The impact of the hepatitis B mass immunisation campaign on the incidence and risk factors of acute hepatitis B in Italy

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

Background: In 1991, a mass immunization campaign against the hepatitis B virus (HBV) for children and teenagers was introduced in Italy. This study evaluated the impact of the immunization campaign on the incidence and modes of HBV transmission. Method: Acute HBV cases of viral hepatitis were reported to the National Surveillance System (SEIEVA). Hepatitis A cases reported to the same system were used as controls to calculate the adjusted odds ratios and the population attributable risk for potential risk factors. Results: The incidence of acute HBV declined from 5.0 in 1990 to 0.4 in 2019 per 100,000 population. The fall was almost total in people targeted by the campaign: in 2019, zero cases (100% reduction) in the age-group 0–14 years and 0.1 cases per 100,000 population (99.4% reduction) in the age-group 15–24 years were reported. In the decade 2010–2019, nearly one-fifth (19.3%) of cases occurred in foreigners. Intravenous drug use is no longer a risk factor (OR = 0.7; 95% CI = 0.5–1.02). Beauty treatments, risky sexual exposure, and household contact with an HBsAg carrier were found to be independent predictors of acute hepatitis B. Conclusions: The HB vaccination campaign proved effective in minimising acute HBV in Italy. Control of the infection is close to being reached for the first time in Europe.

Future Healthcare Workers and Hepatitis B Vaccination: A New Generation

Before the introduction of universal vaccination, hepatitis B caused high morbidity and mortality, especially among healthcare workers. In the present study, the immune status against hepatitis B was assessed in a cohort of 11,188 students of the degree courses of the School of Medicine of the University of Padua (Italy) who had been subjected to mandatory vaccination in childhood or adolescence and who will be future healthcare workers. The variables that influence the antibody response to vaccination are mainly the age at which the vaccine was administered and sex. If vaccination was administered before one year of age, there is a high probability (around 50%) of having an antibody titer lower than 10 IU/L compared to those vaccinated after one year of age (12.8%). The time between vaccine and analysis is not decisive. Furthermore, female sex, but only if vaccination was administered after one year of age, shows a significant (p = 0.0008) lower percentage of anti-HBs below 10 IU/L and a greater antibody titer (p < 0.0001). In conclusion, the differences related to the age of vaccination induce more doubts than answers. The only plausible hypothesis, in addition to the different immune responses (innate and adaptive), is the type of vaccine. This is not easy to verify because vaccination certificates rarely report it.

Hepatocellular carcinoma: old friends and new tricks

Hepatocellular carcinoma (HCC) is the most prevalent primary liver cancer and a leading cause of cancer-related deaths worldwide. Ninety percent of HCC cases arise from cirrhosis, during which liver cells undergo chronic cycles of necrosis and regeneration. The complex genomic landscape of HCC has been extensively investigated to draw correlations between recurrently mutated pathways and patient prognosis. However, our limited success with targeted therapy shows that knowing the presence of somatic mutations alone is insufficient for us to gauge the full spectrum of their functional consequences in the context of tumor evolution. In addition, the current molecular classification of HCC offers little information on the relationship between the molecular features and immunological properties of HCC tumors and their immune microenvironment. This review introduces current challenges and advancements made in HCC surveillance, diagnosis, and treatment. We also discuss the suite of HCC-associated genetic changes and describe recent studies that provide evidence for an evolving functional model and its implications for understanding and targeting HCC progression.

Chronic hepatitis B virus infection in Italy during the twenty-first century: an updated survey in 2019

