infectious Diseases, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
- Department of Infectious Diseases and Applied Immunology, Hospital of the Institute of Medical Science, The University of Tokyo, Tokyo, Japan
- Department of Infection Control and Prevention, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Yotsuyanagi
- Division of Infectious Diseases, Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
- Department of Infectious Diseases and Applied Immunology, Hospital of the Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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Mondelli MU. Does co-administration of vaccines interfere with immune responses? The jury is still out. Clin Microbiol Infect 2023; 29:1482-1484. [PMID: 37805030 DOI: 10.1016/j.cmi.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/28/2023] [Accepted: 09/30/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Mario U Mondelli
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy; Division of Clinical Immunology and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, viale Golgi 19, 27100 Pavia, Italy.
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3
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Van Damme P, Pintó RM, Feng Z, Cui F, Gentile A, Shouval D. Hepatitis A virus infection. Nat Rev Dis Primers 2023; 9:51. [PMID: 37770459 DOI: 10.1038/s41572-023-00461-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 09/30/2023]
Abstract
Hepatitis A is a vaccine-preventable infection caused by the hepatitis A virus (HAV). Over 150 million new infections of hepatitis A occur annually. HAV causes an acute inflammatory reaction in the liver that usually resolves spontaneously without chronic sequelae. However, up to 20% of patients experience a prolonged or relapsed course and <1% experience acute liver failure. Host factors, such as immunological status, age, pregnancy and underlying hepatic diseases, can affect the severity of disease. Anti-HAV IgG antibodies produced in response to HAV infection persist for life and protect against re-infection; vaccine-induced antibodies against hepatitis A confer long-term protection. The WHO recommends vaccination for individuals at higher risk of infection and/or severe disease in countries with very low and low hepatitis A virus endemicity, and universal childhood vaccination in intermediate endemicity countries. To date, >25 countries worldwide have implemented such programmes, resulting in a reduction in the incidence of HAV infection. Improving hygiene and sanitation, rapid identification of outbreaks and fast and accurate intervention in outbreak control are essential to reducing HAV transmission.
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Affiliation(s)
- Pierre Van Damme
- Centre for the Evaluation of Vaccination, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Rosa M Pintó
- Department of Genetics, Microbiology and Statistics, Faculty of Biology, University of Barcelona, Barcelona, Spain
| | - Zongdi Feng
- Centre for Vaccines and Immunity, The Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Fuqiang Cui
- Department of Laboratorial Science and Technology & Vaccine Research Center, School of Public Health, Peking University, Beijing, People's Republic of China
| | - Angela Gentile
- Department of Epidemiology, Hospital de Niños Ricardo Gutierrez, University of Buenos Aires, Buenos Aires, Argentina
| | - Daniel Shouval
- Institute of Hepatology, Hadassah-Hebrew University Hospital, Jerusalem, Israel
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de Brito WI, de Oliveira RM, Silva J, Tubarão LN, Bom APDA, Melgaço JG, Pinto MA, Souto FJD. Persistence of immunity against hepatitis A in Brazilian children vaccinated with a single dose of inactivated virus vaccine. J Viral Hepat 2023; 30:615-620. [PMID: 36807662 DOI: 10.1111/jvh.13819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/01/2023] [Accepted: 02/15/2023] [Indexed: 02/23/2023]
Abstract
In 2014, the Brazilian National Immunization Program implemented the universal vaccination against the hepatitis A virus (HAV) for children aged 12 months and older, applying a single dose of the inactivated virus vaccine. It is essential to carry out follow-up studies in this population, aiming to verify the longevity of HAV immunological memory. This study evaluated the humoral and cellular immune response of a cohort of children vaccinated between 2014 and 2015, and further investigated between 2015 and 2016, and who had their initial antibody response assessed after the single dose. A second evaluation took place in January 2022. We examined 109 children out of the 252 that took part in the initial cohort. Seventy (64.2%) of them had anti-HAV IgG antibodies. Cellular immune response assays were performed in 37 anti-HAV-negative and 30 anti-HAV-positive children. Production of interferon-gamma (IFN-y) stimulated with the VP1 antigen was demonstrated in 34.3% of these 67 samples. Of the 37 negative anti-HAV samples, 12 (32.4%) produced IFN-y. Among the 30 anti-HAV-positive, 11 (36.7%) produced IFN-y. In total, 82 (76.6%) children presented some type of immune response against HAV. These findings demonstrate the persistence of immunological memory against HAV in the majority of children vaccinated between 6 and 7 years with a single dose of the inactivated virus vaccine.
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Affiliation(s)
- Wagner Izidoro de Brito
- Medicine School, Postgraduate Program in Health Sciences, Federal University of Mato Grosso, Brazilian Company of Hospital Services (EBSERH), Cuiabá, Brazil
| | | | - Jane Silva
- Laboratory of Immune Technology, Institute of Immunobiological Technology, Bio-Manguinhos, Oswaldo Cruz Foundation, FIOCRUZ, Rio de Janeiro, Brazil
| | - Luciana Neves Tubarão
- Laboratory of Immune Technology, Institute of Immunobiological Technology, Bio-Manguinhos, Oswaldo Cruz Foundation, FIOCRUZ, Rio de Janeiro, Brazil
| | - Ana Paula Dinis Ano Bom
- Laboratory of Immune Technology, Institute of Immunobiological Technology, Bio-Manguinhos, Oswaldo Cruz Foundation, FIOCRUZ, Rio de Janeiro, Brazil
| | - Juliana Gil Melgaço
- Laboratory of Immune Technology, Institute of Immunobiological Technology, Bio-Manguinhos, Oswaldo Cruz Foundation, FIOCRUZ, Rio de Janeiro, Brazil
| | - Marcelo Alves Pinto
- Laboratory of Immune Technology, Institute of Immunobiological Technology, Bio-Manguinhos, Oswaldo Cruz Foundation, FIOCRUZ, Rio de Janeiro, Brazil
| | - Francisco José Dutra Souto
- Medicine School, Postgraduate Program in Health Sciences, Federal University of Mato Grosso, Brazilian Company of Hospital Services (EBSERH), Cuiabá, Brazil
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Fukushima S, Kiyohara T, Nakano T, Tada Y, Hamada A. Delaying the third dose of Japanese aluminum-free hepatitis A vaccine Aimmugen elicits effective immune responses against hepatitis A in adults. Vaccine 2023:S0264-410X(23)00723-5. [PMID: 37353455 DOI: 10.1016/j.vaccine.2023.06.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/31/2023] [Accepted: 06/13/2023] [Indexed: 06/25/2023]
Abstract
Inactivated aluminum-adsorbed hepatitis A vaccines such as Havrix, Vaqta, and Avaxim are commonly used worldwide. These vaccines are typically administered in a two-dose series (at 0 and 6-12 months). However, a lyophilized inactivated aluminum-free hepatitis A vaccine, Aimmugen, which is approved in Japan, is typically administered in a three-dose series (at 0, 2-4, and 24 weeks). Hence, individuals visiting endemic hepatitis A areas receive the primary two doses of Aimmugen before traveling and the third booster dose much later. It is currently uncertain whether boosting with a delayed third dose of Aimmugen is effective, or whether a new vaccination schedule should instead be initiated. Therefore, we investigated the anti-hepatitis-A viral immune response of adult travelers who received the third dose of Aimmugen more than 24 weeks after the first dose. Participants were vaccinated with the third dose of Aimmugen more than 2 years after the first two doses. Antibody titers were measured at Day 0 (prevaccination) and at 28-42 days after the third dose of Aimmugen. Twenty-nine adult participants were enrolled in the study (14 men and 15 women; mean age ± standard deviation age, 36.2 ± 8.1 years). The interval between the first two doses and the third dose was 3-14 years. The seroprotection rate (i.e., the percentage of participants with anti-hepatitis A virus antibody titers ≥ 10 mIU/mL) was 96.6 % (28/29) at Day 0 and increased to 100 % (29/29) at Days 28-42. Geometric mean concentration increased from 105 to 4,013 mIU/mL. We demonstrated that delaying the third dose of Aimmugen still elicited effective immune responses after priming with two doses of the vaccine. Trial registration: UMIN Clinical Trials Registry (UMIN-CTR): MIN000013624. Registered 03 April 2014. https://center6.umin.ac.jp/cgi-bin/ctr/ctr_view_reg.cgi?recptno=R000015906.
