Rise in the incidence of viral hepatitis in Israel despite improved socioeconomic conditions

Sex differences in hepatitis A incidence rates-a multi-year pooled-analysis based on national data from nine high-income countries

BACKGROUND

Possible sex differences in hepatitis A virus (HAV) incidence rates in different age groups are not well documented. We aimed to obtain stable pooled estimates of such differences based on data from a number of high-income countries.

METHODS

We obtained data on incident cases of HAV by sex and age group over a period of 6-25 years from nine countries: Australia, Canada, Czech Republic, Finland, Germany, Israel, Netherland, New Zealand and Spain. Male to female incidence rate ratios (IRR) were computed for each year, by country and age group. For each age group, we used meta-analytic methods to combine the IRRs. Meta-regression was conducted to estimate the effects of age, country, and time period on the IRR.

RESULTS

A male excess in incidence rates was consistently observed in all age groups, although in the youngest and oldest age groups, where the numbers tended to be lower, the lower bounds of the 95% confidence intervals for the IRRs were less than one. In the age groups <1, 1-4, 5-9, 10-14, 15-44, 45-64 and 65+, the pooled IRRs (with 95% CI) over countries and time periods were 1.18 (0.94,1.48), 1.22 (1.16,1.29), 1.07 (1.03,1.11), 1.09 (1.04,1.14), 1.46 (1.30,1.64), 1.32 (1.15,1.51) and 1.10 (0.99,1.23) respectively.

CONCLUSIONS

The excess HAV incidence rates in young males, pooled over a number of countries, suggest that the sex differences are likely to be due at least in part to physiological and biological differences and not just behavioral factors. At older ages, differential exposure plays an important role. These findings, seen in the context of the excess incidence rates in young males for many other infectious diseases, can provide further keys to the mechanisms of the infection.

Hepatitis E as a cause of adult hospitalization in Bangladesh: Results from an acute jaundice surveillance study in six tertiary hospitals, 2014-2017

In the absence of reliable data on the burden of hepatitis E virus (HEV) in high endemic countries, we established a hospital-based acute jaundice surveillance program in six tertiary hospitals in Bangladesh to estimate the burden of HEV infection among hospitalized acute jaundice patients aged ≥14 years, identify seasonal and geographic patterns in the prevalence of hepatitis E, and examine factors associated with death.

We collected blood specimens from enrolled acute jaundice patients, defined as new onset of either yellow eyes or skin during the past three months of hospital admission, and tested for immunoglobulin M (IgM) antibodies against HEV, HBV and HAV. The enrolled patients were followed up three months after hospital discharge to assess their survival status; pregnant women were followed up three months after their delivery to assess pregnancy outcomes. From December’2014 to September’2017, 1925 patients with acute jaundice were enrolled; 661 (34%) had acute hepatitis E, 48 (8%) had hepatitis A, and 293 (15%) had acute hepatitis B infection. Case fatality among hepatitis E patients was 5% (28/589). Most of the hepatitis E cases were males (74%; 486/661), but case fatality was higher among females—12% (8/68) among pregnant and 8% (7/91) among non-pregnant women. Half of the patients who died with acute hepatitis E had co-infection with HAV or HBV. Of the 62 HEV infected mothers who were alive until the delivery, 9 (15%) had miscarriage/stillbirth, and of those children who were born alive, 19% (10/53) died, all within one week of birth. This study confirms that hepatitis E is the leading cause of acute jaundice, leads to hospitalizations in all regions in Bangladesh, occurs throughout the year, and is associated with considerable morbidity and mortality. Effective control measures should be taken to reduce the risk of HEV infections including improvements in water quality, sanitation and hygiene practices and the introduction of HEV vaccine to high-risk groups.

