From Mystery to Clarity: Uncovering the Possible Cause of Hepatitis Outbreak in Children

Hepatitis A is a viral infection that can cause liver inflammation and damage. Hepatitis A outbreaks in children are of particular concern due to the potential long-term health effects they can have. In recent years, several outbreaks of hepatitis A have been reported worldwide, affecting mainly children and young adults. Since 2016, hepatitis A outbreaks have been reported in 37 states of the United States alone, involving approximately 44,650 cases, 27,250 hospitalizations, and 415 deaths as of September 23, 2022. The epidemiology of hepatitis A outbreaks in children is complex and multifactorial, with various risk factors such as poor sanitation and hygiene practices, crowded living conditions, low socioeconomic status, lack of vaccination, and travel to endemic areas. Investigations of outbreaks involve identifying suspected cases, laboratory testing, contact tracing, and investigation of possible sources of infection. Contaminated food and water, poor sanitation and hygiene procedures, intimate contact with infected people, and environmental variables are all potential causes of outbreaks in children. Preventive measures include vaccination, improving sanitation and hygiene practices, food safety and inspection, and health education and community outreach programs. Understanding the epidemiology of hepatitis A outbreaks in children and the risk factors associated with infection is essential for developing effective preventive strategies and reducing the global burden of this disease.

Clinico-Serological Profile of Infective Causes of Acute Hepatitis in Children Admitted to a Tertiary Care Centre

BACKGROUND

Hepatitis is a major cause of healthcare burden in India. Hepatitis A is the most common cause of acute viral hepatitis in the pediatric population whereas hepatitis E virus (HEV) is the most important cause of epidemic hepatitis. Various other causes of acute infective hepatitis in children are dengue, malaria, and enteric fever. The aim of the present study is to understand the clinico-serological profile in cases of acute infective hepatitis in children.  Methodology: The present study is a cross-sectional study that was carried out from 1 September 2017 to 31 March 2019. A total of 89 children in the age group 1-18 years with clinically suspected acute infective hepatitis and subsequent confirmation on laboratory tests were included in the study.

RESULTS

Hepatitis A (48.3%) was found to be the most common aetiology followed by dengue (22.5%) and hepatitis E (12.4%). No cases of hepatitis B or hepatitis C were found. The most common presenting complaint was fever (90%) and the most common clinical finding was icterus (69.7%). The sensitivity of icterus for the diagnosis of hepatitis was found to be 70%. Lab investigations showed a significant association between different etiologies of infective hepatitis with packed cell volume (PCV), white blood cell (WBC) count, and platelet count. Levels of aspartate aminotransferase (AST) and alanine transaminase (ALT) were raised in samples of patients with hepatitis A, hepatitis E, and combined hepatitis A and E infection as compared to other causes. All cases of hepatitis A and E were diagnosed with positive IgM antibody tests to the respective viral antigens. The most common complication was hepatic encephalopathy which was seen in patients with hepatitis A, dengue, and septicemia. Around 99% of patients recovered well and were discharged. One death occurred in a case of septicemia with septic shock with multiple organ dysfunction syndrome (MODS).

CONCLUSION

The most common cause of infective hepatitis in children is hepatitis A. Other causes like dengue, malaria, and typhoid should also be kept in mind. The absence of icterus does not rule out hepatitis. Lab investigations including serology are important to confirm the diagnosis of various causes of hepatitis. Timely immunization against hepatitis is strongly recommended.

Fulminant Hepatitis A and E Co-infection Leading to Acute Liver Failure: A Case Report

Acute liver failure (ALF) is a severe clinical condition with a high mortality rate. Although several factors can cause ALF, viral hepatitis remains one of the leading causes. Hepatitis A virus (HAV) and hepatitis E virus (HEV), which typically cause self-limiting acute disease, are rare but emerging causes of ALF, especially when both viruses infect the same individual. Both of these hepatotropic viruses share an enteric route and are most commonly transmitted through the fecal-oral route. The impact of HAV/HEV co-infection on acute hepatitis prognosis is not entirely understood, but dual infection can further exacerbate liver damage, leading to fulminant hepatic failure (FHF) with a higher mortality rate than a single virus infection. Here, we present a case of a 32-year-old male with no prior liver disease who presented to the emergency department with a two-week history of jaundice, abdominal pain, and hepatomegaly. Upon admission, he was disoriented with grade 2 encephalopathy. After a thorough investigation, co-infection with hepatitis A and E was identified as the primary cause of his ALF. The patient underwent intensive medical treatment and interventions, including dialysis. Unfortunately, the patient's survival was not possible due to the absence of availability of a transplanted organ, which is currently the only definitive treatment option. This case report underscores the significance of prompt diagnosis, timely intervention, and the accessibility of transplantation in the survival of liver failure, as it remains the sole definitive treatment for acute liver failure. Moreover, it provides a concise overview of the current literature on fulminant co-infection of HAV and HEV, including epidemiology, clinical characteristics, pathogenesis, diagnosis, treatment, and risk factors associated with co-infection of hepatitis A and E and their role in causing ALF. It also highlights the significance of identifying high-risk populations and implementing appropriate prevention and control measures such as vaccination, practising good hygiene and sanitation, and avoiding the consumption of contaminated food and water.

Factors associated with incomplete vaccination and negative antibody test results for measles, mumps, and hepatitis A among children followed in the MINA-BRAZIL cohort

