Hepatitis A among homosexual men and injection drug users: more evidence for vaccination

Delays in Hepatitis A vaccination in people with HIV in Houston, Texas between 2010 and 2018

Background

Studies have demonstrated low hepatitis A virus (HAV) vaccination rates among persons with HIV (PWH).

Methods

We conducted a retrospective study of persons entering HIV care at two clinics in Houston, Texas between 2010 and 2018. We defined those eligible for HAV vaccination as those who had no history of HAV vaccination and had a negative anti-HAV IgG at entry to care. Kaplan-Meier curves summarized time to receipt of HAV vaccines. The proportions of patients who received 1 and 2 HAV vaccines at 6, 12, and 24 months were estimated. Cox proportional hazards regression evaluated associations between patient characteristics and vaccination. Significant factors were included in a multivariable Cox proportional hazards model.

Results

Of 6,515 patients, 1372 were eligible for HAV vaccination. Of eligible patients, 29.2 % received 1 HAV vaccination at 6 months, 37.1 % at 12 months, and 47.8 % at 24 months. At 6 months, 10 % received 2 HAV vaccinations, 21.1 % at 12 months, and 33.4 % at 24 months. In multivariable analysis, men who have sex with men (adjusted HR 1.35, 95 % CI 1.06, 1.73) or those who had CD4 count ≥ 200 cells/µl (adjusted HR 2.52, 95 % CI 1.89, 3.37) had their second vaccination sooner than those who were not men who have sex with men or who had CD4 counts < 200 cells/µl, respectively. Patients > 50 years of age had their second vaccination sooner than those aged 30-50 years (adjusted HR 1.47, 95 % CI 1.08, 1.99). Those with active substance history had a longer time to second vaccination compared to those with no substance use history (adjusted HR 0.57, 95 % CI 0.40, 0.82).

Conclusions

HAV vaccination rates were low and highlight the need for effective solutions to address HAV immunization gaps in PWH, especially among young patients, those with active substance use disorders, and those with significant immunocompromise.

Prolonged Gut Dysbiosis and Fecal Excretion of Hepatitis A Virus in Patients Infected with Human Immunodeficiency Virus

Hepatitis A virus (HAV) causes transient acute infection, and little is known of viral shedding via the duodenum and into the intestinal environment, including the gut microbiome, from the period of infection until after the recovery of symptoms. Therefore, in this study, we aimed to comprehensively observe the amount of virus excreted into the intestinal tract, the changes in the intestinal microbiome, and the level of inflammation during the healing process. We used blood and stool specimens from patients with human immunodeficiency virus who were infected with HAV during the HAV outbreak in Japan in 2018. Moreover, we observed changes in fecal HAV RNA and quantified the plasma cytokine level and gut microbiome by 16S rRNA analysis from clinical onset to at least 6 months after healing. HAV was detected from clinical onset up to a period of more than 150 days. Immediately after infection, many pro-inflammatory cytokines were elicited, and some cytokines showed different behaviors. The intestinal microbiome changed significantly after infection (dysbiosis), and the dysbiosis continued for a long time after healing. These observations suggest that the immunocompromised state is associated with prolonged viral shedding into the intestinal tract and delayed recovery of the intestinal environment.

Insight into an acute hepatitis A outbreak in Indiana

Hepatitis A virus (HAV) infection causes an acute enteric hepatitis associated with substantial morbidity and mortality, particularly in older individuals. Incidence of HAV infection is low in the United States, mostly related to consumption of contaminated food. Starting in 2017, Indiana reported a large HAV outbreak. We sought to characterize the risk-exposures, clinical features and outcomes of HAV and examine the differences based on underlying cirrhosis and age. Adults ≥18 years diagnosed with HAV between January 2017 and April 2019 at two large healthcare systems in Indiana were identified. Demographic data, risk-exposures, clinical features, laboratory data and clinical outcomes were collected for analysis. The HAV cohort constituted 264 individuals with mean age of 41-years, 62% male and 94% Caucasian. Risk-exposures identified were illicit drug use (74%), food-borne (15%), person-to-person (11%) and incarceration (11%). Mortality rate was 2%, acute liver failure (ALF) was seen in 4% and acute on chronic liver failure (ACLF) was seen in 30% (6 of 20 with underlying cirrhosis). Admission MELD score was the only factor associated with ALF [OR = 1.17 (1.08-1.2), p < 0.0001], on multivariable logistic regression analysis. Higher proportion of individuals with underlying cirrhosis developed acute kidney injury (AKI) (26% vs. 9%, p = 0.03), ascites (45% vs. 11%, p < 0.0001) and hepatic encephalopathy (35% vs. 4%, p < 0.0001). In conclusion, illicit drug use was the predominant risk-exposure in the current HAV outbreak, which was associated with 2% mortality rate, and those with cirrhosis had worse outcomes (AKI, ascites and HE), of whom 30% developed ACLF.

Hepatitis A virus survival on drug paraphernalia

The ongoing hepatitis A outbreaks in multiple states in the United States have concerned public health authorities since March 2017. The outbreaks have spread throughout 30 states and include primarily persons who use drugs, including persons who inject drugs (PWID) and persons experiencing homelessness. Contaminated drug injection paraphernalia and sharing of these items could potentially aid in transmission of hepatitis A virus (HAV) among these populations. We examined HAV survival on drug paraphernalia frequently shared among PWIDs. The effect of low pH on HAV survival using citric acid, which is frequently used by PWIDs during dose preparation, was investigated. We compared the plaque assay results with those concurrently obtained by qRT-PCR to establish whether HAV RNA levels could be used as surrogates for plaque assay results. HAV suspended in minimal essential media at room temperature infected FRhK4 cells for more than 17 weeks. HAV remained viable in syringes/needles for up to 10 weeks depending on the gauge of the needles and the syringe dead volumes, and on cookers, tourniquets and cotton balls/filter surfaces for up to 4 weeks. HAV retained its infectivity for more than 10 weeks at pH as low as 2. In conclusion, our findings show that HAV survives and remains infective in or on injection drug use equipment for 1 to 10 weeks depending on the type of paraphernalia examined and environmental conditions. These findings suggest that contaminated drug paraphernalia can potentially facilitate the transmission of HAV within populations who share these items.

Hepatitis A Outbreaks Associated With the Opioid Epidemic in Kentucky Counties, 2017-2018

Objectives. To describe county-level socioeconomic profiles associated with Kentucky's 2017-2018 hepatitis A outbreak that predominately affected communities affected by the opioid epidemic.Methods. We linked county-level characteristics on socioeconomic and housing variables to counties' hepatitis A rates. Principal component analysis identified county profiles of poverty, education, disability, income inequality, grandparent responsibility, residential instability, and marital status. We used Poisson regression to estimate adjusted relative risks (RRs) and 95% confidence intervals (CIs).Results. Counties with scores reflecting an extremely disadvantaged profile (RR = 1.21; 95% CI = 0.99, 1.48) and greater percentage of nonmarried men, residential instability, and income inequality (RR = 1.15; 95% CI = 0.94, 1.41) had higher hepatitis A rates. Counties with scores reflecting more married adults, residential stability, and lower income inequality despite disability, poverty, and low education (RR = 0.77; 95% CI = 0.59, 1.00) had lower hepatitis A rates. Counties with a higher percentage of workers in the manufacturing industry had slightly lower rates (RR = 0.97; 95% CI = 0.94, 1.00).Conclusions. As expected, impoverished counties had higher hepatitis A rates. Evaluation across the socioeconomic patterns highlighted community-level factors (e.g., residential instability, income inequality, and social structures) that can be collected to augment hepatitis A data surveillance and used to identify higher-risk communities for targeted immunizations.