In the absence of reliable surveillance data on the burden of hepatitis E in endemic countries, we conducted a hospital-based acute jaundice surveillance study over a two and a half year period in six tertiary hospitals in Bangladesh. The study confirms that HEV infections occur throughout the year, and is a major (34%) cause of acute jaundice in tertiary hospitals in Bangladesh. Three-quarters of the acute hepatitis E cases were male, and HEV infection was higher among patients residing in urban areas than patients in rural areas (41% vs 32%). The overall case fatality rate of acute HEV infections in hospitals was 5%, but was higher among pregnant women (12%). Hepatitis E patients who died were more likely to have co-infection with HAV or HBV than the HEV infected patients who did not die. Fifteen percent of HEV infected mothers had miscarriage/stillbirth. Of the children who were born alive, 19% died, all within one week of birth. Considering the high burden of hepatitis E among hospitalized acute jaundice patients, Bangladesh could take control measures to reduce this risk including improvements in water quality, sanitation and hygiene practices and the introduction of hepatitis E vaccine in high-risk areas.

Evidence of sustained reductions in the relative risk of acute hepatitis B and C virus infections, and the increasing burden of hepatitis a virus infection in Egypt: comparison of sentinel acute viral hepatitis surveillance results, 2001-17

BACKGROUND

Egypt ranks fifth for the burden of viral hepatitis worldwide. As part of Egypt's renewed national strategy for the elimination of viral hepatitis, surveillance for acute viral hepatitis (AVH) was re-established during 2014-2017 to describe the current epidemiology and associated risk factors, and changes from surveillance conducted during 2001-2004.

METHODS

Patients with suspected AVH were enrolled, completed a questionnaire, and provided blood for testing for hepatitis viruses A (HAV), B (HBV), C (HCV), D, and E (HEV) infections by enzyme-linked immunosorbent assay. Odds ratios and Chi2 were used to detect differences between hepatitis types by patient characteristics and exposures. Newcombe-Wilson method was used to compare results between surveillance periods 2001-2004 and 2014-2017.

RESULTS

Between 2014 and 2017, among 9321 patients enrolled, 8362 (89.7%) had one or more markers of AVH including 7806 (93.4%) HAV, 252 (3.0%) HCV, 238 (2.8%) HBV, and 31 (0.4%) HEV infection. HAV infection occurred most commonly among children < 16 years age, while HBV infection occurred among ages 16-35 years and HCV infection in ages greater than 45 years. Healthcare-associated exposures were significantly associated with HBV and HCV infections compared to HAV infection including receiving therapeutic injections, surgery, wound suture, or urinary catheter and IV line insertions, while significant lifestyle exposures included exposure to blood outside the healthcare system, IV drug use, or incarceration. Exposures significantly associated with HAV infection were attending nursery or pre-school, contact with person attending nursery or pre-school, having meals outside the home, or contact with HAV case. Compared with AVH surveillance during 2001-2004, there was a significant increase in the proportion of HAV infections from 40.2 to 89.7% (RR = 2.3) with corresponding reductions in the proportions of HBV and HCV infections from 30.0 to 2.8% (RR = 0.1) and 29.8 to 3.0% (RR = 0.1), respectively.

CONCLUSIONS

Healthcare-associated exposures were significantly association with and remain the greatest risk for HBV and HCV infections in Egypt. Additional studies to evaluate factors associated with the reductions in HBV and HCV infections, and cost effectiveness of routine HAV immunization might help Egypt guide and evaluate control measures.

Seasonality of hepatitis: a review update

Background:

Viral hepatitis is an infection that has been reported to be present throughout the year, but some particular months are associated with higher incidences. The primary objective was to review and report on the current knowledge and evidence that existed on seasonality of different type of acute viral hepatitis worldwide in order to develop recommendations for future research, prevention and control.

Materials and Methods:

A systematic literature review was performed to identify all the primary reports and studies published during 1970-2013 on acute hepatitis A, B, C and E (AHA, AHB, AHC and AHE) in human subjects by searching PubMed, reference lists of major articles and correspondence with scientific experts. For each report or study included, the following information was extracted (as applicable to study): Location (country and setting), study population (number of cases, patients), seasonal or monthly rate and study duration.