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Affiliation(s)
- Shinji Fukushima
- Travellers' Medical Center, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan.
| | - Tomoko Kiyohara
- Department of Virology II, National Institute of Infectious Diseases, 4-7-1 Gakuen, Musashimurayama-shi, Tokyo 208-0011, Japan.
| | - Takashi Nakano
- Department of Pediatrics, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-0192, Japan.
| | - Yuki Tada
- Travellers' Medical Center, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan.
| | - Atsuo Hamada
- Travellers' Medical Center, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan.
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Urueña A, Badano MN, Baré P, González J, Vicentín R, Calli R, Cañero-Velasco MC, Fink S, Vizzotti C. Humoral and cellular immune memory response 12 years following single dose vaccination against hepatitis A in Argentinian children. Vaccine 2022; 40:114-121. [PMID: 34838323 DOI: 10.1016/j.vaccine.2021.11.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/07/2021] [Accepted: 11/11/2021] [Indexed: 01/01/2023]
Abstract
Infants' universal hepatitis A virus (HAV) single-dose vaccination has been highly effective for controlling HAV infection in Argentina, and in other Latin-American countries that adopted that strategy. Although antibodies wane over time, this has not been associated with HAV outbreaks or breakthrough infections, suggesting a relevant role for memory immunity. This study assessed long term humoral and cellular immune memory response after an average of 12 years follow-up of HAV single-dose vaccination. We selected 81 HAV-single dose vaccinated individuals from a 2015 study, including 54 with unprotective (UAL) and 27 with protective antibody levels (PAL) against HAV. Humoral memory response was assessed by measuring anti-HAV antibody titers at admission in both groups, and 30 days after a booster dose in the UAL group. Flow cytometry analysis of peripheral blood mononuclear cell samples stimulated with HAV antigen was performed in 47/81 individuals (21 with PAL, 26 with UAL) to identify activated CD4 + memory T cells or CD8 + memory T cells. The results showed that 48/52 (92%) individuals from UAL group who completed follow up reached protective levels after booster dose. In the PAL group, anti-HAV Abs waned in 2/27 (7%) individuals lacking seroprotection, while in 25/27 (93%) Abs remained >10 mUI/mL. HAV-specific memory CD4 + T cells were detected in 25/47 (53.2%) subjects while HAV-specific memory CD8 + T cells were observed in 16/47 (34.04%) individuals. HAV-specific memory CD4+ and CD8+ T cell responses were detected in 11/21 (52.4%) and in 9/21 (42.9%) subjects with PAL and in 14/26 (53.8%) and in 7/26 (26.9%) individuals with UAL, showing that the presence of memory T-cells was independent of the level or presence of anti-HAV antibodies. Long-term immunity demonstrated in the present work, including or not antibody persistence, suggests that individuals with waned Ab titers may still be protected and supports the single-dose HAV strategy.
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Affiliation(s)
- A Urueña
- ISALUD University, Centro de Estudios para la Prevención y Control de Enfermedades Transmisibles, Venezuela 931 C1095AAS, Ciudad Autónoma de Buenos Aires, Argentina.
| | - M N Badano
- Instituto de Medicina Experimental (IMEX)-CONICET. Academia Nacional de Medicina., Laboratorio de Patogenia de Infecciones Virales, Av. Gral. Las Heras 3092, C1425ASU Ciudad Autónoma de Buenos Aires, Argentina
| | - P Baré
- Instituto de Medicina Experimental (IMEX)-CONICET. Academia Nacional de Medicina., Laboratorio de Patogenia de Infecciones Virales, Av. Gral. Las Heras 3092, C1425ASU Ciudad Autónoma de Buenos Aires, Argentina
| | - J González
- INEI ANLIS "Dr. C. G. Malbrán", Laboratorio Nacional de Referencia para Hepatitis virales.Departamento Virología, Av. Vélez Sarsfield 601-637, C1282 AFG Ciudad Autónoma de Buenos Aires, Argentina
| | - R Vicentín
- Hospital de niños Orlando Alassia. Mendoza 4151, Ciudad de Santa Fe, Santa Fe, Argentina
| | - R Calli
- Dirección de Epidemiología, Ministerio de Salud Pública Provincia de Tucumán. 25 de Mayo 90, T4000 San Miguel de Tucumán, Tucumán, Argentina
| | - M C Cañero-Velasco
- Hospital Eva Perón de la Municipalidad de Merlo, Colón 502, Merlo, Provincia de Buenos Aires, Argentina
| | - S Fink
- Instituto de Medicina Experimental (IMEX)-CONICET. Academia Nacional de Medicina., Laboratorio de Patogenia de Infecciones Virales, Av. Gral. Las Heras 3092, C1425ASU Ciudad Autónoma de Buenos Aires, Argentina
| | - C Vizzotti
- ISALUD University, Centro de Estudios para la Prevención y Control de Enfermedades Transmisibles, Venezuela 931 C1095AAS, Ciudad Autónoma de Buenos Aires, Argentina
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Herzog C. Immune memory persistence is well documented for hepatitis A vaccines. Vaccine 2021; 39:4775-4776. [PMID: 34332695 DOI: 10.1016/j.vaccine.2021.01.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 09/08/2020] [Accepted: 01/15/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Christian Herzog
- Department of Medicine, Swiss Tropical and Public Health Institute, Socinstrasse 57, CH-4051 Basel, Switzerland; University of Basel, CH-4001 Basel, Switzerland.
