Population-based study on the seroprevalence of hepatitis A, B, and C virus infection in Amsterdam, 2004

Ethnic differences in hepatitis A and E virus seroprevalence in patients attending the Emergency Department, Paramaribo, Suriname

BACKGROUND

Hepatitis A virus (HAV) and hepatitis E virus (HEV) have enteric modes of transmission and are common causes of acute hepatitis in low- and middle-income countries. HEV is also characterised as a zoonotic infection and is prevalent in high-income countries. Data on HAV and HEV prevalence in Suriname, a middle-income country in South America, are scarce.

METHODS

Serum samples of 944 and 949 randomly selected patients attending the Emergency Department at the Academic Hospital of Paramaribo, the capital of Suriname, were analysed for anti-HAV antibodies (anti-HAV) and anti-HEV antibodies (anti-HEV), respectively. Determinants of anti-HAV and anti-HEV positive serology were evaluated using multivariable logistic regression.

RESULTS

Anti-HAV prevalence was 58.3% (95% CI 55.4 to 61.4%) and higher prevalence was independently associated with belonging to the Tribal or Indigenous population and older age. Anti-HEV prevalence was 3.7% (95% CI 2.6 to 5.0%) and higher prevalence was associated with Tribal and Creole ethnicity and older age.

CONCLUSIONS

In Suriname, exposure to HAV is consistent with a very low endemic country and exposure to HEV was rare. Both viruses were more prevalent in specific ethnic groups. As anti-HAVantibodies were less frequently found in younger individuals, they could be susceptible to potential HAV outbreaks and might require HAV vaccination.

Timing of primary three dose hepatitis B vaccination and postvaccination serologic testing among a large cohort of healthy adults

This study evaluated the optimal timing of a primary three‐dose hepatitis B vaccination and postvaccination serologic testing (PVST) among a large group of healthy naïve adults in the Netherlands. Data were collected from the Ease Travel Clinic hepatitis B vaccination database. The study population consisted of 22,997 adults who received three hepatitis B vaccinations. Seroprotection was attained in 97.3% individuals. When compared with PVST performed at 1–2 months (98.2%) after the final dose, lower seroprotection rates were observed with <1 (97.3%, p = 0.128), 3–6 (90.6%, p < 0.001), and ≥7 (88.4%, p < 0.001) months after vaccination. Among the subpopulation with a PVST 1–2 months, no statistically significant difference was observed for the various intervals between the first and second vaccination (<1, 1–2, 3–4, or ≥5 months). When compared with 4–5 months between the second and third vaccine dose, lower seroprotection rates were observed with <4 (odds ratio [OR]: 0.29, p = 0.020) and ≥12 (OR: 0.22, p < 0.001) months, although comparable rates were observed with 6–11 months interval (OR: 0.85, p = 0.262). Our data indicate that PVST should be obtained 1–2 months after the last vaccination and a delayed PVST was the major determinant of a lower seroprotection rate after primary three‐dose hepatitis B vaccination schedule. Based on our data, the hepatitis B vaccination also leaves room for flexibility for the second dose and the third dose without the necessity of restarting the vaccination series or confirmation of the immune response to the vaccine.

The Cost-Effectiveness of Hepatitis C Virus Screening Strategies among Recently Arrived Migrants in the Netherlands

Objective: We aimed to assess the cost-effectiveness of hepatitis C virus (HCV) screening strategies among recently arrived migrants in the Netherlands. Methods: A Markov model was used to estimate the health effects and costs of HCV screening from the healthcare perspective. A cohort of 50,000 recently arrived migrants was used. In this cohort, three HCV screening strategies were evaluated: (i) no screening, (ii) screening of migrants from HCV-endemic countries and (iii) screening of all migrants. Results: Strategy (ii) screening of migrants from HCV-endemic countries compared to strategy (i) no screening, yielded an incremental cost-effectiveness ratio (ICER) of €971 per quality-adjusted life-years (QALYs) gained. Strategy (iii) screening of all migrants compared with strategy (ii) screening of migrants from HCV-endemic countries yielded an ICER of €1005 per QALY gained. The budget impact of strategy (ii) screening of migrants from HCV-endemic countries and strategy (iii) screening of all migrants was €13,752,039 and €20,786,683, respectively. Conclusion: HCV screening is cost-effective. However, the budget impact may have a strong influence on decision making.

Chronic hepatitis B and C infections in the Netherlands: estimated prevalence in risk groups and the general population

Chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are usually asymptomatic for decades, thus targeted screening can prevent liver disease by timely diagnosis and linkage to care. More robust estimates of chronic HBV and HCV infections in the general population and risk groups are needed. Using a modified workbook method, the total number of ever chronically infected individuals in the Netherlands in 2016 was determined using population size and prevalence estimates from studies in the general and high-risk population. The estimated 2016 chronic HBV infection prevalence is 0.34% (low 0.22%, high 0.47%), corresponding to approximately 49 000 (low 31 000, high 66 000) HBV-infected individuals aged 15 years and older. The estimated ever-chronic HCV infection prevalence is 0.16% (low 0.06%, high 0.27%), corresponding to approximately 23 000 (low 8000, high 38 000) ever-chronic HCV-infected individuals. The prevalence of chronic HBV and HCV infections in the Netherlands is low. First-generation migrants account for most infections with 81% and 60% of chronic HBV and HCV infections, respectively. However, about one-fifth of HCV infections is found in the general population at low risk. This method can serve as an example for countries in need of more accurate prevalence estimates, to help the design and evaluation of prevention and control policies.

Ethnicity and response to primary three-dose hepatitis B vaccination in employees in the Netherlands, 1983 through 2017

BACKGROUND AND AIMS

Hepatitis B virus (HBV) vaccination is recommended to all employees who have an occupational risk in the Netherlands. This study assessed the determinants of the immune response to primary standard three-dose HBV vaccination (0, 1, 6 months), with the main focus on ethnicity.

METHODS

Out of 76 239 individuals who received HBV vaccination between April 1983 and December 2017, 11 567 persons with a known country of birth and complete vaccination schedule were included in this study. Weighted multiple logistic regression with Firth's bias adjustment was used to assess the determinants of nonresponse (anti-HBs < 10 mIU/mL) and low response (anti-HBs 10-99 mIU/mL).

RESULTS

Baseline characteristics of the study population (n = 11 567) were as follows: mean age 27.5 years (95% confidence interval [CI], 27.23-27.72), 99.4% born in the Netherlands and 93.5% of Western European origin. Of all identified subjects, 180 (1.6%) were HBV vaccine nonresponders and 549 (4.8%) were low responders. When compared with individuals aged <40 years, the rate of nonresponse (4.3% vs 0.8%; P < .001) and low response (11.9% vs 2.9%; P < .001) was higher in those aged 40 years or older. The height of anti-HBs levels were lower in those subjects aged >40 years in comparison with those younger than 40 years, P < .001. All nonresponders were born in the Netherlands. Although no significant association was found between nonresponse and individuals of Western European origin (adjusted odds ratio [aOR] = 1.20; 95% CI, 0.66-2.44; P = .163), low response to HBV vaccination was significantly associated with Western European origin (aOR = 2.21; 95% CI, 1.41-3.86; P = .001). Significant determinants for nonresponse were older age at vaccination (aOR = 1.06; 95% CI, 1.06-1.07; P < .001) and male gender (aOR = 2.51; 95% CI, 1.97-3.22; P < .001).

CONCLUSIONS

The nonresponse rate was low in our study population. Our findings suggest that the vaccines being used for the primary vaccination are probably less immunogenic for older individuals, males, and persons of Western European origin.

Hepatitis B and C screening needs among different ethnic groups: A population-based study in Amsterdam, the Netherlands

Data on the prevalence of chronic hepatitis B (HBV) and hepatitis C (HCV) virus infections, including the proportion of individuals aware of infection, are scarce among migrants living in Europe. We estimated the prevalence of past and present HBV and HCV infection, along with their determinants and peoples' awareness of infection status, among different groups of first-generation migrants and Dutch-origin residents of Amsterdam.