Emerging Threat: Changing Epidemiology of Hepatitis A and Acute Kidney Injury

In the past decade, hepatitis A has been considered a rare disease in the United States, largely due to targeted vaccination of at-risk children. Evolving epidemiology has resulted in decreasing immunity and increasing hepatitis A infections among adults who are more likely to experience severe disease. A surge in outbreaks has been noted in the past 2 years, resulting in a high volume of hepatitis A related hospitalizations and complications in otherwise healthy individuals. The traditional understanding that acute kidney injury is a rare extrahepatic manifestation is being challenged by the resurgence of hepatitis A in a more vulnerable population. This review examines the epidemiologic factors that contributed to current public health concern and the association between hepatitis A and acute kidney injury.

Epidemiology and Transmission of Hepatitis A Virus and Hepatitis E Virus Infections in the United States

There are many similarities in the epidemiology and transmission of hepatitis A virus (HAV) and hepatitis E virus (HEV) genotype (gt)3 infections in the United States. Both viruses are enterically transmitted, although specific routes of transmission are more clearly established for HAV than for HEV: HAV is restricted to humans and primarily spread through the fecal-oral route, while HEV is zoonotic with poorly understood modes of transmission in the United States. New cases of HAV infection have decreased dramatically in the United States since infant vaccination was recommended in 1996. In recent years, however, outbreaks have occurred among an increasingly susceptible adult population. Although HEV is the most common cause of acute viral hepatitis in developing countries, it is rarely diagnosed in the United States.

An outbreak of acute hepatitis A among young adult men: clinical features and HIV coinfection rate from a large teaching hospital in Rome, Italy

OBJECTIVES

Italy is a low-incidence region for hepatitis A; however, during the last 2 years an increase in the incidence of hepatitis A virus (HAV) infection was reported in Europe. The aim of this study was to describe this recent outbreak.

METHODS

We retrospectively analysed all cases of acute hepatitis A diagnosed at our laboratory between January 2010 and June 2017. We evaluated the following variables at the time of diagnosis: sex, age, nationality, glutamic oxaloacetic transaminase (GOT/AST), glutamic pyruvic transaminase (GPT/ALT), bilirubin concentration, international normalized ratio (INR) and the presence or absence of anti-HIV-1/2 antibodies. Hospitalization was also considered. We analysed these parameters using the χ² test and Mann-Whitney U-test.

RESULTS

A total of 225 cases were analysed; 82.7% were in male patients, 94.2% were in Italians and the median age of the patients was 36.4 years. At diagnosis, the median GOT value was 306 U/L, the median GPT was 1389 U/L, and the median total bilirubin value was 5.88 mg/dL. Hospitalization was required for 142 patients, with a median duration of hospital stay of 8.5 days. In 2016-2017 we registered 141 cases, with a higher prevalence of male patients, higher GPT values and a higher prevalence of patients aged 20-39 years compared with older (2010-2015) cases. Homosexual intercourse was reported as the HAV risk factor in 70.2% of patients. HIV serology was available for 120 patients: 24 were HIV-positive, four of whom represented new diagnoses. HIV-positive patients showed lower bilirubin and GPT values and fewer hospitalizations than HIV-negative patients.

CONCLUSIONS

In 2016-2017, we saw a rise in the number of hepatitis A cases, with a higher prevalence of adult male patients. No significant differences regarding the prevalence of HIV coinfection emerged.

Evolution of hepatitis A virus seroprevalence among HIV-positive adults in Taiwan

OBJECTIVES

The study aimed to describe the seroprevalence of hepatitis A virus (HAV) in HIV-positive adult patients in Taiwan between 2012 and 2016 and to examine the evolution of HAV seroprevalence between 2004-2007 and 2012-2016.

METHODS

Clinical information and data of anti-HAV antibody results were collected from 2,860 antiretroviral-naïve HIV-positive Taiwanese aged 18 years or older who initiated combination antiretroviral therapy at 11 hospitals around Taiwan between 2012 and 2016 (2012-2016 cohort). A multivariate logistic regression model was applied to identify independent variables associated with HAV seropositivity. Comparisons of HAV seroprevalences and associated clinical characteristics were made between this 2012-2016 cohort and a previous cohort of 1580 HIV-positive patients in 2004-2007 (2004-2007 cohort).

RESULTS

Of the 2,860 HIV-positive patients between 2012 and 2016, the overall HAV seropositivity rate was 21.2% (605/2860), which was independently associated with an older age (adjusted odds ratio [AOR], per 1-year increase, 1.13; 95% confidence interval [95% CI], 1.11-1.15) and co-infection with hepatitis B virus (AOR 1.44; 95% CI, 1.08-1.93). Residence in southern Taiwan (AOR 0.49; 95% CI, 0.34-0.72) was inversely associated with HAV seropositivity. The overall HAV seroprevalence in the 2012-2016 cohort was significantly lower than that in the 2004-2007 cohort (21.2% vs 60.9%, p<0.01). The decreases of HAV seropositivity rate were observed in nearly every age-matched group, which suggested the cohort effect on HAV seroepidemiology. However, among individuals aged 25 years or younger, the HAV seropositivity rate increased from 3.8% (2/52) in the 2004-2007 cohort to 8.5% (50/587) in the 2012-2016 cohort, with 95.4% (560/587) being MSM in this age group of the latter cohort.

CONCLUSIONS

HAV seroprevalence has decreased with time among HIV-positive adults in Taiwan. The cohort effect has increased the number of young HIV-positive patients that are susceptible to HAV infection in a country without nationwide childhood vaccination program against HAV.

Hepatitis A and B among young persons who inject drugs--vaccination, past, and present infection

BACKGROUND

Our study aims were to assess hepatitis A virus (HAV) and hepatitis B virus (HBV) susceptibility and infection among young persons who inject drugs (PWID) who may have been vaccinated as children and to evaluate self-report of HAV and HBV vaccination.

METHODS

We recruited PWID aged 18-40 years-old in San Diego during 2009 and 2010 and collected demographic, socioeconomic, health, and behavioral factors. Participants were asked if they had been vaccinated against HAV and HBV, and serum samples were collected for HAV and HBV serologic testing.

