Progress Toward Eliminating Hepatitis A Disease in the United States

The Effectiveness of National Expanded Program on Immunization With Hepatitis A Vaccines in the Chinese Mainland: Interrupted Time-Series Analysis

BACKGROUND

The high prevalence of hepatitis A delivered a blow to public health decades ago. The World Health Organization (WHO) set a goal to eliminate viral hepatitis including hepatitis A by 2030. In 2008, hepatitis A vaccines were integrated into the Expanded Program on Immunization (EPI) in China to alleviate the burden of hepatitis A, although the effectiveness of the EPI has not been well investigated.

OBJECTIVE

We aimed to evaluate the intervention effect at both provincial and national levels on the incidence of hepatitis A in the Chinese mainland from 2005 to 2019.

METHODS

Based on the monthly reported number of hepatitis A cases from 2005 to 2019 in each provincial-level administrative division, we adopted generalized additive models with an interrupted time-series design to estimate province-specific effects of the EPI on the incidence of hepatitis A among the target population (children aged 2-9 years) from 2005 to 2019. We then pooled province-specific effect estimates using random-effects meta-analyses. We also assessed the effect among the nontarget population and the whole population.

RESULTS

A total of 98,275 hepatitis A cases among children aged 2-9 years were reported in the Chinese mainland from 2005 to 2019, with an average annual incidence of 5.33 cases per 100,000 persons. Nationally, the EPI decreased the hepatitis A incidence by 80.77% (excess risk [ER] -80.77%, 95% CI -85.86% to -72.92%) during the study period, guarding an annual average of 28.52 (95% empirical CI [eCI] 27.37-29.00) cases per 100,000 persons among the target children against hepatitis A. Western China saw a more significant effect of the EPI on the decrease in the incidence of hepatitis A among the target children. A greater number of target children were protected from onset in Northwest and Southwest China, with an excess incidence rate of -129.72 (95% eCI -135.67 to -117.86) and -66.61 (95% eCI -67.63 to -64.22) cases per 100,000 persons on average, respectively. Intervention effects among nontarget (ER -32.88%, 95% CI -39.76% to -25.21%) and whole populations (ER -31.97%, 95% CI -39.61% to -23.37%) were relatively small.

CONCLUSIONS

The EPI has presented a lasting positive effect on the containment of hepatitis A in the target population in China. The EPI's effect on the target children also provided a degree of indirect protection for unvaccinated individuals. The continuous surveillance of hepatitis A and the maintenance of mass vaccination should shore up the accomplishment in the decline of hepatitis A incidence to ultimately achieve the goal set by the WHO.

Future directions in acute liver failure

Acute liver failure (ALF) describes a clinical syndrome of rapid hepatocyte injury leading to liver failure manifested by coagulopathy and encephalopathy in the absence of pre-existing cirrhosis. The hallmark diagnostic features are a prolonged prothrombin time (ie, an international normalized ratio of prothrombin time of ≥1.5) and any degree of mental status alteration (HE). As a rare, orphan disease, it seemed an obvious target for a multicenter network. The Acute Liver Failure Study Group (ALFSG) began in 1997 to more thoroughly study and understand the causes, natural history, and management of ALF. Over the course of 22 years, 3364 adult patients were enrolled in the study registry (2614 ALF and 857 acute liver injury-international normalized ratio 2.0 but no encephalopathy-ALI) and >150,000 biosamples collected, including serum, plasma, urine, DNA, and liver tissue. Within the Registry study sites, 4 prospective substudies were conducted and published, 2 interventional ( N -acetylcysteine and ornithine phenylacetate), 1 prognostic [ 13 C-methacetin breath test (MBT)], and 1 mechanistic (rotational thromboelastometry). To review ALFSG's accomplishments and consider next steps, a 2-day in-person conference was held at UT Southwestern Medical Center, Dallas, TX, entitled "Acute Liver Failure: Science and Practice," in May 2022. To summarize the important findings in the field, this review highlights the current state of understanding of ALF and, more importantly, asks what further studies are needed to improve our understanding of the pathogenesis, natural history, and management of this unique and dramatic condition.

Infectious diseases in Indigenous populations in North America: learning from the past to create a more equitable future

The COVID-19 pandemic, although a profound reminder of endured injustices by and the disparate impact of infectious diseases on Indigenous populations, has also served as an example of Indigenous strength and the ability to thrive anew. Many infectious diseases share common risk factors that are directly tied to the ongoing effects of colonisation. We provide historical context and case studies that illustrate both challenges and successes related to infectious disease mitigation in Indigenous populations in the USA and Canada. Infectious disease disparities, driven by persistent inequities in socioeconomic determinants of health, underscore the urgent need for action. We call on governments, public health leaders, industry representatives, and researchers to reject harmful research practices and to adopt a framework for achieving sustainable improvements in the health of Indigenous people that is both adequately resourced and grounded in respect for tribal sovereignty and Indigenous knowledge.

Hepatitis A virus infection

Hepatitis A is a vaccine-preventable infection caused by the hepatitis A virus (HAV). Over 150 million new infections of hepatitis A occur annually. HAV causes an acute inflammatory reaction in the liver that usually resolves spontaneously without chronic sequelae. However, up to 20% of patients experience a prolonged or relapsed course and <1% experience acute liver failure. Host factors, such as immunological status, age, pregnancy and underlying hepatic diseases, can affect the severity of disease. Anti-HAV IgG antibodies produced in response to HAV infection persist for life and protect against re-infection; vaccine-induced antibodies against hepatitis A confer long-term protection. The WHO recommends vaccination for individuals at higher risk of infection and/or severe disease in countries with very low and low hepatitis A virus endemicity, and universal childhood vaccination in intermediate endemicity countries. To date, >25 countries worldwide have implemented such programmes, resulting in a reduction in the incidence of HAV infection. Improving hygiene and sanitation, rapid identification of outbreaks and fast and accurate intervention in outbreak control are essential to reducing HAV transmission.

Vaccination Coverage of Privately Insured Children: Comparing U.S. Survey and Administrative Data

INTRODUCTION

National Immunization Survey-Child data are used widely to assess childhood vaccination coverage in the U.S. This study compares National Immunization Survey-Child coverage estimates with estimates using other supplementary data sources.

METHODS

Retrospective analyses in 2021 assessed vaccination coverage of privately insured children for vaccines recommended by the Advisory Committee on Immunization Practices by age 2 years, using the 2015-2018 MarketScan Commercial Claims and Encounters databases and the 2018-2019 Healthcare Effectiveness Data and Information Set. The coverage estimates were compared statistically with those using the 2016-2018 National Immunization Survey-Child.