METHODS

Cross-sectional data of 998 Surinamese (mostly South-Asian and African-Surinamese), 500 Ghanaian, 497 Turkish, 498 Moroccan and 500 Dutch-origin participants from the observational population-based HELIUS study were used. Blood samples of participants were tested for HBV and HCV infection. Infection awareness was determined using records from participants' general practitioners.

RESULTS

Age- and gender-adjusted chronic HBV prevalence was highest among Ghanaian participants (5.4%), followed by Turkish (4.1%), African-Surinamese (1.9%), Moroccan (1.2%), South-Asian Surinamese (0.9%) and Dutch (0.4%) participants. A total of 58.1% of the cases were aware of their infection. In multinomial logistic regression analyses, Ghanaian (adjusted odds ratio [aOR] 42.23; 95% confidence interval [CI] 9.29-192.01), African-Surinamese (aOR 6.16; 95% CI 1.27-29.79), and Turkish (aOR 13.44; 95% CI 2.94-61.39) participants were at increased risk of chronic HBV infection compared with those of Dutch origin. Older participants were also at increased risk (aOR 1.02 per year; 95% CI 1.00-1.05), whereas women were at lower risk (aOR 0.49; 95% CI 0.29-0.83). HCV prevalence was 0.4% (95% CI 0.1-1.3%) among Dutch and African-Surinamese and 0% (95% CI 0.0-0.5%) for each of the other groups; all cases with follow-up data were aware of their infection.

CONCLUSIONS

Ghanaian, Turkish and African-Surinamese first-generation migrants are at increased risk of chronic HBV infection and many are unaware of their infection, whereas HCV prevalence was low among all ethnic groups. Screening campaigns are urgently warranted and need to consider specific ethnic groups.

LAY SUMMARY

First-generation migrants of Ghanaian, Turkish and African-Surinamese origin were at increased risk of chronic hepatitis B infection, with most infections occurring in older individuals and males. Since over 40% of people were unaware of their chronic hepatitis B infection, screening of these migrant groups is urgently needed. The proportion of first-generation migrants chronically infected with hepatitis C virus was very low among all groups studied.

Hepatitis B in Moroccan-Dutch: a qualitative study into determinants of screening participation

Background

Chronic hepatitis B (HBV) leads to an increased risk for liver cirrhosis and liver cancer. In the Netherlands, chronic HBV prevalence in the general population is 0.20%, but 3.77% in first generation immigrants. Our aim was to identify determinants associated with the intention to participate in HBV testing among first generation Moroccan immigrants, one of the two largest immigrant groups targeted for screening.

Methods

Semi-structured interviews were held with first (n = 9) and second generation (n = 10) Moroccan-Dutch immigrants, since second generation immigrants frequently act as their parents’ brokers in healthcare.

Results

Most participants had little knowledge about hepatitis B, but had a positive attitude towards screening. Facilitators for screening intention were perceived susceptibility to and severity of disease, positive attitude regarding prevention, wishing to know their hepatitis B status and to prevent potential hepatitis B transmission to others. Additional cultural facilitators included fear (of developing cancer), and existing high health care utilization; a religious facilitator was the responsibility for one’s own health and that of others. Barriers included lack of awareness and knowledge, practical issues, not having symptoms, negative attitude regarding prevention, fear about the test result and low-risk perception. A cultural barrier was shame and stigma, and a religious barrier was fatalism.

Conclusion

We identified important facilitators and barriers, which we found, can be interpreted differently. Specific and accurate information should be provided, accompanied by strategies to address shame and stigma, in which Islamic religious leaders could play a role in bringing information across.

Hepatitis B in Moroccan-Dutch: a quantitative study into determinants of screening participation

BACKGROUND

In November 2016, the Dutch Health Council recommended hepatitis B (HBV) screening for first-generation immigrants from HBV endemic countries. However, these communities show relatively low attendance rates for screening programmes, and our knowledge on their participation behaviour is limited. We identified determinants associated with the intention to request an HBV screening test in first-generation Moroccan-Dutch immigrants. We also investigated the influence of non-refundable costs for HBV screening on their intention.

METHODS

Offline and online questionnaires were distributed among first- and second/third-generation Moroccan-Dutch immigrants using respondent-driven sampling. Random forest analyses were conducted to determine which determinants had the greatest impact on (1) the intention to request an HBV screening test on one's own initiative, and (2) the intention to participate in non-refundable HBV screening at €70,-.

RESULTS

Of the 379 Moroccan-Dutch respondents, 49.3% intended to request a test on their own initiative, and 44.1% were willing to attend non-refundable screening for €70,-. Clarity regarding infection status, not having symptoms, fatalism, perceived self-efficacy, and perceived risk of having HBV were the strongest predictors to request a test. Shame and stigma, fatalism, perceived burden of screening participation, and social influence of Islamic religious leaders had the greatest predictive value for not intending to participate in screening at €70,- non-refundable costs. Perceived severity and possible health benefit were facilitators for this intention measure. These predictions were satisfyingly accurate, as the random forest method retrieved area under the curve scores of 0.72 for intention to request a test and 0.67 for intention to participate in screening at €70,- non-refundable costs.

CONCLUSIONS

By the use of respondent-driven sampling, we succeeded in studying screening behaviour among a hard-to-reach minority population. Despite the limitations associated with correlated data and the sampling method, we recommend to (1) incorporate clarity regarding HBV status, (2) stress the risk of an asymptomatic infection, (3) emphasise mother-to-child transmission as the main transmission route, and (4) team up with Islamic religious leaders to help decrease elements of fatalism, shame, and stigma to enhance screening uptake of Moroccan immigrants in the Netherlands.

Ethnic differences in infectious burden and the association with metabolic risk factors for cardiovascular disease: a cross-sectional analysis

Background

The burden of metabolic risk factors for cardiovascular disease (CVD), such as type 2 diabetes, elevated cholesterol and hypertension, is unequally distributed across ethnic groups. Recent findings suggest an association of infectious burden (IB) and metabolic risk factors, but data from ethnic groups are scarce. Therefore, we investigated ethnic differences in IB and its association with metabolic risk factors.

Methods

We included 440 Dutch, 320 Turkish and 272 Moroccan participants, 18–70 years, of the 2004 general health survey in Amsterdam, the Netherlands. IB was defined by seropositivity to the sum of 6 infections: Herpes Simplex Virus 1 and 2; Hepatitis A, B and C; and Helicobacter pylori. Associations between IB categories 4–6 (high), 3 (intermediate) and 0–2 (low) infections and metabolic risk factors were assessed by logistic regression. Finally, we determined the contribution of IB to the association between ethnicity and the metabolic risk factors by comparing adjusted logistic regression models with and without IB categories.

Results

A high IB was more frequently observed among the Turkish and Moroccans than among the Dutch. After adjustment for age, sex, ethnicity, educational level, physical activity and body mass index, high IB was associated with type 2 diabetes (odds ratio high vs low IB (OR) =2.14, 95%-confidence interval (CI) 1.05–4.36). The association was weaker and not statistically significant, for elevated cholesterol (OR = 1.39, 95%-CI 0.82–2.34) and hypertension (OR = 1.49, 95%-CI 0.88–2.51). IB attenuated ethnic differences particularly for type 2 diabetes.

Conclusions

Our study showed that Turkish and Moroccan adults in Amsterdam have a higher IB than Dutch adults, which was associated with the differences in type 2 diabetes. Due to the cross-sectional nature of the study, we cannot draw a conclusions with regards to the time-sequence of cause and effect. Nevertheless, the findings ask for further research into the nature of association of IB with metabolic risk factors in a longitudinal setting.

Effectiveness and cost-effectiveness of nationwide campaigns for awareness and case finding of hepatitis C targeted at people who inject drugs and the general population in the Netherlands

BACKGROUND

Hepatitis C virus infection (HCV) is a serious, but underdiagnosed disease that can generally be treated successfully. Therefore, a nationwide HCV awareness campaign was implemented in the Netherlands targeting people who inject drugs (PWID) in addiction care ('PWID intervention') and high-risk groups in the general population ('public intervention'). The objective of this study is to assess the effectiveness and cost-effectiveness of the interventions used in this campaign.

