Update: Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Postexposure Prophylaxis and for Preexposure Prophylaxis for International Travel

Evaluation of the decision-making process underlying the initial off-label use of vaccines: A scoping review

BACKGROUND

This scoping review aimed to assess the non-standardized decision-making process of National or International Immunization Technical Advisory Groups (NITAG) in developing novel off-label recommendations by examining the supportive evidence.

METHODS

We used the Joanna Briggs Institute framework. A search strategy was developed with a librarian to identify recommendations and evidence from peer-reviewed and gray literature until January 2022, using PubMed, Medline, EMBASE, clinicaltrials.gov, the International Clinical trials registry, governmental agency and pharmaceutical websites, the Global NITAG Network center website, and Google Scholar. Recommendations involving one of 26 pre-identified vaccine-preventable diseases, human use, and the introduction of a novel change across time and countries, were included. Evidence regarding efficacy/effectiveness, safety, or immunogenicity were included. Recommendations for fast-track approval, unlabeled or individual level off-label use, passive immunization, booster doses or provincial strategies were excluded. Only English and French documents were included. Two reviewers reviewed title/abstracts and full-text documents, and three performed data extraction. The primary outcome was the presence and elements of the evidence.

FINDINGS

Out of 4023 documents, 12 were included, and 116 were found through manual search. Over the 40-year span captured (1982-2018), most recommendations were from the last two decades and included evidence, except three from the 1990s. Most included safety (69.2%) and immunogenicity (65.4%) studies and randomized controlled trials (57.7%). Indication-based recommendations included RCTs more often (84.6%) than posology-based recommendations (30.8%). There was evidence involving populations or vaccines different from those in the recommendation.

INTERPRETATION

Critical outcomes evidence is not systematically included in off-label recommendations, nor must it involve the exact population or vaccine(s) of concern. However, in recent years, more off-label recommendations include critical outcome evidence, mainly RCTs.

Subcutaneous anti-COVID-19 hyperimmune immunoglobulin for prevention of disease in asymptomatic individuals with SARS-CoV-2 infection: a double-blind, placebo-controlled, randomised clinical trial

BACKGROUND

Anti-COVID-19 hyperimmune immunoglobulin (hIG) can provide standardized and controlled antibody content. Data from controlled clinical trials using hIG for the prevention or treatment of COVID-19 outpatients have not been reported. We assessed the safety and efficacy of subcutaneous anti-COVID-19 hyperimmune immunoglobulin 20% (C19-IG20%) compared to placebo in preventing development of symptomatic COVID-19 in asymptomatic individuals with SARS-CoV-2 infection.

METHODS

We did a multicentre, randomized, double-blind, placebo-controlled trial, in asymptomatic unvaccinated adults (≥18 years of age) with confirmed SARS-CoV-2 infection within 5 days between April 28 and December 27, 2021. Participants were randomly assigned (1:1:1) to receive a blinded subcutaneous infusion of 10 mL with 1 g or 2 g of C19-IG20%, or an equivalent volume of saline as placebo. The primary endpoint was the proportion of participants who remained asymptomatic through day 14 after infusion. Secondary endpoints included the proportion of individuals who required oxygen supplementation, any medically attended visit, hospitalisation, or ICU, and viral load reduction and viral clearance in nasopharyngeal swabs. Safety was assessed as the proportion of patients with adverse events. The trial was terminated early due to a lack of potential benefit in the target population in a planned interim analysis conducted in December 2021. ClinicalTrials.gov registry: NCT04847141.

FINDINGS

461 individuals (mean age 39.6 years [SD 12.8]) were randomized and received the intervention within a mean of 3.1 (SD 1.27) days from a positive SARS-CoV-2 test. In the prespecified modified intention-to-treat analysis that included only participants who received a subcutaneous infusion, the primary outcome occurred in 59.9% (91/152) of participants receiving 1 g C19-IG20%, 64.7% (99/153) receiving 2 g, and 63.5% (99/156) receiving placebo (difference in proportions 1 g C19-IG20% vs. placebo, -3.6%; 95% CI -14.6% to 7.3%, p = 0.53; 2 g C19-IG20% vs placebo, 1.1%; -9.6% to 11.9%, p = 0.85). None of the secondary clinical efficacy endpoints or virological endpoints were significantly different between study groups. Adverse event rate was similar between groups, and no severe or life-threatening adverse events related to investigational product infusion were reported.

INTERPRETATION

Our findings suggested that administration of subcutaneous human hyperimmune immunoglobulin C19-IG20% to asymptomatic individuals with SARS-CoV-2 infection was safe but did not prevent development of symptomatic COVID-19.

FUNDING

Grifols.

International Travel Vaccine Recommendations for Children

Children are at risk of contracting diseases while traveling internationally. Beyond the importance of receiving routine vaccinations, physicians should also discuss with parents the effectiveness of vaccination as a strategy to protect their child against disease before travel. This article (1) explores the universally recommended routine vaccines that are particularly important for children to be up to date before travel (ie, measles, mumps, rubella; hepatitis A and B; polio; meningococcal; coronavirus disease 2019 [COVID-19]; and influenza) and (2) explains the travel-specific vaccination recommendations (ie, dengue, cholera, typhoid, tick-borne encephalitis, yellow fever, Japanese encephalitis, and rabies). Physicians can encourage parents to consult the Centers for Disease Control and Prevention website for travel vaccine recommendations (https://wwwnc.cdc.gov/travel). Children must remain up to date on universally recommended vaccines and receive the appropriate vaccines before international travel to prevent serious illness and limit the spread of diseases in the United States. [Pediatr Ann. 2023;52(3):e106-e113.].

Dual Infection of Hepatitis A Virus and Hepatitis E Virus- What Is Known?