Results:

There is no definite and consistent seasonal pattern has been observed on AHA; AHB; AHE and AHC, although evidence points towards spring and summer peak for hepatitis A, B, C and E. Multiple source of transmission such as; summer travel to an endemic area, swimming habits of the population in hot months, increase sexual contact, tattoo, poor hygiene and environmental sanitation and food habits (feco-oral transmission of viral hepatitis) probably exists and should be further investigated through analytical and epidemiological.

Molecular characterization of hepatitis A virus isolated from acute gastroenteritis patients in the Seoul region of Korea

Hepatitis A virus (HAV) is a major public health problem throughout the world. As a result of declining HAV endemic in Korea, an increasing number of children and adolescents have become susceptible to HAV infection. HAV is related with sanitation conditions of the environment and is transmitted via the fecal-oral route, either through person-to-person contact or by contaminated water and food. The present study has been carried out to determine the phylogenetic analysis and circulating patterns of HAV strains detected from hospitalized patients with acute gastroenteritis (AGE) in the Seoul region of Korea. In total, 2,782 stool specimens from hospitalized patients with AGE collected in October 2006 to September 2007 in Seoul were tested for HAV. A pair comparison of the nucleic acid sequence of a 159-bp base region at the putative VP1/2A junction of 85 Seoul isolates revealed that the most common HAV strain circulating in the region during 2006-2007 was subgenotype IA. HAV phylogenetic studies can provide important information on the genetic characteristics of HAV from AGE patients who may subsequently become the source of infection in Korea.

Long-term trends in hepatitis A incidence following the inclusion of Hepatitis A vaccine in the routine nationwide immunization program

For many years hepatitis A was one of the most common vaccine preventable diseases in Israel. In 1999, Israel became the first country to introduce an inactivated hepatitis A vaccine into its national childhood vaccination program. The objectives of the present study were to study trends in disease incidence after the implementation of the new vaccination policy and to assess vaccination coverage among children and adults in Israel. We used the databases of the second largest HMO in Israel (1.7 million members) to identify patients who had evidence of hepatitis A in 1998 and 2007 and to collect information on all subjects who received at least one dose of hepatitis A vaccine during the study period. Hepatitis A vaccination coverage in children <5 years and 5-14 years of age increased from 9% and 15% in 1998 to 89% and 68% in 2007, respectively. During this period the annual incidence of hepatitis A dropped from 142.4 per to 7.6 per 100 000. The most prominent reduction in the age-specific annual incidence rates was calculated in children <5 years from 239.4 per 100 000 in 1998 to 2.2 per 100 000 in 2007 and from 310.3 per 100 000 to 3.0 per 100 000 in children aged 5-14 years. In endemic areas, vaccination of infants and children against hepatitis A can greatly reduce the total burden of the disease.

The shifting epidemiology of hepatitis A following routine childhood immunization program in Israel

OBJECTIVES

In 1999 Israel became the first country to introduce immunization against hepatitis A to its national childhood vaccination program. The study objectives were to assess the uptake of hepatitis A vaccine following the new policy and to examine the incidence of hepatitis A and the number of prevented cases.

METHODS

Data on incidence of hepatitis A and vaccination rates were obtained from a large health maintenance organization in Israel covering 1.6 million members. We identified all members that were diagnosed by a primary care physician as suffering from hepatitis A, had a positive hepatitis A virus-IgM test result, or were hospitalized due to hepatitis A between 1998 and 2004.

RESULTS

The results indicate that 5 years following its inclusion in the national childhood immunization program, vaccination coverage levels with at least one dose of hepatitis A vaccine for children aged under 5 years and 5-14 years were 87% and 51%, respectively. During this period the annual incidence rates declined by 88% from 142.4 to 17.3 per 100,000. The most significant reduction in morbidity was observed among children.