METHODS

For the 'PWID' intervention, all addiction care centres in the Netherlands provided proactive individual HCV consultation and testing. The 'public intervention' consisted of health education through mass media and instruction of health care professionals. A Markov chain model was used to estimate incremental cost-effectiveness ratios (ICER, cost per QALY gained). We included a 'DAA treatment' scenario to estimate the effect of these treatment strategies on cost-effectiveness.

RESULTS

The 'PWID intervention' identified 257 additional HCV-carriers. The ICER was €9056 (95% CI: €6043-€13,523) when compared to 'no intervention'. The 'public intervention' identified 38 additional HCV-carriers. The ICER was €18,421 (95% CI: €7376-€25,490,119) when compared to 'no intervention'. Probabilistic sensitivity analysis showed that the probability that the 'PWID intervention' was cost-effective was 100%. It also showed a probability of 34% that the 'public intervention' did not exceed the Dutch threshold for cost-effectiveness (€20,000). New treatment regimens are likely to improve cost-effectiveness of this strategy.

CONCLUSION

In a nationwide HCV awareness and case finding campaign, the intervention targeting PWID was effective and cost-effective. An intervention targeting risk groups in the general population showed only a modest effect and is therefore less likely to be cost-effective.

Seroprevalence of hepatitis B and factors potentially associated in a population-based study in Medellin, Colombia

The seroprevalence of hepatitis B (HB) and of potentially associated factors in Medellin, Colombia, were investigated 17years after the start of universal vaccination. Biological and sociodemographic data from a population survey with a multistage random sampling were analyzed in 6-64year old individuals. HB surface antigen, total HB core antibodies and HB surface antibodies, and in some cases IgM antibodies to HB core antigen, were tested in 2077 samples. Factors potentially associated with and natural, and vaccine immunity relative to susceptibility (absence of any marker) were analyzed using a multinomial logistic regression. The prevalence of serological patterns was: chronic infection 0.20% (95% CI 0.11-0.71), vaccine immunity 25.10% (95% CI 21.72-28.83) and natural immunity 2.60% (95% CI 1.80-3.74). No markers were detected in 71.30% (95% CI 67.70-74.83) of the individuals and evidence of recent infection was not detected. Relative to the absence of markers, natural immunity was potentially associated with age (6-17years and 41-64years) and sleeping less than 6 hours, while vaccine immunity was associated with age (6-17years), reporting vaccination against HB, belonging to high socioeconomic strata, home ownership and being obese, after adjusting for other variables. These results may be a population effect of mass vaccination. It is recommended to complete the vaccination schedule and to study in detail, persistence of antibodies and the role of obesity and socioeconomic strata in the vaccine immunity.

Seroprevalence and susceptibility to hepatitis A in the European Union and European Economic Area: a systematic review

Most of the European Union (EU) and European Economic Area (EEA) is considered a region of very low hepatitis A virus (HAV) endemicity; however, geographical differences exist. We did a systematic review with the aim of describing seroprevalence and susceptibility in the general population or special groups in the EU and EEA. We searched databases and public health national institutes websites for HAV seroprevalence records published between Jan 1, 1975, and June 30, 2014, with no language restrictions. An updated search was done on Aug 10, 2016. We defined seroprevalence profiles (very low, low, and intermediate) as the proportion of the population with age-specific anti-HAV antibodies at age 15 and 30 years, and susceptibility profiles (low, moderate, high, and very high) as the proportion of susceptible individuals at age 30 and 50 years. We included 228 studies from 28 of 31 EU and EEA countries. For the period 2000-14, 24 countries had a very low seroprevalence profile, compared with five in 1975-89. The susceptibility among adults ranged between low and very high and had a geographical gradient, with three countries in the low susceptibility category. Since 1975, EU and EEA countries have shown decreasing seropositivity; however, considerable regional variability exists. The main limitations of this study are that the studies retrieved for analysis might not be representative of all EU and EEA publications about HAV and might have poor national representativeness. A large proportion of EU and EEA residents are now susceptible to HAV infection. Our Review supports the need to reconsider specific prevention and control measures, to further decrease HAV circulation while providing protection against the infection in the EU and EEA, and could be used to inform susceptible travellers visiting EU and EEA countries with different HAV endemicity levels.

Seroprevalence of hepatitis E virus differs in Dutch and first generation migrant populations in Amsterdam, the Netherlands: a cross-sectional study

Background

In the last decade hepatitis E virus (HEV) is increasingly recognized as a cause of acute viral hepatitis in developed countries. HEV is transmitted via the fecal-oral route. In countries like the Netherlands, HEV infection is suspected to be a zoonosis but HEV may also be introduced by migrants. We studied the seroprevalence of HEV among different migrants, mainly Moroccans and Turks, and compared this to that of the native Dutch population in Amsterdam, the Netherlands.

Methods

Data were obtained from a cross-sectional survey of the adult Amsterdam population performed in 2004; the Amsterdam Health Monitor. A total of 1199 plasma samples were tested for IgG-and IgM antibodies to HEV using the Wantai kit according to instructions of the manufacturer. Basic demographic data (gender, age, country of birth, and age at immigration) were used in the analyses. Hepatitis A virus (HAV) serology data were available from a previous study.

Results

The total weighted anti-HEV IgG seroprevalence in the overall Amsterdam population was 26.7 %, based on 1199 samples. In the study population (not-weighted) this HEV seroprevalence was 157/426 (36.9 %) for the Dutch participants and it was 161/257 (62.6 %) for Moroccans, 99/296 (33.4 %) for Turks and 42/220 (19.1 %) for other ethnicities. HEV seroprevalence increased significantly with age. First-generation Moroccan migrants (44.0 %) had a significantly higher weighted HEV seroprevalence than the Dutch participants (29.7 %). In the first generation Turks (20.3 %) and first generation migrants from other countries (16.7 %) this weighted seroprevalence was lower, but this was only significant for the ‘other ethnicities’. The median age of migration was significantly higher in the Moroccan and Turkish migrants who were HEV IgG positive versus HEV IgG negative. However, when stratifying for age at time of study, median migration age was only significantly different for HEV sero-status for younger Turks and younger ‘other ethnicities’. HEV IgM antibodies were found in 0.6 % (n = 7) of participants and none were positive for HEV RNA, showing that there were no acute infections. Despite the common route of fecal-oral transmission for both viruses, there was no relation between HEV and HAV seropositivity.

Conclusion

Within the multi-ethnical capital city of Amsterdam the HEV seroprevalence in first generation migrant populations differed from each other and from the autochthonous Dutch population. The relation between being HEV seropositive and a higher median age of migration suggests that younger migrants got more often infected in their country of origin than in the Netherlands.

Surveillance for hepatocellular carcinoma is associated with increased survival: Results from a large cohort in the Netherlands

BACKGROUND & AIMS

Effectiveness of surveillance for hepatocellular carcinoma is controversial. We here explore its effects in "real life" clinical practice.

METHODS

Patients with hepatocellular carcinoma diagnosed in the period 2005-2012 in five Dutch academic centers were evaluated. Surveillance was defined as ⩾2 screening tests during three preceding years and at least one radiologic imaging test within 18 months before diagnosis.

RESULTS

295 (27%) of 1074 cases underwent surveillance. Median time interval between last negative radiologic imaging and hepatocellular carcinoma diagnosis was 7.5 months. In the surveillance group, cirrhosis (97% vs. 60%, p<0.001) and viral hepatitis were more frequent, and non-alcoholic fatty liver disease or absence of risk factors less frequent. In case of surveillance, tumor size was significantly smaller (2.7 vs. 6.0 cm), with lower alpha-fetoprotein levels (16 vs. 44 μg/L), earlier tumor stage (BCLC 0 and A combined: 61% vs. 21%) and resection/transplantation (34% vs. 25%) or radiofrequency ablation (23% vs. 7%) more often applied, with significantly higher 1-, 3-, and 5-year survival rates. Survival benefit by surveillance remained significant after adjustment for lead-time bias based on assumed tumor doubling time of 90 days, but not with doubling time of ⩾120 days. In multivariate analysis, surveillance was an independent predictor for mortality (for interval ⩽9 respectively >9 months: adjusted HRs 0.51 and 0.50, 95% confidence intervals: 0.39-0.67 and 0.37-0.69).