Viral hepatitis is an infection of human hepatocytes resulting in liver damage. Dual infection of two hepatotropic viruses affects disease outcomes. The hepatitis A virus (HAV) and hepatitis E virus (HEV) are two enterically transmitted viruses; they are single-stranded RNA viruses and have common modes of transmission. They are transmitted mainly by the fecal-oral route and ingestion of contaminated food, though the HAV has no animal reservoirs. The HAV and HEV cause acute self-limiting disease; however, the HEV, but not HAV, can progress to chronic and extrahepatic infections. The HAV/HEV dual infection was reported among acute hepatitis patients present in developing countries. The impact of the HAV/HEV on the prognosis for acute hepatitis is not completely understood. Studies showed that the HAV/HEV dual infection increased abnormalities in the liver leading to fulminant hepatic failure (FHF) with a higher mortality rate compared to infection with a single virus. On the other hand, other reports showed that the clinical symptoms of the HAV/HEV dual infection were comparable to symptoms associated with the HAV or HEV monoinfection. This review highlights the modes of transmission, the prevalence of the HAV/HEV dual infection in various countries and among several study subjects, the possible outcomes of this dual infection, potential model systems for studying this dual infection, and methods of prevention of this dual infection and its associated complications.

Role of bioactive compounds in the treatment of hepatitis: A review

Hepatitis causes liver infection leading to inflammation that is swelling of the liver. They are of various types and detrimental to human beings. Natural products have recently been used to develop antiviral drugs against severe viral infections like viral hepatitis. They are usually extracted from herbs or plants and animals. The naturally derived compounds have demonstrated significant antiviral effects against the hepatitis virus and they interfere with different stages of the life cycle of the virus, viral release, replication, and its host-specific interactions. Antiviral activities have been demonstrated by natural products such as phenylpropanoids, flavonoids, xanthones, anthraquinones, terpenoids, alkaloids, aromatics, etc., against hepatitis B and hepatitis C viruses. The recent studies conducted to understand the viral hepatitis life cycle, more effective naturally derived drugs are being produced with a promising future for the treatment of the infection. This review emphasizes the current strategies for treating hepatitis, their shortcomings, the properties of natural products and their numerous types, clinical trials, and future prospects as potential drugs.

Viral hepatitis in pregnancy

Viral hepatitis is caused by a heterogenous group of viral agents representing a wide range of phylogenetic groups. Many viruses can involve the liver and cause liver injury but only a subset are delineated as 'hepatitis viruses' based upon their primary site of replication and tropism for hepatocytes which make up the bulk of the liver cell population. Since their discovery, beginning with the agent that caused serum hepatitis in the 1960s, the alphabetic designations have been utilized. To date, we have five hepatitis viruses, A through E, though it is postulated that others may exist. This chapter will focus on those viruses. Note that hepatitis D is included as a subset of hepatitis B, as it cannot exist without concurrent hepatitis B infection. Pregnancy has the potential to affect all aspects of these viral agents due to the unique immunologic and physiologic changes that occur during and after the gestational period. In this review, we will discuss the most common viral hepatitis and their effects during pregnancy.

Rare Diagnostic and Clinical Manifestations in an Acute Hepatitis A Infection: A Case Report

The hepatitis A virus (HAV) is a common cause of infectious hepatitis worldwide. In adults, clinical manifestations typically involve fever, nausea/vomiting, fatigue, abdominal pain, and jaundice, although rarer manifestations may be observed. Acute hepatitis A infection is detected via anti-HAV IgM antibodies, which are present in almost all patients at symptom onset. In this case, we present a patient who not only tested negative for acute HAV infection at symptom onset, but also presented with uncommon, extrahepatic manifestations including maculopapular skin rash and polyarthralgia. Wariness of such a presentation can facilitate the timely diagnosis of atypical cases of HAV infection.

We report the case of a 51-year-old man who presented with fever, abdominal pain, headaches, and diarrhea for one week with elevated liver enzymes and leukocytosis. Workup consisting of viral hepatitis panels, various infectious studies, and rheumatologic antibody titers did not initially reveal an etiology for the patient’s presentation. Computed tomography (CT) abdomen and pelvis, abdominal ultrasound, magnetic resonance cholangiopancreatography (MRCP), and hepatobiliary iminodiacetic acid (HIDA) scan did not reveal acute pathology. The patient’s symptoms worsened over the following days, and he additionally developed bilateral wrist pain, digital arthralgias, paraspinal back pain, diffuse muscular weakness, and a pruritic maculopapular rash affecting the flanks and extremities. Eventually, viral hepatitis studies were repeated which revealed elevated levels of anti-HAV IgM antibodies, indicating acute hepatitis A infection. The patient was treated supportively while hospitalized with subsequent improvement of symptoms and lab abnormalities. Since discharge, the patient had not experienced persistent sequelae of the disease.

This case of acute viral hepatitis A infection is notable for two reasons: (1) the patient experienced uncommon, delayed, extrahepatic manifestations of disease, and (2) the initial viral hepatitis studies revealed undetectable anti-HAV IgM levels despite having experienced symptoms of illness for several days. This case suggests that repeat viral hepatitis testing may be warranted in patients who continue to experience manifestations of the infection after initially testing negative. It also emphasizes the importance of recognizing potential atypical manifestations of acute hepatitis A infection.

Viral hepatitis: Past, present, and future

Each hepatitis virus-Hepatitis A, B, C, D, E, and G-poses a distinct scenario to the patient and clinician alike. Since the discovery of each virus, extensive knowledge regarding epidemiology, virologic properties, and the natural clinical and immunologic history of acute and chronic infections has been generated. Basic discoveries about host immunologic responses to acute and chronic viral infections, combined with virologic data, has led to vaccines to prevent Hepatitis A, B, and E and highly efficacious antivirals for Hepatitis B and C. These therapeutic breakthroughs are transforming the fields of hepatology, transplant medicine in general, and public and global health. Most notably, there is even an ambitious global effort to eliminate chronic viral hepatitis within the next decade. While attainable, there are many barriers to this goal that are being actively investigated in basic and clinical labs on the local, national, and international scales. Herein, we discuss pertinent clinical information and recent organizational guidelines for each of the individual hepatitis viruses while also synthesizing this information with the latest research to focus on exciting future directions for each virus.

Therapeutic Advances in Viral Hepatitis A-E

Viral hepatitis remains a significant global health problem. All forms of viral hepatitis A through E (A-E) can lead to acute symptomatic infection, while hepatitis B and C can lead to chronic infection associated with significant morbidity and mortality related to progression to cirrhosis, end-stage-liver disease, and liver cancer. Viral hepatitis occurs worldwide, though certain regions are disproportionately affected. We now, remarkably, have highly effective curative regimens for hepatitis C, and safe and tolerable medications to suppress hepatitis B activity, and to prevent liver damage and slow disease progression. We have effective vaccines for hepatitis A and B which provide long-lasting immunity, while improved sanitation and awareness can curb outbreaks of hepatitis A and E. However, more effective and available preventive and curative strategies are needed to achieve global eradication of viral hepatitis. This review provides an overview of the epidemiology, transmission, diagnosis, and clinical features of each viral hepatitis with a primary focus on current and future therapeutic and curative options.