RESULTS

Estimated coverage ranged from 69.9% (≥2 doses of influenza vaccine) to 95.0% (≥3 doses of diphtheria, tetanus toxoids, and acellular pertussis vaccine) using the MarketScan Commercial Claims and Encounters data and from 68.0% (≥2 doses of influenza vaccine) to 92.2% (≥1 dose of measles, mumps, and rubella vaccine) using the Healthcare Effectiveness Data and Information Set. The difference between the MarketScan Commercial Claims and Encounters and National Immunization Survey-Child estimates ranged from 0.1 to 4.3 percentage points and was statistically significant for 6 of the 13 assessed vaccines/doses and percentage of children receiving no vaccinations. The difference between the Healthcare Effectiveness Data and Information Set and National Immunization Survey-Child estimates ranged from 0.4 to 7.2 percentage points and was statistically significant for 6 of the 10 assessed vaccines/doses.

CONCLUSIONS

For certain vaccines and populations of interest, the National Immunization Survey-Child, MarketScan Commercial Claims and Encounters, and Healthcare Effectiveness Data and Information Set data might give comparable coverage of privately insured children.

Viral hepatitis: A narrative review of hepatitis A–E

Viral hepatitis continues to be a major health concern leading to hepatic decompensation ranging from acute hepatitis to cirrhosis and hepatocellular carcinoma. The hepatic and extrahepatic manifestations are not only debilitating but also associated with a significant economic burden. Over the last two decades, the field of virology has made significant breakthroughs leading to a better understanding of the pathophysiology of viral hepatitis, which in turn has led to new therapeutic options. The advent of direct-acting antiviral agents changed the landscape of hepatitis C virus (HCV) therapy, and new drugs are in the pipeline for chronic hepatitis B virus (HBV) treatment. There has also been a significant emphasis on screening and surveillance programs, widespread availability of vaccines, and linkage of care. Despite these efforts, significant gaps persist in care, and there is a pressing need for increased collaboration and teamwork across the globe to achieve a reduction of disease burden and elimination of HBV and HCV.

Predictors of hepatitis A immunity in adults in California in order to better utilize hepatitis A vaccine

BACKGROUND

Hepatitis A vaccine recommendations now include homelessness, illegal drug use, and HIV, as well as traditional risk factors and travel to areas endemic for hepatitis A. We examined a large diverse population for predictors of Hepatitis A immunity in order to better utilize Hepatitis A vaccine.

METHODS

We performed a cross-sectional descriptive study of members of a large integrated health plan with a test for Hepatitis A Immunoglobulin G (IgG) between January 1st, 2007, and December 31st, 2017. Exclusion criteria included age <18 years, <6 months of continuous enrollment, and Hepatitis A vaccine prior to Hepatitis A test. Variables of interest were age, gender, primary language spoken, ethnicity/race, neighborhood household income, and history of travel or history of jaundice. Multivariable logistic regression was performed to evaluate the association of risk factors on Hepatitis A immunity.

RESULTS

Of the 318,170 persons ≥ 18 years tested for Hepatitis A immunity, 155, 842 persons had a reactive Hepatitis A IgG test (49%). The lowest prevalence was for Whites at 28.1% followed by Blacks at 35.8%. Hispanics and Asian/Pacific Islanders had prevalence rates of 63% and 68.2% respectively. In adjusted analyses, Asian/Pacific Islanders, Hispanics and Blacks were 5.17, 3.44 and 1.42 times more likely to have Hepatitis A immunity than Whites. Those that spoke Spanish or language other than English or Spanish as their primary preferred language were 6.11 and 3.27 time more likely to have immunity than English speakers. Known travel history conferred a 2.16 likelihood of Hepatitis A immunity.

CONCLUSIONS

Persons of Hispanic and Asian/Pacific Islander background as well as persons with a preferred spoken language other than English have a high prevalence of Hepatitis A immunity. Testing for Hepatitis A immunity prior to vaccination should be considered for these groups.

Public Health Role of Academic Medical Center in Community Outbreak of Hepatitis A, San Diego County, California, USA, 2016-2018

During 2016–2018, San Diego County, California, USA, experienced one of the largest hepatitis A outbreaks in the United States in 2 decades. In close partnership with local healthcare systems, San Diego County Public Health led a public health response to the outbreak that focused on a 3-pronged strategy to vaccinate, sanitize, and educate. Healthcare systems administered nearly half of the vaccinations delivered in San Diego County. At University of California San Diego Health, the use of informatics tools assisted with the identification of at-risk populations and with vaccine delivery across outpatient and inpatient settings. In addition, acute care facilities helped prevent further disease transmission by delaying the discharge of patients with hepatitis A who were experiencing homelessness. We assessed the public health roles that acute care hospitals can play during a large community outbreak and the critical nature of ongoing collaboration between hospitals and public health systems in controlling such outbreaks.

Missed Opportunities for Hepatitis A Vaccination Among MSM Initiating PrEP

The incidence of Hepatitis A virus (HAV) among the general population in the United States has decreased by over 95% since the introduction of HAV vaccination in 1995. However, 10% of all new HAV infections occur among men who have sex with men (MSM). However routine HAV is not part of standard of care for provision of PrEP services. Retrospective cohort analysis of MSM assessed for HIV prevention services between 1/1/2016 and 6/30/2017 to evaluate the rates of screening for anti-HAV seroprevalence and subsequent vaccination. HAV IgG was drawn on 96% (96/100) of the patients with 58% (56/96) of patients demonstrating serologic immunity. Of the 40 patients without evidence of immunity, 77% (29/40) returned for a subsequent visit, 48% (14/29) were provided HAV vaccination, and 29% (4/14) received at least two doses. Only 35% (14/40) of patients without documented immunity received HAV vaccination. Visits for PrEP initiation and monitoring in MSM patients are potential opportunities for ensuring HAV vaccination among this high-risk patient population. Public health agencies could optimize HAV vaccination of the high risk MSM by incorporating HAV screening into national PrEP guidelines.

Changing Epidemiology of Hepatitis A in China: Evidence From Three National Serological Surveys and the National Notifiable Disease Reporting System

BACKGROUND AND AIMS

China has conducted surveillance for hepatitis A since 1990, and hepatitis A was highly-to-intermediately endemic in 1992 when a Chinese hepatitis A vaccine (HepA) was licensed and introduced as a family-pay vaccine. In 2008, HepA was introduced into the Expanded Program on Immunization as a free childhood vaccine.

