Hepatitis B immunisation of household contacts: retrospective study of vaccine coverage

Hepatitis B contact tracing: what works?

In 2012, over 239000 people were living in Australia with chronic hepatitis B (CHB). Australia's Second National Hepatitis B Strategy (2014) recommends testing contacts to increase identification of people with CHB, but it is generally poorly performed. CHB prevalence in Australia is increasing and contact tracing (CT) remains an untapped strategy for identifying infected individuals. A systematic CT system has been established in a government-funded primary health centre in Melbourne, which services 2000 refugees. This mixed-methods study aimed to describe the structure of the CT system, determine its effectiveness and identify enablers of success. The CT system's structure was elicited from field notes. CT effectiveness (proportion of contacts traced and serologically confirmed as infected or immune to HBV) was determined by auditing clinical records. Semi-structured interviews with seven health professionals were thematically analysed to identify enablers of CT success. Overall, 122 CHB index cases had 420 contacts. And 90.0% (n=380) of 420 contacts were successfully traced, 68.0% (n=83) of index cases had 100% of their contacts successfully traced and 80.7% (n=339) of all contacts were immune; 28.8% (n=121) had evidence of previous exposure and 55.0% (n=231) had evidence of vaccination. Also, 8.1% (n=34) were chronically infected. Interviews elicited seven themes important to the success of the CT system: Teamwork; Organisation; Health professional expertise; Patient education; Centralisation of the system; Influence of patient culture; and Use of nurses in CT. Teamwork and Organisation were previously unidentified in the literature. This CT system is successful and could be implemented elsewhere, provided an organised, cohesive, nurse-led team is established.

Contact tracing for chronic hepatitis B in primary care? A 'snapshot' audit in Grampian, Northeast Scotland

Introduction Contact tracing for chronic hepatitis B infection is an important activity for preventing the spread of hepatitis B infection. In the UK, the 'Green Book' recommends that all sexual and household contacts of individuals with chronic hepatitis B should be tested and vaccinated if required. This audit aimed to evaluate contact tracing in primary care. Barriers to effective follow-up of contacts of patients with chronic hepatitis B were explored and recommendations made. Methods and results Mixed method, including a survey of general practitioners and review of hepatitis B surveillance data from 1 June 2015 to 31 December 2015 held by NHS Grampian Health Protection Team. The audit was carried out in August 2016. Contact tracing was mainly by patient referral. Only 20% (4/20) of identified close contacts were tested. No contact eligible for vaccination was vaccinated, and 57% (8/14) of general practitioners who completed the audit questionnaire suggested that general practitioners do not have a role in contact tracing. Barriers identified were: lack of time, lack of resources and contacts being registered with a different practice. Conclusions This audit suggests that contact tracing for chronic hepatitis B in primary care is largely incomplete. Moving contact tracing from general practice to health protection teams in Boards may be a pragmatic way of improving follow-up activities.

Barriers and opportunities for hepatitis B testing and contact tracing in a UK Somali population: a qualitative study

BACKGROUND

Chronic hepatitis B virus (HBV) infection frequently causes liver disease, and early identification can improve outcome. The burden of chronic HBV infection in many economically developed nations lies in migrant populations. Targeted HBV testing of migrants, and contact tracing for those diagnosed, are public health objectives but uptake has been fragmentary. This qualitative study aimed to investigate understanding of hepatitis B and response to testing and contact tracing amongst people of Somali ethnicity living in Bristol, UK.

METHODS

The views of 30 people of Somali ethnicity living in Bristol were explored through focus groups and semi-structured interviews. Transcripts of audio-recorded interviews and focus groups were imported into NVivo10 and inductive thematic analysis undertaken.

RESULTS

Most participants lacked awareness of hepatitis B, and often co-identified hepatitis B with 'jaundice'. There were frequent misconceptions regarding transmission, natural history and diagnosis, with hepatitis B commonly viewed as a relatively trivial, short lived, symptomatic disease. Hepatitis B was generally not stigmatised. Lack of understanding of the disease was cited as the major barrier to targeted testing and contact tracing.

CONCLUSION

These findings suggest public health initiatives to promote hepatitis B testing and contact tracing within migrant Somali populations should focus on improving hepatitis B understanding, particularly its natural history and diagnosis, and avoid translation of 'hepatitis B' into terms meaning 'jaundice' to address misperception of low susceptibility and low severity.

Managing HBV in pregnancy. Prevention, prophylaxis, treatment and follow-up: position paper produced by Australian, UK and New Zealand key opinion leaders

Hepatitis B during pregnancy presents unique management issues for both the mother and fetus. These include the lack of a current cohesive strategy for treatment and follow-up of mothers and their babies; the uncertain risk of postpartum HBV flares; the lack of randomised trial data on the safety and efficacy of antiviral treatment in pregnancy; the lack of head-to-head studies comparing different antivirals in pregnancy; and the lack of epidemiologic information regarding infection across different populations globally. This position paper provides a comprehensive review of the management of women with HBV infection prior to conception, throughout each stage of pregnancy and postpartum, as well as recommendations and clinical approaches for the follow-up of children born to infected mothers, based on available evidence in the literature and recommendations from international experts. Prevention of perinatal transmission is an important component of global efforts to reduce the burden of chronic HBV since vertical transmission is responsible for most of the chronic infection worldwide.