Acute hepatitis A in international travellers: a GeoSentinel analysis, 2008-2020

BACKGROUND

Non-immune international travellers are at risk of acquiring hepatitis A. Although hepatitis A vaccination is recommended for unvaccinated travellers to high or intermediate hepatitis A virus endemicity, compliance with this recommendation is not universal.The main objective was to describe the demographic and travel characteristics of international travellers infected with hepatitis A during travel.

METHODS

Available data on travellers with confirmed (positive molecular test) or probable (symptomatic individuals with a single positive IgM test) hepatitis A diagnosed during and after travel from January 2008 to December 2020 were obtained from the GeoSentinel Surveillance Network database. We analysed demographic and travel characteristics of infected travellers.

RESULTS

Among 254 travellers with hepatitis A (185 confirmed and 69 probable), the median age was 28 years (interquartile range: 19-40), 150 (59%) were male, and among 54 travellers with information available, 53 (98%) were unvaccinated. The most common reasons for travel included tourism (n = 120; 47%) and visiting friends or relatives (VFR; n = 72; 28%). About two-thirds of VFR travellers with hepatitis A (n = 50; 69%) were younger than 20 years old. Hepatitis A was acquired most frequently in South-Central Asia (n = 63; 25%) and sub-Saharan Africa (n = 61; 24%), but 16 travellers (6%) acquired hepatitis A in regions with low endemicity including Western Europe (n = 7; 3%), the Caribbean (n = 6; 2%) and North America (n = 3; 1%). Median duration from illness onset to GeoSentinel site presentation was ~7 days (interquartile range : 4-14 days). Among 88 travellers with information available, 59% were hospitalized.

CONCLUSIONS

Despite availability of highly effective vaccines, travellers still acquire hepatitis A, even when traveling to low-endemicity destinations. Providing pre-departure hepatitis A vaccine to susceptible travellers is crucial to reducing travel-associated hepatitis A and should be offered to all travellers as part of the pre-travel consultation, regardless of destination.

Vaccines for International Pediatric Travelers

The pretravel management of the international pediatric traveler is based on provision of preventive education, chemoprophylaxis against malaria and traveler's diarrhea, as well as travel vaccinations. Immunization requirements are determined based on the traveler's pretravel immunization status, age, medical history, and destination. Immunization needs also vary depending on the exposures during the trip. Potential exposure to water, insects, or animals as well as duration of travel will help tailor risk avoidance education and travel immunizations. This review provides clinicians an overview of vaccines recommended for children traveling internationally.

Screening of Hepatitis A and B Seropositivity among Turkish Healthcare Providers Admitted to Occupational Health Services

This study aimed to determine the protection rates against hepatitis A virus (HAV) and hepatitis B virus (HBV), among healthcare providers (HCPs). The occupational health service data of Gaziosmanpaşa Training and Research Hospital between January 2020 and December 2020 were evaluated for this retrospective observational study. Of the 1,722 participants aged 34.40 ± 9.16 years, 48.6% (n = 861) were male, and 55.0% (n = 975) were doctors and nurses. The anti-HBs seropositivity rate was 87.5% (n = 1,501). None of the participants had anti-HCV antibodies. Twelve participants were HBsAg positive. A level of anti-HBs titer ≥10 mIU/mL was maintained in 66.7% of the HCPs vaccinated in childhood, while 71.3% (n = 1,263) of the participants had anti-HAV IgG. HAV vaccination needs were higher in the doctor and nurse groups than in the other groups (60.5% and 39.5%, respectively, p = 0.003). HBV protection was higher among HCPs in polyclinics/wards and surgery/intensive care units than in those working in the emergency department (odds ratio (OR): 2.099, 95% confidence interval (CI) = 1.285-3.429; OR: 1.592, 95% CI = 1.037-2.443, respectively). HAV protection was higher in HCPs aged 31-50 years and over 50 years than in those aged 18-30 years (OR: 2.046, 95% CI = 1.647-2.541; OR: 3.615, 95% CI = 2.164-6.037, respectively). In this study, one out of every two HCPs aged 18-30 years admitted to the occupational health control services had not yet received the HAV vaccine. The low levels of HBV protection among HCPs in the emergency department highlight the need for occupational health screening and HBV vaccination for HCPs working in emergency services in hospitals.

Hepatitis A: Epidemiology, High-Risk Groups, Prevention and Research on Antiviral Treatment

The hepatitis A virus (HAV) is a leading cause of acute viral hepatitis worldwide. It is transmitted mainly by direct contact with patients who have been infected or by ingesting contaminated water or food. The virus is endemic in low-income countries where sanitary and sociodemographic conditions are poor. Paradoxically, improving sanitary conditions in these countries, which reduces the incidence of HAV infections, can lead to more severe disease in susceptible adults. The populations of developed countries are highly susceptible to HAV, and large outbreaks can occur when the virus is spread by globalization and by increased travel and movement of foodstuffs. Most of these outbreaks occur among high-risk groups: travellers, men who have sex with men, people who use substances, and people facing homelessness. Hepatitis A infections can be prevented by vaccination; safe and effective vaccines have been available for decades. Several countries have successfully introduced universal mass vaccination for children, but high-risk groups in high-income countries remain insufficiently protected. The development of HAV antivirals may be important to control HAV outbreaks in developed countries where a universal vaccination programme is not recommended.

Occupational Health Update: Evaluation and Management of Exposures and Postexposure Prophylaxis

Health care personnel (HCP) are at risk of exposure to infectious agents depending on their job duties and other factors. Risks include percutaneous exposure to blood-borne pathogens via sharp injuries (eg, human immunodeficiency virus, hepatitis B virus, hepatitis C virus); exposure by direct contact, droplet, or airborne transmission of pathogens through direct patient care (eg, pertussis, invasive meningococcus infections, tuberculosis); and through indirect contact transmission related to the contaminated health care environment (eg, Clostridioides difficile). Occupational health programs must effectively identify and respond to potential exposures and provide guidance to HCP on postexposure prophylaxis.

