Hepatitis A in young Norwegian drug addicts and prison inmates

Hepatitis A immunity and region-of-origin in a Swiss prison

Purpose - The environmental and demographic characteristics of closed institutions, particularly prisons, precipitate morbidity during hepatitis A virus (HAV) outbreaks. Given the high prevalence of chronic liver disease and other risk factors in the prison setting, the purpose of this paper is to examine HAV-immunity and its associated factors in this population. Design/methodology/approach - The cross-sectional study was conducted in 2009: a serology screening for HAV IgG was carried out among 116 inmates in Switzerland's largest pre-trial prison. Other participant characteristics were collected through a structured face-to-face questionnaire with a physician. Findings - In terms of significant demographics, Africa (53.5 percent) and the Balkans/Eastern Europe (36.2 percent) were the main regions of origin; a minority of inmates were from Western Europe (6.9 percent), Latin America (2.6 percent) or Asia (0.9 percent). The authors identified hepatitis A antibody-negative serology (lack of immunity) in five out of 116 prisoners (4.3 percent, 95 percent CI 1.4-9.7). Among participants of European origin alone, five out of 50 inmates were hepatitis A antibody-negative (10 percent, 95 percent CI 3.3-21.8), whereas the 66 inmates from other all continents were hepatitis A antibody-positive (immune) (p=0.026). Originality/value - In this prison population composed of mostly African migrants, hepatitis A immunity was high. This reaffirms that region of origin is highly associated with childhood immunity against HAV. HAV vaccination should take into account a patient's area of origin and his/her risk factors for systemic complications, if ever infected. This targeted strategy would offer herd immunity, and seek out the most vulnerable individuals who are potentially at risk of new exposure in this precarious setting.

Hepatitis A and considerations regarding the cost-effectiveness of vaccination programs

Hepatitis A vaccines have demonstrated a high degree of immunogenicity and an excellent safety profile. Immunization of certain populations and patient subgroups is recommended according to specific epidemiological and clinical factors, such as a greater likelihood of acquisition of infection or concerns regarding the risk of development of fulminant hepatitis and death. Therefore, the economic implications of routine and/or targeted vaccination programs in the general population and high-risk individuals have been examined. In this manuscript, the available data from the literature regarding the cost-effectiveness of hepatitis vaccination programs in healthy individuals and in those with chronic liver disease are reviewed.

Hepatitis A: old and new

The hepatitis A virus (HAV), a picornavirus, is a common cause of hepatitis worldwide. Spread of infection is generally person to person or by oral intake after fecal contamination of skin or mucous membranes; less commonly, there is fecal contamination of food or water. Hepatitis A is endemic in developing countries, and most residents are exposed in childhood. In contrast, the adult population in developed countries demonstrates falling rates of exposure with improvements in hygiene and sanitation. The export of food that cannot be sterilized, from countries of high endemicity to areas with low rates of infection, is a potentially important source of infection. After ingestion and uptake from the gastrointestinal tract, the virus replicates in the liver and is excreted into the bile. Cellular immune responses to the virus lead to destruction of infected hepatocytes with consequent development of symptoms and signs of disease. Humoral immune responses are the basis for diagnostic serologic assays. Acute HAV infection is clinically indistinguishable from other causes of acute viral hepatitis. In young children the disease is often asymptomatic, whereas in older children and adults there may be a range of clinical manifestations from mild, anicteric infection to fulminant hepatic failure. Clinical variants include prolonged, relapsing, and cholestatic forms. Management of the acute illness is supportive, and complete recovery without sequelae is the usual outcome. Research efforts during World War II led to the development of passive immunoprophylaxis. Pooled immune serum globulin is efficacious in the prevention and attenuation of disease in exposed individuals. More recently, active immunoprophylaxis by vaccination has been accomplished. Future eradication of this disease can now be contemplated.

Multiple modes of hepatitis A virus transmission among methamphetamine users

Methamphetamine users are at increased risk of hepatitis A, but modes of transmission are unclear. The authors conducted a case-control study among methamphetamine users during an outbreak in Iowa in 1997. Twenty-eight reported, laboratory-confirmed, hepatitis A cases did not differ from 18 susceptible controls with respect to age, sex, or number of doses used. When compared with controls in multivariate analysis, case-patients were more likely to have injected methamphetamine (odds ratio (OR) = 5.5, 95% confidence interval (CI): 1.1, 27), to have used methamphetamine with another case-patient (OR = 6.2, 95% CI: 0.95, 41), and to have used brown methamphetamine (OR = 5.5, 95% CI: 0.51, 59). Receptive needle sharing was reported by 10 of the 20 case-patients who injected. Methamphetamine use with another case-patient was also associated with hepatitis A in an analysis restricted to noninjectors (OR = 17, 95% CI: 1.0, 630). During this outbreak, hepatitis A may have been transmitted from person to person among methamphetamine users through the fecal-oral and the percutaneous routes. Methamphetamine users should be vaccinated against hepatitis A and should be given immune globulin if they used methamphetamine with a case-patient in the last 2 weeks. Persons who intend to continue using methamphetamine should be advised about safer practices.