CONCLUSIONS

In endemic areas, vaccination of infants and children against hepatitis A may be efficient to greatly reduce the total burden of the disease.

Routine testing for IgG antibodies against hepatitis A virus in Israel

Background

Viral hepatitis is highly endemic in Israel, with the hepatitis A virus (HAV) responsible for most cases. Improved socioeconomic factors, as well as the universal vaccination of infants (introduced in 1999) has resulted in a decline in infection rates in Israel. This study examines the benefits of routine testing for anti-HAV IgG in high-risk population.

Methods

A retrospective examination of the files of teenage and adult patients (aged 16–99 years; mean 33.9) in two primary care clinics found 1,017 patients who had been tested for anti-HAV IgG antibodies for either general healthcare screening or ongoing follow-up for chronic illness. Seropositive patients were then asked regarding recall of past hepatitis (i.e. jaundice, regardless of viral etiology); post-exposure prophylaxis with immune serum immunoglobulin (ISG); and active immunization with inactivated virus. Seronegative patients were subsequently sent for active immunization.

Results

Of the1,017 patient records studied (503 male, 514 female), a total of 692 were seropositive (354 males, 338 females; P = 0.113). Seropositivity rates increased with age (p < 0.005), and were highest among those born in Middle Eastern countries other than Israel (91.3%) and lowest among immigrants from South America (44.1%; P < 0.005). 456 of the seropositive patients were interviewed, of whom only 91 recalled past illness while 103 remembered receiving post-exposure prophylaxis (ISG) and 8 active vaccination. Those who were unaware of past infection were more likely to have been vaccinated with ISG than those who were aware (26.3% vs. 7.7%; p < 0.005).

Conclusion

The relatively high prevalence rate of anti-HAV seropositivity in our study may me due to the fact that the study was conducted in a primary care clinic or that it took place in Jerusalem, a relatively poor and densely populated Israeli city. Most of the seropostive patients had no recollection of prior infection, which can be explained by the fact that most hepatitis A infections occur during childhood and are asymptomatic. Routine testing for anti-HAV IgG in societies endemic for HAV would help prevent seropositive patients from receiving either post-exposure or preventive immunization and target seronegative patients for preventive vaccination.

Hepatitis A Transmitted by Food

Hepatitis A is caused by hepatitis A virus (HAV). Transmission occurs by the fecal-oral route, either by direct contact with an HAV-infected person or by ingestion of HAV-contaminated food or water. Foodborne or waterborne hepatitis A outbreaks are relatively uncommon in the United States. However, food handlers with hepatitis A are frequently identified, and evaluation of the need for immunoprophylaxis and implementation of control measures are a considerable burden on public health resources. In addition, HAV-contaminated food may be the source of hepatitis A for an unknown proportion of persons whose source of infection is not identified.

Risk of exposure to hepatitis A virus among day-care workers in Israel: implications for preventive measures

Hepatitis A is an important infectious disease in Israel. The high incidence of hepatitis A, the declining prevalence of antibodies against hepatitis A virus throughout the past decade, and the availability of an active immunization for hepatitis A have engendered the identification of occupations in which workers are at increased risk of acquiring the disease. A prevalence study for hepatitis A antibodies was conducted during the first half of 1998 in a random sample of 37 day-care centers in different parts of Israel. A short interview was conducted, and serum samples were then collected from each worker. The control group comprised a sample of factory workers, blood donors, and women in maternity wards. Ninety percent (402 of 446) of the day-care workers had antibodies to hepatitis A. In a logistic-regression analysis, seropositivity was associated with increased age, minimal education, and lack of military service. When the authors compared a subsample of workers aged 18-40 yr with the control group, seropositivity was associated with the following: birth in Israel, duration of residence in Israel, very minimal education, military service, and employment in a day-care center. These results, together with earlier reports, indicate that day-care workers are at high risk of occupational exposure to hepatitis A. These results may imply that seronegative workers have a 2-fold chance of acquiring hepatitis A. Appropriate preventive measures should be considered, and active immunization of susceptible workers should be undertaken.