A Focused Review on Recent Advances in the Diagnosis and Treatment of Viral Hepatitis

The global burden of viral hepatitis remains substantial despite advances in antiviral therapy and effective vaccines. There are five hepatitis viruses (hepatitis A, B, C, D, and E). Mortality related to hepatitis B virus and hepatitis C virus infections is among the top four global infectious diseases, together with human immunodeficiency virus infection, malaria, and tuberculosis. Of those deaths, approximately 47% are attributable to hepatitis B virus, 48% to hepatitis C virus and the remainder to hepatitis A virus and hepatitis E virus. Ending hepatitis epidemics as a major public health threat is feasible with the tools and approaches currently available. Effective vaccines are available for preventing viral hepatitis A, B and E infections. New oral, well-tolerated treatment regimens for chronic hepatitis C patients can achieve cure rates of over 90%. Effective treatment is also available for people with chronic hepatitis B virus infection; although for most people such treatment needs to be long-term, and recent advanced aim at a “functional cure” of hepatitis B. In this review article, we discuss the most recent advances of the diagnosis and treatment of viral hepatitis.

Comparative cost-effectiveness of a 2-dose versus 3-dose vaccine for hepatitis B prevention in selected adult populations

The hepatitis B virus is highly infectious and can cause incurable liver disease, leading to high morbidity rates, increased healthcare utilization, and high mortality. Multiple preventative hepatitis B vaccine options have been available for decades, but adherence to the traditional 6-month vaccine schedule for the approved 3-dose series remains low in adult populations at risk of hepatitis B exposure. A 2-dose hepatitis B vaccine (HEPLISAV-B) approved by the US Food and Drug Administration in 2017 induces rapid seroprotection within 1 month and has a safety profile comparable to a commonly used 3-dose vaccine. In a previous cost-effectiveness study, HEPLISAV-B had a favorable cost-effectiveness profile for multiple at-risk populations. The goal of the current analysis was to update and extend previous findings by evaluating cost-effectiveness of HEPLISAV-B compared with a 3-dose vaccine (Engerix-B) in selected adult populations, including patients with diabetes, chronic liver or kidney disease, end-stage renal disease, healthcare personnel, travelers to countries with endemic hepatitis B, and a public health population. Cost-effectiveness was measured as incremental cost-effectiveness ratios using a health economics Markov model that accounts for adherence rates, seroprotection rates, healthcare costs, and current pricing considerations. Patients progressed between a series of health states, and the difference in lifetime spending and survival for individuals receiving either HEPLISAV-B or Engerix-B was estimated from the perspective of a US managed care payer, HEPLISAV-B had favorable cost-effectiveness profiles for patients with diabetes, healthcare personnel, travelers, and patients with chronic liver disease and dominant incremental cost-effectiveness ratios for patients with chronic kidney disease and end-stage renal disease. A probabilistic sensitivity analysis supported the robustness of the cost-effectiveness profiles, and an additional analysis indicated that HEPLISAV-B was cost-effective in the general adult population. Overall, HEPLISAV-B was cost-effective in multiple adult populations recommended for HBV vaccination in the United States.

Safety and immunogenicity of inactivated hepatitis-A vaccine developed by Human Biologicals Institute in two age groups of healthy subjects: A phase I open label study

BACKGROUND

Hepatitis-A is an acute viral infection of the liver. Hepatitis-A virus has worldwide spread and is endemic in India. Though the disease is self-limiting in most cases, outbreaks are reported frequently from both developing and developed countries of the world. Severity and fatality occur more among infected symptomatic adults. The infection can be prevented with proper and timely immunization. This phase I, single arm, open label, multicenter trial was designed to assess the safety and immunogenicity of the inactivated hepatitis-A vaccine developed by Human Biologicals Institute when administered in a single dose in two age groups of healthy subjects.

METHODS

This study was carried out in 55 subjects in two healthy age groups at two centers in India. Group A included subjects of 19-49 years and group B subjects of 12-18 years of age. Enrolled subjects received a single dose of inactivated hepatitis A vaccine. Blood samples were collected at baseline and 4-6 weeks after vaccination. Safety was assessed by collection and analysis of data on solicited and unsolicited adverse events and immunogenicity was assessed by estimating the seroconversion rate, seroprotection rate and the geometric mean titres of antibodies.

RESULTS

Among the 55 subjects enrolled, 15 reported adverse events. No serious adverse event was reported. Pain at the injection site was the lone local adverse event. Systemic adverse events reported in Group A were: fatigue, headache, diarrhoea, fever, anorexia, nausea and upper respiratory tract infection, whereas there was no systemic event reported in Group B. There was 100% seroconversion and seroprotection and significant rise in antibody titre levels were observed in both the groups post vaccination.

CONCLUSIONS

This study found HBI inactivated hepatitis-A vaccine to be safe and highly immunogenic when administered as a single dose in adolescent and adult subjects.

Endemicity change of hepatitis A infection necessitates vaccination in food handlers: An Indian perspective

In the last two decades, outbreaks due to the foodborne hepatitis A virus (HAV) have been frequently reported in India, with adolescents and adults primarily affected. In India, most food handlers are adolescents and young adults who might be exposed to unsatisfactory environmental conditions and poor water quality. This increases the risk of HAV infection and consequently compounds the risk of HAV transmission from food handlers to susceptible populations. Given the shift in hepatitis A endemicity from high to intermediate levels in India, implementing the vaccination of food handlers has become important as it can also contribute to the elimination of hepatitis A in India. This narrative review makes a case for hepatitis A immunization of food handlers in India considering the growing food industry, evolving food culture, and the substantial burden caused by hepatitis A outbreaks.

What is the context?

Hepatitis A disease is a common form of viral hepatitis and is transmitted through contaminated food and water or through close contact with an infected person. The virus with stands high temperature and can survive on surfaces for long periods of time.

In India, the burden of hepatitis A has shifted from children to adolescents and adults who are more culnerable to infection. They present a high risk of complications, often requiring hopitalization.

The prevention of the disease has often bee neglected, inadequate safety measures for the preparation of food (via food handlers) is a known risk factor for the transmission of hepatitis A.

What is new?