Vaccination coverage has been dropping in Brazil and other countries. In addition, immune responses after vaccination may not be homogeneous, varying according to sociodemographic and clinical factors. Understanding the determinants of incomplete vaccination and negative antibody test results may contribute to the development of strategies to improve vaccination effectiveness. In this study, we aimed to investigate the frequency of vaccine adherence, factors associated with incomplete vaccination for measles, mumps, rubella (MMR) and hepatitis A, and factors associated with the seronegative test results for measles, mumps and hepatitis A at 2 years of age. This was a population-based cohort that addressed health conditions and mother/infant nutrition in Cruzeiro do Sul city, Brazil. Vaccination data were obtained from official certificates of immunization. The children underwent blood collection at the two-year-old follow-up visit; the samples were analyzed using commercially available kits to measure seropositivity for measles, mumps, and hepatitis A. We used modified Poisson regression models adjusted for covariates to identify factors associated with incomplete vaccination and negative serology after vaccination. Out of the 825 children included in the study, adherence to the vaccine was 90.6% for MMR, 76.7% for the MMRV (MMR + varicella), and 74.9% for the hepatitis A vaccine. For MMR, after the adjustment for covariates, factors associated with incomplete vaccination included: white-skinned mother; paid maternity leave; raising more than one child; lower number of antenatal consultations; and attending childcare. For hepatitis A, the factors included: white-skinned mother and not having a cohabiting partner. The factors with statistically significant association with a negative antibody test result included: receiving Bolsa Familia allowance for measles and mumps; incomplete vaccination for measles; and vitamin A deficiency for mumps. Strategies to improve the efficiency of vaccine programs are urgently needed. These include improvements in communication about vaccine safety and efficacy, and amplification of access to primary care facilities, prioritizing children exposed to the sociodemographic factors identified in this study. Additionally, sociodemographic factors and vitamin A deficiency may impact the immune responses to vaccines, leading to an increased risk of potentially severe and preventable diseases.

Spectrum of viral hepatitis in hospitalized children in western India

Viral hepatitis is a major public health problem affecting children globally. Clinical presentation varies from asymptomatic illness to hepatitis, and liver failure. Data on clinical features and laboratory parameters were collected and analysed on 300 children, aged 1-12 years, admitted with confirmed viral hepatitis. A small majority (52%) were boys. The mean age of presentation was 6.9  ±  2.8 years with the commonest symptoms being anorexia or vomiting (in 98%), fever (in 89%) and jaundice (in 71.3%). Tender hepatomegaly was seen in 31.7%. Almost all (97.6%) had hepatitis A, though mixed infection (A & E) was seen in 1.7%. Only 8% had serum bilirubin levels >200 µmol/L. Significantly elevated (>20 μkat/L) levels of aspartate transaminase and alanine transaminase were seen in 19% and 25.3% of cases respectively. Coagulopathy (PT >15 s) was present in 11.0% cases. HAV remains the most common cause of viral hepatitis in children in our environment. Public awareness and universal vaccination should be the focus to prevent morbidity and mortality due to these pathogens.

Clinical outcomes and healthcare utilization of acute hepatitis A virus infection with acute kidney injury in hospitalized patients

BACKGROUND

Patients with acute hepatitis A virus (HAV) infection are at risk of developing acute kidney injury (AKI) which may result in increased healthcare resource utilization and worse clinical outcomes. We investigated the impact of AKI on healthcare utilization and clinical outcomes in patients hospitalized with acute HAV infection utilizing a large database.

METHODS

We queried the National Inpatient Sample (NIS) 2007-2014 to identify acute HAV infection-related hospitalizations with and without AKI. Primary outcomes were prevalence of AKI and its predictors with secondary outcomes included the mean length of stay (LOS), hospitalization cost and mortality in both groups.

RESULTS

Out of 68 364 acute HAV infection-related hospitalizations, 47 620 met our study criteria and 7458 (15.7%) had concurrent AKI. HAV patients with AKI were older (62.5 vs. 53.7 years; P value <0.001). A higher mean LOS (10.03 vs. 5.6 days; P value <0.001) and mean total hospitalization cost ($27 171.35 vs. $12 790.26; P value <0.001) were observed in HAV patients with the AKI group. A total of 1032 patients (13.8%) in the AKI group died during the same hospitalization as compared to 681 patients (1.5%) in the non-AKI group, P value <0.001. AKI in HAV was also found to be an independent predictor of mortality [adjusted odds ratio (aOR), 3.28; 95% confidence interval, 2.23-4.84; P value <0.001) after adjusting for the confounding factors.

CONCLUSION

We found that 15.67% of patients hospitalized with acute HAV had AKI which contributed to increased healthcare utilization and higher mortality which is preventable.

Outbreak of hepatitis A virus infection in Taiwan, June 2015 to September 2017

The Taiwan Centers for Disease Control (CDC) were notified of increasing acute hepatitis A (AHA) in June 2015. Serum and/or stool from AHA patients and sewage samples were tested for hepatitis A virus (HAV). We defined outbreak cases as AHA patients with illness onset after June 2015 and with an HAV sequence less than 0.5% different from that of the TA-15 outbreak strain. We analysed characteristics and food exposures between outbreak and non-outbreak cases between January 2014 (start of enhanced surveillance) and February 2016. From June 2015 to September 2017, there were 1,563 AHA patients with a median age of 31 years (interquartile range (IQR): 26–38); the male-to-female ratio was 8.8 and 585 (37%) had human immunodeficiency virus (HIV) infection. TA-15 was detected in 82% (852/1,033) of AHA patients, and 14% (74/540) of sewage samples tested since July 2015. Infection with the TA-15 strain was associated with having HIV, sexually transmitted infections (STI), recent oral-anal sex and men who have sex with men (MSM). The Taiwan CDC implemented an HAV vaccine campaign starting from October 2016 where 62% (15,487/24,879) of people at risk were vaccinated against HAV. We recommend HAV vaccination for at-risk populations and continuous surveillance to monitor control measures.

Infectious Diseases: The Role of the Healthcare Professional

For the healthcare professional dealing with infections presents two main problems. First, managing detainees or police personnel who have contracted a disease and may be infectious or unwell, and second, handling complainants of assault, including police officers, who have potentially been exposed to an infectious disease. This chapter addresses some general principles of infection control and safety in the working environment and then goes on to discuss some infections that may be encountered in police custody and how they can best be managed.

The situation of vaccines for the prevention of infections in adults: An opinion paper on the situation in Spain

The childhood immunization schedule is well known and generally well implemented in developed countries. For various reasons, the same is not true of vaccines aimed at preventing infections in adults, in which vaccination coverage is incomplete and generally very deficient. In order to assess the situation of adult vaccination in Spain, the Fundación de Ciencias de la Salud has brought together a series of experts in different fields, including doctors, nurses, representatives of patient associations, health managers and economists, health authorities and journalists to deal with this issue. The format was that of a round table in which a series of questions previously formulated by the coordinators were to be answered and debated. The document presented is not an exhaustive review of the topic, nor is it intended to make recommendations, but only to give a multidisciplinary opinion on topics that could be particularly debatable or controversial. The paper reviews the main vaccine-preventable adult diseases, their clinical and economic impact, the possibilities of reducing them with vaccination programmes and the difficulties in carrying them out. The role of nursing, pharmacy services, patient associations and the health administration itself in changing the current situation was discussed. Prospects for new vaccines were discussed and we speculated on the future in this field. Finally, particularly relevant ethical aspects in decision-making regarding vaccination were discussed, which must be faced by both individuals and states. We have tried to summarize, at the end of the presentation of each question, the environment of opinion that was agreed with all the members of the table.