CONCLUSIONS

Surveillance for hepatocellular carcinoma was associated with smaller tumor size, earlier tumor stage, with an impact on therapeutic strategy and was an independent predictor of survival.

Prevalence of viral hepatitis in Croatian adult population undergoing routine check-up, 2010-2011

Seroprevalence data on viral hepatitis in the general population vary widely. The aim of this study was to determine the prevalence of hepatitis A (HAV), hepatitis B (HBV) and hepatitis C (HCV) viruses in the general Croatian adult population undergoing routine check-ups. The seroprevalence of anti-HAV, anti-HBc and anti-HCV was 40.5%, 7.0% and 0.9%, respectively. HBsAg was found in 0.7% and anti-HBs antibodies in 24.4% of participants. Gender was not associated with HAV, HBV or HCV seropositivity. HAV and HBV seropositivity increased progressively with age (HAV from 11.7% to 90.4%, p < 0.001; HBV from 1.7% to 15.8%, p < 0.001). Participants from rural areas showed a significantly higher HBV seroprevalence rate than those from urban areas (10.7% vs. 6.1%, p = 0.007). Results of univariate and multiple logistic regression showed that older age was a significant predictor for both HAV and HBV seropositivity while rural place of residence was a significant predictor for HBV seropositivity.

Trends in hepatitis C virus infections among MSM attending a sexually transmitted infection clinic; 1995-2010

BACKGROUND

Since 2000, there is growing evidence that hepatitis C virus (HCV) infection has emerged as a sexually transmitted infection (STI) among HIV-positive MSM. Here, we present a 15-year overview of the HCV epidemic among MSM visiting a large STI-clinic in the Netherlands.

METHODS

During biannual cross-sectional anonymous surveys (1995-2010), participants were interviewed and tested for HIV and HCV-antibodies. Additional HCV RNA tests were performed in all HIV-positives. Determinants of HCV infection were analysed using logistic regression. Phylogenetic analysis provided evidence for sexual transmission.

RESULTS

HCV prevalence among HIV-positive MSM increased from 1995 onwards (5.6%) and peaked in 2008 (20.9%). Prevalent HCV infection was more strongly associated with fisting in 2007-2008 [adjusted odds ratio (aOR) 2.85, 95% confidence interval (CI) 1.19-6.82] than in 2009-2010 (aOR 0.92, 95% CI0.42-2.02). In addition, HCV infection was independently associated with Chlamydia, injecting drug use, unprotected anal intercourse and older age. Phylogenetic analysis revealed a high degree of MSM-specific clustering from 2000 onwards. Identification of a new MSM-specific HCV lineage and the finding of recent HCV infections (0-4%) in established HCV clusters during recent years argue for ongoing transmission of HCV among HIV-positive MSM. HCV prevalence among HIV-negative MSM remained low (2007-2010: 0.5%).

CONCLUSION

HCV prevalence among HIV-positive MSM significantly increased over calendar time but appears to level off in recent years, possibly due to increased awareness, saturation in the population, decreased risk behaviour and earlier HCV screening and treatment. The association with fisting became less strong over time, but our analyses continue to support sexual transmission. Monitoring HIV-positive and HIV-negative MSM for HCV infection remains needed to guide prevention efforts.

Screening for hepatitis B and C in first-generation Egyptian migrants living in the Netherlands

BACKGROUND

Egypt has high prevalence of hepatitis C virus (HCV) infection and intermediate prevalence of hepatitis B virus (HBV) infection; however, infection prevalence among Egyptian migrants is unknown. Considering the asymptomatic onset and development of disease in chronically-infected patients, many may remain undiagnosed.

AIMS

To evaluate an HCV- and HBV-screening programme designed to identify undetected infections among first-generation Egyptian migrants in Amsterdam, the Netherlands.

METHODS

In 2009 and 2010, viral hepatitis educational and screening sessions were established at Egyptian meeting places. Data regarding demographics and HCV risk factors were collected. Chronically infected participants were referred and followed up. Phylogenetic analyses were used to ascertain the geographic origin of infections.

RESULTS

Eleven of 465 (2.4%; 95% CI = 1.3-4.2%) migrants had HCV antibodies; 10/11 were HCV RNA positive. All had genotype 4a, and strains were typical of those of Egypt and the Middle East. Older age and exposure to parenteral antischistosomal therapy (PAT) were significantly associated with HCV. Anti-HBc prevalence was 16.8% (95% CI = 13.7-20.4%); HBsAg prevalence was 1.1% (95% CI = 0.5-2.5%). All had genotype D, typical of those of the Middle East. Most (9/10 HCV; 3/5 HBV) chronic infections were newly diagnosed; four of the HCV-infected individuals started treatment.

CONCLUSIONS

Anti-HCV and HBsAg prevalence among Egyptian migrants was lower compared with the general Egyptian population, but higher than the general population of Western countries. Phylogenetic analyses suggest that all infections were from the region of origin. HCV-screening programmes should target first-generation Egyptian migrants, especially those of older age and those who received PAT.

Infection with hepatitis B and C virus in Europe: a systematic review of prevalence and cost-effectiveness of screening

BACKGROUND

Treatment for chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is improving but not benefiting individuals unaware to be infected. To inform screening policies we assessed (1) the hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus antibody (anti-HCV-Ab) prevalence for 34 European countries; and (2) the cost-effectiveness of screening for chronic HBV and HCV infection.

METHODS

We searched peer-reviewed literature for data on HBsAg and anti-HCV-Ab prevalence and cost-effectiveness of screening of the general population and five subgroups, and used data for people who inject drugs (PWID) and blood donors from two European organizations. Of 1759 and 468 papers found in the prevalence and cost-effectiveness searches respectively, we included 124 and 29 papers after assessing their quality. We used decision rules to calculate weighted prevalence estimates by country.

RESULTS

The HBsAg and anti-HCV-Ab prevalence in the general population ranged from 0.1%-5.6% and 0.4%-5.2% respectively, by country. For PWID, men who have sex with men and migrants, the prevalence of HBsAg and anti-HCV-Ab was higher than the prevalence in the general population in all but 3 countries. There is evidence that HCV screening of PWID and HBsAg screening of pregnant women and migrants is cost-effective.

CONCLUSION

The prevalence of chronic HBV and HCV infection varies widely between European countries. Anti-HCV-Ab screening of PWID and HBsAg screening of pregnant women and migrants have European public health priority. Cost-effectiveness analyses may need to take effect of antiviral treatment on preventing HBV and HCV transmission into account.

The burden of liver disease in Europe: a review of available epidemiological data

To survey the burden of liver disease in Europe and its causes 260 epidemiological studies published in the last five years were reviewed. The incidence and prevalence of cirrhosis and primary liver cancer are key to understand the burden of liver disease. They represent the end-stage of liver pathology and thus are indicative of the associated mortality. About 0.1% of Hungarian males will die of cirrhosis every year compared with 0.001% of Greek females. WHO estimate that liver cancer is responsible for around 47,000 deaths per year in the EU. Harmful alcohol consumption, viral hepatitis B and C and metabolic syndromes related to overweight and obesity are the leading causes of cirrhosis and primary liver cancer in Europe. Chronic hepatitis B affects 0.5-0.7% of the European population. In the last decade the prevalence of chronic hepatitis C was 0.13-3.26%. It is of great concern that about 90% of people in Europe infected by viral hepatitis are unaware of their status. Available data suggest the prevalence rate of NAFLD is 2-44% in the general European population (including obese children) and 42.6-69.5% in people with type 2 diabetes. Each of these four major causes of liver disease is amenable to prevention and treatment, reducing the burden of liver disease in Europe and saving lives. Further surveys are urgently needed to implement cost-effective prevention programmes and novel treatments to tackle this problem.

[Comparative analysis of serological tests performed in immigrants in the Lleida health area]

Objetivo

Evaluar el proceso de cribado y detección de virus de la inmunodeficiencia humana (VIH), virus de la hepatitis B (VHB) y de la hepatitis C (VHC) y sífilis en los inmigrantes de nuestra región sanitaria, determinando las proporciones de resultados positivos entre colectivos durante un año.