RESULTS

Of 519 participants, 365 (72%) were male, 252 (49%) were white non-Hispanic, 38 (7%) were Black non-Hispanic, 138 (27%) were White Hispanic, and 22 (4%) were born outside the U. S. Of the total participants, 245 (47%) had surface hepatitis B antibody (anti-HBs) titers <10mIU/ml (i.e., HBV susceptible) and 325 (63%) had no detectable HAV antibodies (HAV susceptible). Hepatitis B surface antigen was detected in 7 (1%) of total participants; and 135 (26%) were anti-HCV-antibody positive. Compared to serologic findings, self-report of HBV and HAV vaccination was 71% and 41% sensitive, and 58% and 73% specific, respectively.

CONCLUSION

HAV and HBV antibodies in half or more of this young PWID population did not have levels indicative of protection, and about a quarter had HCV infection, putting them at risk for complications resulting from co-infection with HAV or HBV. Programs serving this population should vaccinate PWIDs against HAV and HBV and not rely on self-report of vaccination.

Durability of response to vaccination against viral hepatitis A in HIV-infected patients: a 5-year observation

The aim of this study was to estimate the prevalence of total antibodies to hepatitis A virus (anti-HAV-T) in the group of HIV-positive adults in Lodz region of Poland, and to evaluate the response and long-term immunity after vaccination against hepatitis A virus. In the group of 234 HIV-infected patients, 72 persons (30.8%) were anti-HAV-T positive (>20 IU/L). In multivariate analysis, two independent factors associated with the presence of anti-HAV-T were identified: the age of patients (OR = 1.07) and the presence of antibodies to hepatitis C virus (OR = 2.87). Vaccination was completed in 83 patients. Good response (anti-HAV-T >20 IU/L one month after the booster dose) was obtained in 79.5% of patients. In patients with CD4 >200 cells/µL in multivariate analysis only presence of antibodies to hepatitis C virus was a prognostic factor for the response to vaccination (OR = 0.13). Among responders available for the follow-up, 82% (50 out of 61) had detectable anti-HAV-T at 1 year and 75.5% (37 out of 49) at 5 years. Our results demonstrate that most of the studied HIV-positive patients were susceptible to hepatitis A virus infection. Most HIV-infected adults with high CD4 counts had a durable response even up to 5 years after vaccination. Patients with a HIV/hepatitis C virus coinfection displayed a worse response to vaccination.

Sexual transmission of viral hepatitis

Identification and vaccination of adults at risk for hepatitis B virus acquisition through sexual contact is a key strategy to reduce new hepatitis B virus infections among at-risk adults. Hepatitis C has emerged as a sexually transmitted infection among men with male sex partners (MSM). Several biological and behavioral factors have been linked to hepatitis C virus transmission among MSM, including human immunodeficiency virus coinfection; participation in sexual practices that result in mucosal damage or result in exposure to blood; presence of sexually transmitted diseases (STIs), particularly ulcerative STIs; multiple/casual sex partners; and unprotected anal intercourse.

Factors associated with the immune response to hepatitis A vaccination in HIV-infected patients in the era of highly active antiretroviral therapy

INTRODUCTION

HIV seropositivity is considered a risk factor for complications in hepatitis A virus (HAV) infection. HAV vaccination schedules are widely implemented in HIV-infected patients, but the immune response remains impaired.

METHODS

We analysed the response to vaccination (antiHAV titres ≥20IU/l) in 282 HIV-infected patients included in a standard (1440 Elisa Units (EU) at 0, 6 months) or rapidly accelerated schedule (720 EU at 0, 7, 21 days and 6 months) between 1997 and 2009. Factors associated with the response to vaccination were analysed using logistic regression.

RESULTS

The overall response rate was 73.4%. Male sex (OR: 0.16, 95% CI 0.05-0.51) and hepatitis C virus co-infection (OR: 0.30, 95% CI 0.14-0.74) were associated with a lower probability of response. Protective antibody response was associated with a higher CD4/CD8 ratio (OR: 3.69, 95% CI 1.3-10.5) and having received two doses of standard schedule (compared with patients receiving only one dose of the same schedule) (OR: 2.51, 95% CI 1.22-5.15). Three doses of the rapidly accelerated schedule were not more effective than a single dose of 1440 EU (OR: 1.32, 95% CI 0.48-3.63).

CONCLUSION

The low responses observed in patients receiving a single dose suggest the need to emphasize adhesion to vaccination protocols to avoid failure. The CD4/CD8 ratio may be considered as an immune status marker which could help to better choose the moment of vaccination. Our findings underscore the importance of identifying strategies that optimize the timing and effectiveness of hepatitis A vaccination in HIV-infected patients and of the need for further studies on individual factors such as sex and hepatitis C co-infection that may affect the response to vaccination. Likewise, the sub-optimal effectiveness of three doses of 720 EU in the rapidly accelerated schedule, if confirmed in future studies, might lead to a revision of the current schedule recommended for HIV-infected travellers.

Seroprevalence of hepatitis virus infection in men who have sex with men aged 18-40 years in Taiwan

BACKGROUND/PURPOSE

Men who have sex with men (MSM) are at increased risk for hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections than the general population. Comparisons of the seroprevalence rates of these hepatitis viruses between HIV-positive and HIV-negative MSM are rarely performed in Taiwan.

METHODS

Between January 2009 and June 2010, data on the serologies for HAV, HBV, and HCV were collected from two groups of patients: HIV-negative MSM, aged 18-40 years, who sought voluntary counseling and testing (VCT) for HIV infection, and HIV-positive MSM of the same age group who sought HIV care at the National Taiwan University Hospital. Both groups of patients were also tested for syphilis.

RESULTS

During the 18-month study period, 690 HIV-negative MSM and 438 HIV-positive MSM were enrolled and tested for anti-HAV antibody, HBV surface antigen (HBsAg), hepatitis B core antibody (anti-HBc antibody), and anti-HCV antibody. HIV-positive MSM were older than HIV-negative MSM (30.5 ± 5.4 vs. 25.8 ± 4.7 years, p < 0.01). For HIV-positive MSM, the mean CD4 lymphocyte count was 477.6 ± 230.0 cells/μL and 46% of them had undetectable plasma HIV RNA load (< 40 copies/mL by reverse transcription-polymerase chain reaction assay). The overall seroprevalence rates of HAV, HBsAg, and HCV in HIV-positive MSM were 15.1%, 16.4%, and 5.5%, respectively, while in HIV-negative MSM, they were 7.4%, 6.2%, and 0.4%, respectively. In the multivariate analysis, age was significantly associated with seropositivity for HAV (OR [per one age group increase]: 1.96; 95% CI: 1.6-2.5), HBsAg (OR: 2.02; 95% CI: 1.6-2.6), anti-HBc (OR: 2.68; 95% CI: 2.3-3.2), anti-HCV (OR: 1.67; 95% CI: 1.0-2.7), and anti-HBs (OR: 1.25; 95% CI: 1.0-1.5). HIV infection was associated with seropositivity for HBsAg (OR: 1.73; 95% CI: 1.1-2.7), anti-HBc (OR: 2.44; 95% CI: 1.8-3.3), HCV (OR: 8.91; 95% CI: 2.5-31.4), and syphilis (OR: 11.21; 95% CI: 6.7-18.9).