Forgotten but Not Gone: Learning From the Hepatitis A Outbreak and Public Health Response in San Diego

The recent hepatitis A virus (HAV) outbreak in San Diego was driven by homelessness, associated sanitation conditions, and illicit drug use. As with an outbreak in Michigan, fueled by similar factors, morbidity and mortality were higher than what has been observed with post-vaccine era foodborne HAV outbreaks. Control of the outbreak in San Diego was accomplished with vaccine, sanitation, and education initiatives that targeted those at highest risk. Mass vaccination events and mobile foot teams and vans brought education and vaccine to high-risk individuals in affected areas. The homelessness crisis in San Diego and in many locales throughout the United States poses risk of increasing numbers of outbreaks of HAV and other infectious illnesses. This article summarizes an IAS-USA continuing education webinar given by Darcy A. Wooten, MD, on July 19, 2018.

Viruses Associated With Foodborne Infections

Foodborne pathogens cause acute and chronic health outcomes of very different durations, severity and mortality, resulting in high costs and burdens to society. The issues of food safety and food poisoning are being increasingly emphasised, particularly in developed countries. Infection/contamination with many agents i.e., bacterial, parasitic and viral entities can result in foodborne illness. This article will focus mainly on viral agents of infection.

A range of different viruses can cause food poisoning/foodborne infection, and infection can result in a myriad of symptoms, ranging from mild, acute disease to chronic, debilitating disease and even death. Due to the inherent differences between bacteria and viruses, namely the fact that viruses do not replicate in food, while bacteria do, viruses are frequently difficult to detect. This is compounded by the fact that many of the viruses associated with enteric disease do not replicate in cell culture. These factors can lead to a lag between reporting, detection and analysis of foodborne viruses versus bacterial agents. Despite these constraints, it is now evident that there are both well-established and emerging viruses implicated in foodborne infections, and the role of molecular detection and characterisation is becoming increasingly important.

Immunization Against Hepatitis A Virus and Hepatitis B Virus in Patients with Chronic Liver Disease: Are We Doing a Good Job?

Introduction: In the era of highly effective vaccines for Hepatitis A Virus (HAV) and Hepatitis B Virus (HBV), acute viral hepatitis in patients with a chronic liver disease remains a public health concern. Vaccination for HAV and HBV is endorsed by all liver society guidelines. The aim of our study was to determine the rates of immunization in an internal medicine resident clinic.

Methods: We identified patients with a chronic liver disease seen at the University of Oklahoma Internal Medicine resident clinic between June 2014 and May 2015. ICD-9 code 571 was used to identify patients with a chronic liver disease. Vaccination records and patient data were reviewed.

Results: A total of 141 patients with a chronic liver disease (mean age 54.1 years, 56% males) were identified. Almost half of the patients (47.5%) were also being seen in the gastroenterology clinic. During the internal medicine resident clinic visit, vaccination against HAV and HBV was addressed for 50% and 46% of the patients, respectively. Patients being seen by senior residents were more likely to be immunized against HAV (OR 2.7, p=0.009) and HBV (OR 2.1, p=0.03). Patients followed in the GI clinic were more likely to be immunized against HAV (OR 2.1, p= 0.02) and HBV (OR 2.0, p=0.02). The gender of the treating physician and etiology had no impact on vaccination rates.

Discussion: Immunization rates for HAV and HBV remain subpar despite clear guidelines for patients with a chronic liver disease. This provides an important avenue for improvement. Different strategies, including resident education, developing vaccination protocols, and referral to the gastroenterology clinic, are likely to improve vaccination status for patients with chronic liver diseases.

Changes in acute viral hepatitis epidemiology in the Turkish adult population: A multicenter study

BACKGROUND/AIMS

The present study aimed to determine the changes in the epidemiology of hepatitis in recent years in an adult Turkish population.

MATERIALS AND METHODS

Overall, 852 patients with acute viral hepatitis from 17 centers were included in this study. Their sociodemographic characteristics, clinical courses, treatments, and laboratory findings were retrospectively analyzed.

RESULTS

The most commonly found microorganisms were the hepatitis B virus (55.2%) and hepatitis A virus (37.6%), and the types of acute viral hepatitis differed significantly according to the age group (p≤0.001). The most frequently reported symptom was fatigue (73.7%), and the most common complications were cholecystitis (0.4%) and fulminant hepatitis (0.4%). The median hospital stay was 9 days (range 1-373). In total, 40.8% patients with acute hepatitis B virus developed immunity.

CONCLUSION

In Turkey, there are significantly large adolescent and adult populations susceptible to acute viral hepatitis. Therefore, larger vaccination programs covering these age groups should be implemented.

Acute hepatitis A infection after hepatitis A immunity in a HIV-positive individual

Hepatitis A is a self-limiting infection caused by the hepatitis A virus (HAV), transmitted predominantly by the faecal-oral route including some sexual practices. Outbreaks are commonly reported in the men who have sex with men (population. Previous exposure is thought to provide life-long immunity against subsequent infections with the development of an HAV IgG response. This paper reports a case of acute Hepatitis A infection, despite evidence of a previously positive Hepatitis A IgG results in an HIV-positive individual.

Hepatotropic viruses as etiological agents of acute liver failure and related-outcomes among children in India: a retrospective hospital-based study

BACKGROUND

Acute liver failure (ALF) is marked by a sudden loss of hepatic function and is associated with a high mortality rate in children. The etiology of ALF is shown to vary geographically. This study assessed the frequency of hepatotropic viruses as etiological agents of ALF in Indian children.

METHODS

This retrospective study enrolled children aged 0-18 years with confirmed ALF admitted to Christian Medical College, Vellore and King Edward Memorial Hospital and Research Center, Pune between January 2003 and December 2005. The frequency of hepatotropic viruses as etiological agents in children with ALF aged ≤18 years was calculated with 95% confidence interval (CI). Descriptive analyses of demographic characteristics, clinical signs and symptoms of ALF, choice of treatment and outcomes were performed.

