Clinical characteristics of acute liver failure associated with hepatitis A infection in children in Mogadishu, Somalia: a hospital-based retrospective study

Modelling the Cost-Effectiveness of Hepatitis A in South Africa

The World Health Organization (WHO) recommends the consideration of introducing routine hepatitis A vaccination into national immunization schedules for children ≥ 1 years old in countries with intermediate HAV endemicity. Recent data suggest that South Africa is transitioning from high to intermediate HAV endemicity, thus it is important to consider the impact and cost of potential routine hepatitis A vaccination strategies in the country. An age-structured compartmental model of hepatitis A transmission was calibrated with available data from South Africa, incorporating direct costs of hepatitis A treatment and vaccination. We used the calibrated model to evaluate the impact and costs of several childhood hepatitis A vaccination scenarios from 2023 to 2030. We assessed how each scenario impacted the burden of hepatitis A (symptomatic hepatitis A cases and mortality) as well as calculated the incremental cost per DALY averted as compared to the South African cost-effectiveness threshold. All costs and outcomes were discounted at 5%. For the modelled scenarios, the median estimated cost of the different vaccination strategies ranged from USD 1.71 billion to USD 2.85 billion over the period of 2023 to 2030, with the cost increasing for each successive scenario and approximately 39-52% of costs being due to vaccination. Scenario 1, which represented the administration of one dose of the hepatitis A vaccine in children < 2 years old, requires approximately 5.3 million vaccine doses over 2023-2030 and is projected to avert a total of 136,042 symptomatic cases [IQR: 88,842-221,483] and 31,106 [IQR: 22,975-36,742] deaths due to hepatitis A over the period of 2023 to 2030. The model projects that Scenario 1 would avert 8741 DALYs over the period of 2023 to 2030; however, it is not cost-effective against the South African cost-effectiveness threshold with an ICER per DALY averted of USD 21,006. While Scenario 3 and 4 included the administration of more vaccine doses and averted more symptomatic cases of hepatitis A, these scenarios were absolutely dominated owing to the population being infected before vaccination through the mass campaigns at older ages. The model was highly sensitive to variation of access to liver transplant in South Africa. When increasing the access to liver transplant to 100% for the baseline and Scenario 1, the ICER for Scenario 1 becomes cost-effective against the CET (ICER = USD 2425). Given these findings, we recommend further research is conducted to understand the access to liver transplants in South Africa and better estimate the cost of liver transplant care for hepatitis A patients. The modelling presented in this paper has been used to develop a user-friendly application for vaccine policy makers to further interrogate the model outcomes and consider the costs and benefits of introducing routine hepatitis A vaccination in South Africa.

Acute liver failure in low-income and middle-income countries

Acute liver failure is a rare condition involving the rapid development, progression, and worsening of liver dysfunction, characterised by coagulopathy and encephalopathy, and has a high mortality unless liver transplantation is performed. Population-based studies are scarce, and most published data are from high-income countries, where the main cause of acute liver failure is paracetamol overdose. This Review provides an overview of the scanty literature on acute liver failure in low-income and middle-income countries, where patients are often admitted to primary care hospitals and viral hepatitis (especially hepatitis E), tropical infections (eg, dengue), traditional medicines, and drugs (especially anti-tuberculosis drugs) have an important role. We discuss incidence, cause, occurrence in children and pregnant women, prognostic factors and scores, treatment, and mortality. To conclude, we advocate for international collaboration, the establishment of central registries for the condition, and better diagnostics.

Recovery fulminant hepatitis A in systemic juvenile idiopathic arthritis patient treated with tocilizumab: a case report

Introduction

Systemic juvenile idiopathic arthritis (sJIA) is a rare systemic immune disorder that affects patients before 16 years of age. Several viruses have been reported to trigger this disease. Increased use of biologics, such as tocilizumab and anakinra, and decreased use of glucocorticoid may lead to improved outcomes in patients with sJIA. Serious liver injuries induced by tocilizumab include acute liver failure, hepatitis, and jaundice.Hepatitis A remains a highly prevalent disease in low-income countries.

Case presentation

A 14-year-old Syrian child was diagnosed with sJIA and treated with different DMARDs, including MTX. Tocilizumab was then added as monotherapy and stopped after 12 doses after full diseases remission and normal laboratory tests. He presented with a very high alanine transferase, aspartate transferase, a spiked fever, and fatigue. He was infected with hepatitis A.

Discussion

Liver abnormalities are uncommon in sJIA. Acute liver failure may develop a few months after the onset of sJIA.Although acute infections with the hepatitis A virus in children are self-limited, 0.1% of patients progress to fulminant hepatic failure, which spontaneously recovers in 40% of cases. No data are available concerning the coexistence of hepatitis A and sJIA. Our case was the first case presenting fulminant Hepatitis A in a sJIA patient treated with tocilizumab, which had recovered, and the authors initiated Anakinra as a treatment.

Conclusion

Further follow-up and cohort studies are needed to find the exact prevalence and coexistence of Fulminant Hepatitis A in the coarse of sJIA treated with tocilizumab.