APPROACH AND RESULTS

Three nationally representative surveys conducted in 1992, 2006, and 2014 assessed hepatitis B serology. The 1992 survey included hepatitis A virus (HAV) serology, and we tested sera from the 2006 and 2014 surveys for HAV antibodies. We used surveillance, seroprevalence, and vaccination status data to describe the changing epidemiology of hepatitis A in China from 1990 through 2014. Before HepA licensure, anti-HAV seroprevalence was 60% at 4 years of age, 70% at 10 years, and 90% at 59 years; incidence was 52/100,000 and peaked at 4 years. In 2006, after >10 years of private sector vaccination, HepA coverage was <30% among children <5 years, and incidence was 5.4/100,000 with a peak at 10 years. In 2014, coverage was >90% among children under 5 years; incidence was 1.9/100,000. Individuals born before the national introduction of HepA (1988-2004) had lower anti-HAV seroprevalence than earlier and later birth cohorts.

CONCLUSIONS

The incidence of hepatitis A declined markedly following HepA introduction and improvement of sanitation and hygiene. The emerging epidemiology is consistent with disease-induced immunity having been replaced by vaccine-induced immunity, resulting in a low incidence of hepatitis A. Catch-up HepA campaigns to close the immunity gap among the 1998-2004 birth cohorts should be considered.

One or two doses of hepatitis A vaccine in universal vaccination programs in children in 2020: A systematic review

BACKGROUND

Hepatitis A virus (HAV) is a global health concern as outbreaks continue to occur. Since 1999, several countries have introduced universal vaccination (UV) of children against HAV according to approved two-dose schedules. Other countries have implemented one-dose UV programs since 2005; the long-term impact of this schedule is not yet known.

METHODS

We conducted a systematic literature search in four electronic databases for data published between January 2000 and July 2019 to assess evidence for one-dose and two-dose UV of children with non-live HAV vaccines and describe their global impact on incidence, mortality, and severity of hepatitis A, vaccine effectiveness, vaccine efficacy, and antibody persistence.

RESULTS

Of 3739 records screened, 33 peer-reviewed articles and one conference abstract were included. Rapid declines in incidence of hepatitis A and related outcomes were observed in all age groups post-introduction of UV programs, which persisted for at least 14 years for two-dose and six years for one-dose programs according to respective study durations. Vaccine effectiveness was ≥95% over 3-5 years for two-dose programs. Vaccine efficacy was >98% over 0.1-7.5 years for one-dose vaccination. Antibody persistence in vaccinated individuals was documented for up to 15 years (≥90%) and ten years (≥74%) for two-dose and one-dose schedules, respectively.

CONCLUSION

Experience with two-dose UV of children against HAV is extensive, demonstrating an impact on the incidence of hepatitis A and antibody persistence for at least 15 years in many countries globally. Because evidence is more limited for one-dose UV, we were unable to draw conclusions on immune response persistence beyond ten years or the need for booster doses later in life. Ongoing epidemiological monitoring is essential in countries implementing one-dose UV against HAV. Based on current evidence, two doses of non-live HAV vaccines are needed to ensure long-term protection.

Susceptibility to Hepatitis A Virus Infection in the United States, 2007-2016

BACKGROUND

Despite national immunization efforts, including universal childhood hepatitis A (HepA) vaccination recommendations in 2006, hepatitis A virus (HAV)-associated outbreaks have increased in the United States. Unvaccinated or previously uninfected persons are susceptible to HAV infection, yet the susceptibility in the US population is not well known.

METHODS

Using National Health and Nutrition Examination Survey 2007-2016 data, we estimated HAV susceptibility prevalence (total HAV antibody negative) among persons aged ≥2 years. Among US-born adults aged ≥20 years, we examined prevalence, predictors, and age-adjusted trends of HAV susceptibility by sociodemographic characteristics. We assessed HAV susceptibility and self-reported nonvaccination to HepA among risk groups and the "immunization cohort" (those born in or after 2004).

RESULTS

Among US-born adults aged ≥20 years, HAV susceptibility prevalence was 74.1% (95% confidence interval, 72.9-75.3%) during 2007-2016. Predictors of HAV susceptibility were age group 30-49 years, non-Hispanic white/black, 130% above the poverty level, and no health insurance. Prevalences of HAV susceptibility and nonvaccination to HepA, respectively, were 72.9% and 73.1% among persons who reported injection drug use, 67.5% and 65.2% among men who had sex with men, 55.2% and 75.1% among persons with hepatitis B or hepatitis C, and 22.6% and 25.9% among the immunization cohort. Susceptibility and nonvaccination decreased over time among the immunization cohort but remained stable among risk groups.

CONCLUSIONS

During 2007-2016, approximately three-fourths of US-born adults remained HAV susceptible. Enhanced vaccination efforts are critically needed, particularly targeting adults at highest risk for HAV infection, to mitigate the current outbreaks.

The Impact of Vaccination Efforts on the Spatiotemporal Patterns of the Hepatitis A Outbreak in Michigan, 2016-2018

BACKGROUND

The United States is currently experiencing the largest hepatitis A virus (HAV) outbreak since the introduction of a vaccine in 1996. More than 31,000 cases have been reported since 2016. Although HAV had largely been considered a foodborne pathogen in recent years, this outbreak has been spread primarily through person-to-person transmission in urban settings and has been associated with homelessness and substance use. Michigan was one of the first states to report an outbreak, with 910 reported cases between August 2016 and December 2018.

METHODS

We analyzed surveillance and vaccination data from Michigan using a disease transmission model to investigate how vaccine timing and coverage influenced the spatiotemporal patterns of the outbreak, distinguishing between Southeast Michigan, where the outbreak began, and the rest of the state.

RESULTS

We estimated that vaccination had little impact in Southeast Michigan (3% cases averted [95% confidence interval (CI) = 1%, 8%]) but had a substantial impact in the rest of the state, preventing a larger outbreak (91% cases averted [95% CI = 85%, 97%]) lasting several more years.

CONCLUSIONS

Our results emphasize the value of targeting populations where local transmission is not yet sustained rather than populations where transmission is already waning. Simulation modeling can aid in proactive rather than reactive decision-making and may help direct the response to outbreaks emerging in other states. See video abstract: http://links.lww.com/EDE/B704.

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.

Hepatitis A hospitalizations among kidney transplant recipients in the United States: nationwide inpatient sample 2005-2014

BACKGROUND

This study aimed to evaluate the hospitalization rate for Hepatitis A virus (HAV) among kidney transplant (KTx) recipients and its outcomes as well as resource utilization.

METHODS

The 2005-2014 National Inpatient Sample database was used to identify all hospitalized KTx recipients with an associated diagnosis of HAV. The hospital mortality, resource utilization, and associated liver conditions were compared between patients with and without HAV, adjusting for potential confounders.

