Effectiveness of Hepatitis B Vaccination Campaign in Italy: Towards the Control of HBV Infection for the First Time in a European Country

Knowledge, Attitudes, and Practices of European Healthcare Professionals towards Hepatitis A and Hepatitis B Vaccination in at-Risk Adults

Despite the occurrence of several hepatitis A (hepA) and hepatitis B (hepB) outbreaks in Europe in the last few decades, not all European countries have implemented hepA and hepB vaccinations in their national immunization programs, especially for adults at risk for hepA and/or hepB infection, such as men who have sex with men or patients with chronic liver disease. Currently, little is known on the attitudes of European healthcare professionals (HCPs) towards hepA and hepB vaccinations for at-risk adults. We conducted an online survey among HCPs in Germany, Spain, and the United Kingdom to assess their awareness of and adherence to their national hepA and hepB vaccination guidelines for at-risk adults. Among the 698 HCPs who took the survey, most (91.1%) were familiar with their national vaccination recommendations and always followed them or followed them most of the time when advising or prescribing hepA or hepB vaccines. Major and moderate barriers for recommending or administering such vaccines were the non-disclosure of risk factors by the patient (53.0-57.6%) and the patient's lack of motivation or knowledge about the risk of the disease (50.3-52.9%). These results may help inform strategies to improve and accelerate hepA and hepB vaccination in European at-risk adults.

Vaccination Campaign against Hepatitis B Virus in Italy: A History of Successful Achievements

In Italy, the vaccination campaign against hepatitis B virus has been characterized by two phases. In the first phase (1984-1991), vaccination with plasma-derived vaccines was first recommended for the high-risk group. In the second phase (1991-nowadays), recombinant vaccine targeted, by law, infants 2 months old and teenagers 12 years old (limited to the first 12 years of campaign); screening for HBsAg became compulsory for all pregnant women during the third trimester of pregnancy. Successful achievements have been attained: No acute HBV case has been observed in the age group targeted by vaccination, the pool of chronic HBsAg carriers is strongly reduced, perinatal HBV transmission is under control, and acute delta virus hepatitis cases are nearly eliminated. The key point of this success has been the peculiar vaccination policy adopted. The combined vaccination of teenagers has generated an early immune cohort of youths, who are no longer at risk of acquiring HBV infection by sources of exposure (i.e., drug use and unsafe sex practices) typical of the young adults. Vaccination of household contacts with HBsAg-positive subjects represents an area of improvement; providing migrants and refugees access to healthcare services is also a focal point. In 2020, Italy became the first country in Europe to achieve the WHO's regional hepatitis targets.

Trends of infections and mortality due to hepatitis B virus (2005-2022) and the potential impact of the COVID-19 pandemic: a population-based study in Poland

Aim of the study

To analyze the hepatitis B virus (HBV) infection and mortality in Poland according to sociodemographic characteristics, trends over time, and the impact of the COVID-19 pandemic on hepatitis B epidemiology.

Material and methods

We examined HBV infection cases and deaths reported by national registries and used Joinpoint analysis to estimate time trends in the years 2005-2021. To assess the impact of the COVID-19 pandemic on HBV infection, we used monthly information and compared 2020-2022 with 2019.

Results

The Joinpoint analysis showed that in Poland between 2005 and 2021, there were pronounced decreasing trends of acute HBV infection, and during the pandemic period, acute HBV infection dramatically decreased (annual percent change, APC2019-2021 for men -57.65%, and women -42.10%, both ptrend < 0.05). There was a fluctuation in trends for chronic HBV infection, shifting from positive to negative in both genders in 2016, and over the pandemic, there were decreasing trends (APC2019-2021 for men -26.94% and women -28.96%, both ptrend < 0.05). From March to July 2022, the value of the diagnosis rate of HBV infection was lower compared to the respective months in 2019, but from September to December 2022, the rate changes were positive. Mortality due to HBV infection decreased in both genders, mainly within the 2005-2019 period.

Conclusions

During the COVID-19 pandemic, a sharp decrease in HBV diagnosis rates in Poland, especially in acute cases, was observed. However, trends of hepatitis B infection require further monitoring. It is necessary to introduce a national screening program that also encompasses the population of migrants and improve the linkage to care.

Five Decades of HBV Infection in Italy: A Continuous Challenge

In Italy, Hepatitis B virus (HBV) infection has been characterized by several changes over the last five decades. In 2019, the incidence of acute HBV among subjects targeted by the vaccination campaign was 0 cases in the age group 0-14 years and 0.1/100,000 in the age group 15-24. Nowadays, the burden of different stages of HBV-related chronic liver diseases is minimal. Intravenous drug use is no longer a risk factor (O.R. 0.7; 95% C.I. 0.5-1.02) for acquiring acute HBV; the proportion of cases reporting this exposure fell from 29.8% to 3.3% over the last two decades. The key public health intervention has been the compulsory vaccination campaign started in 1991 for infants 3 months old and 1-2 years old (the latter group for the first 12 years of the campaign). Moreover, non-immunogenic factors and the availability of effective oral antiviral drugs have played and continue to play a prominent role. The potential availability of new oral antiviral drugs with the inherent ability to eliminate the genomic HBV reservoirs may represent a further crucial step in the elimination of the virus in people that are already infected.