Hepatitis A virus infections in the United States: model-based estimates and implications for childhood immunization

OBJECTIVE

The high prevalence of antibody to hepatitis A virus (HAV) in the US population suggests that the incidence of infection is much higher than reported, but the infection rate is difficult to measure directly because of anicteric infection and underreporting. We present a model that reconciles the reported incidence of hepatitis A with the observed prevalence of antibody to HAV and provides an estimate of the true incidence of HAV infection.

METHODS

In the model, reported incidence of hepatitis A in the United States was adjusted to account first for anicteric infection and then for underreporting and declining incidence over time such that the prevalence predicted by the model approximated that observed in 2 nationwide surveys.

RESULTS

The model showed incidence in the susceptible population declining by 4.5% per year. As incidence declined early in the 1900s, the average age at infection increased, leading to a paradoxical increase in the incidence of icteric infection followed by a slow decline. The model estimated approximately 270 000 (range: 190 000-360 000) infections annually from 1980 to 1999, 10.4 times the number of hepatitis A cases actually reported during this period. More than half of these infections occurred in children who were younger than 10 years, most of which would have been clinically unrecognizable as hepatitis.

CONCLUSIONS

These results suggest a large reservoir of infection in children and that interruption of transmission in children may substantially reduce incidence of hepatitis A overall.

Does immune serum globulin confer protection against skin diseases?

BACKGROUND

Following a case of serologically proven hepatitis A in a food-handling worker serving several military bases in the same vicinity, the entire military population was vaccinated with immune serum globulin (ISG).

OBJECTIVE

To evaluate the effectiveness of ISG in preventing skin disease.

METHODS

The data for this study were drawn from the military archives of the Medical Corps. The population of the bases was followed for a period of 3 months after immunization. Rates of selected skin diseases were compared with those of a nearby base during the same period, and with those in the population of the same bases a year earlier.

RESULTS

The rates of several skin diseases (bacterial skin infections, dermatitis and eczema, fungal infections, acne, warts, nail disorders, and nonspecific skin diseases) among the vaccinated population were significantly lower when compared to the historical control group and to the contemporary control group of the nearby base.

CONCLUSIONS

ISG provides a protecting effect for skin diseases, especially those of infectious origin.

Risk of hepatitis A virus infection among sewage workers in Israel

Sewage workers are exposed to a wide range of chemicals and biological agents, including the hepatitis A virus. Inasmuch as Israel is an endemic area for hepatitis A, it is unclear if sewage workers are at increased risk for hepatitis A or which factors contribute to such risk. The authors compared seropositivity of hepatitis A in 100 sewage workers with that in 100 blue-collar worker controls. Hepatitis A seropositivity was highly prevalent, but nonsignificant, in both sewage workers and controls (82% and 91%, respectively). In sewage workers, the major risk for serological positivity was age (odds ratio = 4.5, 95% confidence interval = 1.6, 12.4 for every 10 y). The factors associated negatively with seropositivity were years of education and years of seniority. The authors concluded that exposure to sewage is not a risk factor for hepatitis A infection in Israel, and, therefore, sewage workers do not require special attention in this regard.

Decline of hepatitis A antibodies during the first 7 months of life in full-term and preterm infants