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Ayouni K, Chouikha A, Khamessi O, Touzi H, Hammemi W, Triki H. Evidence of Circulation of Several HAV Genetic Variants and Emergence of Potential Antigenic Variants in an Endemo-Epidemic Country before Vaccine Introduction. Viruses 2021; 13:v13061056. [PMID: 34204862 PMCID: PMC8227776 DOI: 10.3390/v13061056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/20/2021] [Accepted: 05/27/2021] [Indexed: 11/21/2022] Open
Abstract
Similar to several other countries in the world, the epidemiology of hepatitis A virus changed from high to intermediate endemicity level in Tunisia, which led to the occurrence of outbreaks. This study aimed to determine the genetic and antigenic variability of HAV strains circulating in Tunisia during the last few years. Genotyping using complete VP1 gene and VP1-2A junction confirmed the predominance of genotype IA, with co-circulation of several genetic and antigenic variants. Phylogenetic analysis including Tunisian and strains from other regions of the world showed the presence of at least two IA-variants within IA subgenotype. Amino-acid analysis showed several mutations in or close to epitope regions in the VP1-region. This study provides a baseline on the genetic and antigenic variability of HAV circulating strains before the introduction of vaccination into the national immunization schedule.
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Affiliation(s)
- Kaouther Ayouni
- Laboratory of Clinical Virology, WHO Reference Laboratory for Poliomyelitis and Measles in the Eastern Mediterranean Region, Pasteur Institute of Tunis, University Tunis El Manar (UTM), Tunis 1002, Tunisia; (H.T.); (W.H.); (H.T.)
- Faculty of Sciences of Tunis, University of Tunis El Manar, Campus Universitaire, El Manar, Tunis 2092, Tunisia
- Correspondence: (K.A.); (A.C.); Tel.: +216-26-199-695 (K.A.); +216-98-528-682 (A.C.)
| | - Anissa Chouikha
- Laboratory of Clinical Virology, WHO Reference Laboratory for Poliomyelitis and Measles in the Eastern Mediterranean Region, Pasteur Institute of Tunis, University Tunis El Manar (UTM), Tunis 1002, Tunisia; (H.T.); (W.H.); (H.T.)
- Correspondence: (K.A.); (A.C.); Tel.: +216-26-199-695 (K.A.); +216-98-528-682 (A.C.)
| | - Oussema Khamessi
- Institut Pasteur de Tunis, Université de Tunis El Manar, LR11IPT08 Venins et Biomolecules Therapeutiques, Tunis 1002, Tunisia;
| | - Henda Touzi
- Laboratory of Clinical Virology, WHO Reference Laboratory for Poliomyelitis and Measles in the Eastern Mediterranean Region, Pasteur Institute of Tunis, University Tunis El Manar (UTM), Tunis 1002, Tunisia; (H.T.); (W.H.); (H.T.)
| | - Walid Hammemi
- Laboratory of Clinical Virology, WHO Reference Laboratory for Poliomyelitis and Measles in the Eastern Mediterranean Region, Pasteur Institute of Tunis, University Tunis El Manar (UTM), Tunis 1002, Tunisia; (H.T.); (W.H.); (H.T.)
| | - Henda Triki
- Laboratory of Clinical Virology, WHO Reference Laboratory for Poliomyelitis and Measles in the Eastern Mediterranean Region, Pasteur Institute of Tunis, University Tunis El Manar (UTM), Tunis 1002, Tunisia; (H.T.); (W.H.); (H.T.)
- Faculty of Medicine of Tunis, University of Tunis El Manar, 15 Rue Djebel Lakhdhar, La Rabta, Tunis 1007, Tunisia
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Ayouni K, Kharroubi G, Mallekh R, Hammami W, Marouani R, Mhamdi M, Ben Salah A, Triki H, Bettaieb J. Seroprevalence of hepatitis A virus infection in Central-West of Tunisia. J Med Virol 2021; 93:3666-3671. [PMID: 32986240 DOI: 10.1002/jmv.26563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/28/2020] [Accepted: 09/23/2020] [Indexed: 11/06/2022]
Abstract
Hepatitis A infections still represent a major global health concern. During the past years, a transition pattern of the hepatitis A epidemiology was noted in many parts of the world. In Tunisia, there is not a recent survey on age-specific hepatitis A virus seroprevalence. This study aimed to investigate the seroprevalence of hepatitis A virus infection in Central-West Tunisia, representative of regions with lowest socioeconomic level in the country, before vaccine implementation. Sera obtained from the blood samples of subjects were screened for the detection of hepatitis A virus. The seroprevalence was evaluated by detection of total antibodies to hepatitis A virus using commercially available immunoassay kits. A total of 1379 subjects, aged 5-75 years (mean age: 29.0 ± 17.3 years) were studied. The global anti-hepatitis A virus seroplevalence was 84.7% (95% confidence interval: [82.6-86.5]). A higher hepatitis A virus seroprevalence was showed in subjects aged 10-14 years compared to those aged less than 10 years (50.0% vs. 31.0%). In subjects aged 20-29 years, a rapid increase in the hepatitis A virus prevalence was noted; it reached 97.0%. The seroprevalence of anti-hepatitis A virus differed by zone of residence (81.1% in rural area vs. 72.4% in urban area, p = .005) and increased significantly with lower level of education (p = .019). There was no statistical significant seroprevalence difference between male and female: 84.2% versus 85.2%, respectively. Our study confirm the transition pattern of the hepatitis A virus endemicity in Tunisia from high to intermediate and provide an evaluation of the hepatitis A virus epidemiological situation before vaccine implementation.
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Affiliation(s)
- Kaouther Ayouni
- Laboratory of Clinical Virology, Pasteur Institute of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Clinical Investigation Center, Pasteur Institute of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Ghassen Kharroubi
- Clinical Investigation Center, Pasteur Institute of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Department of Epidemiology, Clinical Investigation Center, Pasteur Institute of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Rym Mallekh
- Department of Epidemiology, Clinical Investigation Center, Pasteur Institute of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Walid Hammami
- Laboratory of Clinical Virology, Pasteur Institute of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Clinical Investigation Center, Pasteur Institute of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | | | - Moncef Mhamdi
- Regional Health Direction of Kasserine, Kasserine, Tunisia
| | - Afif Ben Salah
- Clinical Investigation Center, Pasteur Institute of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Department of Epidemiology, Clinical Investigation Center, Pasteur Institute of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Department of Family and Community Medicine, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Henda Triki
- Laboratory of Clinical Virology, Pasteur Institute of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Clinical Investigation Center, Pasteur Institute of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Jihène Bettaieb
- Clinical Investigation Center, Pasteur Institute of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Department of Epidemiology, Clinical Investigation Center, Pasteur Institute of Tunis, University of Tunis El Manar, Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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10
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Herzog C, Van Herck K, Van Damme P. Hepatitis A vaccination and its immunological and epidemiological long-term effects - a review of the evidence. Hum Vaccin Immunother 2021; 17:1496-1519. [PMID: 33325760 PMCID: PMC8078665 DOI: 10.1080/21645515.2020.1819742] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/16/2020] [Accepted: 09/01/2020] [Indexed: 01/11/2023] Open
Abstract
Hepatitis A virus (HAV) infections continue to represent a significant disease burden causing approximately 200 million infections, 30 million symptomatic illnesses and 30,000 deaths each year. Effective and safe hepatitis A vaccines have been available since the early 1990s. Initially developed for individual prophylaxis, HAV vaccines are now increasingly used to control hepatitis A in endemic areas. The human enteral HAV is eradicable in principle, however, HAV eradication is currently not being pursued. Inactivated HAV vaccines are safe and, after two doses, elicit seroprotection in healthy children, adolescents, and young adults for an estimated 30-40 years, if not lifelong, with no need for a later second booster. The long-term effects of the single-dose live-attenuated HAV vaccines are less well documented but available data suggest they are safe and provide long-lasting immunity and protection. A universal mass vaccination strategy (UMV) based on two doses of inactivated vaccine is commonly implemented in endemic countries and eliminates clinical hepatitis A disease in toddlers within a few years. Consequently, older age groups also benefit due to the herd protection effects. Single-dose UMV programs have shown promising outcomes but need to be monitored for many more years in order to document an effective immune memory persistence. In non-endemic countries, prevention efforts need to focus on 'new' risk groups, such as men having sex with men, prisoners, the homeless, and families visiting friends and relatives in endemic countries. This narrative review presents the current evidence regarding the immunological and epidemiological long-term effects of the hepatitis A vaccination and finally discusses emerging issues and areas for research.