RESULTS

Of 871 024 KTx recipients identified, 204 had HAV. The overall inpatient prevalence of HAV in KTx recipients over 10 years in the United States was 23.42 cases per 100 000 admissions. There were no statistically significant changes in the inpatient prevalence of HAV in KTx recipients during the study period (P = 0.77), ranging from 9.2 to 34.3 per 100 000 admissions. Among hospitalized KTx recipients with HAV, 27.9% were from Northeast, 29.2% were from Midwest, 23.8% were from South, and 19.1% were from West. HAV was not significantly associated with increased hospital mortality, multiorgan failure, need for abdominal ultrasound, hospital length of stay, and total hospitalization costs and charges when compared with those without HAV. However, it is significantly associated with increased ICU stay, coexisting hepatitis B and C infection, and liver failure.

CONCLUSION

Overall, inpatient prevalence of HAV in KTx recipients in the United States (years 2005-2014) was 23.42 cases per 100 000 admissions. Hospitalization for HAV after KTx is associated with increased ICU stay, coexisting hepatitis B and C infection, and liver failure.

Plasma Donors in the Southwestern United States Positively Contribute to the Diverse Therapeutic Antibody Profile of Immune Globulin Products

Human-plasma-derived immune globulin (IG) is used in augmentation therapy to provide protective levels of antibodies to patients with primary immune deficiency diseases (PIDD) and for prophylaxis against infectious diseases. To maintain the breadth of antibodies necessary for clinical protection, it is important to understand regional patterns of antibody seroprevalence in source plasma from which IG products are manufactured. In this study, source plasma from donation centers in various locations of the Southwestern quarter of the United States was surveyed for antibody titers to hepatitis A virus (HAV), measles virus (MeV), and cytomegalovirus (CMV). A broad range of anti-HAV Ig plasma titers was observed among these centers, with some centers exhibiting 3-5 times the titers of the others. Minor to no differences were observed for levels of anti-MeV and anti-CMV, respectively. Importantly, elevated anti-HAV Ig titers were broadly observed across plasma units obtained from the centers exhibiting high titers, indicative of a potential regional phenomenon among donors as opposed to few donors with singularly high titers. Plasma from these high-titer centers conferred significantly greater neutralization against HAV in vitro. The outcomes of this study give a glimpse of the antibody diversity inherent in human plasma used to manufacture IG products..

Seroprevalence of viral hepatitis A, B, C, D and E viruses in the Hormozgan province southern Iran

BACKGROUND

Viral hepatitis is a global public health problem affecting millions of people worldwide, causing thousands of deaths due to acute and persistent infection, cirrhosis, and liver cancer. Providing updated serologic data can improve both surveillance and disease control programs. This study is aimed to determine the seroprevalence of markers for viral hepatitis (A, B, C, D and E) and the epidemiology of such infections in the general population of southern Iran's Hormozgan province.

METHODS

Between 2016 and 2017, a total of 562 individuals with ages ranging from 1 to 86 years, who visited governmental public laboratories for routine check-ups, were tested for the presence of serological markers to hepatitis virus types A to E using enzyme-linked immunosorbent assays.

RESULTS

The overall anti-hepatitis A virus (HAV) antibody seroprevalence was 93.2% (524/562). The prevalence of anti-hepatitis E virus (HEV) antibodies was 15.8% (89/562) among which 1.6% (9/562) of the seropositive individuals also had evidence of recent exposure to the virus (IgM positivity). Two and a half percent (14/562) were positive for hepatitis B surface (HBs) antigen, whereas 11.6% (65/562) tested positive for anti-hepatitis B core (HBc) antibodies. Among anti-HBc positive patients, 11% (7/65) had HBs Ag and 5% (3/65) were positive for anti-hepatitis D virus (HDV) antibodies. The prevalence of anti-hepatitis C virus (HCV) antibodies was 0.7% (4/562). The seroprevalence of anti-HAV, HEV IgG, anti-HBc antibodies, and HBs Ag increased with age.

CONCLUSION

The present study confirms a high seroprevalence of HAV infection among the examined population and reveals high levels of endemicity for HEV in the region. Planned vaccination policies against HAV should be considered in all parts of Iran. In addition, improvements on public sanitation and hygiene management of drinking water sources for the studied area are recommended.

Changes in the epidemiology of hepatitis A in three socio-economic regions of China, 1990-2017

Background

Hepatitis A (HepA) vaccination and economic transitions can change the epidemiology of HepA. China’s Gross Domestic Product (GDP) per capita was known to be inversely associated with the incidence of HepA, but a deeper understanding of the epidemiology of HepA in different socio-economic regions is lacking. We compare the changing epidemiology of HepA in three socioeconomic-geographic regions of China.

Methods

We obtained data on all HepA cases reported through the National Notifiable Disease Reporting System and assessed trends and changes in age-specific incidence rates by age quartile and season. We categorized the country into three regions, the sequential years into five era, compared the incidence, quartile age, seasonal intensity and coverage of HepA of the three regions. Linear regression was performed to analyse trends in incidence of HepA and to analyse the association between coverage and incidence.

Results

The annual mean incidences of HepA in the eastern, central, and western regions decreased from 63.52/100 000, 50.57/100 000 and 46.39/100 000 in 1990–1992 to 1.18/100 000, 1.05/100 000 and 3.14/100 000 in 2012–2017, respectively. Decreases in incidence were seen in all age groups in the three regions; the incidence was highest (9.3/100 000) in the youngest age group (0–4 years) of the western region, while in the central region, the age group with the highest incidence changed from 0 to 9 years to adults ≥60 years old. In 2017, the median age of HepA cases was 43 years (Q₁–Q₃: 33–55), 47 years (Q₁–Q₃: 32–60) and 33 years (Q₁–Q₃: 9–52) in the eastern, central, and western provinces, respectively. Seasonal peaks became smaller or were nearly elimination nationwide, but seasonality persisted in some provinces. After the Expanded Program on Immunization (EPI) included HepA vaccine into the routine schedule in 2007, HepA coverage increased to > 80% in the three regions and was negatively association with the HepA incidence.

Conclusion

The incidence of HepA decreased markedly between 1990 and 2017. A socioeconomic inequity in coverage of HepA vaccine was almost eliminated after HepA vaccine was introduced into China’s EPI system, but inequity in incidence still existed in lower socio-economic developed region.

Electronic supplementary material

The online version of this article (10.1186/s40249-019-0591-z) contains supplementary material, which is available to authorized users.

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

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

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

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

Accuracy of rapid test for diagnosis of hepatitis A with different infection rate settings and with predictive modeling

AIM

We evaluated the accuracy of a commercial rapid immunochromatographic test (rapid test [RT]) for hepatitis A (HA) diagnosis and epidemiological studies.

MATERIALS & METHODS

The accuracy of a RT was evaluated in laboratory and in field conditions. Predictive modeling estimated the test performance in a hypothetical population.

RESULTS

The RT showed sensitivities of 66-86%, and specificities of 21-100%, depending on the antibody isotype (IgM or IgG) analyzed and prevalence of infection.