Diseño

Estudio descriptivo multicéntrico donde se analizaron todas las serologías realizadas a inmigrantes y autóctonos atendidos durante todo el año 2007.

Emplazamiento

Provincia de Lleida (España).

Participantes

Se incluyeron 255.410 usuarios.

Mediciones principales

Edad, sexo, país de origen y tiempo de permanencia en nuestro país y los resultados para VIH, hepatitis B, hepatitis C y sífilis. Se evaluó si había asociación entre las tasas de marcadores positivos y la zona geográfica de procedencia. Se calcularon las tasas ajustadas por grupos de edad estandarizadas según el método directo.

Resultados

El colectivo de origen inmigrante presenta 4,6 veces más probabilidades de tener VHB que el colectivo autóctono (razón de porcentajes [RP] = 4,6), siendo el colectivo sudafricano y de Europa del Este el que presenta una mayor probabilidad de VHB (RP = 11,7 y 4,5). En la sífilis el porcentaje de positivos es 3 veces mayor en el colectivo inmigrante con las diferencias mayores detectadas en el colectivo latinoamericano (RP = 5,5). En el VIH la RP en inmigrantes fue de 2,3 (específicamente en subsaharianos una RP = 7,4). En la hepatitis C los inmigrantes obtienen un menor riesgo de ser positivos que los autóctonos (RP = 0,4).

Conclusiones

Se constatan diferencias importantes en la probabilidad de detectar un resultado positivo de hepatitis B, sífilis o VIH en el cribado cuando el usuario es de origen inmigrante.

Hepatitis C virus prevalence in The Netherlands: migrants account for most infections

A population-based anti-hepatitis C virus (HCV) prevalence is important for surveillance purposes and it provides insight into the burden of disease. The outcomes of recent studies in the general Dutch population as well as recent HCV data from specific risk groups including migrants, men who have sex with men (MSM) and injecting drug users (IDUs), were implemented in a modified version of the Workbook Method (a spreadsheet originally designed for HIV estimations), to estimate Dutch HCV seroprevalence. The estimated national seroprevalence of HCV was 0·22% (min 0·07%, max 0·37%), corresponding to 28 100 (min n = 9600, max n = 48 000) HCV-infected individuals in The Netherlands. Of these, first-generation migrants from HCV-endemic countries (HCV prevalence ≥2%) accounted for the largest HCV-infected group, followed by IDUs and HIV-positive MSM.

Incidence of acute hepatitis B in different ethnic groups in a low-endemic country, 1992-2009: increased risk in second generation migrants

BACKGROUND

The Netherlands is a low-incidence country for acute hepatitis B (HBV) infection (1.2/100,000 in 2010), where it is typically acquired in adulthood through injecting drug use or homosexual exposure. Recently, the number of heterosexually acquired acute infections in the Netherlands has increased. Ethnicity may be a risk factor. We describe trends in the incidence of acute HBV among heterosexual adults in ethnic groups in Amsterdam from 1992 to 2009 and discuss future control of HBV in the Netherlands.

METHODS

We studied all cases of acute HBV acquired in heterosexuals aged ≥15 years in the Amsterdam region (1992-2009, n=238) by ethnic group. Incidence rates were estimated as the average number of cases per 100,000 per year. Using Poisson regression, we calculated univariable and multivariable incidence rate ratios (IRR) by ethnic group over calendar year, by age and gender.

RESULTS

The incidence in first generation migrants from HBV-endemic countries (FGM) was 4.1/100,000 showing no trend over time. Since 1999, incidence in Dutch-born cases in Amsterdam has increased by 13% annually from 0.2/100,000 in 1999 to 2.1/100,000 in 2009 (annual IRR 1.13, 95% CI:1.0-1.22). From 2004 to 2009, the incidence in native Dutch/Western in Amsterdam was 1.6/100,000 (reference for IRR), in FGM was 4.3/100,000 (IRR of 2.7, 95% CI:1.8-4.2) and in Dutch-born second generation migrants (SGM) was 3.7/100,000 (IRR:2.4, 95% CI:1.2-4.7).

CONCLUSION

Incidence of acute hepatitis B in Amsterdam in FGM and SGM is higher than in the native Dutch population. Low-endemic countries with migrant populations from HBV-endemic areas should consider offering screening and vaccination to both FGM and SGM.

Seroprevalence of varicella-zoster virus and predictors for seronegativity in the Amsterdam adult population

BACKGROUND

In the Netherlands, infection with varicella-zoster virus (VZV) is considered a benign common childhood illness and routine vaccination against VZV is not done. In 1995 it was estimated that 98-100% of the adult Dutch general population is immune, yet the estimate is based on a database in which a relative small number of people of non-Dutch ethnic origin were represented. As the city of Amsterdam has large immigrant communities originating from various subtropical and tropical countries, such as Morocco, Surinam, and Turkey with probably lower VZV transmission, this study aimed to estimate the seroprevalence of VZV IgG antibodies (anti-VZV) among various ethnic groups in Amsterdam, and identify factors associated with seronegative VZV status.

METHODS

The study was a cross-sectional survey of the Amsterdam population (2004), and the study sample was stratified by age and ethnicity, with deliberate oversampling of minority ethnic groups. Serum samples obtained from 1,341 residents in 2004 were tested for antibodies to VZV. Basic demographic data (gender, age, country of birth, age at immigration and number of children) were also available.

RESULTS

The anti-VZV seroprevalence in the overall Amsterdam population was estimated to be 94% (95% confidence intervals; 92-96%). Regarding ethnic origin, first generation immigrants (Moroccan immigrants 90%, Surinamese or Antillean immigrants 91%, and Turkish 92%), especially those that migrated after the age of 11 years, were more likely to be anti-VZV seronegative compared to those arriving at an earlier age or those born in the Netherlands (97-98%). Both ethnic origin and generation of immigration were positive predictors for IgG seronegativity to VZV (p<0.015). No other predictors for seronegativity were found.

CONCLUSION

The results of this study imply that about 4-8% of the general adult Amsterdam population is still susceptible to infection with VZV, and that susceptibility is even higher in some immigrant groups. When assessing the risk of infection after VZV exposure alertness is needed for vulnerable persons like pregnant women, patients with hematological malignancies or organ transplants in particular among first-generation immigrants.

Hepatitis C virus seroprevalence in the Netherlands

A population-based anti-hepatitis C virus (HCV) prevalence is important for surveillance purposes and it provides an insight into the burden of disease. In The Netherlands, a recent HCV seroprevalence estimate is not available. This national population-based cross-sectional serosurvey (PIENTER-2) resulted in a weighted national HCV seroprevalence of 0.30% (95% confidence interval 0.05-0.55%). About 70% of the HCV positive individuals found were born in an HCV-endemic country.

Hepatitis C in the general population of various ethnic origins living in the Netherlands: should non-Western migrants be screened?

BACKGROUND & AIMS

Little is known about the HCV prevalence in non-Western migrant populations. To determine whether targeted HCV screening and prevention programs for migrants are needed, we examined HCV prevalence and determinants among non-Western, Western migrants, and the native Dutch population in the Netherlands.

METHODS

Data were obtained from four surveys: (1) 3895 heterosexual visitors recruited during biannual surveys at the STI-clinic Amsterdam, 2007-2009; (2) random sample of 4563 pregnant women in Amsterdam, 2003; (3) population-based random sample of 1309 inhabitants of Amsterdam, 2004; (4) population-based random sample of 4428 people living in the Netherlands, 2006-2007. Characteristics associated with HCV-positivity were examined and phylogenetic analysis was used to obtain insight in the geographical origin of HCV strains.

RESULTS

HCV seroprevalence in the four surveys was low (0.3-0.6%). In total 4860/14,195 (34%) were non-Western and 9329/14,195 (66%) Western participants (including Dutch). First-generation non-Western migrants were more likely to be HCV-positive (0.7-2.3%) than Western participants (0.1-0.4%). Except for survey 3, second-generation non-Western migrants had a lower HCV prevalence than first-generation migrants, comparable to Western migrants and the Dutch population. Phylogenetic analysis showed that the majority of the HCV-positive, first-generation non-Western non-European migrants were infected with endemic strains which are rarely observed in Europe.