CONCLUSION

HIV-positive MSM have a higher seroprevalence rate of HBV and HCV infection than HIV-negative MSM in Taiwan. Vaccination and safe-sex counseling should be provided to prevent the transmission of hepatitis viruses among MSM who may be engaged in high-risk behaviors.

Seroprevalence and correlates of hepatitis a among HIV-negative American men who have sex with men

BACKGROUND

Hepatitis A outbreaks are well documented among men who have sex with men (MSM). This analysis examines characteristics associated with hepatitis A virus (HAV) infection among a large group of young adult MSM from five USA cities.

METHODS

The Young Men's Survey was a cross-sectional prevalence study of HIV infection and related behavioural risk factors among MSM aged 15-29 years during 1994-2000. Serum specimens from HIV-negative participants were retrospectively tested for antibodies to HAV (anti-HAV). Data were stratified by ethnicity and analysed with logistic regression.

RESULTS

Overall anti-HAV prevalence was 18.4% among the 2708 participants, and varied by ethnicity from 6.9 to 45.3% and was highest among Hispanic and Asian men (P < 0.001). Prevalence increased with age across all racial/ethnic groups. Among white men, anti-HAV positivity was associated with having 20 or more lifetime male sex partners for those aged 15-22 years (adjusted odds ratio (AOR)=2.1, 95% confidence interval (CI)=1.0-4.1) and ever having had unprotected anal sex for those aged 23-29 years (AOR=2.4, 95% CI=1.2-4.5).

CONCLUSIONS

Factors associated with a history of HAV infection among MSM in non-outbreak settings are probably similar to those among non-MSM. MSM are still at risk for HAV infection as a result of outbreaks occurring in MSM communities. Additional studies of hepatitis A vaccination coverage are needed to determine if strategies to vaccinate MSM are adequate.

Combined hepatitis A and B vaccine: providing a bright future for preventing hepatitis

The first combined hepatitis A and B vaccine has been available in the United States since 2001. The vaccine provides protection against viral hepatitis with rapid seroprotection and lasting immunogenicity. This review outlines the product's components, clinical efficacy and opportunities for use in special circumstances. The vaccine has a good safety profile and has good tolerability. The combined hepatitis A and B vaccine is a well studied vaccine that provides rapid seroconversion with a good safety profile.

Hepatitis A seroprevalence and risk factors among homeless adults in San Francisco: should homelessness be included in the risk-based strategy for vaccination?

OBJECTIVES

Homeless adults have an increased risk of infectious diseases due to sexual and drug-related behaviors and substandard living conditions. We investigated the prevalence and risk factors for presence of hepatitis A virus (HAV) antibodies among homeless and marginally housed adults.

METHODS

We analyzed serologic and questionnaire data from a study of marginally housed and homeless adults in San Francisco from April 1999 to March 2000. We tested seroprevalance for total antibodies to HAV (anti-HAV) and analyzed data using Chi-square tests and logistic regression.

RESULTS

Of the 1,138 adults in the study, 52% were anti-HAV positive. The anti-HAV prevalence in this study population was 58% higher than the expected prevalence based on age-specific prevalence rates from the general population. Number of years of homelessness (< or =1, 2-4, and > or =5 years) was associated with anti-HAV prevalence (46%, 50%, and 61%, respectively, p < 0.001). We found other differences in anti-HAV prevalence (p < 0.05) for ever having injected drugs (63% vs. 42% for non-injectors), being foreign-born (75% vs. 51% among U.S.-born), race/ethnicity (72%, 53%, and 45% for Hispanic, white, and black people, respectively), and increasing age (38%, 49%, and 62% among those aged <35, 35-45, and >45 years, respectively). These variables all remained significant in a multivariate model.

CONCLUSIONS

We found overall anti-HAV prevalence elevated in this San Francisco homeless population compared with the general U.S. population. These data show that anti-HAV was associated with homelessness independent of other known risk factors, such as being foreign-born, race/ethnicity, and injection drug use. This increase indicates an excess risk of HAV infection and the potential need to offer hepatitis A vaccination as part of homeless services.

Response to hepatitis A and B vaccine alone or in combination in patients with chronic hepatitis C virus and advanced fibrosis

Patients with advanced fibrosis are at increased risk of severe outcomes if they develop acute infection with hepatitis A (HAV) or hepatitis B (HBV) viruses. There are no data on the efficacy of combined HAV/HBV vaccination in patients with advanced fibrosis. Our aim was to evaluate the response to the HAV and HBV vaccine alone or in combination for patients with chronic hepatitis C (HCV) and advanced fibrosis and to evaluate the impact of administering the vaccine while patients were receiving peginterferon for treatment of chronic HCV. In this prospective study of patients with advanced fibrosis (Ishak 3-6), those without serologic evidence of prior exposure were vaccinated with either Havrix HAV, Engerix( HBV, or the TWINRIX HAV/HBV combination vaccine as appropriate, and response was defined as the development of anti-HAV or anti-HBV surface antibodies. Of the 162 eligible patients, the prevalence of prior exposure to HAV and HBV was 30 and 18%, respectively. Of the 84 patients vaccinated, 38% received Havrix, 14% Engerix, and 48% TWINRIX. The response to the HAV vaccine was 75% in those receiving Havrix compared to 78% receiving TWINRIX. In contrast, the response to HBV vaccination was 42% in patients receiving Engerix compared to 60% in those vaccinated with TWINRIX (difference 18.3%; OR 0.29; 95% CI: 0.57-7.79). The presence of diabetes was the only risk factor identified for reduced HBV response (P = 0.01). Responses to both HAV and HBV vaccines when administered alone or in combination were lower than expected in patients with HCV and advanced fibrosis, especially in those with diabetes. The observation that the decline in HBV vaccine response was somewhat lower when this was administered alone as opposed to the combination A/B vaccine suggests that the administration of a combination vaccine may enhance the vaccination response to HBV.

The role of injection versus socioeconomic factors in hepatitis A virus infection among young heroin users: Implications for vaccination policies

The aim of this study was to determine whether heroin users have a higher prevalence of HAV infection than the general population in Spain, and whether injection is an independent risk factor. A cross-sectional cohort study was conducted between April 2001 and December 2003 in Spain that included 953 current heroin users aged 18-30 years. Dried blood spot samples were tested for HAV by ELISA. The prevalence of HAV infection (35.5%) was higher than in the general population of the same age. The logistic regression analysis did not show association between HAV infection and injection. HAV infection was associated with low educational level (OR=4.8; 95% CI=2.1-10.9) and other low-income variables. Injection is not an independent risk factor for HAV infection; rather, the principal determinants are socioeconomic factors. Consequently, HAV vaccination should be recommended not only in IDUs but also in non-IDUs depending on their socioeconomic characteristics.