CONCLUSION

The RT is a good alternative for diagnostic in HA outbreaks. The predictive model indicates that it should not be used alone for HA diagnosis in low prevalence populations. These data can be used in the future to strengthen decision-making during the implementation of rapid diagnostic methods in health services.

Modelling the decline and future of hepatitis A transmission in Australia

Hepatitis A incidence has declined in most countries through a combination of prevention measures, augmented through the use of a highly effective vaccine. In Australia, the proportion of the population susceptible to hepatitis A infection has declined over time due to high rates of opportunistic vaccination as well as the sustained inflow of seropositive immigrants from high-endemicity countries. These factors have contributed to a rapid decline in incidence. An age-structured hepatitis A transmission model incorporating demographic changes was fitted to seroprevalence and disease notification data and used to project incidence trends and transmission potential for hepatitis A in the general population. Robustness of findings was assessed through worst-case scenarios regarding vaccine uptake, migration and the duration of immunity. The decline in age-specific seroprevalence until the introduction of hepatitis A vaccine in 1994 was well explained through a declining basic reproduction number (R₀ ) that remained >1. Accounting for existing immunity, we estimated that the effective reproduction number (R_eff ) <1 in the general population of Australia since the early 1990s, declining more rapidly after the introduction of the hepatitis A vaccine. Future projections under a variety of scenarios support R_eff remaining <1 with continued low incidence in the general population. In conclusion, our results suggest that sustained endemic transmission in the general Australian population is no longer possible although risks of sporadic outbreaks remain. This suggests potential for local elimination of hepatitis A infection in Australia, provided that elimination criteria can be defined and satisfied in risk groups. The methodology used here to investigate elimination potential can easily be replicated in settings such as in the USA where sequential seroprevalence studies are supported by routine notification data.

Hepatitis A surveillance: sensitivity of two information sources

BACKGROUND

The frequency of mild forms of hepatitis A, especially in children, could lead to underreporting. The objective of the study was to investigate the sensitivity of two surveillance systems, mandatory Statutory Disease Reports and the Microbiological Reporting System of Catalonia, using capture-recapture techniques.

METHODS

The study was conducted in Catalonia between 2011 and 2015. Hepatitis A cases reported to two independent surveillance systems were included: Statutory Disease Reports (SDR) and Microbiological Reporting System of Catalonia (MRS). The variables collected were: age, sex, year of declaration, size of municipality (< 10,000 and ≥ 10,000), country of birth (Spain or abroad), reporting centre (primary care/hospital) and notification method (electronic or paper). The capture-recapture analysis and the estimate of 95% confidence intervals were made using the Chapman formula for comparison of two sources, both for the estimate of the total number of cases and the stratification according to variables. Multinomial logistic regression was performed to obtain an adjusted estimate.

RESULTS

The SDR had a greater overall sensitivity than the MRS (48.8%; 43.5-55.6 vs. 19.3%; 17.2-21.9). In cases aged < 15 years the sensitivity of both systems was higher (76.6%; 72.7-81 vs. 25.2%; 20.9-29.5) than in cases aged > 15 years (25.5%; 22.8-28.3 vs. 12.1%; 10-14.2). For those born in Spain, the sensitivity was 57.2% (49.6-67.4) in the SDR and 27.1% (23.5-31.9) in the MRS, lower than that for foreign-born patients (58%; 51.2-66.8 vs. 49.1%; 43.4-56.6). In electronically-reported cases, the sensitivity was much higher in the SDR than in the MRS (47.2%; 42.3-52.1 vs. 9.4%; 6.5-12.3). No differences were observed according to sex, size of municipality, and year of declaration or reporting centre. The estimated total number of cases using the Chapman formula was very similar to the adjusted estimate (1121; 985-1258 vs. 1120; 876-1525), indicating the robustness of the results.

CONCLUSIONS

The sensitivity of the SDR was greater than that of MRS, especially in patients aged < 15 years, although for patients born abroad the difference in sensitivity was lower. Reinforced surveillance combining the SDR and MRS improves the efficiency in the detection of cases.

Hepatitis A virus infections, immunisations and demographic determinants in children and adolescents, Germany

Hepatitis A is a vaccine-preventable disease with a global distribution. It predominantly occurs in regions with inadequate living conditions, but also affects populations in industrialised countries. Children are frequently involved in the transmission of hepatitis A virus (HAV) and thus play a central role in the epidemiology of hepatitis A. Here, we investigated HAV infections, immunisations, and associated demographic determinants in a nationwide, population-based, cross-sectional survey conducted in Germany from 2003-2006. Out of 17,640 children and adolescents, complete data sets (HAV serology, demographic information and vaccination card) were available for 12,249 (69%), all aged 3-17 years. We found protective antibody levels (>=20 IU/L) in 1,755 (14%) individuals, 1,395 (11%) were vaccinated against hepatitis A, 360 (3%) individuals were HAV seropositive without prior hepatitis A vaccination, thus indicating a previous HAV infection. Antibody prevalence (attributable to vaccination or infection) increased significantly with age. Multivariate logistic regression revealed that predominantly children and adolescents with migration background-even if they were born in Germany-are affected by HAV infections. Our results provide a rationale to emphasise existing vaccination recommendations and, moreover, to consider additional groups with a higher risk of infection for targeted vaccination, especially children with a migration background.

Distribution of hepatitis A antibodies in US blood donors

BACKGROUND

Recently, there has been an increase in the number of hepatitis A outbreaks in the United States. Although the presence of hepatitis A virus (HAV) RNA in blood donors is known to be low, HAV antibody prevalence in this population is unknown.

STUDY DESIGN AND METHODS

Samples from 5001 US blood donors collected primarily in the midwestern United States in 2015 were tested for the presence of HAV IgG antibodies using chemiluminescent microparticle immunoassays on the ARCHITECT platform (Abbott Laboratories).

RESULTS

The overall prevalence of IgG anti-HAV was 60%. Only one specimen was IgM anti-HAV positive, for an incidence of 0.02%. IgG anti-HAV prevalence among donors aged 16 to 19 years was 67%, decreased to 54% among donors aged 40 to 49 years and increased to 70% among donors aged 80 to 93 years. No differences were seen by sex with overall IgG anti-HAV prevalence of 61% and 60% for males and females, respectively. Among the five states (Illinois, Indiana, Kansas, Kentucky, and Missouri) with the highest number of donors tested, IgG anti-HAV prevalence in Missouri (65%) was significantly higher (p <0.01) than that in Illinois (52%) or Kentucky (59%). No other significant differences between states were noted.

CONCLUSION

This study demonstrates the overall high rates of IgG anti-HAV in US blood donors, with the low associated risk of HAV transfusion transmission likely the result of low incidence and effective vaccination.