A Historical Overview on the Role of Hepatitis B and C Viruses as Aetiological Factors for Hepatocellular Carcinoma

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are the leading cause of hepatocellular carcinoma (HCC) worldwide. Currently, HBV-related HCC predominates in Sub-Saharan Africa and South-East-Asia, while HCV-related HCC predominates in northern Africa and in the western world. Liver cirrhosis is the underlying condition in most HBV cases and in nearly all HCV cases. Several cofactors, viral and non-viral, play a role in the progression toward HCC: dual HBV/HCV infection, HDV, HIV, alcohol intake, smoking, diabetes mellitus, obesity, and NAFLD/NASH. HBV vaccine is effective in preventing both infection and HCC; antiviral drugs may suppress HBV replication and eradicate HCV infection, halting progression to HCC. Inequalities exist between high- and low-income countries with respect to vaccine availability and access to antivirals. These factors represent barriers to the control of HCC incidence. Lack of an effective vaccine against HCV is also a serious barrier to HCV elimination and HCC prevention. The most crucial steps and knowledge that have arisen over time on the association between the two major hepatotropic viruses and HCC are discussed in this historical review.

Cancers attributable to infectious agents in Italy

OBJECTIVES

To provide an evidence-based, comprehensive assessment of the current burden of infection-related cancers in Italy.

METHODS

We calculated the proportion of cancers attributable to infectious agents (Helicobacter pylori [Hp]; hepatitis B virus [HBV] and hepatitis C virus [HCV]; human papillomavirus [HPV]; human herpesvirus-8 [HHV8]; Epstein-Barr virus [EBV]; and human immunodeficiency virus [HIV]) to estimate the burden of infection-related cancer incidence (2020) and mortality (2017). Data on the prevalence of infections were derived from cross-sectional surveys of the Italian population, and relative risks from meta-analyses and large-scale studies. Attributable fractions were calculated based on the counterfactual scenario of a lack of infection.

RESULTS

We estimated that 7.6% of total cancer deaths in 2017 were attributable to infections, with a higher proportion in men (8.1%) than in women (6.9%). The corresponding figures for incident cases were 6.5%, 6.9% and 6.1%. Hp was the first cause of infection-related cancer deaths (3.3% of the total), followed by HCV (1.8%), HIV (1.1%), HBV (0.9%), HPV, EBV and HHV8 (each ≤0.7%). Regarding incidence, 2.4% of the new cancer cases were due to Hp, 1.3% due to HCV, 1.2% due to HIV, 1.0% due to HPV, 0.6% due to HBV and <0.5% due to EBV and HHV8.

CONCLUSIONS

Our estimate of 7.6% of cancer deaths and 6.9% of incident cases that were attributable to infections in Italy is higher than those estimated in other developed countries. Hp is the major cause of infection-related cancer in Italy. Prevention, screening and treatment policies are needed to control these cancers, which are largely avoidable.

Incidence trends of acute viral hepatitis caused by four viral etiologies between 1990 and 2019 at the global, regional and national levels

BACKGROUND

Hepatitis is a major public health challenge and a leading cause of death worldwide. We aimed to study the cause-specific incidence and temporal trends of acute viral hepatitis (AVH).

METHODS

Data on AVH etiologies were available from the Global Burden of Disease study 2019. Estimated annual percentage change (EAPC) was used to quantify temporal trend in AVH age-standardized incidence rates (ASIRs) by region, sex and aetiology.

RESULTS

From 1990 to 2019, the global incidence of AVH increased by 8.02%, from 244 350 063 in 1990 to 263 951 645 in 2019, with an average decreasing ASIR of 0.52% (95% CI -0.58% to -0.45%) annually. The ASIR of AVH due to hepatitis B virus (HBV) decreased, while those of hepatitis A (HAV), hepatitis C (HCV) and hepatitis E (HEV) remained stable, with EAPCs (95% CI) of -1.47 (-1.58 to -1.36), 0 (-0.09 to 0.09), -0.35 (-0.83 to -0.13), and -0.16 (-0.41 to 0.09) respectively. Although the number of new AVH cases increased in the low sociodemographic index (SDI), low-middle SDI regions, the ASIRs decreased in all five SDI regions. Globally, HAV and HBV are the leading causes of acute hepatitis. The EAPC is significantly associated with a baseline ASIR of less than 5500 per 100 000 population (ρ = -0.44), and with the 2019 human development index (HDI) (ρ = 0.16) for AVH.