The aim of this study is to provide updates on the characteristics of chronic HBsAg carriers in Italy before the advent of new drugs eliminating or functionally inactivating the genome HBV reservoirs. HBV endemicity has greatly decreased in Italy over the past decades. A not negligible number of chronic HBsAg carriers are still alive in the country. Chronic HBsAg carriers consecutively referring to 9 units in Italy were prospectively enrolled for a 6-month period in 2019. Multiple logistic regression analysis was performed to identify independent predictors of treatment. A total of 894 cases was recruited (sex ratio 1.6; mean age 53.7 ± 13.5 years). The proportion of subjects born abroad was 19.0%; only 1% of cases reported current heavy alcohol intake (> 4 units/day). Chronic HBV infection, chronic HBV hepatitis, and subjects with liver cirrhosis and/or HCC represented 24.8%, 55%, and 19.3% of cases, respectively. After exclusion of the 222 subjects with chronic HBV infection, the proportion of subjects under therapy was as high as 89.3%. A more severe liver disease (OR 2.52; 95% CI = 1.25-5.14) resulted an independent predictor of the likelihood of treatment; male sex was marginally associated (OR 1.67; 95% CI = 1.02-2.76) to the chance of treatment. People born abroad had same chance than Italians native to be treated (OR 2.12; 95% CI = 0.9-4.97). The high proportion of subjects under treatment and the absence of gender and ethnic barrier against treatment sound good news. These updated figures may represent reference data for evaluating the potential impact of forthcoming new therapy against HBV-related disease.

The association between education level and chronic liver disease of any etiology

BACKGROUND

The potential link between educational level and chronic liver diseases (CLD) were explored using the mortality records of liver cirrhosis, which lack accuracy and are unable to identify the different etiological factors of liver cirrhosis. Information on the association of low educational level with the severity of CLD is lacking.

AIM

To evaluate the potential association linking education level to etiology and clinical stage of CLD cases.

METHODS

Consecutive enrolment of 11,107 subjects with CLD aged≥18 years prospectively recruited in two national surveys in 2001 and 2014 at one of the participating Italian liver units throughout the country. Subjects were pooled in two groups: low education level (less than high school) and high education level (completed high school or beyond). The association of demographic, etiological, and clinical stage of subjects with educational level was assessed using logistic regression analysis. In the analysis low educational level was the outcome variable.

RESULTS

A total of 11,107 subjects born in Italy (mean age 55.5 years, sex ratio 1.5) were evaluated. Multiple logistic regression analysis shows that chronic HCV infection (O.R.1,38:95%,C.I.1.23-1.55), risky alcohol intake (O.R.1.96;95%,C.I.1.73-2.21) and liver cirrhosis (O.R.1.65;95%,C.I.1.46-1.85) all resulted independently associated with less than a completed high school education. HBV infection resulted independently associated with high education level (O.R.0.74;95%,C.I.0.64-0.86), reflecting changes in HBV modes of transmission in recent decades. No association was found with CLD related to non-alcoholic fatty liver disease (O.R.1.03;95%, C.I.0.81-1.30).

CONCLUSIONS

These findings show an independent association linking education level with viruses and alcohol-related CLD. Low educational level is associated with the severity of CLD.

High chance to overcome the non-responder status to hepatitis B vaccine after a further full vaccination course: results from the extended study on healthcare students and workers in Florence, Italy

Healthcare workers (HCWs) are considered high-risk subjects for Hepatitis B Virus (HBV) infection due to occupational exposure to blood and body fluids. Vaccination represents the core strategy for HBV infection prevention. Following our previous publication on this topic, we aimed to assess the effectiveness of booster vaccine doses in eliciting the immunological response in seronegative (<10 mIU/mL) HCWs and students of Careggi Teaching Hospital, Florence (Italy). All subjects received primary vaccination course, and they were tested for serum anti-HBs antibodies. In seronegative subjects, a challenge dose of vaccine was administered and the test was repeated 1 month later. Six hundred and ninety-eight (87.8%) of 795 HCWs and students tested responded to the challenge dose. After this challenge dose, males more often had negative anti-HBs titer compared with females (15.9% vs 10.2%; p < .05). The completion of the second vaccination course was offered to subjects with persistently negative anti-HBs titer. 76.2% (32) of those who accepted the fifth dose, and 3 of the 5 who accepted the sixth dose seroconverted. This report shows the importance to convey a strong message to negative subjects at the initial anti-HBs dosage: accepting all the three additional vaccine doses allows the vast majority of them to obtain protection.