In pursuit of control and elimination: update on hepatitis A and B epidemiology and prevention strategies

PURPOSE OF REVIEW

This review describes the impact of recommendations for routine immunization of infants and children against hepatitis A and hepatitis B, the changing epidemiology of these infections, and the remaining challenges to controlling or eliminating these diseases in the United States.

RECENT FINDINGS

Rates of hepatitis A and B have significantly declined because of childhood vaccination programs and long-term protection provided by infant immunization. However, hepatitis A immunization rates remain lower than other vaccines, and outbreaks continue to occur in part due to a growing number of susceptible adults. The Advisory Committee on Immunization Practice has updated pre and postexposure prophylaxis and travel recommendations for hepatitis A prevention in young infants, as well as recommendations to reduce ongoing perinatal transmission of hepatitis B.

SUMMARY

Pediatric healthcare providers should continue to immunize all infants against hepatitis A and B and ensure that no child outgrows the pediatric practice without being vaccinated. To address hepatitis A, providers should be aware of new recommendations for unimmunized travelers, use vaccines to prevent and control outbreaks, and ensure postexposure prophylaxis. Universal vaccination of infants against hepatitis B should begin before hospital discharge. The prevention of perinatal transmission is critical for control and possible eradication of hepatitis B.

A Description of a Health System's Emergency Department Patients Who Were Part of a Large Hepatitis A Outbreak

BACKGROUND

A recent hepatitis A virus (HAV) outbreak in San Diego, California represents one of the largest HAV outbreaks in the United States. The County of San Diego Health and Human Services Agency identified homelessness and illicit or injection drug use as risk factors for contracting HAV during this outbreak.

OBJECTIVE

We describe those patients who presented to our Emergency Department (ED) and were identified as HAV positive.

METHODS

This was a retrospective descriptive study conducted at a tertiary care university health system's EDs from November 2016 to February 2018. Included were those of all ages who tested positive for HAV immunoglobulin M antibody. Outcome measures included: 1) demographic data; 2) number of patients testing positive for HAV by week and month of the outbreak; 3) homeless status, illicit and injection drug use, and alcohol use; 4) ED chief complaint; 5) initial liver function and coagulopathy test results, hepatitis B and C test results, and initial vital signs; 6) admission status; 7) death; and 8) the 7-day ED revisit rate for nonadmitted patients and the 30-day all-cause readmission rate for admitted patients.

RESULTS

We identified 57,721 patients with at least one ED visit, and 1,453 of these were tested for HAV; 133 patients (9.2%) tested positive. Average age was 45.1 years, and 91 (68.4%) were male. Eighty-six patients (64.7%) were homeless and 53 patients (39.8%) reported illicit or injection drug use; 64 patients (48.1%) had chief complaints consistent with typical HAV symptoms. Most patients (112 or 84.2%) were admitted. Nine patients (6.8%) were admitted to a critical care setting; 8 patients (6%) died.

CONCLUSIONS

During this large HAV outbreak, 9% of those screened for HAV tested positive. The majority were homeless, and 40% reported illicit or injection drug use. Most required hospitalization, and 6% of patients died.

A Q-Probes Study Involving Utilization of Free Prostate-Specific Antigen, Factor V Leiden, and Hepatitis A Serology Tests

Context.—

Managing the utilization of laboratory tests is an important quality improvement activity that adds value to health care.

Objective.—

To examine utilization of 3 laboratory tests and identify factors that impact performance.

Design.—

Test utilization performance was evaluated by determining the frequency with which appropriate preconditions for testing were met. This included 30 testing episodes each involving (1) free prostate-specific antigen (PSA) when total PSA was within an appropriate interpretable range, (2) total anti–hepatitis A virus antibody when previous anti–hepatitis A virus antibody results were either negative or not done, and (3) factor V Leiden mutation when a previous result was not already available. Participants also provided information regarding some of their utilization policies and procedures for these 3 tests.

Results.—

The overall frequency with which testing criteria were met was 20.6% (163 of 790), 91.5% (649 of 709), and 95.2% (799 of 839) for free PSA, anti–hepatitis A virus antibody, and factor V Leiden, respectively. Utilization review was infrequent and done by 20.7% (6 of 29) of participants for factor V Leiden, 3.6% (1 of 28) for anti–hepatitis A virus antibody, and 3.6% (1 of 28) for free PSA. No practice or demographic characteristics were significantly associated with utilization performance for any test.

Conclusions.—

Utilization review was infrequent for the 3 tests examined. Variable amounts of unnecessary testing were observed for all tests, most frequently for free PSA, for which reporting results carried the added risk of diagnostic error from misinterpretation of results.

Natural History, Clinical Manifestations, and Pathogenesis of Hepatitis A

Hepatitis A virus (HAV) is transmitted by the fecal-oral route and is a major cause of acute viral hepatitis. The clinical manifestations of HAV infection range from asymptomatic infection to acute liver failure (ALF), but do not include progression to chronic hepatitis. Risk factors for severe acute hepatitis A are older age (>40 years) and preexisting liver disease. Some patients may show atypical clinical features such as relapsing hepatitis, prolonged cholestasis, or extrahepatic manifestations. Almost all hepatitis A patients spontaneously recover with supportive care. However, in the case of ALF (<1%), intensive care and urgent decision on liver transplantation are required. Liver injury during hepatitis A is not directly caused by HAV but is known to be caused by immune-mediated mechanisms. In this review, the natural history and clinical manifestations of hepatitis A are described. In addition, mechanisms of immunopathogenesis in hepatitis A are discussed.

Trends and risk factors of hepatitis A in Catalonia after the introduction of a hepatitis A+B vaccination programme

At the end of 1998, universal hepatitis A+B vaccination of 12 year olds was introduced in Catalonia. The aim was to examine trends in hepatitis A during 2005-2015 and assess risk factors by age group. We carried out an observational epidemiological study of the incidence and risk factors of hepatitis A reported to the surveillance system. Information on exposure was recorded for each case for the 2-6 weeks before symptom onset. Spearman's coefficient was used to evaluate the trends of rates. The chi-square test was used to compare categorical. We studied 2621 hepatitis A cases; the age mean was 26.6 years (SD=18.2), and >50% of cases were in the 20-49 years age group. The incidence decreased from 3.28/100 000 in 2005 to 1.50/100 000 in 2015. The rate for women decreased over time (P = .008), but the reduction was not significant in men (P = .234). Men consistently had higher rates than women with the biggest difference being in the 20-34 years age group (rate 8.8 vs 2.8). The greatest risk factor was travel to an endemic country (42.1%) in the 0-19 years age group and male-to-male sexual contact (18.6%) in the 20-49 years age group. The case fatality rate in adults aged >49 years was 0.4%. In conclusion, the vaccination programme of preadolescents resulted in a reduction in hepatitis A cases. However, a significant amount of cases still appear in immigrants and men who have sex with men. Hepatitis A in adults is an emerging health problem that will require new strategies.