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Affiliation(s)
- Christian Herzog
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Koen Van Herck
- Centre for the Evaluation of Vaccination, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
- Department of Public Health, Ghent University, Ghent, Belgium
| | - Pierre Van Damme
- Centre for the Evaluation of Vaccination, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
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11
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Ayouni K, Naffeti B, Ben Aribi W, Bettaieb J, Hammami W, Ben Salah A, Ammar H, Ben Miled S, Triki H. Hepatitis a virus infection in Central-West Tunisia: an age structured model of transmission and vaccination impact. BMC Infect Dis 2020; 20:627. [PMID: 32842988 PMCID: PMC7477833 DOI: 10.1186/s12879-020-05318-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 08/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The epidemiological pattern of hepatitis A infection has shown dynamic changes in many parts of the world due to improved socio-economic conditions and the accumulation of seronegative subjects, which leads to possible outbreaks and increased morbidity rate. In Tunisia, the epidemiological status of hepatits A virus is currently unknown. However, over the past years higher numbers of symptomatic hepatitis A virus infection in school attendants and several outbreaks were reported to the Ministry of Health, especially from regions with the lowest socio-economic levels in the country. The aim of this study was to investigate the current seroprevalence of hepatitis A virus antibodies in central-west Tunisia and assess the impact of hepatitis A virus vaccination on hepatitis A epidemiology. METHODS Serum samples from 1379 individuals, aged 5-75 years, were screened for hepatitis A virus antibodies. Adjusted seroprevalence, incidence and force of infection parameters were estimated by a linear age structured SEIR (Susceptible-Exposed-Infectious-Recovered) compartmental model. A vaccine model was then constructed to assess the impact on hepatitis A virus epidemiology of 3 scenarios of vaccination strategies: one dose at 12-months of age, one dose at 6-years and one dose at 12-months and another at 6-years of age during 6 years. RESULTS A rapid increase in anti-hepatitis A virus seroprevalence was noted during infancy and adolescence: 47% of subjects under 10-years-old are infected; the prevalence increases to 77% at 15-years and reaches 97% in subjects aged 30-years. The force of infection is highest between 10 and 30-years of age and the incidence declines with increasing age. The vaccine model showed that the 3-scenarios lead to a significant reduction of the fraction of susceptibles. The two doses scenario gives the best results. Single-dose vaccination at 6-years of age provides more rapid decrease of disease burden in school-aged children, as compared to single-dose vaccination at 12-months, but keeps with a non-negligible fraction of susceptibles among children < 6-years. CONCLUSIONS Our study confirms the epidemiological switch from high to intermediate endemicity of hepatitis A virus in Tunisia and provides models that may help undertake best decisions in terms of vaccinations strategies.
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Affiliation(s)
- Kaouther Ayouni
- Laboratory of Clinical Virology - Pasteur Institute of Tunis, University of Tunis El Manar, 13, Place Pasteur, BP: 74-1002, Tunis, Tunisia. .,Clinical Investigation Center - Pasteur Institute of Tunis, University of Tunis El Manar, Street 15 Medenine Bardo, Tunis, Tunisia. .,Faculty of Sciences of Tunis, University of Tunis El Manar, Campus Universitaire 2092-El Manar, Tunis, Tunisia.
| | - Bechir Naffeti
- Laboratory of Intelligent Networks and Nanotechnology, LARINA, University of Carthage, Tunis, Tunisia.,Faculty of Sciences of Bizerte, University of Carthage, Avenue de la République, P. O. Box 77-1054, Tunis, Amilcar, Tunisia
| | - Walid Ben Aribi
- Laboratory of Intelligent Networks and Nanotechnology, LARINA, University of Carthage, Tunis, Tunisia.,Faculty of Sciences of Bizerte, University of Carthage, Avenue de la République, P. O. Box 77-1054, Tunis, Amilcar, Tunisia
| | - Jihène Bettaieb
- Clinical Investigation Center - Pasteur Institute of Tunis, University of Tunis El Manar, Street 15 Medenine Bardo, Tunis, Tunisia.,Department of Epidemiology - Clinical Investigation Center - Pasteur Institute of Tunis, University of Tunis El Manar, 13, Place Pasteur, BP: 74-1002, Tunis, Tunisia.,Faculty of Medicine of Tunis, University of Tunis El Manar, 15 Rue Djebel Lakhdhar. La Rabta, 1007, Tunis, Tunisia
| | - Walid Hammami
- Laboratory of Clinical Virology - Pasteur Institute of Tunis, University of Tunis El Manar, 13, Place Pasteur, BP: 74-1002, Tunis, Tunisia.,Clinical Investigation Center - Pasteur Institute of Tunis, University of Tunis El Manar, Street 15 Medenine Bardo, Tunis, Tunisia
| | - Afif Ben Salah
- Clinical Investigation Center - Pasteur Institute of Tunis, University of Tunis El Manar, Street 15 Medenine Bardo, Tunis, Tunisia.,Department of Epidemiology - Clinical Investigation Center - Pasteur Institute of Tunis, University of Tunis El Manar, 13, Place Pasteur, BP: 74-1002, Tunis, Tunisia.,Faculty of Medicine of Tunis, University of Tunis El Manar, 15 Rue Djebel Lakhdhar. La Rabta, 1007, Tunis, Tunisia
| | - Hamadi Ammar
- Laboratory of Intelligent Networks and Nanotechnology, LARINA, University of Carthage, Tunis, Tunisia.,Faculty of Economic Sciences and Management of Nabeul, University of Carthage, Avenue de la République, BP 77-1054, Tunis, Amilcar, Tunisia
| | - Slimane Ben Miled
- Laboratory of Bioinformatics, Biomathématics and Biostatistics, Pasteur Institute of Tunis, University of Tunis El Manar, 13, Place Pasteur, BP: 74-1002, Tunis, Tunisia
| | - Henda Triki
- Laboratory of Clinical Virology - Pasteur Institute of Tunis, University of Tunis El Manar, 13, Place Pasteur, BP: 74-1002, Tunis, Tunisia.,Clinical Investigation Center - Pasteur Institute of Tunis, University of Tunis El Manar, Street 15 Medenine Bardo, Tunis, Tunisia.,Faculty of Medicine of Tunis, University of Tunis El Manar, 15 Rue Djebel Lakhdhar. La Rabta, 1007, Tunis, Tunisia