A Study on Hepatitis B Viral Seromarkers and Associated Risk Factors among the Patients Suffering from Acute and Chronic Hepatitis B Infection

Background:

Hepatitis B viral infection is the most common cause of hepatitis, and it leads to serious liver diseases such as cirrhosis and hepatocellular carcinoma.

Aim:

The aim of the study is to differentiate acute hepatitis B and chronic hepatitis B (CHB) among patients seropositive for hepatitis B surface antigen (HBsAg).

Materials and Methods:

This study was carried out in the Department of Microbiology, Chettinad Hospital and Research Institute, Kelambakkam, Tamil Nadu, India, for a period of 6 months (January 2018–June 2018). Blood samples were collected from 87 patients for the detection of hepatitis B virus (HBV) serological markers. HBsAg, hepatitis B e antigen (HBeAg), anti-HBc total, anti-HBc IgM, and antibody to hepatitis B surface antigen were screened using the ELISA method. Detailed demographic profile including history of previous hepatitis infection, previous blood transfusion, and other related details were collected and documented using a structured questionnaire.

Results:

A total of 87 patients were HBsAg seropositive; among them, 55 (63.2%) were male and 32 (36.9%) were female. Based on the serological markers tested, 24 and 63 were suffering from acute and chronic HBV infections, respectively. Among the acute hepatitis B patients, all samples were seropositive for HBsAg, anti-HBc total, and anti-HBc IgM. HBeAg seromarker was found in 15 patients (62.5%). Among the CHB patients, all samples were seropositive for HBsAg and anti-HBc total. HBeAg seromarker was found in 28 patients with 44.4%. Alcohol consumption was the major risk factor for the transmission of HBV infection.

Conclusion:

An increased sample size and detailed study of high-risk behavior will provide an alarming awareness of their association.

Long-term persistency of hepatitis B immunity: an observational cross-sectional study on medical students and resident doctors

Hepatitis B virus (HBV) is a main cause of chronic and acute hepatitis. Healthcare workers (HCWs), including medical students and resident doctors, have an occupational risk of HBV infection.

The study aimed to evaluate the long-term persistence of protective anti-HBs antibody levels in healthcare students and resident doctors at risk for occupational exposure to HBV at 15 years after primary vaccination course. Further objective was to evaluate the anamnestic response observed in non-seroprotected subjects receiving a booster dose.

Data were collected from the clinical documentation filled in during the occupational medical check of medical students and resident doctors undergoing Occupational Health Surveillance by the University of Ferrara.

Of the 621 included individuals, 27.7% had an anti-HBs concentration < 10 mIU/mL. Subjects vaccinated during infancy had more frequently a concentration < 10 mIU/mL than those vaccinated during adolescence (42.7% vs 6.9%; p-value < 0.001). Multivariate analysis confirmed the statistical significance of the vaccination age. 94 subjects who had an anti-HBs concentration < 10 mIU/mL received a booster dose. The proportion of subjects who had an anamnestic response was higher in those vaccinated in infancy rather than during adolescence (94.1% vs 77.8% respectively).

These findings suggest that the anti-HBs concentration decreases below 10 mIU/mL more frequently in subjects vaccinated during infancy. Immunological memory seems to persist after the decline of the anti-HB titer, as observed in response to a booster dose. In conclusion, vaccinated subjects at increased risk of HBV infection should be monitored and a booster dose administered if anti-HBs titer is below 10 mIU/mL.

The changing epidemiology of primary liver cancer

Purpose of Review

In prior decades, liver cancer was viewed as a neoplasm that almost exclusively arose among high-risk populations in low- and middle-income countries. Incidence rates in some high-risk populations, however, have been declining, while rates in low-risk populations have been increasing, reflecting changes in underlying etiology. In this review, we highlight the evolving epidemiology of liver cancer, focusing on recent research and advances.

Recent Findings

Efforts to reduce or eliminate the risk associated with major risk factors such as hepatitis B virus (HBV), hepatitis C virus (HCV) and aflatoxin B₁ (AFB₁) have met with some success. As opposed to these favorable trends, the joint epidemics of obesity and diabetes have begun to affect liver cancer rates around the world.