Hepatitis A virus immunity and vaccination among at-risk persons receiving HIV medical care

United States guidelines recommend hepatitis A virus (HAV) vaccination for persons living with HIV (PLWH) who are at increased risk for HAV infection, including men who have sex with men (MSM) and persons who inject drugs (PWID). However, nationally representative estimates of vaccine coverage and immunity for this population are lacking. We used medical record and interview data from the 2009-2012 cycles of the Medical Monitoring Project, a nationally representative surveillance system of PLWH receiving HIV medical care in the United States, to estimate the prevalence of HAV immunity, defined as receipt of at least one dose of vaccine or laboratory documentation of anti-HAV antibodies, among 8695 MSM and PWID. Among HAV-nonimmune PLWH, we then examined factors associated with HAV vaccination during the 12-month retrospective observation period using Rao-Scott chi-square tests. Among MSM and PWID receiving HIV medical care, 64% had evidence of HAV immunity. Among those who were nonimmune, 10% were vaccinated during the 12-month retrospective observation period. Factors associated with vaccination during follow-up included younger age (i.e., 18-29 years), self-reported black non-Hispanic race/ethnicity, having detectable HIV RNA, and having been diagnosed with HIV within the past 5 years. Over one third of MSM and PWID receiving HIV medical care during 2009-2012 cycles were not immune to HAV. This analysis suggests that a sizeable proportion of at risk MSM and PWID receiving HIV medical care do not receive HAV vaccination, which is currently recommended.

Hepatitis A vaccine immune response 22 years after vaccination

In the United States, the incidence of hepatitis A virus (HAV) infection has been reduced through universal childhood vaccination. However, the duration of immunogenicity for the hepatitis A vaccine is not known. We report on the 22 year follow-up time point of a cohort of Alaska children who were randomized to three different vaccine schedules: A) 0, 1, and 2 months; B) 0, 1, and 6 months; and C) 0, 1, and 12 months. Among 46 participant available for follow-up, 40 (87%) maintained protective levels of anti-hepatitis A antibody. These results indicate that a supplemental booster dose is not yet necessary at or before the 22-year time point.

Evaluation of candidate genes associated with hepatitis A and E virus infection in Chinese Han population

Background

Recent GWAS-associated studies reported that single nucleotide polymorphisms (SNPs) in ABCB1, TGFβ1, XRCC1 genes were associated with hepatitis A virus (HAV) infection, and variants of APOA4 and APOE genes were associated with and hepatitis E virus (HEV) infection in US population. However, the associations of these loci with HAV or HEV infection in Chinese Han population remain unclear.

Methods

A total of 3082 Chinese Han persons were included in this study. Anti-HAV IgG and anti-HEV IgG were detected by enzyme-linked immunosorbent assay (ELISA). Genotypes in ABCB1, TGFβ1, XRCC1, APOA4 and APOE SNPs were determined by TaqMan MGB technology.

Results

In Chinese Han population, rs1045642 C to T variation in ABCB1 was significantly associated with the decreased risk of HAV infection (P < 0.05). However, the effect direction was different with the previous US study. Rs1001581 A to G variation in XRCC1, which was not identified in US population, was significantly associated with the protection against HAV infection in our samples (P < 0.05). In addition, our results suggested that rs7412 C to T variation in APOE was significantly associated with lower risk of HEV infection in males (adjusted OR < 1.0, P < 0.05) but not in females.

Conclusions

ABCB1 and XRCC1 genes variants are significantly associated with the protection against HAV infection. Additionally, Chinese Han males with rs7412 C to T variation in APOE gene are less prone to be infected by HEV.

Electronic supplementary material

The online version of this article (10.1186/s12985-018-0962-2) contains supplementary material, which is available to authorized users.

Physician Knowledge and Attitudes About Hepatitis A and Current Practices Regarding Hepatitis A Vaccination Delivery

OBJECTIVE

To assess physicians': 1) knowledge and attitudes about hepatitis A disease and hepatitis A (HepA) vaccine, 2) child care and school HepA vaccine mandates, 3) practices related to HepA vaccine delivery, 4) factors associated with strongly recommending HepA vaccine to all 1- to 2-year-olds, and 5) feasibility of implementing HepA catch-up vaccination at health maintenance visits.

METHODS

A national survey was conducted among representative networks of pediatricians and family medicine physicians (FMs) from March to June, 2014 via e-mail or mail on the basis of provider preference.

RESULTS

Response rates were 81% (356 of 440) among pediatricians and 75% (348 of 464) among FMs. Less than 50% correctly identified that hepatitis A virus (HAV) infection is usually asymptomatic in young children and that morbidity from HAV disease increases with age. Ninety-two percent of pediatricians and 59% of FMs strongly recommend HepA vaccine for all 1- to 2-year-olds. In addition to practice specialty, belief that HepA vaccine is required for kindergarten enrollment was the most robust predictor of strong physician recommendation.

CONCLUSIONS

Gaps in knowledge regarding HAV infection and hepatitis A recommendations and lack of a strong recommendation for routine HepA vaccination of young children among FMs likely contribute to suboptimal coverage. Closing knowledge gaps and addressing barriers that prevent all physicians from strongly recommending HepA vaccine to 1- to 2-year-olds could help increase HepA vaccine coverage and ultimately improve population protection against HAV infection.

Hepatitis A virus infections and outbreaks in asylum seekers arriving to Germany, September 2015 to March 2016

From September 2015 to March 2016, hepatitis A notifications in Germany increased by 45% to 699 cases compared to 482 cases in the same period of the previous year. Children aged five to nine years were predominantly affected (22% of all cases in this period). We hypothesized that this increase could be explained by the marked influx of asylum seekers in this time period. We analysed national surveillance data and estimated the number of imported and autochthonous hepatitis A cases in asylum seekers. We also investigated molecular signatures of hepatitis A viruses sampled from asylum seekers to identify chains of transmission. We found that 40% (278 cases) of all 699 hepatitis A cases notified between September 2015 and March 2016 in Germany concerned asylum seekers. Most infections were acquired abroad, but at least 24% accounted for autochthonous infections. Among asylum seekers, children aged five to nine years were overrepresented with 97 of 278 (35%) notified cases. The analysed hepatitis A virus sequences were primarily subgenotype IB strains and clustered with previously isolated samples from the Middle East, Turkey, Pakistan and East Africa. Except one transmission from an asymptomatic child to a nursery nurse working in a mass accommodation, we are not aware of infection chains involving asylum seekers and German residents. We conclude that asylum-seeking children and adolescents are susceptible to hepatitis A virus infections, particularly children aged five to nine years. Measures to prevent secondary infections in asylum seekers such as extended hygiene measures and post-exposure prophylaxis seem advisable.