In a previous study we have shown that transplacental transfer of hepatitis A antibodies to preterm infants does not differ from that observed in full-term infants. This follow-up study was designed to investigate the decline of hepatitis A virus (HAV) antibodies during the first 7 months of life in full-term and preterm infants, in an endemic region for hepatitis A. Two hundred and fifty newborn infants--147 full-term and 103 preterm infants--were enrolled. Blood samples from the infants were taken at birth, and at 3 and 7 months of age. Anti-HAV titers were determined by ELISA. A concentration of > or = 1:20 mlU/ml was considered protective. Protective hepatitis A antibodies were present at birth in 48.3% of all full-term and 49.5% of all premature infants. By the age of 7 months only 13% of full-term and 21.7% of preterm infants still had protective titers. For the seropositive full-term infants the geometric mean titers (GMT) were 15,698, 6,107 and 345 at birth, 3 months and 7 months, respectively, and for preterm infants, 10,378, 2,307 and 225 at birth, 3 months and 7 months, respectively. Significant differences in GMT between preterm and full-term infants were found at birth and at 3 months of age (P < 0.05). In a region endemic for hepatitis A, low levels of anti-HAV at 7 months of age may justify trials on infant vaccination since this is the most effective way to eliminate hepatitis A from circulation.

Prevalence of antibodies against hepatitis A virus among new immigrants in Israel

Israel, located in a region endemic for hepatitis A virus (HAV), recently absorbed a large population of immigrants who came from the former USSR. To assess the risk of high morbidity in this population a serosurvey of HAV antibodies was undertaken. Serum samples were collected from 965 new immigrants, of whom 664 came from the European, non-endemic region, and 301 from the Asian and Caucasian endemic regions of the former Soviet Union. They were compared to 240 Israelis. Each population was divided into six age groups: 1-9, 10-19, 20-29, 30-39, 40-49, and 50 years of age and older. The Asian/Caucasian immigrants and the Israeli population were found to share similar characteristics. In both groups, antibodies to HAV (anti-HAV) were present in the 1-9-year-old age group and reached maximum prevalence (90% and 86.7%, respectively) in the 20-29-year-old age group. In contrast, among the European immigrants anti-HAV was first found in the 10-19-year-olds and peaked (93%) in the age group of 50 years and older. It is concluded that immigrants originating from the European part of the former USSR may require vaccination against hepatitis A.

Single and booster dose responses to an inactivated hepatitis A virus vaccine: comparison with immune serum globulin prophylaxis

Pre- and postexposure prophylaxis against hepatitis A virus (HAV) infection with immune serum globulin (Ig) is only effective for 4-6 months. We compared the safety, tolerability and immunogenicity of a single i.m. injection of Ig with a single and booster dose of an inactivated hepatitis A virus vaccine (iHAV) in adults. Healthy volunteers (18-50 years) received a single Ig i.m. injection (n = 30), or iHAV i.m. (n = 15) at 0 and 24 weeks, or placebo (n = 4) at the same intervals. Anti-HAV seroconversion was measured by radioimmunoassay (RIA) and neutralizing antibodies by an antigen reduction assay. After Ig injection (0.06 ml/kg), anti-HAV seroconversion occurred in 100% of recipients at week 1, declining to 10% at week 12 and 0% by week 20. In contrast, after a single 25 ng dose, RIA seropositivity in iHAV vaccinees was 80% by week 2, reaching 100% by week 5 and persisted up to week 24, at which time anti-HAV geometric mean titres (GMT) were two fold higher than those seen at week 1 after Ig. Postbooster anti-HAV titres in iHAV recipients rose within 4 weeks to 73-fold greater than the peak GMT seen one week after Ig, and 400-fold higher than GMT at 12 weeks after Ig. Neutralizing antibody titres after iHAV followed a similar pattern, as observed for anti-HAV. iHAV was well tolerated; placebo and vaccine tolerability were indistinguishable, with no serious adverse experiences observed. In conclusion, active vaccination with a single iHAV dose may eventually replace Ig for pre-exposure prophylaxis.(ABSTRACT TRUNCATED AT 250 WORDS)