Seroprevalence of hepatitis A virus infection in persons with HIV infection in Taiwan: implications for hepatitis A vaccination

OBJECTIVES

To retrospectively determine the prevalence of anti-hepatitis A virus (HAV) antibody in HIV-positive persons with different routes of HIV exposure and to describe its characteristics in order to guide vaccination policy.

METHODS

The prevalence of anti-HAV antibody was compared between 1580 HIV-positive persons seeking medical attention and 2581 HIV-negative controls seeking health check-ups, who had undergone anti-HAV tests between 2004 and 2007. Comparisons were also made among groups of the HIV-positive patients who had acquired HIV via different routes of transmission. A multivariate logistic regression model was built to identify independent variables associated with anti-HAV seropositivity.

RESULTS

The overall prevalence of anti-HAV antibody was 60.9% in the HIV-positive and 48.0% in the controls (p<0.001). The overall adjusted odds ratio (AOR) for positive anti-HAV antibody was 2.604 (95% confidence interval (CI) 2.106-3.219) in HIV-positive persons compared with HIV-negative persons. In addition, HIV-positive men who have sex with men (MSM), heterosexuals, and injecting drug users (IDU) all had significantly higher AOR for positive anti-HAV antibody than HIV-negative persons. In HIV-positive persons, older age (AOR 1.284, 95% CI 1.246-1.322) and IDU (AOR 5.137, 95% CI 3.499-7.542) were independently associated with an increased prevalence of anti-HAV antibody. Nearly 90% of the IDU had become seropositive for HAV after age 36-40 years, compared with heterosexuals and MSM after age 46-50 years, and controls after age 51-55 years.

CONCLUSION

Our findings suggest that age groups to be targeted for HAV vaccination vary with the different routes of HIV exposure.

Twinrix®vaccination schedules among injecting drug users

Twinrix is the only licensed vaccine that provides dual protection against infection with hepatitis A virus (HAV) and hepatitis B virus (HBV). The standard vaccination schedule for Twinrix is 0, 1 and 6 months. However, many high-risk populations, such as injecting drug users (IDUs), do not complete the vaccination series and, thus, do not acquire sufficient immunity against HAV and HBV. Twinrix can be administered using an accelerated vaccination schedule of 0, 7 and 21 days, with a booster recommended at 12 months. This manuscript reviews the available literature on vaccinating IDUs against HAV and HBV. The authors conclude that there is insufficient evidence regarding whether the accelerated Twinrix HAV/HBV vaccination schedule would yield a greater number of IDUs protected against both HAV and HBV.

Injection drug use, multiple hepatitis virus infections, and migration: a German study

This article examines infection with viral hepatitis A, B, and C and socioethnic factors in a population of injection drug users seeking treatment. The study was conducted between 2001 and 2003 in a rural German hospital; selected sociodemographic and drug-related data as well as a serology for hepatitis A, B, and C were obtained from 1499 patients. Statistical analyses were performed by univariate analysis of variance and post hoc Scheffé tests or with the chi(2) test and Bonferroni adjustment. Ethnic minority patients manifested a more severe course of addiction and showed a higher frequency of infection with hepatitis A, B, and C. Low-threshold culture-sensitive drug user treatment programs should be implemented and evaluated. The study's limitations are noted.

Multiple viral hepatitis in injection drug users and associated risk factors

BACKGROUND

While infections due to hepatitis B virus (HBV) and hepatitis C virus (HCV) have been well-studied in injection drug users (IDUs), hepatitis A virus (HAV) infection and coinfection with multiple hepatitis viruses have received less attention.

METHODS

Hepatitis serology as well as sociodemographic and drug-related parameters were explored in patients (n = 1512) admitted for opiate detoxification.

RESULTS

Antibodies to HAV were positive in 57.7%, to HBV in 53.0%, and to HCV in 75.0% of the sample. Lack of any hepatic marker was reported in 11.2%; one marker was positive in 24.7%; two markers were positive in 31.2%; and all markers were positive in 32.9%. In patients with one positive marker, 58.8% had had exposure to HCV, and 27% had exposure to HAV. In patients with two positive markers, 46.7% were HAV/HCV and 41.8% HBV/HCV antibody positive. Presence of HBV and HCV antibodies was associated with older age, longer duration of (i.v.) heroin use, and a higher number of rehabilitation treatment episodes (anova), current coconsumption of cocaine was associated with presence of antibodies to either HAV, HBV, and HCV.

CONCLUSIONS

Coinfection with hepatic viruses is highly relevant in IDUs, although HAV does not necessarily share the same risk factors relevant for HBV or HCV transmission. The need for outreach vaccination programs is emphasized for HAV and HBV in the target population. Primary prevention should be implemented before initiation or at early stages of a drug career. Epidemiology and transmission of HAV in IDUs requires further research.

Molecular epidemiology of hepatitis A virus in metropolitan areas in Japan

BACKGROUND

Transmission routes of hepatitis A virus (HAV) in Japan have changed. The present study investigated changes of transmission routes in relation to genetic drift.

METHODS

All 60 patients who were admitted between 1993 and 2003 with a diagnosis of hepatitis A were retrospectively analyzed. Nucleotide sequences of the VP1/2A region of the HAV recovered from their sera were determined.

RESULTS

The suspected transmission routes were household contact, 19 (31%); food or waterborne, 16 (27%); homosexual activity, 11 (18%); international travel, 4 (7%); and unknown 10. (17%). The 11 patients presumably infected through homosexual activity were found exclusively in 1998 and 1999. The proportion of patients exposed through homosexual behavior and household contact was higher in those 2 years than in other years. Nucleotide sequences could be determined for 58 patients. Fifty-seven of the 58 sequences belonged to genotype IA HAV, with less than 10% nucleotide diversity. Of the 27 sequences isolated during 1998 and 1999, 25 had an identical nucleotide sequence regardless of the suspected transmission route. In contrast, sequences obtained in the other years differed from one another. A phylogenetic tree constructed from sequences recovered from patients without a history of travel abroad showed several clusters.

CONCLUSIONS

Our results suggest that (1) HAV acquired through homosexual activity may be transmitted to nonhomosexual individuals; (2) hepatitis A in metropolitan areas in Japan is caused mainly by sporadic infection with genotype IA HAV; and (3) several subtypes of genotype IA HAV are endemic in Japan.

Prevalence of hepatitis and HIV infections and vaccination rates in patients entering the heroin-assisted treatment in Switzerland between 1994 and 2002

BACKGROUND

Hepatitis C virus (HCV) remains very prevalent in injection drug users (IDUs). In spite of recommended vaccinations against hepatitis A virus (HAV) and hepatitis B virus (HBV), many IDUs remain susceptible to HAV and HBV.

STUDY POPULATION AND METHODS

Patients entering heroin-assisted treatment between 2000 and 2002 (N = 210) were compared for infectious disease status with patients entering this treatment in 1998 (N = 243) and between 1994 and 1996 (N = 1035). Infection status was determined with the aid of questionnaires and blood tests for antibodies against HAV, HBV core antigen, HCV and HIV.