Antibodies against Hepatitis A and Hepatitis B Virus in Intravenous Immunoglobulin Products

The worldwide seroprevalence of hepatitis A virus (HAV) and hepatitis B virus (HBV) has changed over the last two decades, indicating a declining incidence of HAV and HBV infections. Therefore, vaccinations against HAV and HBV are recommended for unimmunized people before traveling to an endemic area. Unfortunately, primary antibody deficiency (PAD) patients can only obtain humoral immunity through intravenous immunoglobulin G (IVIG) replacement and not from vaccination because of a defect in antibody production. However, few studies have analyzed the titers of antibodies against HAV or HBV in IVIG products. In this study, the titers of anti-HAV and anti-HBs antibodies were measured in nineteen lots of IVIG products from five manufacturers from three countries (A, B from Korea; C, D from Japan; and E from the USA), and trough titers in plasma were estimated. Concentrations of anti-HAV antibody ranged from 1,888-8,927 mIU/mL and estimated trough titers exceeded the minimal protective value in all evaluated IVIG products. Concentrations of anti-HBs antibody ranged from 438-965 mIU/mL in products A and B and were 157, 123, and 1,945 mIU/mL in products C, D, and E, respectively. Estimated trough titers in products A, B, and E exceeded the minimal protective value but those in products C and D did not reach this threshold. These data demonstrated that available IVIG products generally provide sufficient antibodies against HAV and HBV to protect patients with PAD, although the trough concentrations of anti-HBs antibody in two IVIG products did not reach the minimum protective value.

Impact of the national targeted Hepatitis A immunisation program in Australia: 2000-2014

In November 2005, hepatitis A vaccine was funded under the Australian National Immunisation Program for Aboriginal and Torres Strait Islander (Indigenous) children aged 12-24months in the targeted jurisdictions of Queensland, South Australia, Western Australia and the Northern Territory. We reviewed the epidemiology of hepatitis A from 2000 to 2014 using data from the Australian National Notifiable Diseases Surveillance System, the National Hospital Morbidity Database, and Australian Bureau of Statistics causes-of-death data. The impact of the national hepatitis A immunisation program was assessed by comparison of pre-vaccine (2000-2005) and post-vaccine time periods (2006-2014), by age group, Indigenous status and jurisdiction using incidence rate ratios (IRR) per 100,000 population and 95% confidence intervals (CI). The national pre-vaccine notification rate in Indigenous people was four times higher than the non-Indigenous rate, and declined from 8.41 per 100,000 (95% CI 5.03-11.79) pre-vaccine to 0.85 per 100,000 (95% CI 0.00-1.99) post-vaccine, becoming similar to the non-Indigenous rate. Notification and hospitalisation rates in Indigenous children aged <5years from targeted jurisdictions declined in the post-vaccine period when compared to the pre-vaccine period (notifications: IRR=0.07; 95% CI 0.04-0.13; hospitalisations: IRR=0.04; 95% CI 0.01-0.16). As did notification rates in Indigenous people aged 5-19 (IRR=0.08; 95% CI 0.05-0.13) and 20-49years (IRR=0.06; 95% CI 0.02-0.15) in targeted jurisdictions. For non-Indigenous people from targeted jurisdictions, notification rates decreased significantly in children aged <5years (IRR 0.47; 95% CI 0.31-0.71), and significantly more overall (IRR=0.43; 95% CI 0.39-0.47) compared to non-Indigenous people from non-targeted jurisdictions (IRR=0.60; 95% CI 0.56-0.64). The national hepatitis A immunisation program has had a significant impact in the targeted population with relatively modest vaccine coverage, with evidence suggestive of substantial herd protection effects.

HAV & HBV vaccination among travellers participating in the National Health and Wellness Survey in five European countries

BACKGROUND

A main cause of hepatitis A and B infections in European countries is travel to endemic countries. Most research on hepatitis vaccination among travellers from Europe has been conducted in airports or travel clinics, samples which potentially overrepresented frequent travellers.

METHODS

2102 respondents across France, Germany, Italy, Spain, and UK completed an internet-based questionnaire. Vaccination status, travel to endemic countries, and other characteristics were compared across frequent, occasional, and non-travellers. Logistic regressions tested association between vaccination and travel adjusting for potential confounders.

RESULTS

Most respondents were occasional travellers (61%) and 24% were frequent travellers. Frequent travellers had 2.3-2.4 times the odds of being vaccinated relative to non-travellers, and odds of vaccination were 2.5-3.1 times higher among travellers to endemic areas relative to others (all p < .05). Frequent travellers were more aware of their vaccination status (HAV: 80% vs. 72%; HBV: 82% vs. 74%), though many who were vaccinated could not identify the number of injections to complete the series (47% vs. 29%) (all p < .05).

CONCLUSION

Travel frequency and destination endemicity are associated with increased hepatitis A and B vaccination. The number of unvaccinated travellers and the lack of recall for the dosing schedule suggest the need to improve travellers' awareness and adherence to recommendations.

Background and Rationale

In 2011, CDC published the first CDC Health Disparities and Inequalities Report (CHDIR). This report examined health disparities in the United States associated with various characteristics, including race/ethnicity, sex, income, education, disability status, and geography. Health disparities were defined as "differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic attributes". Among other recommendations, the 2011 CHDIR emphasized the need to address health disparities with a dual intervention strategy focused on populations at greatest need and on improving the health of the U.S. population by making interventions available to everyone. The 2013 CHDIR updated the 2011 CHDIR and included additional reports on social and environmental determinants of health; the supplement emphasized the importance of multisectoral collaboration, highlighting the need for a comprehensive, community-driven approach to reducing health disparities in the United States. A follow-up report described five interventions that were shown to be effective or demonstrated promise for reducing health disparities. These publications have focused attention on the need to address health disparities in the United States, as well as on programs and interventions that address them. This supplement describes additional interventions that address particular disparities observed by race and ethnicity, socioeconomic status, geographic location, disability, and/or sexual orientation across a range of conditions, including asthma, infection with HIV and hepatitis A, use of colorectal cancer screening, youth violence, food security, and health-related quality of life.

Epilogue

In 1985, the Report of the Secretary's Task Force on Black and Minority Health was published after the federal government convened the first group of health experts to analyze racial/ethnic health disparities among minorities. This analysis, also known as the Heckler report, revealed higher illness and death rates among minorities. The year 2015 marks the 30th anniversary of the Heckler Report and presents an opportunity to evaluate and continue to improve minority health at the national, state, tribal, territorial, and local levels.