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12
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Nelson NP, Weng MK, Hofmeister MG, Moore KL, Doshani M, Kamili S, Koneru A, Haber P, Hagan L, Romero JR, Schillie S, Harris AM. Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020. MMWR Recomm Rep 2020; 69:1-38. [PMID: 32614811 PMCID: PMC8631741 DOI: 10.15585/mmwr.rr6905a1] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
HEPATITIS A IS A VACCINE-PREVENTABLE, COMMUNICABLE DISEASE OF THE LIVER CAUSED BY THE HEPATITIS A VIRUS (HAV). THE INFECTION IS TRANSMITTED VIA THE FECAL-ORAL ROUTE, USUALLY FROM DIRECT PERSON-TO-PERSON CONTACT OR CONSUMPTION OF CONTAMINATED FOOD OR WATER. HEPATITIS A IS AN ACUTE, SELF-LIMITED DISEASE THAT DOES NOT RESULT IN CHRONIC INFECTION. HAV ANTIBODIES (IMMUNOGLOBULIN G [IGG] ANTI-HAV) PRODUCED IN RESPONSE TO HAV INFECTION PERSIST FOR LIFE AND PROTECT AGAINST REINFECTION; IGG ANTI-HAV PRODUCED AFTER VACCINATION CONFER LONG-TERM IMMUNITY. THIS REPORT SUPPLANTS AND SUMMARIZES PREVIOUSLY PUBLISHED RECOMMENDATIONS FROM THE ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP) REGARDING THE PREVENTION OF HAV INFECTION IN THE UNITED STATES. ACIP RECOMMENDS ROUTINE VACCINATION OF CHILDREN AGED 12-23 MONTHS AND CATCH-UP VACCINATION FOR CHILDREN AND ADOLESCENTS AGED 2-18 YEARS WHO HAVE NOT PREVIOUSLY RECEIVED HEPATITIS A (HEPA) VACCINE AT ANY AGE. ACIP RECOMMENDS HEPA VACCINATION FOR ADULTS AT RISK FOR HAV INFECTION OR SEVERE DISEASE FROM HAV INFECTION AND FOR ADULTS REQUESTING PROTECTION AGAINST HAV WITHOUT ACKNOWLEDGMENT OF A RISK FACTOR. THESE RECOMMENDATIONS ALSO PROVIDE GUIDANCE FOR VACCINATION BEFORE TRAVEL, FOR POSTEXPOSURE PROPHYLAXIS, IN SETTINGS PROVIDING SERVICES TO ADULTS, AND DURING OUTBREAKS.
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13
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Melgaço JG, Azamor T, Ano Bom APD. Protective immunity after COVID-19 has been questioned: What can we do without SARS-CoV-2-IgG detection? Cell Immunol 2020; 353:104114. [PMID: 32361409 PMCID: PMC7187813 DOI: 10.1016/j.cellimm.2020.104114] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 04/25/2020] [Accepted: 04/26/2020] [Indexed: 12/30/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) induces a severe acute respiratory syndrome that is called COVID-19. Clinical manifestations of COVID-19 include diarrhea, pneumonia, lymphopenia, exhausted lymphocytes, and pro-inflammatory cytokine production. Immunology is part of the process of clinical evolution, but there are some questions around immunity-based protection: (1) why some infected people have only mild symptoms of the disease or are asymptomatic; (2) why delayed and weak antibody responses are associated with severe outcomes; and (3) why positivity in molecular tests does not represent protective antibody IgG. Perhaps T cell responses may be the key to solving those questions. SARS-CoV-2-specific memory T cells persist in peripheral blood and may be capable of providing effective information about protective immunity. The T cells studies can be helpful in elucidating the pathways for development of vaccines, therapies, and diagnostics for COVID-19 and for filling these immunology knowledge gaps.
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Affiliation(s)
- Juliana Gil Melgaço
- Laboratory of Immunological Technology, Immunobiological Technology Institute, Bio-Manguinhos, Oswaldo Cruz Foundation, FIOCRUZ, Rio de Janeiro, Brazil.
| | - Tamiris Azamor
- Laboratory of Immunological Technology, Immunobiological Technology Institute, Bio-Manguinhos, Oswaldo Cruz Foundation, FIOCRUZ, Rio de Janeiro, Brazil
| | - Ana Paula Dinis Ano Bom
- Laboratory of Immunological Technology, Immunobiological Technology Institute, Bio-Manguinhos, Oswaldo Cruz Foundation, FIOCRUZ, Rio de Janeiro, Brazil
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14
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Vacunas en salud laboral… una oportunidad para prevenir e invertir en salud. REVISTA MÉDICA CLÍNICA LAS CONDES 2020. [DOI: 10.1016/j.rmclc.2020.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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15
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Mutsaerts EAML, Nunes MC, Bhikha S, Ikulinda BT, Jose L, Koen A, Moultrie A, Grobbee DE, Klipstein-Grobusch K, Weinberg A, Madhi SA. Short-term immunogenicity and safety of hepatitis-A and varicella vaccines in HIV-exposed uninfected and HIV-unexposed South African children. Vaccine 2020; 38:3862-3868. [PMID: 32307279 DOI: 10.1016/j.vaccine.2020.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/18/2020] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND HIV-exposed uninfected (HEU) children have increased risk of infectious morbidity during early childhood. We evaluated the short-term immunogenicity and safety of single dose inactivated hepatitis-A virus (HAV) vaccine and live attenuated varicella zoster virus (VZV) vaccine in South African children. METHODS 195 HIV-unexposed and 64 HEU children received either one dose of HAV or VZV vaccine at 18 months of age. Blood samples were tested for hepatitis-A or VZV antibodies before and one month after vaccination by chemiluminescent microparticle immunoassay and enzyme-linked immunosorbent assay, respectively. All children were evaluated for solicited adverse events (AEs). RESULTS One-month post-vaccination, a similar percentage of HIV-unexposed (91.8%) and HEU (82.9%) children were seropositive for hepatitis-A (p = 0.144). VZV antibody geometric mean fold-rise was also similar in HIV-unexposed (5.6; 95%CI: 4.6-6.7) and HEU children (5.1; 95%CI: 3.7-7.2); however, only 44% HIV-unexposed and HEU seroconverted (titers > 50 mIU/ml). AEs occurred with similar frequency and severity between groups, except for more systemic AEs after VZV vaccination in HEU than HIV-unexposed children. CONCLUSIONS Single dose HAV and VZV vaccine was similarly immunogenic in HIV-unexposed and HEU children. We did not identify differences in short-term humoral immunity after administration of either a live attenuated or inactivated vaccine. Seroconversion rates after a single dose of VZV vaccine were, however, lower compared to reports from previous studies (85-89%). CLINICAL TRIALS REGISTRATION NCT03330171.