Summary

While there has been progress in combating the effects of some risk factors, the increasing prevalence of others poses a major threat to attempts to tackle the rising incidence of liver cancer globally.

Persistence of protective anti-HBs antibody levels and anamnestic response to HBV booster vaccination: A cross-sectional study among healthcare students 20 years following the universal immunization campaign in Italy

Vaccination against Hepatitis B Virus (HBV) became mandatory in Italy for all newborns and 12 years-old individuals in the 1991. The immunogenicity of HBV vaccine and the effectiveness of the universal immunization strategy have been widely demonstrated. However the need to assess the antibody concentrations above the well known serological correlate of protection for HBV infection (≥10 mIU/mL), established in individuals immunized with a 3 doses vaccination course, is still recommended in subjects exposed to occupational risks in different settings, particularly the healthcare services. This practice has to be performed during the preventive medical examination, before the worker's exposure to biological hazards, as a fundamental part of Occupational Health Surveillance Programs in several Countries, including Italy: the goal is to assure individual protection, also providing booster doses when needed, after many years following the primary vaccination. During the 2011–2013 period, an observational study was performed in Healthcare students (HCSs) trained at a regional university acute-care hospital in North-Western Italy, properly immunized against HBV during infancy or adolescence, in order to evaluate the persistence of seroprotection and to assess the anamnestic response to booster vaccination. Data from 717 subjects undergoing HbsAg Ab and HBc Ab testing during the preventive medical examination, and receiving a booster dose of HBV vaccine when resulting with a non-protective titer (<10 mIU/mL), were collected and analyzed. Most of the HCSs (74.6%) included in the survey, mean age 24.8 y ( ± 4.6 SD), had received the primary vaccination course during the first year of life (3–5–11 months). Globally, 507 (70.7%) HCSs showed protective antibody titres, and an anamnestic response was observed in more than 95% subjects receiving the booster dose. Our study demonstrated the long-term persistence of protection of HBV vaccine, more than 20 y following the primary immunization, in HCSs who are exposed to occupational health risk. The anamnestic response observed in non-seroprotected subjects who received the booster further confirms the capability of the HBV vaccine to create a strong immunological memory.

Long-term persistence of immunity after hepatitis B vaccination: Is this substantiated by the literature?

Hepatitis B vaccination is held to provide life-long protection against hepatitis B virus (HBV) infection, but evidence for this notion remains wanting, since no studies have assessed the vaccinees in their fourth decade of life. Indeed, there are several reports indicating that despite vaccination in infancy, the prevalence of HBV infection still increased with age in the vaccinees, and that both anti-HBs titer and anamnestic response declined with age. Clearly it is time to clarify the long-term protection conferred by vaccination in infancy, and to implement remedial measures such as booster doses of vaccine in subjects without immunoprotection.

Long-term persistence of immunity after hepatitis B vaccination: A fact, not a fancy

On the basis of an article previously published in the journal regarding immune persistence after hepatitis B vaccination in infancy, I discuss why this persistence is a fact and not a fancy. Immune memory after a primary vaccination series has been widely demonstrated by prompt response to booster doses and the proliferation of T cells secreting IFNγ. In a large cohort of medical students, 79% of subjects were positive for anti-HBs antibodies, and only 1.9% of the subjects had serological evidence of past hepatitis B infection. To prevent severe diseases, such as hepatitis B, it is very important that the majority of the population is vaccinated, especially those employed in health care, as vaccination is the most effective weapon to hepatitis B, which is still widespread worldwide.

Epidemiology of Hepatitis B Virus Infection and Impact of Vaccination on Disease

Integration of hepatitis B vaccination into national immunization programs has resulted in substantial reductions of hepatitis B virus (HBV) transmission in previously high endemic countries. The key strategy for control of the HBV epidemic is birth dose and infant vaccination. Additional measures include use of hepatitis B immunoglobulin (HBIG) and diagnosis of mothers at high risk of transmitting HBV and use of antiviral agents during pregnancy to decrease maternal DNA concentrations to undetectable concentrations. Despite the substantial decrease in HBV cases since vaccination introduction, implementation of birth dose vaccination in low-income and middle-income countries and vaccination of high-risk adults remain challenging.