CONCLUSIONS

Although the ASIR of AVH showed a generally decreasing trend, the burden of AVH remains a major public health challenge globally. The findings may be helpful for policymakers in establishing appropriate policies to reduce the viral hepatitis burden.

Highly dynamic changes of regional HBV epidemiology over two decades

BACKGROUND & AIM

HBV epidemiology is highly heterogeneous and rapidly evolving worldwide: we studied its last two-decades dynamics in a large single center cohort.

METHODS

In all consecutive HBsAg-positive subjects firstly admitted (2000-2019) at the Pisa-University-Hospital Hepatology-Referral-Center, demographic, virologic and clinical variables were analyzed by admission decade (2000-2009 vs 2010-2019) and origin (Italian vs non-Italian natives).

RESULTS

Of 2003, 1878 (93.7%) subjects were eligible: 1798(95.7%) with HBV-chronic [126(7%) HDV, 72(4%) HCV, 11(0.6%) HIV co-infected] and 80(4.3%) HBV-primary infections (93.7% Italians). Among 1589(88.4%) mono-infected, 496(31.2%) were immigrants, younger than Italians [34.0(5.1-77.1)-52.5(10.0-87.2) years], with female prevalence [204/496(41.1%)-340/1093(31.1%); p<0.001] increasing overtime (14.6-45.0%; p<0.001). Italians aged across decades [50.3(11.1-87.2)-56.2(10.0-86.7) years; p<0.001], HBeAg-positivity remained stable (12.3-14.5%) and acute hepatitis increased (4.0-8.0%; p = 0.003). CHB declined [439/721(60.9%)-320/868(36.9%); p<0.001] whereas HBeAg-negative infection increased [277/626(44.2%)-538/755(71.3%); p<0.001]. Cirrhosis declined [195/721(27.0%)-125/868(14.4%); p<0.001], except in anti-HDV-patients [93/126(73.8%); 42(45.1%) non-Italians], younger than HBV-mono-infected (47.4-57.6 years; p<0.001).

CONCLUSION

Effective preventive health care policies and immigration flows account for increasing prevalence of HBeAg-negative infection across the last two decades. Antiviral therapy mitigated disease progression in aging Italian CHB but not in CHD patients, mainly young immigrants, emphasizing the unmet need of effective CHD therapies; HBeAg-positive CHB and acute hepatitis B persist in non-vaccinated Italian adults, prompting vaccination in the elderly with risky behaviors.

Epidemiological and clinical aspects of hepatitis B virus infection in Italy over the last 50 years

A relevant gradual reduction of both the incidence rate of acute hepatitis B (AHB) and prevalence of chronic hepatitis B has occurred in Italy in the last 50 years, due to substantial epidemiological changes: Improvement in socioeconomic and hygienic conditions, reduction of the family unit, accurate screening of blood donations, abolition of re-usable glass syringes, hepatitis B virus (HBV)-universal vaccination started in 1991, use of effective well tolerated nucleo(t)side analogues able to suppress HBV replication available from 1998, and educational mediatic campaigns against human immunodeficiency virus infection focusing on the prevention of sexual and parenteral transmission of infections. As an example, AHB incidence has gradually decreased from 10/100000 inhabitants in 1985 to 0.21 in 2020. Unfortunately, the coronavirus disease 2019 (COVID-19) pandemic has interrupted the trend towards HBV eradication. In fact, several HBV chronic carriers living in the countryside have become unable to access healthcare facilities for screening, diagnosis, clinical management, and nucleo(t)side analogue therapy in the COVID-19 pandemic, mainly for anxiety of becoming infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), movement restrictions, and reduced gains from job loss. In addition, one-third of healthcare facilities and personnel for HBV patients have been devolved to the COVID-19 assistance.

Hepatitis B Vaccination: A Historical Overview with a Focus on the Italian Achievements

Vaccination is the most effective way to control and prevent acute and chronic hepatitis B, including cirrhosis and HCC, on a global scale. According to WHO recommendations, 190 countries in the world have introduced hepatitis B vaccination into their national childhood immunization programs with an excellent profile of safety, immunogenicity, and effectiveness. Following vaccination, seroprotection rates are close to 100% in healthy children and over 95% in healthy adults. Persistence of anti-HBs is related to the antibody peak achieved after vaccination. The peak is higher the longer the antibody duration is. Loss of anti-HBs does not necessarily mean loss of immunity since most vaccinated individuals retain immune memory for HBsAg and rapidly develop strong anamnestic responses when boosted. Evidence indicates that the duration of protection can persist for at least 35 years after priming. Hence, booster doses of vaccines are currently not recommended to sustain long-term immunity in healthy vaccinated individuals. In Italy, vaccination against hepatitis B is met with success. In 2020, Italy became one of the first countries in Europe to be validated for achieving the WHO regional hepatitis B control targets.