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Affiliation(s)
- Eleonora A M L Mutsaerts
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.
| | - Marta C Nunes
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sutika Bhikha
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Benit T Ikulinda
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lisa Jose
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Anthonet Koen
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Moultrie
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Diederick E Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands; Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Adriana Weinberg
- Department of Pediatrics, Medicine and Pathology, Anschutz Medical Center University of Colorado Denver, Aurora, CO, USA
| | - Shabir A Madhi
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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16
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Espul C, Cuello H, Lo Castro I, Bravo C, Thollot Y, Voznica J, Vigne C, Coudeville L. Statistical modeling alongside observational data predicts long-term immunogenicity of one dose and two doses of pediatric hepatitis A vaccine in the Mendoza province of Argentina. Vaccine 2020; 38:1715-1722. [PMID: 31928855 DOI: 10.1016/j.vaccine.2019.12.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Follow-up for anti-hepatitis A (HA) antibody persistence up to 10 years was conducted after implementation of universal vaccination against HA virus (HAV) in Mendoza, Argentina. Based on these data, statistical modeling was used to predict the antibody persistence to 30 years. METHODS A non-interventional study evaluated long-term immunogenicity (geometric mean concentrations [GMCs] and seroprotection rate) following routine vaccination with 1 dose (Group 1: N = 436) or 2 doses (Group 2: N = 108) of HA vaccine. Associated statistical modeling based on a Bayesian approach of mixed effects models on log transformed titers evaluated three models (linear, piecewise linear, and exponential decay, with and without a natural boosting effect). RESULTS From the initial cohort, 9 participants (Group 1) and 1 participant (Group 2) showed antibody titers below the seroprotective threshold and received a booster. At Year 10, 190 (Group 1) and 51 (Group 2) participants remained in the study without a booster dose and all were seroprotected. Regarding statistical modeling, the piecewise linear model showed the best fit and demonstrated high and similar seroprotection for each schedule up to 30 years (89% [1-dose schedule], 85% [2-dose schedule]). The 2-dose schedule showed higher GMC (95% CI) than the 1-dose schedule (Year 10: 352 [271-456] versus 78 [69.8-87.6] mIU/mL) and Year 30 (predicted) (37 [13-97] versus 19 [11-34] mIU/mL). Natural boosting had little impact on predicted seroprotection rates at 30 years for the 1-dose schedule (89% [0.8-0.96] and 84% [0.73-0.94] with and without a natural booster, respectively). CONCLUSIONS Long-term persistence of anti-HAV antibodies was observed up to 10 years with 1-dose and 2-dose vaccine schedules, supporting booster flexibility. Statistical modeling predicted good persistence of seroprotection for each schedule up to 30 years. Natural boosting had a limited impact on seroprotection rate predictions, enabling extrapolation of these results to non-endemic settings for traveler vaccination.
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Affiliation(s)
- C Espul
- Ministerio de Salud/Hospital Central de Mendoza, Mendoza, Argentina.
| | - H Cuello
- Seccíon Virología, Hospital Central de Mendoza, Mendoza, Argentina
| | - I Lo Castro
- Seccíon Virología, Hospital Central de Mendoza, Mendoza, Argentina
| | - C Bravo
- Sanofi Pasteur, Lyon, France.
| | | | - J Voznica
- Sanofi Pasteur, Lyon, France; Department of Biology, École Normale Supérieure Paris-Saclay, Cachan, France.
| | - C Vigne
- Sanofi Pasteur, Lyon, France.
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17
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Doornekamp L, GeurtsvanKessel C, Slobbe L, Te Marvelde MR, Scherbeijn SMJ, van Genderen PJJ, van Gorp ECM, Goeijenbier M. Adherence to hepatitis A travel health guidelines: A cross-sectional seroprevalence study in Dutch travelling families - The Dutch travel Vaccination Study (DiVeST). Travel Med Infect Dis 2019; 32:101511. [PMID: 31704482 DOI: 10.1016/j.tmaid.2019.101511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/14/2019] [Accepted: 11/04/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND This Dutch travel Vaccination Study (DiVeST) aimed to study adherence or compliance to Dutch travel health guidelines in travelling families and to identify risk groups to provide better advice and protection for international travellers. METHODS Between 2016 and 2018, family members who travelled to Eastern Europe or outside Europe during the preceding year were recruited via Dutch secondary schools. The vaccination status of the travellers was assessed using questionnaires and vaccination records and hepatitis A virus antibody concentrations in dried blood spot (DBS) eluates. Subgroups of travellers with lower adherence to guidelines were identified. RESULTS Of the 246 travellers that participated in this study, 155 (63%) travelled to destinations for which the HAV vaccination was recommended. Of these 155 travellers, 56 (36%) said they visited a pre-travel clinic, and 64 of them (41%) showed a valid HAV vaccination in their vaccination records. Of the 145 travellers with available DBS eluates, anti-HAV antibodies were detected in 98 (68%) of them. CONCLUSIONS We found that adherence to travel health guidelines, in terms of HAV vaccination, was suboptimal. According to our results, specific attention should be paid to children, persons visiting friends and relatives and those who travel relatively short distances.
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Affiliation(s)
- Laura Doornekamp
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Travel Clinic, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Corine GeurtsvanKessel
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Lennert Slobbe
- Travel Clinic, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Merel R Te Marvelde
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sandra M J Scherbeijn
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Perry J J van Genderen
- Travel Clinic, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Eric C M van Gorp
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marco Goeijenbier
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Askling HH, Herzog C. Hepatitis A vaccination in immunocompromised patients – the need for individualized vaccination strategies and correct methodology. Travel Med Infect Dis 2019; 32:101526. [PMID: 31759140 DOI: 10.1016/j.tmaid.2019.101526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 11/20/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Helena H Askling
- Department of Medicine Solna, Division of Infectious Diseases, Karolinska Institutet, Stockholm, Sweden; Department of Communicable Diseases Control and Prevention, Sörmland County, Eskilstuna, Sweden.
| | - Christian Herzog
- Medical Department, Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Switzerland
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Urbiztondo L, Pérez-Martin JJ, Borràs-López E, Navarro-Alonso JA, Limia A. Immunization recommendations against hepatitis A in Spain: Effectiveness of immunization in MSM and selection of antigenic variants. EBioMedicine 2019; 45:19-20. [PMID: 31248837 PMCID: PMC6642267 DOI: 10.1016/j.ebiom.2019.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 06/14/2019] [Accepted: 06/14/2019] [Indexed: 11/24/2022] Open
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Bravo C, Mege L, Vigne C, Thollot Y. Clinical experience with the inactivated hepatitis A vaccine, Avaxim 80U Pediatric. Expert Rev Vaccines 2019; 18:209-223. [PMID: 30806110 DOI: 10.1080/14760584.2019.1580578] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Hepatitis A, caused by hepatitis A virus (HAV), is primarily transmitted via the fecal/oral route either through ingestion of contaminated food and water or through direct contact with an infectious person. Prevalence of hepatitis A is strongly correlated with socioeconomic factors, decreasing with increased socio-economic development, access to clean water and sanitation. Vaccination against HAV should be part of a comprehensive plan for the prevention and control of viral hepatitis, either as part of regular childhood immunization programs or with other recommended vaccines for travelers. Areas covered: We present here evidence for the immunogenicity and safety of an inactivated HAV pediatric vaccine (Avaxim® 80U Pediatric, Sanofi Pasteur), indicated for use in children aged 12 months to 15 years. Data evaluated are from trials undertaken during the clinical development of this vaccine, a systematic literature review and post-market pharmacovigilance. Expert opinion: The pediatric HAV vaccine is highly immunogenic and generates long-lasting protection against hepatitis A disease in children. The safety and immunogenicity data presented in this review suggest that the pediatric HAV vaccine is a valuable option in the prevention of HAV infection in children in many areas of the world where the disease remains a healthcare issue.