Transmission route and genotype of chronic hepatitis B virus infection in children in Japan between 1976 and 2010: A retrospective, multicenter study

AIM

The aim of this study was to clarify the trends of the infectious source of chronic hepatitis B virus (HBV) infection and the HBV genotype in the Japanese pediatric population over the last three decades.

METHODS

The present study was a retrospective, nationwide, multicenter study. Patients who were under 20 years of age when diagnosed with chronic HBV infection were eligible for enrollment in this study. A total of 430 patients (male/female, 256/174; age at the time of writing, 1-37 years; median age, 14 years; birth year, 1976-2010) from 11 hospitals were evaluated.

RESULTS

The incidence of chronic HBV infection from 1976 to 1980, 1981-1985, 1986-1990, 1991-1995, 1996-2000, 2001-2005 and 2006-2010 was 56, 52, 34, 37, 81, 92 and 78, respectively. Of the 430 patients, 304 (71%), 61 (14%), 11 (3%) and 54 (13%) were infected via mother-to-child transmission, close contact, blood transfusion and unknown source, respectively. After the introduction of perinatal immunoprophylaxis, the rate of mother-to-child transmission increased from 62% during the 1991-1995 period to 86% during the 2006-2010 period. The distributions of genotypes A, B, C, D and F were 3%, 9%, 86%, 2% and 1%, respectively. No obvious change was observed in the distribution of genotypes. Genotype C was significantly associated with mother-to-child transmission.

CONCLUSION

Mother-to-child transmission remains the primary source of chronic HBV infection after the introduction of immunoprophylaxis. Taking measures to prevent immunoprophylaxis failure is essential to reduce pediatric chronic HBV infection in Japan.

Lack of implementation of Hepatitis B Virus (HBV) vaccination policy in household contacts of HBV carriers in Italy

Background

In Italy, HBV vaccination is recommended and offered free of charge through the National Health Service to selected population groups – e.g., family members of an HBsAg carrier, healthcare workers, newborns and those who were 12-years old in 1991. However, a significant proportion of cases of acute hepatitis B still occur in Italy among persons who should have been vaccinated. We analysed HBV sero-prevalence data of two vaccination target populations (people born after 1980 and household contacts of an HBV carrier) living in a southern Italian area in order to evaluate HBV vaccine coverage and its possible determinants.

Methods

Between 2003 and 2006, we carried out a cross-sectional, population-based, sero-epidemiological survey on HBV infection on 4496 randomly selected individuals (aged 20 years or more) from the general population of the province of Naples. Sera were tested for antibodies to hepatitis B core antigen (anti-HBc) and to hepatitis B surface antigen (anti-HBsAg) by commercial immunoassays. Prevalence of past or current HBV infection and of HBV vaccination-induced immunity was calculated in two vaccination target populations. To analyze the association of epidemiological and socioeconomic characteristics with HBV vaccination of household contacts, we calculated crude and multiple logistic regression (MLR) odds ratio (OR).

Results

Prevalence of HBV vaccine-induced immunity (anti-HBs alone) was much lower among household contacts (25%) than among those who had been targeted for universal adolescent vaccination (81.6%). Male sex, older age, unemployment and lower education levels were associated to lower immunization rates.

Conclusion

Understanding the different uptake of hepatitis B vaccination in these populations may provide useful information for optimizing vaccination campaigns in other contexts. Our data clearly demonstrated the need of improving the uptake of vaccination for household contacts of HBV carriers.

Enhanced surveillance of hepatitis B infection in inner-western Sydney

OBJECTIVES

We developed an enhanced surveillance system for hepatitis B to improve the detection of newly acquired cases and to collect epidemiological data.

METHODS

The study was undertaken from February to June (inclusive) 2005 at the Sydney South West Area Health Service Eastern Zone Public Health Unit. A letter was sent to treating doctors on receipt of a notification, requesting additional information on cases. Cases identified by the treating doctors as newly acquired were followed up by telephone.

RESULTS

There were 295 notifications of hepatitis B in the period, of which three were newly acquired infections. Only one of these three cases was identified through enhanced surveillance. Information on ethnicity was obtained.

CONCLUSIONS

This enhanced surveillance system is of limited value as an ongoing process. We recommend that it be undertaken periodically to monitor the epidemiology of the disease.

Partner notification for persons with chronic hepatitis B virus infection: use of a syphilis model service

BACKGROUND

Adults with chronic hepatitis B virus (HBV) infection are usually the source of infection for persons who acquire sexually transmitted HBV infection. Vaccinating sex- and needle-sharing partners is recommended.

GOAL

To evaluate the usefulness of a syphilis model partner notification (PN) service for high-risk persons with chronic HBV infection.

STUDY DESIGN

Locatable partners were offered serologic testing and HBV vaccination.

RESULTS

Of 190 eligible case patients, 129 (68%) were interviewed, which included 47 men who have sex with men (MSM), 26 who reported injecting drug use (IDU), and 12 who were MSM and injected drugs. Among the 129 interviewed, 85 (66%) reported having =1 recent sex partner, 46 (36%) provided locating information for 47 partners, 38 partners accepted PN services, 15 were not immune, and 14 (7% of total eligible case patients) started and 9 completed the HBV vaccine series. Overall, 15% of case patients were also hepatitis C positive, and 29% were HIV infected. PN services cost was estimated at 1472 US dollars per vaccinee.

CONCLUSION

High-risk persons with chronic HBV infection provided few names or locating information for their partners, and the proportion eligible for vaccination was low. An integrated approach that provides hepatitis C screening, human immunodeficiency virus testing, and referral might be more useful and should be evaluated.