Our review highlights the relationship between food handling and hepatitis A infection among adolescents and adults in Inida.

The lack of knowledge of food safety regulations and hygiene measures among food handlers and the organizations that guide them may contribute to the spread of hepatitis A.

What is the impact?

Sanitation efforts, awareness and educational programs for food are needed to help reduce the transmission of hepatitis A virus and disease, yet these measures alone may not be sufficient.

Vaccination among high-risk populations such as food handlers can prevent hepatitis A infection and its complications as well as transmission.

Epidemiological investigation on hepatitis A virus infection outbreak in the area of Rzeszow city during the years 2017/18

Aim of the study

To define the threats and epidemiological differences between outbreaks of hepatitis A (HA) in adults and children, and to assess the efficiency of implemented prophylaxis. We also present a summary of treatment and sick leave costs as compared to the predicted money-load in the case of properly initiated prophylaxis in hepatitis A virus (HAV)-exposed persons.

Material and methods

The cause of two outbreaks was contamination related to food mishandling by a person infected with HAV. Especially health-threatening was exposure to the infection of 137 pre-school children. A second outbreak caused by the same source was observed among 25 exposed adults. On the basis of medical documentation we determined costs related to hospitalization and sickness leave absence at work, comparing it with money load related to implementation of required prophylaxis in both groups of people exposed to risk of HAV infection.

Results

As a consequence of exposure in the kindergarten area, an infection was confirmed in 32 patients from the first and subsequent generations and 7 cases were observed in the second outbreak. Costs of hospitalization and related to the sick leave were estimated to double the predicted costs of prophylaxis.

Conclusions

In the case of lack of proper hand hygiene of a food handler with HA or in the case of food-borne exposure of children to HAV it is necessary to apply post-exposure prophylaxis. Costs of the prophylaxis are significantly lower than costs of HA. Both outbreaks underwent self-limitation with longer course of morbidity and larger number in the case of the kindergarten focus.

Vaccination and Immunoprotection in People with HIV

Vaccines play an important role in HIV primary care and are available for several sexually transmitted infections, including those caused by hepatitis A virus (HAV), hepatitis B virus (HBV), and human papillomavirus (HPV). HAV vaccination is increasingly important, given recent hepatitis A outbreaks and lack of immunity in many adults. A novel formulation of the hepatitis B vaccine shows promise in increasing rates of seroprotection. The Advisory Committee on Immunization Practices recommends the meningococcal conjugate vaccine for all individuals with HIV and has expanded the age range for administration of the HPV vaccine, recommending shared decision making about its administration in adults aged 27 to 45 years. This article summarizes a presentation by Steven C. Johnson, MD, at the International Antiviral Society-USA (IAS-USA) annual continuing education program held in New York, New York, in September 2019.

Convalescent Plasma Therapy for Management of COVID-19: Perspectives and Deployment in the Current Global Pandemic

The world is striving against the severe crisis of the COVID-19 pandemic. Healthcare professionals are struggling to treat their patients based on nonspecific therapies. Amidst this uncertainty, convalescent plasma therapy (CPT) has appeared to be an interim adjuvant therapy for severely ill patients of COVID-19 until long-term clinical trial treatment options are available. Considering the transfusion-related hazards, especially lung injuries and microbial transmission, where sensitivity is not ensured, rigorous trials should be conducted to determine this therapy's efficacy. Moreover, the ratio of recovered cases to plasma donors is not satisfying, which questioning this therapy's availability and accessibility. Although some countries are making the treatment free, the attributable cost mandates a justification for its suitability and sustainability. Our article aimed to review the published facts and findings of CPT's effectiveness in lowering the mortality rate of COVID-19. This pandemic showed that healthcare systems worldwide need core reform. A unified global collaboration must align and coordinate to face the current pandemic and enhance world readiness for future outbreaks based on health equity and equality.

Routine Childhood Vaccines Given From 1 through 18 Years of Age

In addition to the vaccines due in the first year of life, the US Advisory Committee on Immunization Practices recommends that children continue to receive vaccines regularly against a variety of infectious diseases. Starting at 12 to 15 months of life, these include the two-dose measles-mumps-rubella vaccine series and the two-dose varicella vaccine series. Also in the second year of life, infants should begin the two-dose hepatitis A vaccine series and complete the Haemophilus influenzae type B vaccine series as well as the pneumococcal conjugate vaccine series. Before 19 months of life, infants should receive the third dose of the poliovirus vaccine and the fourth dose of diphtheria-tetanus-acellular pertussis (DTaP) vaccine. The final doses of poliovirus and tetanus-diphtheria-acellular pertussis vaccines are both due at 4 to 6 years of life. Before each influenza season, every child should receive the influenza vaccine. Those less than 9 years of age who previously received less than two doses need two doses a month apart. At 11 to 12 years of life, all should get two doses of the human papillomavirus vaccine, the adolescent/adult version of the tetanus-diphtheria-acellular pertussis vaccine, and begin a two-dose series of meningococcal ACWY vaccine. Each of these vaccines is due when the vaccine works to protect against both an immediate risk as well as to provide long-term protection. Each vaccine-preventable disease varies in terms of the nature of exposure, the form of the morbidity, the risk of mortality, and potential to prevent or ameliorate its harm.

The Pretravel Consultation: Recent Updates

Estimates suggest that 43%-79% of international travelers may develop travel-related illnesses. Most such illnesses are considered mild and self-limited; however, some are life-threatening. The pretravel consultation is aimed at assessing risks for a range of illnesses, communicating these risks, and then providing individualized recommendations and interventions to minimize or manage such risks. The effective consultation is predicated on a well-prepared clinician and motivated traveler, understanding the traveler's perception of, and tolerance for, risk, and providing education applicable to the actual itinerary. Integral to the clinician's preparation is regular review of up-to-date trip-specific recommendations; country-specific information and recommendations are readily available and can now be efficiently accessed. From the infectious diseases perspective, immunizations, malaria chemoprophylaxis, insect repellent use, and travelers' diarrhea and its self-management are cornerstones of the consultation. This review focuses primarily on updating these 4 topics with recently published information relevant to adult travelers.