Worldwide epidemiology of hepatitis A virus infection

Patterns of hepatitis A virus (HAV) infection and clinical disease differ worldwide, and correlate with socioeconomic conditions (and hygienic and sanitary conditions) of each geographic area. In least developed countries with very poor sanitary and hygienic conditions, HAV spreads readily, and most persons are infected as young children. Because most persons become infected at an age when HAV infection is often asymptomatic, reported disease rates in these areas are low and outbreaks of disease are rare. In developing countries and some regions of developed countries, sanitary conditions are variable, and transmission can predominate in children, adolescents or adults, depending on the geographic region. Paradoxically, since HAV transmission occurs in these areas in older age groups compared with least developed countries where HAV transmission is highly endemic, reported rates of hepatitis A can be higher. In developed countries, sanitation and hygienic conditions are good, and infection rates in children are generally low. Communitywide epidemics can contribute significantly to the burden of disease, as can occasional day care center and common-source outbreaks. In some areas, disease tends to be among specific risk groups, such as travellers to hepatitis A endemic areas, and intravenous drug users among whom hygienic practices may be poor. As countries develop economically with improvement of sanitary conditions, overall endemicity of HAV infection decreases, and disease patterns may change. As the endemicity of HAV transmission decreases, the reported rate of clinical hepatitis A can increase, due to the shift in the average age of infection to an age when clinical illness is more frequent.

Safety, tolerability, and immunogenicity of an inactivated hepatitis A vaccine: effects of single and booster injections, and comparison to administration of immune globulin

Hepatitis A virus (HAV) infection in adults is often symptomatic and disabling. The present article summarizes our experience with phase 2 studies of an inactivated hepatitis A virus vaccine. Pre- and post-exposure prophylaxis with immune globulin (IG) is only effective for 4-6 months. We compared the safety, tolerability, and immunogenicity of a single i.m. injection of IG with single and booster doses of an inactivated hepatitis A virus vaccine (iHAV) in adults. A total of 75 healthy volunteers (aged 18-50 years) were evaluated in two separate studies. The first included 15 volunteers who received 25 units iHAV i.m. at 0 and 24 weeks. The second, a randomly controlled study, consisted of three groups receiving 25 units iHAV i.m. at 0, 1, and 6 months, or at 0, 2, and 6 months, or 0.06 ml/kg IG i.m. given once. Anti-HAV seroconversion was measured by radioimmunoassay (RIA). After IG injection, anti-HAV seroconversion occurred in 100% of recipients at week 1, declining to 10% at week 12, and 0% by week 20. In contrast, after a single 25-unit dose, RIA seropositivity in iHAV vaccines was 73% by week 2, reaching 100% by week 5, and persisted in all up to week 24, at which time anti-HAV geometric mean titers (GMT) were 2-fold higher than those seen at week 1 after IG. Administration of a booster dose given 1 or 2 months after primary immunization did not significantly improve the quantitative anti-HAV response at 6 months as compared to the effect of the primary dose.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost-benefit analysis of a nationwide neonatal inoculation programme against hepatitis B in an area of intermediate endemicity

STUDY OBJECTIVE

The aim was to estimate the costs and benefits of a nationwide neonatal vaccination campaign against hepatitis B in Israel for the 1990-2034 period.

DESIGN

Using morbidity, mortality, utilisation, and cost data from Israeli and international sources, a spreadsheet model was constructed to carry out the cost-benefit analysis.

SETTING

The entire State of Israel, an area of intermediate endemicity.

PARTICIPANTS

The population of Israel from 1990-2034.

MAIN RESULTS

A policy of immunising all Israeli neonates would, for a cost of $13.8 million, reduce the number of cases of hepatitis B during the 1990-2035 period in the cohort from 359,000 to 166,000 and save the nation around $21.5 million in health resources alone, $16.6 million in averted work absences, and a further $0.6 million in averted premature mortality costs. Even when the savings to the health services ($0.6 million) arising from the reduction in hepatocellular carcinoma are excluded, the direct benefit to cost ratio is 1.51/1, still in excess of unity.

CONCLUSIONS

The decision to adopt a nationwide neonatal inoculation policy, starting in January 1992, appears to be not only medically but also economically justifiable.