Impact and long-term protection of hepatitis B vaccination: 17 years after universal hepatitis B vaccination in Tunisia

Hepatitis B virus (HBV) vaccination has been part of the Expanded Programme of Immunization (EPI) in Tunisia since 1995. The aim of this study was to evaluate, for the first time, the impact of mass vaccination in Tunisia 17 years after this programme was implemented, and in parallel, assess the long-term persistence of anti-HBs antibody in the vaccinated Tunisian population. A total of 1422 students were recruited (703 vaccinated, 719 non-vaccinated). HBV seromarkers were checked. None of the students from either group had positive HBsAg. The overall prevalence of anti-HBc was 0·8%. A Significantly higher prevalence of anti-HBc was noted in unvaccinated students than in vaccinated (1·4% vs. 0·3%, P = 0·02). The overall seroprotection rate (anti-HBs titre ⩾10 mIU/ml) was 68·9% in vaccinated subjects. Seroprotection rates and geometric mean titres decreased significantly with increasing age, reflecting waning anti-HBs titre over time. No significant difference was detected between seroprotection rates and gender or students' area of origin. Incomplete vaccination was the only factor associated with an anti-HBs titre <10 mIU/ml. This study demonstrates the excellent efficacy of the HBV vaccination programme in Tunisia 17 years after its launch. However, a significant decline of anti-HBs seroprotection has been observed in ⩾15-year-old adolescents which places them at risk of infection. Additional studies are needed in hyperendemic regions in Tunisia.

Chronic hepatitis B: Virology, natural history, current management and a glimpse at future opportunities

The host immune system plays an important role in chronic hepatitis B (CHB), both in viral clearance and hepatocellular damage. Advances in our understanding of the natural history of the disease have led to redefining the major phases of infection, with the "high replicative, low inflammatory" phase now replacing what was formerly termed the "immune tolerant" phase, and the "nonreplicative phase" replacing what was formerly termed the "inactive carrier" phase. As opposed to the earlier view that HBV establishes chronic infection by exploiting the immaturity of the neonate's immune system, new findings on trained immunity show that the host is already somewhat "matured" following birth, and is actually very capable of responding immunologically, potentially altering future hepatitis B treatment strategies. While existing therapies are effective in reducing viral load and necroinflammation, often restoring the patient to near-normal health, they do not lead to a cure except in very rare cases and, in many patients, viremia rebounds after cessation of treatment. Researchers are now challenged to devise therapies that will eliminate infection, with a particular focus on eliminating the persistence of viral cccDNA in the nuclei of hepatocytes. In the context of chronic hepatitis B, new definitions of 'cure' are emerging, such as 'functional' and 'virological' cure, defined by stable off-therapy suppression of viremia and antigenemia, and the normalization of serum ALT and other liver-related laboratory tests. Continued advances in the understanding of the complex biology of chronic hepatitis B have resulted in the development of new, experimental therapies targeting viral and host factors and pathways previously not accessible to therapy, approaches which may lead to virological cures in the near term and functional cures upon long term follow-up. This article forms part of a symposium in Antiviral Research on "An unfinished story: from the discovery of the Australia antigen to the development of new curative therapies for hepatitis B."

Therapeutic management of chronic hepatitis B in clinical practice: a region-wide survey

GOALS

To characterize the clinical and treatment pattern in a large population of hepatitis B virus (HBV) patients managed at tertiary referral centers in clinical practice.

BACKGROUND

Successful treatment, either with interferon (IFN) or nucleos(t)ide analogs (NUCs), of chronic HBV infection is associated with improved long-term patient outcome. However, in clinical practice, the actual management of these patients is not well characterized, and data regarding treatment pattern in this setting are lacking.

METHODS

In this cross-sectional study, we evaluated 505 patients chronically infected with HBV alone and who had at least 1-year follow-up. We assessed indication to, rate of, and type of treatment as well as the characteristics of treated patients.