Hepatitis A vaccination

Hepatitis A is an important public health issue worldwide. Hepatitis A vaccine (HepA) was first licensed in 1992. Both inactivated HepA (HepA-I) and live attenuated HepA (HepA-L) are highly immunogenic and well tolerated, and immune protection postvaccination can persist for at least 20 y. HepA is effective for both preexposure and postexposure prophylaxis, especially among children and young adults. The strategy of HepA vaccination varies in different countries and mainly includes vaccination among high-risk populations, regional childhood vaccination and universal childhood vaccination. The incidence of hepatitis A has decreased greatly in many countries in the last 30 y, but hepatitis A outbreaks frequently occur among high-risk populations and those who have not been covered by universal child vaccination programs in recent years. Disease surveillance and serosurveys are suggested to clarify the shift in the epidemiology of hepatitis A. The long-term persistence of immune protection after one dose of HepA should be further studied, as well as the cost-effective evaluation of different strategies of HepA vaccination. Based on this evidence, the recommendation on HepA vaccination should be put forward scientifically and updated in a timely and well-implemented manner.

Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020

HEPATITIS A IS A VACCINE-PREVENTABLE, COMMUNICABLE DISEASE OF THE LIVER CAUSED BY THE HEPATITIS A VIRUS (HAV). THE INFECTION IS TRANSMITTED VIA THE FECAL-ORAL ROUTE, USUALLY FROM DIRECT PERSON-TO-PERSON CONTACT OR CONSUMPTION OF CONTAMINATED FOOD OR WATER. HEPATITIS A IS AN ACUTE, SELF-LIMITED DISEASE THAT DOES NOT RESULT IN CHRONIC INFECTION. HAV ANTIBODIES (IMMUNOGLOBULIN G [IGG] ANTI-HAV) PRODUCED IN RESPONSE TO HAV INFECTION PERSIST FOR LIFE AND PROTECT AGAINST REINFECTION; IGG ANTI-HAV PRODUCED AFTER VACCINATION CONFER LONG-TERM IMMUNITY. THIS REPORT SUPPLANTS AND SUMMARIZES PREVIOUSLY PUBLISHED RECOMMENDATIONS FROM THE ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP) REGARDING THE PREVENTION OF HAV INFECTION IN THE UNITED STATES. ACIP RECOMMENDS ROUTINE VACCINATION OF CHILDREN AGED 12-23 MONTHS AND CATCH-UP VACCINATION FOR CHILDREN AND ADOLESCENTS AGED 2-18 YEARS WHO HAVE NOT PREVIOUSLY RECEIVED HEPATITIS A (HEPA) VACCINE AT ANY AGE. ACIP RECOMMENDS HEPA VACCINATION FOR ADULTS AT RISK FOR HAV INFECTION OR SEVERE DISEASE FROM HAV INFECTION AND FOR ADULTS REQUESTING PROTECTION AGAINST HAV WITHOUT ACKNOWLEDGMENT OF A RISK FACTOR. THESE RECOMMENDATIONS ALSO PROVIDE GUIDANCE FOR VACCINATION BEFORE TRAVEL, FOR POSTEXPOSURE PROPHYLAXIS, IN SETTINGS PROVIDING SERVICES TO ADULTS, AND DURING OUTBREAKS.

Vaccination in Inflammatory Bowel Disease: Utility and Future Perspective

Inflammatory bowel disease (IBD) is an immune-mediated disease, which often require lifetime treatment with immunomodulators and immunosuppressive drugs. Both IBD and its treatments are associated with an increased risk of infectious disease and mortality. Several of these diseases are vaccine preventable and could be avoided, reducing morbidity and mortality. However, vaccination rates among patients with IBD are lower than in the general population and both patients and doctors are not fully aware of the problem. Education campaigns and well planned vaccination schemes are necessary to improve vaccination coverage in patients with IBD. Immunomodulators and immunosuppressive drugs may reduce the seroprotection levels. For this reason, new vaccination schemes are being studied in patients with IBD. It is therefore important to understand which and when vaccines can be administrated based on immunocompetence or immunosuppression of patients. Usually, live-attenuated vaccines should be avoided in immunosuppressed patients, so assessing vaccination status and planning vaccination before immunosuppressive treatments are pivotal to reduce infection risk. The aim of this review is to increase the awareness of the problem and provide a quick reference for vaccination plan tailoring, especially for gastroenterologists and primary care physicians, who have the skills and knowledge to implement vaccination strategies.

Hepatitis A: Epidemiology, Natural History, Unusual Clinical Manifestations, and Prevention

Hepatitis A virus (HAV) is a positive-strand RNA virus that is transmitted feco-orally through person-to-person contact. Outbreaks are often linked to poor sanitation, overcrowding, or food and water contamination. Infection is often asymptomatic in children, but adults present with jaundice, abdominal pain, hepatitis, and hyperbilirubinemia. Diagnosis is through detection of immunoglobulin M antibodies against HAV, and treatment is supportive. Vaccination is the mainstay of prevention and should be given before exposure whenever possible.

Polyvalent Human Immune Globulin: A Prospective, Open-Label Study Assessing Anti-Hepatitis A Virus (HAV) Antibody Levels, Pharmacokinetics, and Safety in HAV-Seronegative Healthy Subjects

BACKGROUND

Analytical data suggesting that immunoglobulin given intramuscularly (IGIM) may have reduced protection against hepatitis A virus (HAV) infection led to an update in the recommended IGIM dose (0.2 ml/kg).

METHODS

This prospective, open-label, single-arm clinical study evaluated whether a single 0.2 ml/kg dose of IGIM provided protective levels of anti-HAV antibodies (≥ 10 mIU/ml for up to 60 days) in HAV-seronegative healthy adults.

RESULTS

Of the 28 subjects enrolled and dosed, 26 (93%) completed the study. Mean uncorrected anti-HAV antibody titers peaked at 109 mIU/ml on day 5 and stayed above 10 mIU/ml through day 60 (N = 26). The mean uncorrected anti-HAV antibody titers had a median Tmax of 95.33 h, a mean Cmax of 118 mIU/ml, and a mean observed Thalf of 63.3 days; baseline-corrected titers had a median Tmax of 95.33 h, a mean Cmax of 114 mIU/ml, and a mean observed Thalf of 47.1 days (N = 27). All subjects (28/28) experienced at least 1 treatment-emergent adverse event (TEAE), with a total of 83 TEAEs reported; none was serious, and 96% (80/83) resolved without sequelae. Most (63%) events judged definitely and possibly related to study treatment involved localized pain due to intramuscular injections. There were no serious adverse events and no deaths or discontinuations due to TEAEs.