RESULTS

Of 76 children enrolled, 54 were included in the per-protocol analyses. Mean age of children with ALF was 5.43 years (standard deviation = 3.62); 51.9% (28/54) were female. The percentage of children positive for anti-hepatitis A virus (HAV) IgM and hepatitis B surface antigen was 65.9% (27/41; 95% CI 49.4-79.9) and 15.9% (7/44; 95% CI 6.6-30.1), respectively. The final cause of ALF was HAV (36.3%) followed by hepatitis B virus (HBV; 8.8%). Before and during admission, encephalopathy was observed in 77.8% (42/54) and 63.0% (34/54) of children, respectively. A high number of children (46/54; 85.2%) required intensive care and ALF was fatal in 24.1% (13/54). The proportion of deaths due to HAV and HBV was 18.5% (5/27) and 57.1% (4/7), respectively.

CONCLUSIONS

HAV and HBV were the most common etiological agents of ALF in Indian children. Primary prevention by vaccination against HAV and HBV in young children may be useful in the prevention of ALF due to viral hepatitis in India.

Isolation and genomic sequence of hepatitis A virus from mixed frozen berries in Italy

Hepatitis A virus (HAV) was detected in two samples of mixed frozen berries linked to Italian hepatitis A outbreak in April and September 2013. Both viruses were fully sequenced by next-generation sequencing and the genomes clustered with HAV complete genomes of sub-genotype IA with nucleotide identities of 95-97%.

Source identification through social networks in an epidemiological investigation of a hepatitis A outbreak at an elementary school in Anhui province, China

In May 2011, the Center for Disease Control and Prevention of a Chinese county found a rapid increase in the number of hepatitis A case notification; these were traced to an outbreak in an elementary school. Twenty-eight cases aged between 7 and 13 years with onset between 7 May and 8 June were serologically confirmed. Network method was conducted to reconstruct an outbreak network and to quantify the relative importance of those involved in the outbreak. A case-control study was used to study the association between the outbreak and putative risk factors. The network analysis suggested this was a disseminated outbreak originating from a 4-year-old boy with propagated spread. Evidence from the case-control study supported consumption of well water as a potential risk factor; however, this was unable to be established through field investigation. Outbreak networks can be used to identify the possible source of infectious disease outbreak, especially when the environmental investigation information is negative or not available.

Circulation of hepatitis A genotype IIIA virus in paediatric patients in central India

Hepatitis A virus (HAV) infection, a major cause of childhood hepatitis is transmitted by orofaecal route. Children mostly suffer with subclinical infection but may have serious clinical implications leading to hospitalization and mortality. IgM ELISA and nRT PCR were conducted on the blood samples collected from HAV suspected paediatric cases referred to the viral diagnostic laboratory in the Regional Medical Research Centre for Tribals at Jabalpur, Central India. The nRT PCR products were sequenced and phylogenetic analysis was done. Of the 195 samples tested, 41 (21%) were positive for HAV antibodies, among which 38 (92%) belonged to paediatric age group and 32 per cent of these were hospitalized. nRT PCR and sequencing confirmed the presence of HAV. Phylogenic analysis revealed circulation of genotype III A in central India. Regular serological and molecular monitoring would aid in understanding epidemiology of HAV and plan intervention strategies.

Hepatitis A vaccination coverage among adults 18-49 years traveling to a country of high or intermediate endemicity, United States

BACKGROUND

Since 1996, hepatitis A vaccine (HepA) has been recommended for adults at increased risk for infection including travelers to high or intermediate hepatitis A endemic countries. In 2009, travel outside the United States and Canada was the most common exposure nationally reported for persons with hepatitis A virus (HAV) infection.

OBJECTIVE

To assess HepA vaccination coverage among adults 18-49 years traveling to a country of high or intermediate endemicity in the United States.

METHODS

We analyzed data from the 2010 National Health Interview Survey (NHIS), to determine self-reported HepA vaccination coverage (≥1 dose) and series completion (≥2 dose) among persons 18-49 years who traveled, since 1995, to a country of high or intermediate HAV endemicity. Multivariable logistic regression and predictive marginal analyses were conducted to identify factors independently associated with HepA vaccine receipt.

RESULTS

In 2010, approximately 36.6% of adults 18-49 years reported traveling to high or intermediate hepatitis A endemic countries; among this group unadjusted HepA vaccination coverage was 26.6% compared to 12.7% among non-travelers (P-values<0.001) and series completion were 16.9% and 7.6%, respectively (P-values<0.001). On multivariable analysis among all respondents, travel status was an independent predictor of HepA coverage and series completion (both P-values<0.001). Among travelers, HepA coverage and series completion (≥2 doses) were higher for travelers 18-25 years (prevalence ratios 2.3, 2.8, respectively, P-values<0.001) and for travelers 26-39 years (prevalence ratios 1.5, 1.5, respectively, P-value<0.001, P-value=0.002, respectively) compared to travelers 40-49 years. Other characteristics independently associated with a higher likelihood of HepA receipt among travelers included Asian race/ethnicity, male sex, never having been married, having a high school or higher education, living in the western United States, having greater number of physician contacts or receipt of influenza vaccination in the previous year. HepB vaccination was excluded from the model because of the significant correlation between receipt of HepA vaccination and HepB vaccination could distort the model.

CONCLUSIONS

Although travel to a country of high or intermediate hepatitis A endemicity was associated with higher likelihood of HepA vaccination in 2010 among adults 18-49 years, self-reported HepA vaccination coverage was low among adult travelers to these areas. Healthcare providers should ask their patients' upcoming travel plans and recommend and offer travel related vaccinations to their patients.

Assessment of vaccine candidates for persons aged 50 and older: a review

BACKGROUND

The increasing life expectancy in most European countries has resulted in growth of the population 50 and older. This population is more susceptible to infectious diseases because of immunosenescence, co-morbidity and general frailty. Thus, to promote healthy aging, vaccination against vaccine-preventable-diseases could be one strategy. In addition to its possible individual benefits, vaccination may also yield social benefits, such as a lower overall cost of healthcare. Most European countries, however, offer only influenza vaccine although vaccines for pneumococcal disease, herpes zoster, pertussis, and hepatitis A are also available. Our aim is to review the knowledge of these vaccines for persons aged 50 and older and explore the arguments for expanding current vaccination programmes beyond just influenza.