Hepatitis A outbreaks among illicit drug users and their contacts in Queensland, 1997

OBJECTIVE

To describe five outbreaks of hepatitis A virus (HAV) infection associated with illicit drug use during a statewide outbreak of HAV infection in Queensland.

DESIGN

Risk factor prevalence survey.

PATIENTS AND SETTING

All 875 cases of HAV infection notified to Public Health Units in Queensland in the 12 months to 30 November 1997.

MAIN OUTCOME MEASURE

Type and prevalence of illicit drug use.

RESULTS

Risk factor assessment was completed for 804 cases (91.9%). We identified five outbreaks of HAV infection linked to illicit drug use. These outbreaks accounted for 24.6% (215/875) of all notified cases and 39% (190/482) of notified cases in the 15-34 years age group. The main type of illicit drug use in four of the five outbreaks was injecting drug use (74%; 118/160), while in the other outbreak it was sharing of smoking implements for marijuana (38%; 21/55).

CONCLUSION

Illicit drug use may be an under-recognised risk factor for HAV infection, particularly in young people. Faecal-oral transmission through poor personal hygiene, including sharing of implements for smoking marijuana, is the most probable route of transmission in these drug-linked outbreaks. The role of contaminated drug and needle-sharing remains to be clarified.

Identifying target groups for a potential vaccination program during a hepatitis A communitywide outbreak

OBJECTIVES

This study sought to identify groups for targeted vaccination during a communitywide hepatitis A outbreak in 1996.

METHODS

Residents of the Sioux City, Iowa, metropolitan area reported with hepatitis A between September 1995 and August 1996 were sampled and compared with population-based controls.

RESULTS

In comparison with 51 controls, the 40 case patients were more likely to inject methamphetamine, to attend emergency rooms more often than other health care facilities, and to have a family member who used the Special Supplemental Nutrition Program for Women, Infants, and Children.

CONCLUSIONS

Groups at increased risk of hepatitis A can be identified that might be [corrected] accessed for vaccination during communitywide outbreaks.

Hepatitis A in Western Austria--the epidemiological situation before the introduction of active immunisation

Several European countries report a decreasing prevalence of antibodies to hepatitis A virus (anti-HAV). This trend is most pronounced in the youngest age groups. In 1979, however, 58% of young Austrians aged 20 to 30 years were shown to possess anti-HAV. Here we describe the current epidemiological situation in western Austria. Prevalence of anti-HAV has decreased to 7% in those 18 to 30 years old. This percentage rises to 20% (31 to 40 years of age) and 57% (41 to 50 years of age) and is highest in those older than 50 years (87%). Of 180 cases of clinical hepatitis A occurring from 1985 to 1992 45% were imported by travel to HAV-endemic areas. Seventy-one percent of the cases in children (59/83) occurred in foreign workers' families and were also predominantly acquired abroad. A change in prevention policy should be considered in this respect, as vaccination is available now.

Prevalence of markers of hepatotropic viruses among drug addicts in Warsaw, Poland

We studied 100 unselected parenteral drug abusers for infection with hepatitis C, B, A and D virus (HCV, HBV, HAV and HDV). Seventy-six percent had serological evidence of HCV infection. 12% were positive for HBsAg and at least one marker of HBV infection was present in 69%. These results were significantly higher than in a matched control population. Compared to controls, the prevalence of anti-HAV (65%) was not significantly increased in drug addicts. Of the anti-HCV-positive drug addicts, 80.3% had at least one marker of HBV infection compared to 33.3% of anti-HCV-negative cases (p less than 0.001). No such correlation was found between the prevalence of HCV or HBV infection markers and the presence of anti-HAV. Antibodies against HDV were detected in 16 (16%) of the samples from drug addicts. No significant association was found between antibodies to HCV and gender, age and duration of drug abuse. The risk of HBV infection increased significantly with years of drug abuse but was not associated with age and sex. The presence of anti-HAV was related to age only. Sixteen (16%) of the subjects were definitely positive for anti-HIV-1, but at the time of the study they were asymptomatic. No significant association was found between the presence of anti-HIV and the prevalence of serological markers of HBV, HCV, HAV and HDV infection.

Safety and immunogenicity of an inactivated hepatitis A candidate vaccine in healthy adult volunteers

The reactogenicity and immunogenicity of a formaldehyde-inactivated hepatitis A vaccine have been investigated. Three different dose levels of vaccine (180, 360 and 720 ELISA units) were administered to healthy volunteers according to a 0, 1, 2 and 12 month schedule. The vaccine was safe and well tolerated. Reactions observed following vaccination were essentially mild and were not dependent upon the quantity of antigen administered. All subjects had measurable titres of anti-HAV antibodies after the full vaccination course; the immune response to the vaccine was dose-related. Antibody titres in vaccinees at month 13 were between 60- and 190-fold higher than those observed in a group of subjects given anti-HAV immunoglobulin.