RESULTS

In the cohort 2000-2002 78.3% of the patients were HCV positive, 53.3% were HBV positive, 41.2% were HAV positive and 12.6% were HIV positive. In comparison to the cohorts entering the heroin- assisted treatment at an earlier time, there was a significant reduction of HBV and HAV infections, but not of HCV and HIV infections. 15.6% of the patients entering between 2000 and 2002 were vaccinated against HBV and 10.3% against HAV. 31.1% of patients at entrance were susceptible for HBV and 48.5% for HAV. In comparison to patients entering treatment in 1998 there was no significant increase in patients who were vaccinated against HBV.

CONCLUSIONS

This data illustrates the need for improving HCV prevention and more consequent vaccination against HBV and HAV in IDUs.

Prevention of hepatitis A by Havrix: a review

Hepatitis A is one of the most common vaccine-preventable infectious diseases in the world. With at least 1.5 million cases of hepatitis A worldwide each year, disease management constitutes a substantial economic burden. The first effective vaccine against hepatitis A, Havrix was introduced in 1992. This review summarizes data accumulated following more than a decade of clinical experience with this vaccine and compares clinical data with other currently available hepatitis A vaccines. Based on this data and on the current immunological knowledge, a recent consensus concluded that hepatitis A vaccines induce lifelong protection, and thus booster vaccinations against hepatitis A are unnecessary in fully immunized, healthy people. In view of this, current regulatory recommendations for the use of hepatitis A vaccines are reviewed and possible future strategies identified.

Response to hepatitis A vaccine in HIV patients in the HAART era

We evaluated the development of hepatitis A antibody after vaccination in a large cohort of patients studied in a clinical setting after the introduction of HAART. Overall, 130 of 214 vaccinated individuals developed hepatitis A antibody. In a multivariate analysis, only the CD4 cell count at the time of vaccination was associated with an absence of response. The lack of association with the nadir CD4 cell count suggests that patients will respond to vaccine after immunological reconstitution in response to HAART.

Screening for hepatitis A and B antibodies in patients with chronic liver disease

Chronic liver disease (CLD) is highly prevalent, and hepatitis C is one of the leading causes. Acute hepatitis A or B in patients with chronic hepatitis C can lead to more severe hepatic injury and a higher fatality rate than in patients without hepatitis C. Thus, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention and the World Health Organization recommend that persons with CLD be vaccinated against hepatitis A virus (HAV), and the ACIP and the National Institutes of Health recommend vaccination against both HAV and hepatitis B virus (HBV) in patients with chronic hepatitis C. Because coinfection with HAV or HBV in patients with chronic hepatitis C or CLD is common, antibody screening prior to hepatitis A or B vaccination can identify patients who are already immune to these viruses and thus do not need to be vaccinated. Selective hepatitis A vaccination (i.e., vaccination of patients who test negative for either HAV antibody immunoglobulin G or total antibodies to HAV) is most cost-effective in areas where the local prevalence of hepatitis A is higher than the national prevalence and in populations with higher background rates of HAV exposure compared with the general population, such as older adults, foreign-born patients, African Americans, and persons with CLD or hepatitis C. Although not usually recommended for healthy adults or those with compensated CLD because of virtually 100% postvaccination seroconversion, serologic testing after hepatitis A vaccination is recommended in patients with decompensated or advanced end-stage liver disease because of the much lower seroconversion rates in these patients. Selective vaccination against HBV in patients with CLD or hepatitis C is also recommended. Testing for hepatitis B surface antigen (HBsAg) and antibodies to HBsAg (anti-HBs) is considered the most efficient and reasonably cost-effective method to screen for hepatitis B serologic markers because HBsAg identifies individuals with both acute and chronic HBV infection, and anti-HBs identify those who are immune secondary to vaccination or past infection. Testing for antibodies to hepatitis B core antigen is needed to further distinguish between immunity due to vaccination and immunity due to past infection, but it is not recommended as the only screening test for HBV immunity. Postvaccination testing for hepatitis B seroconversion is recommended in all patients with CLD, especially in those with more advanced disease, because the rate of seroconversion is generally lower than in healthy adults. If patients with CLD are not adequately protected after a standard course of hepatitis B vaccination, a repeat course of vaccination using the standard schedule or an accelerated schedule (days 0, 7, and 21) should be considered.

Prevalence of hepatitis A among drug users in north-eastern Italy. Is vaccination necessary in low prevalence areas?

BACKGROUND

The authors report on the prevalence of, and risk factors for, hepatitis A virus (HAV) in a group of drug users in Italy.

METHODS

404 heroin users were recruited and compared with a control group of 107 subjects in the general population.

RESULTS

Drug users born in north-eastern Italy have a prevalence of anti-HAV similar to the control group. A much higher prevalence was found in drug users born in southern Italy.

CONCLUSION

The similar prevalence of anti-HAV in drug users born in north-eastern Italy and in the general population, suggests that their lifestyle does not involve a substantial additional risk of HAV. The much higher prevalence found in drug users born in southern Italy is more likely to be related to infection during infancy.

Séroprévalence de l'hépatite A chez des patients infectés par le VIH

OBJECTIVE

The authors had for aim to prospectively study the hepatitis A seroprevalence of an HIV-infected population, followed-up in an outpatient clinic (CISIH Strasbourg).

DESIGN

Blood tests were performed on all patients from September 2003 to March 2004 to screen for hepatitis A (total antibodies with Elisa).

RESULTS

The overall seroprevalence was 219/514 (56.6%), similar in male and female patients. It increased with age, especially in European patients (P = 0.003). The seroprevalence was lower in European subjects: 46.3% (while it reached 100% in sub-Saharan Africans), the prevalence was similar whatever the HIV risk group (46% in homosexual as well as in heterosexual patients, 44% in intravenous drug users). Hepatitis B or C co-infection did not increase the seroprevalence of hepatitis A. The hepatitis A seroprevalence was similar in various CD4 T cell count categories.

CONCLUSIONS

Our results stress the utility of hepatitis A serology in HIV-infected patients (more than 50% of European patients are non immune), and the importance of assessing hepatitis A vaccination.

Hepatitis A--related mortality in California, 1989-2000: analysis of multiple cause-coded death data

OBJECTIVES

We estimated the hepatitis A (HA) mortality rate in California, assessed demographic differences in HA-related mortality, and examined comorbidities listed on death certificates in order to provide information for health policy and planning related to HA vaccination.

METHODS

We identified HA-related deaths in California from 1989 to 2000 with multiple-cause-of-death files and calculated mortality rates and rate ratios.

RESULTS

We identified 402 HA-related deaths between 1989 and 2000; the annual age-adjusted HA-related mortality rate was 1.20 deaths per 1 million persons. Older individuals, men, Latinos, and American Indians/Alaska Natives had elevated mortality rates. Liver conditions and non-A viral hepatitis infections were more common among HA-related deaths than among all other deaths.

CONCLUSIONS

Current immunization practices should be reevaluated and the expansion of current vaccination guidelines for groups that have elevated HA-related mortality rates should be considered.