METHODS

The evaluation model of Kimman et al. was used to assess herpes zoster, pneumococcal disease, pertussis and hepatitis A in terms of four domains: pathogen, vaccine, disease outcomes and cost-effectiveness. The sources were Dutch surveillance systems, seroprevalence studies and the international literature.

RESULTS

Herpes zoster, pneumococcal disease and pertussis are prevalent among persons aged 50 and older. Vaccines vary in effectiveness and have mild and self-limiting side effects. Vaccination against pneumococcal disease and pertussis causes adaptation of the responsible pathogen. For pertussis and hepatitis A, the vaccine is not registered specifically for the elderly population. Vaccination against herpes zoster and pertussis could improve quality of life, while vaccination against pneumococcal disease and hepatitis A prevents mortality. However, only vaccination against herpes zoster and pneumococcal disease appear to be cost-effective.

CONCLUSIONS

Vaccination can improve the health of the elderly population. As our review shows, however, the data are too incomplete to accurately judge its potential impact. More research is needed to determine how vaccination can most effectively improve the health of the growing population 50 years and older.

Hepatitis A immunisation in persons not previously exposed to hepatitis A

BACKGROUND

In many parts of the world, hepatitis A infection represents a significant cause of morbidity and socio-economic loss. Whilst hepatitis A vaccines have the potential to prevent disease, the degree of protection afforded against clinical outcomes and within different populations remains uncertain. There are two types of hepatitis A virus (HAV) vaccine, inactivated and live attenuated. It is important to determine the efficacy and safety for both vaccine types.

OBJECTIVES

To determine the clinical protective efficacy, sero-protective efficacy, and safety and harms of hepatitis A vaccination in persons not previously exposed to hepatitis A.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and China National Knowledge Infrastructure (CNKI) up to November 2011.

SELECTION CRITERIA

Randomised clinical trials comparing HAV vaccine with placebo, no intervention, or appropriate control vaccines in participants of all ages.

DATA COLLECTION AND ANALYSIS

Data extraction and risk of bias assessment were undertaken by two authors and verified by a third author. Where required, authors contacted investigators to obtain missing data. The primary outcome was the occurrence of clinically apparent hepatitis A (infectious hepatitis). The secondary outcomes were lack of sero-protective anti-HAV immunoglobulin G (IgG), and number and types of adverse events. Results were presented as relative risks (RR) with 95% confidence intervals (CI). Dichotomous outcomes were reported as risk ratio (RR) with 95% confidence interval (CI), using intention-to-treat analysis. We conducted assessment of risk of bias to evaluate the risk of systematic errors (bias) and trial sequential analyses to estimate the risk of random errors (the play of chance).

MAIN RESULTS

We included a total of 11 clinical studies, of which only three were considered to have low risk of bias; two were quasi-randomised studies in which we only addressed harms. Nine randomised trials with 732,380 participants addressed the primary outcome of clinically confirmed hepatitis A. Of these, four trials assessed the inactivated hepatitis A vaccine (41,690 participants) and five trials assessed the live attenuated hepatitis A vaccine (690,690 participants). In the three randomised trials with low risk of bias (all assessing inactivated vaccine), clinically apparent hepatitis A occurred in 9/20,684 (0.04%) versus 92/20,746 (0.44%) participants in the HAV vaccine and control groups respectively (RR 0.09, 95% CI 0.03 to 0.30). In all nine randomised trials, clinically apparent hepatitis A occurred in 31/375,726 (0.01%) versus 505/356,654 (0.18%) participants in the HAV vaccine and control groups respectively (RR 0.09, 95% CI 0.05 to 0.17). These results were supported by trial sequential analyses. Subgroup analyses confirmed the clinical effectiveness of both inactivated hepatitis A vaccines (RR 0.09, 95% CI 0.03 to 0.30) and live attenuated hepatitis A vaccines (RR 0.07, 95% CI 0.03 to 0.17) on clinically confirmed hepatitis A. Inactivated hepatitis A vaccines had a significant effect on reducing the lack of sero-protection (less than 20 mIU/L) (RR 0.01, 95% CI 0.00 to 0.03). No trial reported on a sero-protective threshold less than 10 mIU/L. The risk of both non-serious local and systemic adverse events was comparable to placebo for the inactivated HAV vaccines. There were insufficient data to draw conclusions on adverse events for the live attenuated HAV vaccine.

AUTHORS' CONCLUSIONS

Hepatitis A vaccines are effective for pre-exposure prophylaxis of hepatitis A in susceptible individuals. This review demonstrated significant protection for at least two years with the inactivated HAV vaccine and at least five years with the live attenuated HAV vaccine. There was evidence to support the safety of the inactivated hepatitis A vaccine. More high quality evidence is required to determine the safety of live attenuated vaccines.

Epidemiological and serological aspects of hepatitis A among children and teenagers in the city of Santos: a cross-sectional study

CONTEXT AND OBJECTIVE

Viral hepatitis A is still a concern at public health level in Brazil and around the world, due both to the number of affected subjects and the possibility of complications in the acute forms. The Brazilian Ministry of Health estimates that at least 70% of this country's population has already had contact with the hepatitis A virus (HAV). The aim here was to discover the prevalence of serological markers for the hepatitis A virus among children and teenagers at daycare facilities, kindergartens and elementary schools in the city of Santos.

DESIGN AND SETTING

Cross-sectional study in kindergartens and elementary schools within the municipal education network in several regions of the city of Santos.

METHOD

Students' family members were surveyed using a questionnaire and 4,680 finger-prick blood samples were taken and assayed by means of the ELISA technique.

RESULTS

The general prevalence of anti-HAV IgG was 9.72% and, of these cases, 74.6% were reactive to anti-HAV IgM. There was higher prevalence of anti-HAV IgG among older children, females, children who played in streams, those whose homes were not connected to the sewage system, those whose parents had low education levels, those with low household income and those who did not live along the seashore. The prevalence of anti-HAV IgM peaked in the early years and subsequently fell, and it was lower on the hills and in the Northwestern Zone.

CONCLUSION

The general prevalence of serological markers for hepatitis A was low in Santos.