RESULTS

Overall prevalence of positivity for HBe antigen was 19.3%, and the majority of patients had chronic hepatitis (47.5%). Non-Italian patients represented approximately one third of the population (27.1%). Among patients with indication to antiviral therapy (n=318), treatment was actually carried out in 264 patients (83.0%), prevalently with NUCs (65.9%). IFN-treated patients were younger (P<0.001), more frequently male (P=0.025) and HBeAg positive (P=0.003), and less frequently cirrhotics (P<0.001) as compared with patients treated with NUCs.

CONCLUSIONS

In a geographical area with a low positivity for HBe antigen, antiviral therapy is actually carried out in the majority of patients who have indication to treatment, prevalently with NUCs, whereas IFN treatment is more frequently carried out in young, HBe antigen-positive patients who do not have advanced liver disease.

Hepatitis B: prevention, protection and occupational risk

ABSTRACT 

Since 1992, the inclusion of HBV vaccination has been recommended by the WHO for all immunization programs implemented by nations. In Europe, the introduction of HBV vaccination has markedly reduced the incidence of acute HBV, and before the introduction of HBV vaccine, healthcare workers (HCW) were at considerable risk of infection. The present review discusses the main problems regarding three fundamental issues in hospital settings: prevention of HBV in HCW, protection induced by vaccination (problems regarding nonresponders) and risk for HCW exposed to blood-borne pathogens (occupational risk). The screening of HBV markers plays a decisive role in evaluating the degree of immune coverage in subjects exposed to biological risk and permits an increase in immune coverage through vaccine implementation.

HBV Infection Among HIV-Infected Cohort and HIV-Negative Hospital Attendees in South Western Nigeria

BACKGROUND

Prevalence, association and probable mode of acquisition of HBV and HIV dual infections have not been fully explored. Thus, HBV intervention plan and services are sometimes exclusively targeted towards HIV-infected population. We investigated HBV infection among HIV-infected cohort in comparison with HIV-negative hospital attendees to ascertain dual infectivity pattern; thereby encouraging appropriate allotment of intervention services.

MATERIALS AND METHODS

A total of 349 (M=141; F=208; Mean=33.98 years; Range= 0.33-80 years) plasma specimens from two virus diagnostic laboratories in south-western Nigeria were analysed. These include 182 HIV-positive and 167 HIV-negative specimens from ART and GDV laboratories respectively. The specimens were initially screened for detectable HIV antigen/antibody, and subsequently HBsAg by ELISA technique.

RESULTS

Overall, HBsAg was detected in 20.92% (95% CI: 16.65-25.19%) of the patients. Also, 24.82% (95% CI: 17.69-31.95%) and 18.27% (95% CI: 13.02-23.52%) HBsAg positivity was recorded for males and females respectively. CHI square analysis showed no association (P=0.14) between gender and prevalence of HBsAg. Similarly, comparison of prevalence of HBsAg by age groups shows no significant difference (P=0.24). Overall, no significant difference (P=0.59) was observed in the prevalence of HBsAg among the HIV-infected cohort and HIV-negative hospital attendees.

CONCLUSIONS

Results of the study confirm endemicity and comparable rates of HBV infection independent of HIV-status.

Epidemiology of acute and chronic hepatitis B and delta over the last 5 decades in Italy

The spread of hepatitis B virus (HBV) infection has gradually decreased in Italy in the last 5 decades as shown by the steady reduction in the incidence rates of acute hepatitis B, from 10/100000 inhabitants in 1984 to 0.85/100000 in 2012, and by the reduced prevalence of hepatitis B surface antigen (HBsAg)-positive cases among chronic hepatitis patients with different etiologies, from 60% in 1975 to about 10% in 2001. The prevalence of HBsAg chronic carriers in the general population also decreased from nearly 3% in the 1980s to 1% in 2010. Linked to HBV by its characteristics of defective virus, the hepatitis delta virus (HDV) has shown a similar epidemiological impact on the Italian population over time. The incidence of acute HDV infection decreased from 3.2/100000 inhabitants in 1987 to 0.8/100000 in 2010 and the prevalence of HDV infection in HBsAg chronic carriers decreased from 24% in 1990 to 8.5% in 2006. Before the beneficial effects of HBV mass vaccination introduced in 1991, the decreased endemicity of HBV and HDV infection in Italy paralleled the improvement in screening blood donations, the higher standard of living and impressive reduction in the birth rate associated with a marked reduction in the family size. A further contribution to the decline in HBV and HDV infections most probably came from the media campaigns to prevent the spread of human immunodeficiency virus infection by focusing the attention of the general population on the same routes of transmission of viral infections such as unsafe sexual intercourse and parenteral exposures of different kinds.