Seroepidemiology of hepatitis A in patients with chronic liver disease

Hepatitis A virus (HAV) rarely causes fulminant hepatic failure in the general population. Yet it is a cause of significant morbidity and mortality in patients with chronic liver disease (CLD), in whom routine HAV vaccination is recommended. However, studies of HAV seroprevalence and exposure predictors in populations with CLD are scarce. We have studied a cohort of 473 patients with various causes of CLD between July 2000 and June 2002. Patients were stratified on the basis of age, gender, ethnicity and aetiology of liver disease. The HAV seroprevalence in patients with CLD was compared with that in the general population. We used a logistic regression analysis to identify independent predictors of HAV exposure. Of the 473 patients studied, HAV seroprevalence was available for 454 individuals. HCV, HBV, alcohol, and HCV and alcohol were the causes of CLD in 337, 72, 37 and eight patients, respectively. The overall HAV seroprevalence was 55% in the studied cohort. The age-stratified HAV prevalence for ages 21-30, 31-40, 41-50, 51-60, 61-70 and greater than 70 years was 44, 51, 44, 63, 65 and 64%, respectively. Hispanic ethnicity, Asian ethnicity, alcohol use and ages of 51-70 years were found to be independent predictive variables of prior exposure to HAV. HAV infection in patients with CLD causes considerable morbidity and mortality. We demonstrated that age-stratified seroprevalence of HAV in patients with CLD of various aetiologies is significantly higher than that of the general population, and identified several independent predictors of HAV prior exposure.

Immunogenicity, reactogenicity and adherence to a combined hepatitis A and B vaccine in illicit drug users

AIMS

The use of illegal drugs is associated with an increase in infective risk for the hepatitis viruses, against which the vaccination of drug users (DUs) is recommended unanimously. The aim of the study was to determine tolerability, adherence and immune response of a combined vaccine providing dual protection against hepatitis A virus (HAV) and hepatitis B virus (HBV).

METHODS

The vaccine was administered to 38 DU, attending three public health centres for drug users in northern Italy, with a three-dose schedule (at 0, 1 and 6 months). The vaccine was well tolerated: only one adverse reaction (fever) was recorded after the 110 doses administered (0.9%). The vaccine schedule was completed successfully in 35 cases (92.1%). At month 8, in 34 subjects (89.5%) antibody response was evaluated: all showed seroprotection for HAV and in 33 subjects (97.1%) for HBV.

CONCLUSIONS

The vaccine, studied for the first time in DUs, proved to be safe, well accepted and immunogenic; anti-HAV response was 1272 mIU/ml and 1726 mIU/ml for anti-HBV, titres lower than reported in literature for the general population. This study suggests that DUs who are HAV/HBV-negative could be vaccinated with combined vaccine.

Safety and immunogenicity of an inactivated hepatitis A vaccine among HIV-infected subjects

BACKGROUND

Hepatitis A is a major health risk for many human immunodeficiency virus (HIV)-infected individuals. Vaccination is a potentially attractive measure to reduce the incidence of hepatitis A among this population, but data on its safety and immunogenicity are incomplete.

METHODS

Ninety HIV-uninfected adults received an inactivated hepatitis A vaccine (VAQTA; Merck), and 90 HIV-infected subjects were randomized, in double-blind fashion, to receive either the vaccine or placebo. The HIV-infected subjects were stratified by CD4 cell count, with 45 subjects having CD4 cell counts of > or =300 cells/mm3 and 45 subjects having CD4 cell counts of <300 cells/mm3. Vaccine was given at weeks 0 and 24 of the study.Results. Seroconversion rates at week 28 of the study were 94% among the HIV-infected subjects and 100% among the HIV-uninfected control subjects. HIV-infected subjects with CD4 cell counts of <300 cells/mm3 had a seroconversion rate of 87%, and HIV-infected subjects with CD4 cell counts of > or =300 cells/mm3 had a seroconversion rate of 100%. The vaccine was generally well tolerated, and no adverse effect on either HIV load or CD4 cell count was found.

CONCLUSION

Hepatitis A vaccine was both immunogenic and safe among HIV-infected subjects.

Hepatitis A virus and injecting drug misuse in Aberdeen, Scotland: a case-control study

To describe an epidemiological investigation of an outbreak of hepatitis A virus (HAV) infection among injecting drug users in Aberdeen, Scotland. A case-control study to determine whether transmission was facilitated by poor personal hygiene or through sharing injecting equipment. Cases were more likely to report not washing their hands after using the toilet [odds ratio (OR) = 12.9, 95% confidence interval (CI) = 1.58-105.89] or before preparing food (OR = 4.0, 95% CI = 1.01-15.8), and less likely to have washed their hands prior to preparing drugs (OR = 10.67, 95% CI = 2.14-53.07). Cases were also more likely to report recipient sharing of needles/syringes (OR = 8.27, 95% CI = 1.68-40.57), and to have had injecting contact with someone who was jaundiced (OR = 29.4, 95% CI = 3.18-271.44). The results indicate that the lack of hygiene within the context of individuals gathering to prepare and inject drugs provides ample opportunity for the transmission of HAV. Although the promotion of good hygiene and the avoidance of sharing injecting equipment are important measures in preventing HAV transmission, they are unlikely to effect major behavioural change. Such measures should, therefore, be reinforced by routinely offering HAV vaccine to injectors.

Hepatitis A and B infection and vaccination in a cohort of homosexual men in Sydney

Objectives: To determine the prevalence and incidence of hepatitis A (HAV) and B (HBV) infection and vaccination in HIV-negative homosexual men in Sydney, and associated risk factors. Methods: An open prospective cohort study was conducted among a community-based sample of HIV-negative homosexual men in Sydney in 2001–02. Participants underwent a face-to-face interview, regarding demographics, sexual behavioural risk factors and sexually transmitted infections, and blood samples were collected. They were followed annually. Results: Nine hundred and three men completed a baseline interview by the end of 2002. Among them, 68% were seropositive to hepatitis A. The seroprevalence of prior hepatitis B infection was 19%, and 53% had serological evidence of HBV vaccination. Younger men were much more likely to be seronegative, with 48% and 46% of <25-year-olds being seronegative to HAV and HBV respectively. In multivariate analysis HAV and HBV infection were associated with increasing age, greater number of lifetime sex partners and HBV infection was also associated with previous sexually transmitted infections. HAV vaccination was associated with increasing age, greater number of lifetime sex partners, overseas travel in the last year and self-reported anogenital warts. HBV vaccination was associated with higher occupational status, greater lifetime number of sex partners and previous sexually transmitted infections. Conclusion: Substantial proportions of gay community attached young homosexual men are still at risk of HAV and HBV infection. This study points to a need for vaccination strategies which ensure high levels of hepatitis A and B immunity in young sexually active gay men.

Outbreak of hepatitis A in the injecting drug user and homeless populations in Bristol: control by a targeted vaccination programme and possible parenteral transmission

OBJECTIVE

To study the use of hepatitis A virus (HAV) vaccination in controlling an outbreak of HAV in inner-city Bristol among injecting drug users (IDUs). To study whether hepatitis C virus (HCV) and hepatitis B virus (HBV) co-infection increases morbidity.