Clinical features of re-emerging hepatitis A: an analysis of patients hospitalized during an urban epidemic in Korea

From April 2008 to November 2008, many cases of hepatitis A were reported in Seoul and Gyeonggi Province in Korea. Furthermore, the rate of severe or fulminant hepatitis have significantly increased during the latest epidemic (13.4% vs. 5.2%, p=0.044). Therefore, widespread use of vaccine is warranted to reduce the burden of hepatitis A in Korea.

What factors determine the severity of hepatitis A-related acute liver failure?

The reason(s) that hepatitis A virus (HAV) infection may progress infrequently to acute liver failure are poorly understood. We examined host and viral factors in 29 consecutive adult patients with HAV-associated acute liver failure enrolled at 10 sites participating in the US ALF Study Group. Eighteen of twenty-four acute liver failure sera were PCR positive while six had no detectable virus. HAV genotype was determined using phylogenetic analysis and the full-length genome sequences of the HAV from a cute liver failure sera were compared to those from self-limited acute HAV cases selected from the CDC database. We found that rates of nucleotide substitution did not vary significantly between the liver failure and non-liver failure cases and there was no significant variation in amino acid sequences between the two groups. Four of 18 HAV isolates were sub-genotype IB, acquired from the same study site over a 3.5-year period. Sub-genotype IB was found more frequently among acute liver failure cases compared to the non-liver failure cases (chi-square test, P < 0.01). At another centre, a mother and her son presented with HAV and liver failure within 1 month of each other. Predictors of spontaneous survival included detectable serum HAV RNA, while age, gender, HAV genotype and nucleotide substitutions were not associated with outcome. The more frequent appearance of rapid viral clearance and its association with poor outcomes in acute liver failure as well as the finding of familial cases imply a possible host genetic predisposition that contributes to a fulminant course. Recurrent cases of the rare sub-genotype IB over several years at a single centre imply a community reservoir of infection and possible increased pathogenicity of certain infrequent viral genotypes.

Seroprevalence of hepatitis A among Thai population residing near Myanmar border

hen compared with Thailand, the seroprevalence of hepatitis A virus (HAV) is extremely high among its neighbouring countries. To investigate the seroprevalence of HAV among the Thai people residing in the border area between Thailand and Myanmar, 308 residents in Umphang, Maesod district, Tak, were recruited. Sera were tested for HAV IgG antibodies by enzyme-linked immunosorbent assay. The overall seroprevalence among the Thai people residing in the border area of Thailand was significantly higher than that among the general Thai population (71% vs 27% respectively, p < 0.05). As asymptomatic or mild HAV infection typically occurs in children, the Thai people residing in the border area may receive little benefit from universal HAV vaccination. Lower protective antibodies against HAV, along with the exclusion of HAV vaccine from the Expanded Programme on Immunization, potentially increase the susceptibility to HAV among the general Thai population and may lead to more future outbreaks if HAV is introduced from the border areas. The findings suggest that HAV vaccines should be recommended to travellers before their journey to the border between Thailand and Myanmar where HAV is endemic.

Hepatitis A outbreaks in China during 2006: application of molecular epidemiology

BACKGROUND

In China, hepatitis is a huge public health problem. Outbreaks of hepatitis A are the most frequent cause of acute hepatitis, and to date, few epidemiologic investigations or molecular surveillance studies have been performed.

MATERIALS AND METHODS

In 2006, two major outbreaks of hepatitis A occurred, one in Guigang City, southern China, and the other in Hetian City, northwestern China. Field and molecular epidemiologic investigations were conducted.

RESULTS

In Guigang, a single outbreak occurred in a school; 35 patients and 25 asymptomatic individuals were infected with 1 strain of hepatitis A virus (HAV). A case-control study showed that contaminated water was the likely transmission source. In Hetian, the epidemic of hepatitis A consisted of sporadic, small outbreaks involving as many as 20 wild HAV strains. A molecular epidemiology approach allowed us to identify two groups infected by individual HAV strains. Further fieldwork and a case-control study showed that ice cream was the suspected transmission source in one group. Our molecular epidemiology study showed that genetic variability between the HAV strains isolated from Guigang and Hetian and previously reported HAV strains was at least 4.3%.

CONCLUSION

Contaminated water and suspected ice cream were associated with outbreaks of hepatitis A. Viral genetic analysis may advance field investigations in complex situations.

Investigation of a hepatitis A outbreak in children in an urban slum in Vellore, Tamil Nadu, using geographic information systems

BACKGROUND & OBJECTIVE

An outbreak of symptomatic viral hepatitis in children less than 10 yr of age in Vellore, south India, was investigated and the disease pattern studied using serological and epidemiological methods, supplemented by geographic information systems (GIS) mapping.

METHODS

Three cases of hepatitis A were identified during routine surveillance in a birth cohort House-to-house visits were undertaken to identify other symptomatic cases and samples collected for anti- HAV IgM, ELISA testing. All cases and controls were mapped and geo-referenced using Arc View GIS 3.3. Spatial clustering was investigated using SaTScan 7.0.1 software. Drinking water sources were tested for coliform counts with the most probable number technique.

RESULTS

Of the 965 children surveyed, 26 (2.78%) had jaundice between February to July 2006. From the 26 patients, 11 (42.3%) blood samples were obtained and tested for anti-HAV IgM; 10 (90.9%) were found to be positive. Water analysis showed high coliform counts in all samples. No spatial clustering of cases could be detected.

INTERPRETATION & CONCLUSION

The outbreak was identified because of the symptomatic presentation of the cases. Our study highlighted the increasing detection of symptomatic children with hepatitis A virus infection. Water sources in the area were contaminated and may have served as the source of infection. The lack of clustering in GIS analysis could be due to the common water source.

Feasibility and Acceptability of an English-as-a-Second Language Curriculum on Hepatitis B for Older Chinese American Immigrants

Asian immigrants to the U.S. have an increased prevalence of hepatitis B virus (HBV) infection compared to native born individuals; an estimated 10 percent of Chinese immigrants are infected with HBV. Using qualitative data from focus groups, we developed an English-as-a-Second Language (ESL) curriculum that aimed to improve knowledge about key hepatitis B facts. The curriculum was pilot-tested among 56 students aged 50 and older from intermediate-level ESL classes at a community-based organization that serves Chinese immigrants. Post-curriculum data showed increases in knowledge that hepatitis B can cause liver cancer (73% at pre-test vs. 91% at post-test; p value = 0.01) and that individuals can be infected with hepatitis B for life (34% vs. 81%; p value <0.0001). These findings suggest that an ESL curriculum can successfully improve knowledge about the severity of hepatitis B and its routes of transmission among older Chinese American adults.