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Affiliation(s)
| | - Larissa Mege
- b Global Pharmacovigilance , Sanofi Pasteur , Marcy-l'Étoile , France
| | - Claire Vigne
- c Research & Development , Sanofi Pasteur , Marcy-l'Étoile , France
| | - Yael Thollot
- a Global Medical Affairs , Sanofi Pasteur , Lyon , France
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Jayasundara D, Hui BB, Regan DG, Heywood AE, MacIntyre CR, Wood JG. Modelling the decline and future of hepatitis A transmission in Australia. J Viral Hepat 2019; 26:199-207. [PMID: 30315680 DOI: 10.1111/jvh.13018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/23/2018] [Accepted: 09/17/2018] [Indexed: 12/13/2022]
Abstract
Hepatitis A incidence has declined in most countries through a combination of prevention measures, augmented through the use of a highly effective vaccine. In Australia, the proportion of the population susceptible to hepatitis A infection has declined over time due to high rates of opportunistic vaccination as well as the sustained inflow of seropositive immigrants from high-endemicity countries. These factors have contributed to a rapid decline in incidence. An age-structured hepatitis A transmission model incorporating demographic changes was fitted to seroprevalence and disease notification data and used to project incidence trends and transmission potential for hepatitis A in the general population. Robustness of findings was assessed through worst-case scenarios regarding vaccine uptake, migration and the duration of immunity. The decline in age-specific seroprevalence until the introduction of hepatitis A vaccine in 1994 was well explained through a declining basic reproduction number (R0 ) that remained >1. Accounting for existing immunity, we estimated that the effective reproduction number (Reff ) <1 in the general population of Australia since the early 1990s, declining more rapidly after the introduction of the hepatitis A vaccine. Future projections under a variety of scenarios support Reff remaining <1 with continued low incidence in the general population. In conclusion, our results suggest that sustained endemic transmission in the general Australian population is no longer possible although risks of sporadic outbreaks remain. This suggests potential for local elimination of hepatitis A infection in Australia, provided that elimination criteria can be defined and satisfied in risk groups. The methodology used here to investigate elimination potential can easily be replicated in settings such as in the USA where sequential seroprevalence studies are supported by routine notification data.
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Affiliation(s)
- Duleepa Jayasundara
- Faculty of Medicine, School of Public Health and Community Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Ben B Hui
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - David G Regan
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Anita E Heywood
- Faculty of Medicine, School of Public Health and Community Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - C Raina MacIntyre
- Faculty of Medicine, School of Public Health and Community Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - James G Wood
- Faculty of Medicine, School of Public Health and Community Medicine, UNSW Sydney, Sydney, New South Wales, Australia
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Initial evaluation of universal immunization with a single dose against hepatitis A virus in Central Brazil. Braz J Infect Dis 2018; 22:166-170. [PMID: 29684320 PMCID: PMC9425659 DOI: 10.1016/j.bjid.2018.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 03/26/2018] [Accepted: 04/02/2018] [Indexed: 01/19/2023] Open
Abstract
Vaccination against the hepatitis A virus (HAV) administered in two doses has been used effectively in universal child immunization programs in several countries. A single-dose vaccination was adopted in some low-income countries in an attempt to reduce costs without losing effectiveness. In 2014, single-dose universal vaccination was introduced in Brazil for children aged two years. Since such strategy is still not universally accepted, its efficacy should be compared to the two-dose strategy. To assess the humoral response after the single-dose HAV vaccination schedule, a cross-sectional study was conducted in Primavera do Leste, in Mato Grosso state, Central Brazil, including 265 children vaccinated through the National Immunization Program. Blood was collected by using a digital puncture and further applied to filter paper cards. Anti-HAV was detected in 218 out of 265 dried blood spots (DBS). Blood venous samples were collected from 34 out of 47 children who were not anti-HAV positive in DBS samples. Eighteen of them tested positive for anti-HAV, giving a final score of 93.6% (236/252) of seropositivity. In conclusion, this study demonstrated a high rate of anti-HAV positivity in the short term after single-dose hepatitis A vaccination in the population investigated. Moreover, the DBS was shown to be a reliable tool for detecting anti-HAV antibodies.
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Lemon SM, Ott JJ, Van Damme P, Shouval D. Type A viral hepatitis: A summary and update on the molecular virology, epidemiology, pathogenesis and prevention. J Hepatol 2017; 68:S0168-8278(17)32278-X. [PMID: 28887164 DOI: 10.1016/j.jhep.2017.08.034] [Citation(s) in RCA: 154] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/30/2017] [Accepted: 08/30/2017] [Indexed: 02/08/2023]
Abstract
Although epidemic jaundice was well known to physicians of antiquity, it is only in recent years that medical science has begun to unravel the origins of hepatitis A virus (HAV) and the unique pathobiology underlying acute hepatitis A in humans. Improvements in sanitation and the successful development of highly efficacious vaccines have markedly reduced the worldwide prevalence and incidence of this enterically-transmitted infection over the past quarter century, yet the virus persists in vulnerable populations and remains a common cause of food-borne disease outbreaks in economically-advantaged societies. Reductions in the prevalence of HAV have led to increases in the median age at which infection occurs, often resulting in more severe disease in affected persons and paradoxical increases in disease burden in some developing nations. Here, we summarize recent advances in the molecular virology of HAV, an atypical member of the Picornaviridae family, survey what is known of the pathogenesis of hepatitis A in humans and the host-pathogen interactions that typify the infection, and review medical and public health aspects of immunisation and disease prevention.