DESIGN

Community-based cohort study.

SETTING

Avon Health Authority area, UK.

PARTICIPANTS

All laboratory-confirmed cases of HAV infection notified in 2000.

INTERVENTION

Administration of a targeted vaccination, education and liaison programme.

MAIN OUTCOME MEASURES

Number of cases of HAV before and after introduction of HAV vaccination programme. Mortality and number of patients requiring hospital admission. Association of HCV and HBV co-infection with hospital admission.

RESULTS

Ninety cases of HAV were reported in the first 6 months of 2000, of whom a substantial number were IDUs and/or inner-city hostel residents. In the second 6 months of 2000, following the introduction of a vaccination programme among homeless people, hostel residents, and IDUs, the number of HAV cases fell to 33. Sixteen patients had evidence of HCV co-infection. No patient had chronic HBV infection. Two patients died as a result of HAV, and two subsequently died from drug misuse. Fifty-six per cent of HCV-co-infected patients required admission to hospital compared with 28% non-HCV-co-infected patients.

CONCLUSIONS

This is the first reported successful use of vaccination to control an outbreak of HAV in a population of IDUs and to prevent transmission to the wider population. HCV co-infection appears to increase the severity of HAV illness, as demonstrated by increased incidence of hospital admission.

Risk groups for hepatitis A virus infection

We report the conduct and results of a systematic search for evidence of risk of infection with hepatitis A virus (HAV) among blood transfusion recipients, travellers, the military, healthcare workers, sewage workers, foodhandlers, day care assistants, institutionalised subjects, blood transfusion recipients, drug addicts, homosexuals, prisoners and other risk groups such a liver transplantees. We report our recommendations for the use of the HAV vaccine in these groups.

Transmission of hepatitis A via WBC-reduced RBCs and FFP from a single donation

BACKGROUND

Currently, individuals donating whole blood and cellular components are not screened for hepatitis A (HA). However, transfusion-transmitted HA can occur, albeit very rarely. Although infection is typically mild and self-limited, it may be catastrophic in a small percentage of cases. Two cases of HA transmission from a single donation to two patients with subsequent variable morbidity are reported.

CASE REPORTS

A 50-year-old, asymptomatic, volunteer blood donor made a whole-blood donation. He was found to have HA 18 days later. When notified, the donor center initiated a recall of the components produced from the donated unit. However, the RBCs and FFP had already been transfused. Subsequently, both recipients developed HA as documented by IgM anti-HA serology. The RBC recipient was a 49-year-old woman, transfused after a hysterectomy, who was found to have HA at the time of unit recall (20 days after transfusion). Her condition required the use of medical disability leave. The FFP was infused to a 52-year-old female cardiac surgical patient. Her course was marked by multiple complications, including postoperative development of mild hepatic dysfunction. After testing negative for HA, hepatitis B, and hepatitis C (24 days after transfusion), she suffered a second bout of more severe hepatic dysfunction and was documented to have HA at Day 55 after transfusion. Evaluation of both recipients' close contacts revealed no evidence for exposure to HA by any route other than transfusion.

CONCLUSION

HA can be transmitted by transfusion of units obtained from asymptomatic, infectious donors. Two patients contracted HA from components obtained from a single whole-blood donation. The RBC recipient had a typical self-limited course of HA. The FFP recipient developed HA of relatively delayed onset. Both recovered from HA.

Preventing hepatitis A and hepatitis B virus infections among men who have sex with men

Hepatitis A and hepatitis B are 2 common sexually transmitted diseases that are preventable by vaccination. Men who have sex with men (MSM) are at increased risk of acquiring hepatitis A virus and hepatitis B virus through sexual exposure. Current guidelines from the Centers for Disease Control and Prevention recommend that MSM receive immunizations against hepatitis A and hepatitis B. Many health care providers and most MSM are unaware of the risks and the potentially dangerous consequences posed by hepatitis A and B virus infection, and the MSM thus remain unvaccinated and unprotected from exposure to these viruses. It is important for health care providers to educate and vaccinate their at-risk male patients against hepatitis A and hepatitis B virus infections.

Sexually acquired hepatitis

OBJECTIVES

To assess current knowledge of sexually transmitted viral hepatitis in relation to epidemiology, clinical presentation, management, and diagnosis with particular reference to resource-poor settings.

METHOD

A search of published literature identified through Medline from 1966 to October 2001, the Cochrane Library, and reference lists taken from each article obtained. Textword and MeSH searches for hepatitis A, B, C, D, E, G, delta, GB virus, GBV-C, and TT virus were linked to searches under the textword terms sex$, prevent$, and MeSH subheadings, microbiology, complications, drug therapy, therapy, diagnosis, epidemiology, transmission, and prevention and control.

CONCLUSIONS

In heterosexual relationships, hepatitis B is readily transmitted sexually and hepatitis C and D less so, with no evidence for sexual transmission of hepatitis A. Hepatitis types A-D are all transmissible sexually in male homosexual relationships under certain conditions. In resource-poor countries sexual transmission is generally only a significant route of transmission for hepatitis B.

Seroprevalence of hepatitis A immunity in male genitourinary medicine clinic attenders: a case control study of heterosexual and homosexual men

OBJECTIVES

To compare the seroprevalence of hepatitis A in homosexual and heterosexual men to determine their susceptibility to infection and provide guidance for a policy on vaccination.

METHODS

A case-control study design was utilised to compare the risk factors associated with hepatitis A in homosexual and heterosexual men attending a city centre genitourinary medicine clinic. Demographic and sexual behavioural characteristics were included in univariate and multivariate models.

RESULTS

The overall seropositivity rate was 29% with no significant difference between homosexual and heterosexual men. Ethnicity and age were strongly associated with hepatitis A seropositivity in both homosexuals and heterosexuals. A history of sex in a sauna in homosexual men, and being born outside the United Kingdom for heterosexual men, was associated with hepatitis A seropositivity.

CONCLUSIONS

Targeted hepatitis A screening and vaccination of homosexual men attending UK genitourinary medicine clinics is not supported by the results of this study.

Inactivated hepatitis A vaccine: immunogenicity, efficacy, safety and review of official recommendations for use

There is 10 years of marketing experience with the hepatitis A vaccine Havrix. It is highly immunogenic, provides lasting protection in healthy individuals and generates protective levels of antibodies in patients with chronic liver disease or impaired immunity. Postmarketing surveillance data have confirmed the outstanding safety profile of the vaccine. The timing of the booster dose is not critical to effectiveness, which has advantages for the protection of travelers to regions of high endemicity. The vaccine is effective in curbing outbreaks of hepatitis A and also when administered postexposure, due to rapid seroconversion and the long incubation period of the disease. In intermediate endemic regions, an epidemiological shift in hepatitis A infection has driven the development of universal preventive strategies to be added to the targeting of at-risk groups. Existing official recommendations and future directions for vaccine use are reviewed.