CONCLUSIONS

A single 0.2 ml/kg dose of IGIM provided protective anti-HAV levels for at least 60 days, with acceptable safety and tolerability profiles in healthy subjects. Uncorrected and baseline-corrected pharmacokinetic findings were similar and consistent with the corresponding sampling points in previous research.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier, NCT03351933.

Prevention and management of viral hepatitis in inflammatory bowel disease: a clinical practice guideline by the Korean Association for the Study of Intestinal Diseases

The treatment of inflammatory bowel disease (IBD) has been revolutionized for the last 10 years by the increasing use of immunomodulators and biologics. With immunosuppression of this kind, opportunistic infection is an important safety concern for patients with IBD. In particular, viral hepatitis is determined by the interaction between the virus and the host's immunity, and the risk of reactivation increases if immunity is compromised by immunosuppression therapy. Parts of Asia, including Korea, still show intermediate endemicity for the hepatitis A virus and hepatitis B virus compared with the United States and Western Europe. Thus, members of IBD research group of the Korean Association for the Study of Intestinal Diseases have produced a guideline on the prevention and management of viral hepatitis in IBD.

Vaccines for International Travel

The pretravel management of the international traveler should be based on risk management principles. Prevention strategies and medical interventions should be based on the itinerary, preexisting health factors, and behaviors that are unique to the traveler. A structured approach to the patient interaction provides a general framework for an efficient consultation. Vaccine-preventable diseases play an important role in travel-related illnesses, and their impact is not restricted to exotic diseases in developing countries. Therefore, an immunization encounter before travel is an ideal time to update all age-appropriate immunizations as well as providing protection against diseases that pose additional risk to travelers that may be delineated by their destinations or activities. This review focuses on indications for each travel-related vaccine together with a structured synthesis and graphics that show the geographic distribution of major travel-related diseases and highlight particularly high-risk destinations and behaviors. Dosing, route of administration, need for boosters, and possible accelerated regimens for vaccines administered prior to travel are presented. Different underlying illnesses and medications produce different levels of immunocompromise, and there is much unknown in this discipline. Recommendations regarding vaccination of immunocompromised travelers have less of an evidence base than for other categories of travelers. The review presents a structured synthesis of issues pertinent to considerations for 5 special populations of traveler: child traveler, pregnant traveler, severely immunocompromised traveler, HIV-infected traveler, and traveler with other chronic underlying disease including asplenia, diabetes, and chronic liver disease.

Hepatitis A virus-associated fulminant hepatitis with human immunodeficiency virus coinfection

Hepatitis A virus (HAV) commonly causes acute hepatitis in humans and is transmitted through the fecal-oral route or by ingestion of contaminated food or water. HAV infection generally follows a self-limiting course; it can seldom cause fulminant hepatitis that increases the risk of mortality. To the best of our knowledge, this is the first reported fatal case of fulminant hepatitis caused by HAV in a 40-year-old male with human immunodeficiency virus (HIV) infection. The HAV genotype in this case was IA, which has recently become common globally among people living with HIV (PLWHIV), intravenous drug users, and homeless people especially in developed countries. His HIV infection was stabilized by antiretroviral drugs and his CD4 values were stable. He developed acute hepatic encephalopathy, did not respond to repeated plasma exchange therapy, and died rapidly. It is known that HIV co-infection sometimes leads to fulminant non-HAV hepatitis, although evidence supporting a correlation between fulminant hepatitis A risk and HIV infection is still lacking. This case demonstrated the fatal risk of HAV infection in PLWHIV; it was suggested that education about appropriate preventive measures and vaccination are important for preventing HAV infections among PLWHIV.

Hepatitis A vaccine immunogenicity in patients using immunosuppressive drugs: A systematic review and meta-analysis

INTRODUCTION

Inactivated hepatitis A (HepA) vaccines are very immunogenic in healthy individuals; however, it remains unclear how different immunosuppressive regimens affect HepA vaccine immunogenicity. Our objective was to summarise the current evidence on immunogenicity of HepA vaccination in patients using immunosuppressive drugs.

METHODS

We systematically searched the literature for studies on immunogenicity of inactivated HepA vaccines in adults using immunosuppressive drugs. Studies reporting seroconversion rates (SCR) 4-8 weeks after 1 and 2 doses of HepA vaccine in organ transplant recipients and patients with chronic inflammatory conditions were included in a meta-analysis.

RESULTS

We included 17 studies, comprising 1,332 individuals. In healthy controls (2 studies), SCRs were 90-94% after the first dose and 100% after the second dose. In organ transplant recipients, SCRs ranged from 0 to 67% after the first dose of vaccine and 0-97% after the second dose. In patients with chronic inflammatory conditions, SCRs ranged from 6% to 100% after the first dose and from 48 to 100% after the second dose of vaccine. Patients using a TNF-alpha inhibitor versus conventional immune-modulators (e.g. methotrexate, azathioprine, corticosteroids) were more likely to seroconvert after the first dose of vaccine (OR12.1 [2.14-68.2]) but not after the second dose of vaccine (OR 0.78 [0.21-2.92]) in a meta-analysis.

CONCLUSION

Studies evaluating HepA vaccine immunogenicity in immunosuppressive agents are heterogeneous. Overall, there is an impaired immune response following HepA vaccination in patients using immunosuppressive drugs, especially after only one dose of vaccine and in organ transplant recipients. HepA vaccination should therefore be considered before immunosuppressive therapy. Future research should focus on alternative vaccination regimens and long-term immunogenicity.

PROSPERO ID

CRD42018102607.

Pediatric Travelers and Immigrant Children

Children comprise a special group of international travelers. Immigrant and refugee children, along with children traveling to visit friends and relatives abroad or on leisure trips, require special attention by clinicians to prevent and treat travel-related conditions. [Pediatr Ann. 2019;48(9):e360-e369.].