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Affiliation(s)
- Stanley M Lemon
- Lineberger Comprehensive Cancer Center, and the Departments of Medicine and Microbiology & Immunology, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7292, USA.
| | - Jördis J Ott
- Department of Epidemiology, Helmholtz Centre for Infection Research, Braunschweig, Germany; Hannover Medical School, Hannover, Germany.
| | - Pierre Van Damme
- Centre for the Evaluation of Vaccination, Vaccine & Infectious Disease Institute, Antwerp University, Antwerp, Belgium
| | - Daniel Shouval
- Liver Unit, Institute for Gastroenterology and Hepatology, Hadassah-Hebrew University Hospital, P.O.Box 12000, Jerusalem 91120, Israel
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Single-dose Universal Hepatitis A Immunization in One-year-old Children in Argentina: High Prevalence of Protective Antibodies up to 9 Years After Vaccination. Pediatr Infect Dis J 2016; 35:1339-1342. [PMID: 27636725 DOI: 10.1097/inf.0000000000001322] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Single-dose hepatitis A virus (HAV) vaccination was implemented in all Argentinean children 12 months of age in 2005. Previous studies demonstrated high prevalence of protective antibody response 4 years after single-dose vaccination. This study assessed long-term seroprotection against HAV after vaccination. METHODS Children who received 1 dose of HAV vaccine at 1 year of age at least 6 years before enrollment were included at 5 centers in Argentina between 2013 and 2014. Demographic and socioeconomic characteristics were collected through a questionnaire. Blood samples were tested for anti-HAV antibodies. Antibody values ≥10 mIU/mL were considered seroprotective. Logistic regression analysis was performed to evaluate the association between demographic and socioeconomic variables and seroprotection. RESULTS A total of 1088 children were included, with a median postvaccination interval of 7.7 years (range 6.3-9.2 years). Of these children, 97.4% (95% confidence interval: 96.3%-98.3%) had protective antibodies against HAV. No association between demographic or socioeconomic variables and seroprotection was found. Geometric mean concentration of antibody levels against HAV was 170.5 mUI/mL (95% confidence interval: 163.2-178.2 mUI/mL). CONCLUSIONS Single-dose universal hepatitis A immunization in 1-year-old children resulted in sustained immunologic protection for up to 9 years in Argentina. These findings, along with the low current disease burden, confirm the success of the intervention.
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Curran D, de Ridder M, Van Effelterre T. The impact of assumptions regarding vaccine-induced immunity on the public health and cost-effectiveness of hepatitis A vaccination: Is one dose sufficient? Hum Vaccin Immunother 2016; 12:2765-2771. [PMID: 27428611 PMCID: PMC5137541 DOI: 10.1080/21645515.2016.1203495] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/01/2016] [Accepted: 06/15/2016] [Indexed: 11/26/2022] Open
Abstract
Hepatitis A vaccination stimulates memory cells to produce an anamnestic response. In this study, we used a mathematical model to examine how long-term immune memory might convey additional protection against clinical/icteric infections. Dynamic and decision models were used to estimate the expected number of cases, and the costs and quality-adjusted life-years (QALYs), respectively. Several scenarios were explored by assuming: (1) varying duration of vaccine-induced immune memory, (2) and/or varying levels of vaccine-induced immune memory protection (IMP), (3) and/or varying levels of infectiousness in vaccinated individuals with IMP. The base case analysis assumed a time horizon of 25 y (2012 - 2036), with additional analyses over 50 and 75 y. The analyses were conducted in the Mexican public health system perspective. In the base case that assumed no vaccine-induced IMP, the 2-dose hepatitis A vaccination strategy was cost-effective compared with the 1-dose strategy over the 3 time horizons. However, it was not cost-effective if we assumed additional IMP durations of at least 10 y in the 25-y horizon. In the 50- and 75-y horizons, the 2-dose strategy was always cost-effective, except when 100% reduction in the probability of icteric Infections, 75% reduction in infectiousness, and mean durations of IMP of at least 50 y were assumed. This analysis indicates that routine vaccination of toddlers against hepatitis A virus would be cost-effective in Mexico using a single-dose vaccination strategy. However, the cost-effectiveness of a second dose depends on the assumptions of additional protection by IMP and the time horizon over which the analysis is performed.
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Mayorga O, Bühler S, Jaeger VK, Bally S, Hatz C, Frösner G, Protzer U, Van Damme P, Egger M, Herzog C. Single-Dose Hepatitis A Immunization: 7.5-Year Observational Pilot Study in Nicaraguan Children to Assess Protective Effectiveness and Humoral Immune Memory Response. J Infect Dis 2016; 214:1498-1506. [DOI: 10.1093/infdis/jiw411] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 08/26/2016] [Indexed: 11/13/2022] Open
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Ma F, Yang J, Kang G, Sun Q, Lu P, Zhao Y, Wang Z, Luo J, Wang Z. Comparison of the safety and immunogenicity of live attenuated and inactivated hepatitis A vaccine in healthy Chinese children aged 18 months to 16 years: results from a randomized, parallel controlled, phase IV study. Clin Microbiol Infect 2016; 22:811.e9-811.e15. [PMID: 27345175 DOI: 10.1016/j.cmi.2016.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 06/10/2016] [Accepted: 06/11/2016] [Indexed: 11/25/2022]
Abstract
For large-scale immunization of children with hepatitis A (HA) vaccines in China, accurately designed studies comparing the safety and immunogenicity of the live attenuated HA vaccine (HA-L) and inactivated HA vaccine (HA-I) are necessary. A randomized, parallel controlled, phase IV clinical trial was conducted with 6000 healthy children aged 18 months to 16 years. HA-L or HA-I was administered at a ratio of 1: 1 to randomized selected participants. The safety and immunogenicity were evaluated. Both HA-L and HA-I were well tolerated by all participants. The immunogenicity results showed that the seroconversion rates (HA-L versus HA-I: 98.0% versus 100%, respectively, p >0.05), and geometric mean concentrations in participants negative for antibodies against HA virus IgG (anti-HAV IgG) before vaccination did not differ significantly between the two types of vaccines (HA-L versus HA-I first dose: 898.9 versus 886.2 mIU/mL, respectively, p >0.05). After administration of the booster dose of HA-I, the geometric mean concentrations of anti-HAV IgG (HA-I booster dose: 2591.2 mIU/mL) was higher than that after the first dose (p <0.05) and that reported in participants administered HA-L (p <0.05). Additionally, 12 (25%) of the 48 randomized selected participants who received HA-L tested positive for HA antigen in stool samples. Hence, both HA-L and HA-I could provide acceptable immunogenicity in children. The effects of long-term immunogenicity after natural exposure to wild-type HA virus and the possibility of mutational shifts of the live vaccine virus in the field need to be studied in more detail.
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Affiliation(s)
- F Ma
- Jiangsu Provincial Centre of Disease Control and Prevention, Nanjing, Jiangsu Province, China
| | - J Yang
- Institute of Medical Biology, Chinese Academy of Medical Sciences, Kunming, Yunnan Province, China
| | - G Kang
- Jiangsu Provincial Centre of Disease Control and Prevention, Nanjing, Jiangsu Province, China.
| | - Q Sun
- Institute of Medical Biology, Chinese Academy of Medical Sciences, Kunming, Yunnan Province, China
| | - P Lu
- Jiangsu Provincial Centre of Disease Control and Prevention, Nanjing, Jiangsu Province, China
| | - Y Zhao
- Institute of Medical Biology, Chinese Academy of Medical Sciences, Kunming, Yunnan Province, China
| | - Z Wang
- Jiangsu Provincial Centre of Disease Control and Prevention, Nanjing, Jiangsu Province, China
| | - J Luo
- Institute of Medical Biology, Chinese Academy of Medical Sciences, Kunming, Yunnan Province, China
| | - Z Wang
- Xiangshui County Centre of Disease Control and Prevention, Jiangsu Province, China
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