CONCLUSIONS

First-generation non-Western migrants are at increased risk for HCV. Phylogenetic analysis suggests that transmission likely took place in the country of origin, causing introduction but no further transmission of endemic HCV strains in the Netherlands. HCV screening and prevention programs should target first-generation, but not second-generation, non-Western migrants.

Prevalence of hepatitis B virus infection in The Netherlands in 1996 and 2007

We aimed to assess differences in the prevalence of hepatitis B virus (HBV) infection in The Netherlands between 1996 and 2007, and to identify risk factors for HBV infection in 2007. Representative samples of the Dutch population in 1996 and 2007 were tested for antibodies to hepatitis B core antigen (anti-HBc), hepatitis B surface antigen (HBsAg) and HBV-DNA. In 2007, the weighted anti-HBc prevalence was 3·5% (95% CI 2·2-5·5) and the HBsAg prevalence was 0·2% (95% CI 0·1-0·4). In indigenous Dutch participants, the anti-HBc prevalence was lower in 2007 than in 1996 (P=0·06). First-generation migrants (FGMs) had a 13-fold greater risk of being HBsAg- and/or HBV-DNA-positive than indigenous Dutch participants. In indigenous Dutch participants, risk factors for anti-HBc positivity were older age and having received a blood product before 1990. In FGMs, being of Asian origin was a risk factor. In second-generation migrants, having a foreign-born partner and injecting drug use were risk factors. FGMs are the main target group for secondary HBV prevention in The Netherlands.

Hepatitis C virus infection among transmission-prone medical personnel

Hepatitis C virus (HCV)-infected physicians have been reported to infect some of their patients during exposure-prone procedures (EPPs). There is no European consensus on the policy for the prevention of this transmission. To help define an appropriate preventive policy, we determined the prevalence of HCV infection among EPP-performing medical personnel in the Academic Medical Center in Amsterdam, the Netherlands. The prevalence of HCV infection was studied among 729 EPP-performing health care workers. Serum samples, stored after post-hepatitis B virus (HBV) vaccination testing in the years 2000–2009, were tested for HCV antibodies. Repeat reactive samples were confirmed by immunoblot assay and the detection of HCV RNA. The average age of the 729 health care workers was 39 years (range 18–66), suggesting a considerable cumulative occupational exposure to the blood. Nevertheless, only one of the 729 workers (0.14%; 95% confidence interval [CI]: <0.01% to 0.85%) was tested and confirmed to be positive for anti-HCV and positive for HCV RNA, which is comparable to the prevalence of HCV among Amsterdam citizens. Against this background, for the protection of personnel and patients, careful follow-up after needlestick injuries may be sufficient. If a zero-risk approach is desirable and costs are less relevant, the recurrent screening of EPP-performing personnel for HCV is superior to the follow-up of reported occupational exposures.

Anti-hepatitis A seroprevalence among chronic viral hepatitis patients in Kelantan, Malaysia

AIM: To determine the seroprevalence of anti-hepatitis A virus (HAV) antibodies in patients with chronic liver disease (CLD) and to justify the need for hepatitis A vaccination.

METHODS: Patients (n = 119) were enrolled between July and September 2009. The diagnosis of CLD was based on the presence of viral markers for more than 6 mo. The diagnosis of liver cirrhosis was based on clinical, biochemical and radiological profiles. Patient serum was tested for anti-HAV IgG.

RESULTS: The overall anti-HAV seroprevalence was 88.2%. The aetiology of CLD was hepatitis B in 96 patients (80.7%) and hepatitis C in 23 patients (19.3%). Mean age was 44.4 ± 14 years. Patients were grouped according to age as follows: 24 (20.2%) patients in the 21-30 years age group, 22 (18.5%) in the 31-40 years age group, 31 (26.1%) in the 41-50 years age group, 23 (19.3%) in the 51-60 years age group and 19 (16.0%) patients aged greater than 60 years, with reported seroprevalences of 66.7%, 95.5%, 93.5%, 91.3% and 94.7%, respectively. There was a marked increase of seroprevalence in subjects older than 30 years (P = 0.001).

CONCLUSION: Our study demonstrated that patients aged greater than 30 years of age were likely to have natural immunity to hepatitis A. Therefore, hepatitis A vaccination may not be routinely required in this age group.

People with multiple tattoos and/or piercings are not at increased risk for HBV or HCV in The Netherlands

Background

Although published results are inconsistent, it has been suggested that tattooing and piercing are risk factors for HBV and HCV infections. To examine whether tattooing and piercing do indeed increase the risk of infection, we conducted a study among people with multiple tattoos and/or piercings in the Netherlands who acquired their tattoos and piercings in the Netherlands and/or abroad.

Methods

Tattoo artists, piercers, and people with multiple tattoos and/or piercings were recruited at tattoo conventions, shops (N = 182), and a biannual survey at our STI-outpatient clinic (N = 252) in Amsterdam. Participants were interviewed and tested for anti-HBc and anti-HCV. Determinants of HBV and HCV infections were analysed using logistic regression analysis.

Results

The median number of tattoos and piercings was 5 (IQR 2–10) and 2 (IQR 2–4), respectively. Almost 40% acquired their tattoo of piercing abroad. In total, 18/434 (4.2%, 95%CI: 2.64%–6.46%) participants were anti-HBc positive and 1 was anti-HCV positive (0.2%, 95%CI: 0.01%–1.29%). Being anti-HBc positive was independently associated with older age (OR 1.68, 95%CI: 1.03–2.75 per 10 years older) and being born in an HBV-endemic country (OR 7.39, 95%CI: 2.77–19.7). Tattoo- and/or piercing-related variables, like having a tattoo or piercing in an HBV endemic country, surface percentage tattooed, number of tattoos and piercings etc., were not associated with either HBV or HCV.

Conclusions

We found no evidence for an increased HBV/HCV seroprevalence among persons with multiple tattoos and/or piercings, which might be due to the introduction of hygiene guidelines for tattoo and piercing shops in combination with the low observed prevalence of HBV/HCV in the general population. Tattoos and/or piercings, therefore, should not be considered risk factors for HBV/HCV in the Dutch population. These findings imply the importance of implementation of hygiene guidelines in other countries.

Development of a culturally tailored Internet intervention promoting hepatitis B screening in the Turkish community in the Netherlands

Hepatitis B virus infections are an important health problem in the Turkish community in the Netherlands. Screening for hepatitis B should be promoted through public health interventions, which take into account the socio-cultural and behavioural determinants that influence screening. The Intervention Mapping protocol was used to develop a culturally tailored Internet intervention for first-generation Turkish immigrants in Rotterdam, aged 16-40 year. Behavioural factors and cultural motivators and barriers, identified in the first steps of the protocol, were incorporated in the intervention. To ensure participation, members of the target population were involved in all steps of programme development. A theory- and evidence-based culturally tailored intervention was developed. Both surface structure and deep structure elements were used; surface structure tailoring resulting in different Internet skins and peer-stories for subgroups, such as young women. Deep structure elements comprised cultural motivators such as the religiously inspired feelings of responsibility and strong family values, and perceived community rules regarding health and disease. Cultural barriers that were addressed were the satisfaction and trust in Dutch health care, and the association of hepatitis B screening with sexual behaviour. Intervention Mapping provided a useful framework for the systematic development of our theory- and evidence-based intervention to promote hepatitis B screening in the Turkish community in the Netherlands.

Hepatitis B prevalence in the Turkish population of Arnhem: implications for national screening policy?

Despite the increased prevalence of hepatitis B and C in most migrant groups in The Netherlands, a national screening policy for these infections is not available. In order to estimate the prevalence of hepatitis B and C in the largest group of first-generation migrants (FGM) in The Netherlands, we conducted a screening project in the Turkish community of Arnhem. In a separate project we identified patients from the target population with chronic hepatitis B and C from hospital records (1990-2008). Educational meetings concerning hepatitis were organized, with all participants being offered a blood screening test. Participants were tested for hepatitis B surface antigen (HBsAg), antibodies to hepatitis B core antigen (anti-HBc) and antibodies to hepatitis C virus (anti-HCV). In total 709 persons were tested, a complete dataset was available for 647 patients. We found that 3·0% and 0·4% of Turkish FGM aged >24 years in Arnhem had active hepatitis B, defined as HBsAg positive, and tested positive for anti-HCV, respectively. The hospital records revealed another 32 patients, 28 with hepatitis B and four with hepatitis C representing 0·7% for hepatitis B and 0·1% for hepatitis C in relation to the total number of Turkish FGM in Arnhem. We believe that active hepatitis screening of FGM from Turkey should be part of the national health policy as it will benefit the individual and public health.