The indications and safety of polyvalent immunoglobulin for post-exposure prophylaxis of hepatitis A, rubella and measles

Derived from pooled blood donations, polyvalent immunoglobulins are used for post-exposure prophylaxis as one aspect of the public health management of hepatitis A, rubella and measles. This review summarizes the safety profile of these blood products and the current recommendations for their use for the prevention of hepatitis A, rubella and measles among people who have been exposed to these diseases. The current recommendations are drawn from the most recent publicly available national guidelines of the United States, Australia, New Zealand, Canada and the United Kingdom as accessed in February 2019.

Disparities in hepatitis A virus (HAV) vaccination coverage among adult travelers to intermediate or high-risk countries: The role of birthplace and race/ethnicity

BACKGROUND

While the hepatitis A virus (HAV) vaccine is recommended for United States (US) travelers to endemic regions, vaccination rates are lower among non-US-born adults and some racial minority groups.

PURPOSE

We aimed to examine the relationship between birthplace, race and their interaction as predictors of self-reported HAV vaccination among adult travelers to high-risk countries (HRCs) through analysis of the National Health Interview Survey (NHIS), 2012-2015.

METHODS

The study included 36,872 US adult participants in the 2012-2015 NHIS who traveled to countries where HAV is endemic. The main outcome was self-reported HAV vaccination (≥2 doses). Complex survey methods were applied to all models to provide statistical estimates that were representative of US adults. Multivariable logistic regression models adjusting for demographic, socioeconomic, medical, and access-to-care characteristics were fitted to examine the association between birthplace, race, race-by-birthplace (for interaction) and vaccination status.

RESULTS

For adult travelers to HRCs, the adjusted odds ratio (AOR) of HAV vaccination was lower for non-US-born compared to US-born adults, AOR 0.86 (95% CI; 0.76, 0.98). For Hispanics, the AOR of HAV vaccination was 0.80 (95% CI; 0.70, 0.91) as compared to non-Hispanic-Whites. Furthermore, a significant qualitative interaction between birthplace and race was found (P-value 0.0005). Among non-Hispanic Blacks, the adjusted odds of HAV vaccination for non-US-born adults were 1.35 (95% CI; 1.06, 1.72) times the odds for US-born adults. In contrast, the AORs of HAV vaccination of non-US-born versus US-born adults were 36% (95% CI; 17%, 51%) and 30% (95% CI; 12%, 44%), lower for Asians and Hispanics, respectively.

CONCLUSIONS

The association between birthplace and HAV vaccination status differs by race among travelers to HRCs, with US-born non-Hispanic Black and non-US-born Asian and Hispanic adults having lower odds of vaccination. Health care resources should be focused on these target populations to improve travel vaccination compliance.

Low adherence with national travel medicine recommendations in Belgian expatriate children: A retrospective analysis

BACKGROUND

Expatriates (expats) from European countries regularly migrate to low-income countries where infectious diseases are more prevalent. Little evidence exists however on pediatric expatriates' compliance with preventive measures related to infectious diseases. This study aims to evaluate compliance in Belgian expat-children.

METHODS

Data of 135 Belgian expat-children, visiting the Institute of Tropical Medicine (Antwerp, Belgium), were collected from clinical notes, laboratory results and from a web-based immunization-register. Information on routine vaccinations, yellow fever, hepatitis A, rabies, typhoid fever, meningococcal ACW₁₃₅Y, Japanese encephalitis, BCG vaccine and anti-malaria chemoprophylaxis was collected.

RESULTS

Overall, 87% of expat-children were up-to-date with their routine vaccinations. Although all children were eligible for hepatitis A, typhoid and rabies vaccination, only 8-21% were fully vaccinated. Only 29 and 61% of eligible children were vaccinated against meningococcal (ACW₁₃₅Y) or yellow fever respectively. Finally, only 10% of children who lived in malaria-endemic-areas, reported chemoprophylaxis-use.

CONCLUSION

Although routine vaccination coverage in expat-children seems adequate, additional preventive measures are often needed. Whether this is due to lack of high-quality health care-access, fear of side-effects or insufficient knowledge about the risks/available preventive measures, remains elusive. Nevertheless, expats seem to constitute a separate risk-group for infectious diseases and destination-related health issues.

The As and Bs of HIV and Hepatitis Co-Infection

Hepatitis A and B co-infection among people living with HIV are public health challenges that account for an increasing degree of morbidity and mortality. Understanding the changing epidemiology, clinical manifestations, and new approaches to treatment and prevention continues to be important in the care of people living with HIV. We conducted a review of the literature that included studies on hepatitis A and HIV co-infection and hepatitis B and HIV co-infection, focusing on epidemiology, clinical manifestations, treatment, and prevention. Important updates include the changing epidemiology of hepatitis A outbreaks among the homeless and individuals who use substances, and novel approaches to hepatitis B vaccination and hepatitis B cure strategies.

Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Persons Experiencing Homelessness

Hepatitis A (HepA) vaccination is recommended routinely for children at age 12-23 months, for persons who are at increased risk for hepatitis A virus (HAV) infection, and for any person wishing to obtain immunity. Persons at increased risk for HAV infection include international travelers to areas with high or intermediate hepatitis A endemicity, men who have sex with men, users of injection and noninjection drugs, persons with chronic liver disease, person with clotting factor disorders, persons who work with HAV-infected primates or with HAV in a research laboratory setting, and persons who anticipate close contact with an international adoptee from a country of high or interme-diate endemicity (1-3). Persons experiencing homelessness are also at higher risk for HAV infection and severe infection-associated outcomes. On October 24, 2018, the Advisory Committee on Immunization Practices (ACIP)* recommended that all persons aged 1 year and older experiencing homelessness be routinely immunized against HAV. The ACIP Hepatitis Vaccines Work Group conducted a systematic review of the evidence for administering vaccine to persons experiencing homelessness, which included a set of criteria assessing the benefits and adverse events associated with vaccination. HepA vaccines are highly immunogenic, and >95% of immunocompetent adults develop protective antibody within 4 weeks of receipt of 1 dose of the vaccine (1). HAV infections are acquired primarily by the fecal-oral route by either person-to-person transmission or via ingestion of contaminated food or water. Among persons experiencing homelessness, effective implementation of alternative strategies to prevent exposure to HAV, such as strict hand hygiene, is difficult because of living conditions among persons in this population. Integrating routine HepA vaccination into health care services for persons experiencing homelessness can reduce the size of the at-risk population over time and thereby reduce the risk for large-scale outbreaks.