Incidence and seroprevalence of hepatitis A virus infections among young Korean soldiers

This study was performed to determine the incidence and seroprevalence of hepatitis A virus (HAV) infections in young soldiers in the Republic of Korea Army. From January 2000 through December 2004, a total of 147 hepatitis A cases were reported to the Armed Forces Medical Command. The annual incidence rates were 7.4 per 100,000 persons in 2000, 1.6 in 2001, 4.4 in 2002, 9.8 in 2003, and 6.2 in 2004, based on the reported cases among approximately 500,000 soldiers. All patients were males with a median age of 21 yr (range, 19-27). The most common symptom was nausea (86.5%), and all patients had recovered without complications. In addition, in order to evaluate the seroprevalence of HAV infection in young adults, serum samples were obtained from randomly selected young subjects among those who had been admitted to the Armed Forces Capital Hospital from September 2005 to February 2006. A total of 200 subjects were enrolled in the study to analyze the anti-HAV immune status. The overall anti-HAV IgG seropositive rate was 2% (4/200, 95% CI, 0.60-5.21%). Given the changing epidemiology of the disease and the associated increase in morbidity, it was suggested that routine HAV vaccination for Korean military personnel might be necessary.

Emerging need for vaccination against hepatitis A virus in patients with chronic liver disease in Korea

Vaccination against hepatitis A virus (HAV) is recommended for patients with chronic liver disease (CLD), but this has been deemed unnecessary in Korea since the immunity against HAV was almost universal in adults. However, this practice has never been reevaluated with respect to the changing incidence of adult acute hepatitis A. We retrospectively reviewed the medical records of 278 patients with acute hepatitis A diagnosed from January 1995 to November 2005 and prospectively tested 419 consecutive CLD patients from July to December 2005 for the presence of IgG anti-HAV. The number of patients with acute hepatitis A has markedly increased recently, and the proportion of adult patients older than 30 yr has been growing from 15.2% during 1995-1999, to 28.4% during 2000-2005 (p=0.019). Among 419 CLD patients, the seroprevalences of IgG anti-HAV were 23.1% for those between 26 and 30 yr, 64% between 31 and 35 yr, and 85.0% between 36 and 40 yr. These data demonstrate that immunity against HAV is no more universal in adult and substantial proportion of adult CLD patients are now at risk of HAV infection in Korea. Therefore, further study on seeking proper strategy of active immunization against HAV is warranted in these populations.

Vaccination for its control and acceptance of the measure]

OBJECTIVE

To study a community outbreak of hepatitis A in a marginal population and the public health response in order to bring it under control.

DESIGN

Descriptive study of the outbreak that occurred in February-June, 2004. An epidemiological survey was conducted to detect prior cases and active vigilance was set up. Case and susceptibility definitions were established.

SETTING

A gypsy population in Madrid, Spain. They had basic provision of sewerage, water supply and waste disposal.

PARTICIPANTS

A population of 550 in census; estimated population, 800. 70% were under 40 and 55% were illiterate.

INTERVENTIONS

Control measures were: a) health education activities to strengthen habits of hygiene, and b) immunisation of susceptible individuals. A total of 646 people were vaccinated, with the active help of staff from the Institute of Rehousing and Integration into Society.

RESULTS

The outbreak affected 26 people, with an average age of 8 (95% CI, 6.2-9.8), similar distribution by sex and 3.3% attack rate. Fourteen cases were students at state schools, not all in the same classes. There were 7 pairs of siblings among the cases. The diagnosis was conformed by serology in 17 cases. Five needed hospital admission.

CONCLUSIONS

The epidemic curve suggested person-person transmission. All those affected were under 20 years old. Vaccination was seen to be effective in controlling the outbreak. Interventions were assisted by intermediaries in order to respect the gypsies' cultural context and were well accepted.

Dual modes of modification of hepatitis A virus 3C protease by a serine-derived beta-lactone: selective crystallization and formation of a functional catalytic triad in the active site

Hepatitis A virus (HAV) 3C proteinase is a member of the picornain cysteine proteases responsible for the processing of the viral polyprotein, a function essential for viral maturation and infectivity. This and its structural similarity to other 3C and 3C-like proteases make it an attractive target for the development of antiviral drugs. Previous solution NMR studies have shown that a Cys24Ser (C24S) variant of HAV 3C protein, which displays catalytic properties indistinguishable from the native enzyme, is irreversibly inactivated by N-benzyloxycarbonyl-l-serine-beta-lactone (1a) through alkylation of the sulfur atom at the active site Cys172. However, crystallization of an enzyme-inhibitor adduct from the reaction mixture followed by X-ray structural analysis shows only covalent modification of the epsilon2-nitrogen of the surface His102 by the beta-lactone with no reaction at Cys172. Re-examination of the heteronuclear multiple quantum coherence (HMQC) NMR spectra of the enzyme-inhibitor mixture indicates that dual modes of single covalent modification occur with a >/=3:1 ratio of S-alkylation of Cys172 to N-alkylation of His102. The latter product crystallizes readily, probably due to the interaction between the phenyl ring of the N-benzyloxycarbonyl (N-Cbz) moiety and a hydrophobic pocket of a neighboring protein molecule in the crystal. Furthermore, significant structural changes are observed in the active site of the 3C protease, which lead to the formation of a functional catalytic triad with Asp84 accepting one hydrogen bond from His44. Although the 3C protease modified at Cys172 is catalytically inactive, the singly modified His102 N(epsilon2)-alkylated protein displays a significant level of enzymatic activity, which can be further modified/inhibited by N-iodoacetyl-valine-phenylalanine-amide (IVF) (in solution and in crystal) or excessive amount of the same beta-lactone inhibitor (in solution). The success of soaking IVF into HAV 3C-1a crystals demonstrates the usefulness of this new crystal form in the study of enzyme-inhibitor interactions in the proteolytic active site.