Hepatitis A seroprevalence in a population of immigrants at a French vaccination center

BACKGROUND

Hepatitis A vaccination is recommended to people traveling to countries where the disease is endemic. Until recently, people originating from developing countries were considered to be "naturally" immunized. Because of improving socioeconomic conditions, hepatitis A incidence has decreased in most previously highly endemic countries during the last three decades, especially in the younger age groups.

METHODS

We analyzed hepatitis A seroprevalence of 989 travelers who had been born and lived at least 1 year in a developing country, wanted to travel to a hepatitis A endemic area, and consulted at the vaccination center of the Institut Pasteur of Paris between September 1, 2008 and February 28, 2010.

RESULTS

Hepatitis A serology results were available for 646 subjects. Overall seroprevalence was 82.4%. A total of 90, 82.6, 81.2, 68.4, 56.9, and 50% of people of sub-Saharan African, Near and Middle Eastern, North African, Asian, Latin American, and Eastern European origin had hepatitis A antibodies, respectively. The difference in seroprevalence according to the continent of origin, age, and length of stay in an endemic country was significant (p < 0.0001). More than 75% of seronegatives and less than 50% of seropositives were younger than 36 years. Almost three quarters of the positive group (while less than half of the negative group) lived longer than 18 years in a developing country. Multivariate analysis showed that seroprevalence increases with age, length of stay in a country at risk, and varies significantly from one continent to another.

CONCLUSION

We recommend extending serologic confirmation of immigrants' hepatitis A immunity. If time is lacking, vaccination should be considered.

Cultural tailoring for the promotion of hepatitis B screening in Turkish Dutch: a protocol for a randomized controlled trial

BACKGROUND

Chronic hepatitis B virus infection (HBV) is an important health problem in the Turkish community in the Netherlands, and promotion of screening for HBV in this risk group is necessary. An individually tailored intervention and a culturally tailored intervention have been developed to promote screening in first generation 16-40 year old Turkish immigrants. This paper describes the design of the randomized controlled trial, which will be used to evaluate the effectiveness of the two tailored internet interventions as compared to generic online information on HBV, and to assess the added value of tailoring on socio-cultural factors.

METHODS/DESIGN

A cluster randomized controlled trial design, in which we invite all Rotterdam registered inhabitants born in Turkey, aged 16-40 (n = 10,000), to visit the intervention website is used. A cluster includes all persons living at one house address. The clusters are randomly assigned to either group A, B or C. On the website, persons eligible for testing will be selected through a series of exclusion questions and will then continue in the randomly assigned intervention group. Group A will receive generic information on HBV. Group B will receive individually tailored information related to social-cognitive determinants of screening. Group C will receive culturally tailored information which, next to social-cognitive factors, addresses cultural factors related to screening. Subsequently, participants may obtain a laboratory form, with which they can be tested free of charge at local health centres. The main outcome of the study is the percentage of eligible persons tested for HBV through to participation in one of the three groups. Measurements of the outcome behaviour and its determinants will be at baseline and five weeks post-intervention.

DISCUSSION

This trial will provide information on the effectiveness of a culturally tailored internet intervention promoting HBV-screening in first generation Turkish immigrants in the Netherlands, aged 16-40. The results will contribute to the evidence base for culturally tailored (internet) interventions in ethnic minority populations. An effective intervention will lead to a reduction of the morbidity and mortality due to HBV in this population. This may not only benefit patients, but also help reduce health inequalities in western countries.

TRIAL REGISTRATION

The Netherlands National Trial Register NTR 2394.

Awareness, knowledge and self-reported test rates regarding Hepatitis B in Turkish-Dutch: a survey

Background

Hepatitis B virus infection is an important health problem in the Turkish community in the Netherlands. To prevent transmission and progression of the disease in this community, increased screening is necessary. This study aimed to determine 1) the levels of awareness and knowledge regarding hepatitis B, comparing these in tested and non-tested Turkish-Dutch in Rotterdam; 2) the self-reported hepatitis B test status in this population, and how this is related to demographic characteristics, knowledge and awareness.

Methods

We conducted a postal survey amongst first and second generation migrants, aged 16 - 40 years.

Results

The response rate was 30.2% (n = 355 respondents). Levels of awareness and knowledge regarding hepatitis B were low, as the majority of respondents (73%) never thought about the disease and 58% of the respondents scored 5 or less out of ten knowledge items. Weighted analysis of self-reports showed a test rate of 15%, and a vaccination rate of 3%. Regression analysis showed that having been tested for hepatitis B was related to being married and higher levels of awareness and knowledge.

Conclusions

This study shows low levels of hepatitis B awareness and knowledge in the Turkish community in Rotterdam. Self-reported test rates are lower in people who are not currently married, and in those who have low levels of awareness and knowledge. Especially, knowledge about the consequences of hepatitis B, such as liver cancer, was lacking. Therefore, a health promotion intervention should foremost raise awareness, and increase knowledge on the seriousness of this disease.

Screening and early treatment of migrants for chronic hepatitis B virus infection is cost-effective

BACKGROUND & AIMS

Persons with chronic hepatitis B virus (HBV) infection are at risk of developing cirrhosis and hepatocellular carcinoma. Early detection of chronic HBV infection through screening and treatment of eligible patients has the potential to prevent these sequelae. We assessed the cost-effectiveness in The Netherlands of systematically screening migrants from countries that have high and intermediate HBV infection levels.

METHODS

Epidemiologic data of the expected numbers of patients with active chronic HBV infection in the target population and information about the costs of a screening program were used in a Markov model and used to determine costs and quality-adjusted life years (QALY) for patients who were and were not treated.

RESULTS

Compared with the status quo, a 1-time screen for HBV infection can reduce mortality of liver-related diseases by 10%. Using base case estimates, the incremental cost-effectiveness ratio (ICER) of screening, compared with not screening, is euros (euro) 8966 per QALY gained. The ICER ranged from euro7936 to euro11,705 based on univariate sensitivity analysis, varying parameter values of HBV prevalence, participation rate, success in referral, and treatment compliance. Using multivariate sensitivity analysis for treatment effectiveness, the ICER ranged from euro7222 to euro15,694; for disease progression, it ranged from euro5568 to euro60,418.

CONCLUSIONS

Early detection and treatment of people with HBV infection can have a large impact on liver-related health outcomes. Systematic screening for chronic HBV infection among migrants is likely to be cost-effective, even using low estimates for HBV prevalence, participation, referral, and treatment compliance.

Hepatitis B screening in the Turkish-Dutch population in Rotterdam, the Netherlands; qualitative assessment of socio-cultural determinants

Background

Hepatitis B is an important health problem in the Turkish community in the Netherlands. Increased voluntary screening is necessary in this community, to detect individuals eligible for treatment and to prevent further transmission of the disease.

Methods

We investigated socio-cultural determinants associated with hepatitis B screening in male and female, first and second generation Turkish migrants, by means of Focus Group Discussions.

Results

Socio-cultural themes related to hepatitis B screening were identified; these were social norm, social support, sensitivity regarding sexuality, reputation, responsiveness to authority, religious responsibility, cleanliness and religious doctrine regarding health and disease, and the perceived efficacy of Dutch health care services. Motivating factors were the (religious) responsibility for one's health, the perceived obligation when being invited for screening, and social support to get tested for hepatitis B. Perceived barriers were the association of hepatitis B screening with STDs or sexual activity, the perception of low control over one's health, and the perceived low efficacy of the Dutch health care services. Reputation could act as either a motivator or barrier.

Conclusion

This study identified relevant socio-cultural themes related to hepatitis B screening, which may serve to customize interventions aimed at the promotion of voluntary hepatitis B screening in the Turkish-Dutch population in the Netherlands.

Population-based study on the seroprevalence of parvovirus B19 in Amsterdam

A study was undertaken to estimate the seroprevalence of parvovirus B19 infection in the general adult population of Amsterdam, The Netherlands. To our knowledge this is the first study testing parvovirus B19 in a random sample of the Dutch adult population. The study was a cross-sectional survey, and the study sample was stratified by age and ethnicity, with deliberate oversampling of minority ethnic groups. Serum samples obtained from 1,323 residents in 2004 were tested for antibodies to parvovirus B19. Basic demographic data (gender, age, country of birth, and number of children) were also available. Sixty-two percent of the participants were seropositive; corrected for the oversampling the estimated prevalence in the Amsterdam adult population was 61%. No specific predictors or risk groups for seropositivity were identified. In our urban adult study population no positive correlation with increasing neither age, nor significant differences between age groups were found. These results imply that almost 40% of the adult Amsterdam population is susceptible to infection. J. Med. Virol. 81:1305-1309, 2009. (c) 2009 Wiley-Liss, Inc.

Seroepidemiology of hepatitis A among Greek children indicates that the virus is still prevalent: Implications for universal vaccination

A national cross-sectional seroprevalence survey was conducted in order to evaluate the current seroepidemiology of hepatitis A among 1,383 children, aged 0-14 years, residing in Greece. Stratification of the study population was conducted according to age and area of residence. Sera from study participants were tested for the presence of anti-HAV IgG antibodies. Immigrant children, as well as children residing in rural areas, had lower immunization rates. Among unvaccinated children, the seroprevalence rate of anti-HAV was 17.1%. Nationality was shown to have a marginally significant effect since non-immunized immigrant children had a higher seroprevalence rate (22.4% vs. 15.9%, OR = 1.52, P = 0.064). Significant differences between geographic areas for both vaccination coverage and natural immunity were observed. The study findings indicate that hepatitis A is prevalent in Greece and therefore universal infant hepatitis A immunization should be implemented.

Risk of hepatitis B for travelers: is vaccination for all travelers really necessary?

OBJECTIVES

Behavioral studies in travelers suggest that 33% to 76% of all travelers to hepatitis B virus (HBV)-endemic countries are at risk for HBV infection. We study the incidence and risk factors for HBV infection in travelers.

METHODS

Retrospective analysis of the characteristics and risk factors of all reported acute HBV patients in Amsterdam, the Netherlands, from January 1, 1992, until December 31, 2003.

RESULTS

The estimated incidence in travelers from Amsterdam to HBV-endemic countries is 4.5/100,000 travelers. Two thirds of these patients were immigrants who lived in Amsterdam and who had visited their friends and relatives in their country of origin. In 12 years, only three Dutch short-term tourists contracted HBV while traveling, all by heterosexual contacts.

CONCLUSIONS

Dutch tourists who travel to HBV-endemic countries run a very low risk of contracting HBV. Vaccination of short-term Dutch tourists is not necessary. Immigrants run a higher risk irrespective of travel or duration of travel. This group should be advised vaccination.

[Hepatitis B in pregnant women and children]

In pregnant women and children, the hepatitis B virus can cause acute or chronic hepatitis or liver cirrhosis. Perinatally-acquired infection causes persistent infection in 90% of cases and can be avoided through administration of the hepatitis B vaccine and specific immunoglobulin in the first day of life. Prevention of mother-to-child transmission requires screening for hepatitis B surface antigen (HBsAg) in pregnant women to identify which newborns should be immunized. In some countries this strategy is substituted by universal vaccination of neonates. In infected children, inactivation of viral replication with conversion of HBeAG-positive to anti-HBe-positive status usually occurs. If this seroconversion does not take place and necroinflammatory activity persists in the liver, the use of antiviral agents such as interferon or nucleoside and nucleotide analogs is warranted.

Trends in hepatitis A, B, and shigellosis compared with gonorrhea and syphilis in men who have sex with men in Amsterdam, 1992-2006

BACKGROUND

Since the mid-1990s, sexually transmitted infections (STIs) among men who have sex with men (MSM) have increased and appear to be related to more risky sexual behavior. We compare trends in hepatitis A, acute hepatitis B, and shigellosis with the trends of gonorrhea and infectious syphilis in Amsterdam MSM more than a period of 15 years.

METHODS

We used data of all reported hepatitis A, acute hepatitis B, and shigellosis, and from all patients newly diagnosed with gonorrhea and infectious syphilis who visited the Public Health Service STI outpatient department in Amsterdam between January 1, 1992 and December 31, 2006.

RESULTS

Hepatitis A incidence remained unchanged in MSM (mean 0.97 per 1000 MSM, range 0.04-2.27), who had 21% of all 1697 infections. Hepatitis B likewise remained unchanged in MSM (mean 0.47 per 1000 MSM, range 0.19-0.77), who had 41% of all 448 infections. Most shigellosis is travel-related (657/974), and 16% of the infections occurred in MSM. Its incidence dropped in general, but not in MSM. Both gonorrhea and infectious syphilis in MSM show a steep increase, mainly after 1998.

DISCUSSION

Hepatitis A, B, and shigellosis do not follow the rising trends of conventional STI in MSM, which are believed to result from increased risky sexual behavior. This disparity in trends implies differences in transmission dynamics. Recent molecular epidemiologic studies suggest that clustered transmission in social MSM networks plays a major role.

High impact of migration on the prevalence of chronic hepatitis B in the Netherlands

OBJECTIVES

A representative serosurveillance study (1995) resulted in an estimate of 0.2% for the HBsAg prevalence in the Netherlands. Some risk groups, especially migrants, were not well represented in the study, which probably led to an underestimation of the true HBsAg prevalence. The aim of this study was to calculate an adjusted HBsAg prevalence estimate for the total Dutch population including these risk groups.

METHODS

According to their country of origin first-generation migrants (FGM) were classified into groups with low, intermediate and high prevalence using data from the WHO and Statistics Netherlands. The number of chronic HBsAg carriers in different age and population groups was estimated based on studies about age-specific prevalence in different countries. The number of carriers in the indigenous population was estimated using the serosurveillance study. A combination of these estimates led to an estimate of the total prevalence rate in the Netherlands.

RESULTS

Nearly 10% of the Dutch population are FGM. Of these, about 18% were born in low-endemic, 71% in middle-endemic and 11% in high-endemic countries. The overall prevalence of HBsAg in FGM is estimated to be at 3.77%. Combining these results with the results of the serosurveillance study the HBsAg prevalence in the Dutch population is estimated to be between 0.32 and 0.51%, and when including injecting drug users and mentally handicapped persons the prevalence rates are 0.36 and 0.55%, respectively.

CONCLUSION

Our results show the high importance of targeting migrants and their close contacts adequately in screening programmes, vaccination and treatment for chronic hepatitis B.

Viral hepatitis in a multi-ethnic neighborhood in the Netherlands: results of a community-based study in a low prevalence country

OBJECTIVES

The prevalence of viral hepatitis varies worldwide. Although the prevalence of hepatitis A virus (HAV) and hepatitis B virus (HBV) infection is generally low in Western countries, pockets of higher prevalence may exist in areas with large immigrant populations. The aim of this study was to obtain further information on the prevalence of viral hepatitis in a multi-ethnic area in the Netherlands.

METHODS

We conducted a community-based study in a multi-ethnic neighborhood in the city of Rotterdam, the Netherlands, including both native Dutch and migrant participants, who were tested for serological markers of hepatitis A, hepatitis B, and hepatitis C infection.

RESULTS

Markers for hepatitis A infection were present in 68% of participants. The prevalence of hepatitis B core antibodies (anti-HBc), a marker for previous or current infection, was 20% (58/284). Prevalence of hepatitis A and B varied by age group and ethnicity. Two respondents (0.7%) had chronic HBV infection. The prevalence of hepatitis C was 1.1% (3/271). High levels of isolated anti-HBc were found.

CONCLUSIONS

We found a high prevalence of (previous) viral hepatitis infections. This confirms previous observations in ethnic subgroups from a national general population study and illustrates the high burden of viral hepatitis in areas with large immigrant populations.