Viral hepatitis and the surgeon

BACKGROUND

Viral hepatitis is an infection of the liver caused by one or more of six known (HAV-HGV) hepatotropic viruses. It is a common problem among health care workers and their patients. Surgeons are at particular risk of both acquiring and transmitting some of these viruses from and to their patients. Unfortunately, specific immunoprophylaxis for viral hepatitis is presently limited to protecting against the spread of hepatitis A and B viral infections, leaving a high degree of vigilance and careful surgical technique as the only means available to prevent the transmission of other viruses relative to the surgeon. The purpose of this paper is to review the various forms of viral hepatitis including the nature of the virus, serologic testing, clinical features, epidemiology (with specific reference to those issues that arise in surgical practice), treatment and prevention.

[Epidemiological study of the hepatitis C virus in our population and vaccine coverage]

OBJECTIVE

Epidemiological study of patients with chronic hepatitis C and its serological status in relation to the hepatitis A (HA) and B (HB) viruses.

DESIGN

Descriptive cross-sectional study.

SETTING

Two urban health centres. Participants. 291 patients with chronic hepatitis C.

MAIN MEASUREMENTS

VARIABLES

age, sex, year and reason for diagnosis, personal histories, alcohol intake, serological status of the HA and HB viruses and HIV, and initial level of transaminases.

RESULTS

Mean age, 55 +/- 16. Sex, 52% women. Prevalence, 0.98%. Reason for diagnosis, 41% health study, 15% study of hepatic pathology, 18% study of other pathologies. Personal histories, surgical intervention, 37.5%; intravenous drug users, 21.4%; transfusion, 14%; high-risk sexual conduct, 2.4%; health material used more than once, 2.4%; family member HC positive, 1.4%; no personal history recorded, 26.5%. Alcoholism, 17.9%. Mean transaminases: AST, 79.7 +/- 100 (9-920); ALT, 114.8 +/- 160 (6-1640). HB serological status: natural immunity, 22%; chronic, 9%; vaccine immunity, 3%; negative, 44%; not recorded, 21%. HA serological status: natural immunity, 2%; vaccine immunity, 2.5%; negative, 9%; not recorded, 87%. HIV-positive: 4.5%.

CONCLUSIONS

Prevalence was below the expected level. Knowledge of serological status needs to be improved, especially for HA. The degree of vaccine coverage in these patients for HA and HB should be increased.

[Carriers of hepatitis C: should they all be vaccinated for hepatitis A?]

AIM

To investigate the prevalence of immunization against hepatitis A virus (HAV) in persons with hepatitis C virus (HCV) infection, in order to determine who should be vaccinated for the former.

DESIGN

Descriptive, cross-sectional study.

SETTING

Urban health center serving 12 000 inhabitants.

PARTICIPANTS

Patients older than 14 years positive for HCV infection.

MAIN MEASURES

VARIABLES

presence of chronic liver disease, serological indications of hepatitis B, A, and immune deficiency virus (HIV) infection, vaccination for hepatitis B.

RESULTS

A total of 134 persons (70.9% men and 29.1% women) comprised the sample of patients positive for HCV infection. Mean age was 41.75 years (SD, 16.55 years). Nearly all patients (93.3%) had chronic liver disease, 56.7% were intravenous drug users, 56% were positive for Hbc antibodies and 32.8% were positive for HIV. Serological testing for HAV was done in 75 patients (56%); the result was positive in 86.7%. Mean age in this subgroup was 50.4 years (SD, 17.8 years). In the HAV-negative subgroup, mean age was 36.6 years (SD, 15 years; P=.02). Serological testing for HAV could not be done in 44% of the patients: 33.6% did not respond to attempts to contact them by telephone or in writing, 6% were temporarily away from home, and 1 patient declined to be tested. The response to requests to obtain blood samples was better in women (66.7%), HIV-negative patients (34.7%), persons who were not intravenous drug users (43.3%) and persons with chronic liver disease (60%).

CONCLUSIONS

In persons younger than 40 years, the proportion of seronegative individuals is similar to that in the general population. Vaccination should be considered for all patients positive for HCV infection. In persons older than 40 years with chronic liver disease, the decision to vaccinate for HAV should be made in the light of serological findings.

Foodborne viral illness--status in Australia

Norwalk-like virus contamination of oysters and orange juice, and hepatitis A virus contamination of oysters have been responsible for large outbreaks of foodborne viral disease in Australia. Rotavirus, adenovirus, astrovirus, parvovirus and other enteroviruses also contribute to the incidence of gastroenteritis in this country but the role of foods and waters in transmitting these viruses is unclear. Protocols for the investigation, surveillance and reporting of foodborne viral illness require further development to enable a more accurate description of the problem. Few laboratories have the capability to analyse foods for viruses and specific training in this technology is needed. Management of food safety in Australia largely relies on the implementation of HACCP principles, but these need to be adapted to address the specific risks from viruses.

[Prevalence of anti-HAV antibodies and efficacy of pre-vaccine detection at institutions for mentally retarded of the city of Alicante]

OBJECTIVE

The aim of this study was to investigate the prevalence and efficacy of the anti-HAV antibodies detection in institucions for mentally retarded people in the city of Alicante.

DESIGN

Prevalence study.

SETTING

Two institucions for mentally retarded people in the city of Alicante.

PARTICIPANTS

One hundred and seven residents and seventy seven in care of them.

MEASUREMENTS AND MAIN RESULTS

We have investigated the anti-HAV antibodies prevalence by enzymeinmunoanalysis of microparticle test. The efficacy of the anti-HAV antibodies detection before the vaccination has been studied by calculating the threshold of prevalence with the following formula: unit cost of detection + (1 - X) x unit cost vaccination anti-HAV negative subjects = unit cost vaccination.

RESULTS

The global prevalence of anti-HAV antibodies was 56.5% (95% CI, 49-63.7). The prevalence of the residents was 55.1% (95% CI, 45.2-64.7) and 58.4% in care of them (95% CI, 46.6-69.5). Among the sociodemographic variables evaluated only the age was associated with the prevalence of anti-HAV antibodies (p < 0.001). The unit cost of prevaccination detection of anti-HAV antibodies was calculated as 998 pesetas and the unit cost of the vaccination as 3595, obtaining a prevalence anti-HAV threshold of 27.8%.

CONCLUSIONS

The prevalence of anti-HAV antibodies in this collective studied is similar to the prevalence of anti-HAV antibodies of the spaniard population. The direct vaccination without a previous marker study is recommended to people under the age of 31 in this population group.