Trends of hepatitis B notification rates in Turkey, 1990 to 2012

Turkey is a country with intermediate endemicity for hepatitis B, and approximately 4% of the population are HBsAg-positive. A number of measures have been implemented to prevent hepatitis B infection. In 1998, hepatitis B antigen was included in the national immunisation programme, and infants have since been vaccinated with three doses. Catch-up strategies, vaccination for high risk groups and screening measures were also adopted. The aim of this study was to evaluate the impact of the prevention and control strategies on hepatitis B notification rates in Turkey in the period from 1990 to 2012, using data from the national surveillance system. Secular trends revealed that rates showed an initial increasing trend, followed by a steady decline from 2005. The most dramatic decline occurred among children younger than 15 years, highlighting the benefits of vaccination and catch-up strategies. However, vaccination cannot fully explain the decrease in this age group. Socioeconomic development, through interrupting the horizontal transmission may also have contributed. After 2005, a steady decline was achieved also among those 15 years and older. The rates in adults were higher, which indicates that stronger prevention measures are needed to target this group, particularly men.

Hepatitis B vaccination at three months of age: a successful strategy?

Vaccination of infants, children and adolescents against the hepatitis B virus (HBV) is mandatory in Italy. It is crucial to assess whether vaccinated subjects have protective antibody level during adulthood when the risk of HBV infection increases due to lifestyle or occupational exposure. Two groups of students attending to University of Padova Medical School were enrolled between 2004 and 2011 and HBV antibodies and antigens were measured. The first group (Group A) comprised students vaccinated at three months of age and the second group (Group B) comprised students vaccinated after the first year of life. The follow-up was 18.0 (Group A) and 17.9 (Group B) years. The students vaccinated at three months of age had a higher rate of non-protective antibodies (47.2%) comparing to those vaccinated after the first year of life (17.0%, P<0.0001) with a significantly lower antibody level (P<0.001). The rate of non-protective antibodies was inversely related to vaccination age. The results clearly show that children vaccinated after the first year of life are better protected against HBV. On the other hand, both groups show a good immunological memory as evidenced by the achievement of protective antibody level after the booster dose in 97.8% of subjects.

Hepatitis B and immigrants: a SIMIT multicenter cross-sectional study

BACKGROUND

The continuing migration of individuals from geographic areas with high/medium endemicity has determined the arrival of new chronic hepatitis B virus (HBV) carriers in Italy. The magnitude of this phenomenon and clinical/virological features of HBsAg-positive migrants remain not very well defined.

AIMS

To evaluate the proportion of HBsAg-positive immigrants enrolled in this multicenter Società Italiana di Malattie Infettive e Tropicali (SIMIT) cross-sectional study and to compare the characteristics of chronic hepatitis B infection in migrants to those of Italian carriers.

METHODS

From February 1 to July 31 2008, anonymous data were obtained from all HBsAg-positive patients aged ≥ 18 years observed at 74 Italian centers of infectious diseases.

RESULTS

Of the 3,760 HBsAg-positive subjects enrolled, 932 (24.8 %) were immigrants, with a prevalent distribution in central to northern Italy. The areas of origin were: Far East (37.1 %), Eastern Europe (35.4 %), Sub-Saharan Africa (17.5 %), North Africa (5.5 %), and 4.5 % from various other sites. Compared to Italian carriers, migrants were significantly younger (median age 34 vs. 52 years), predominantly female (57.5 vs. 31 %), and most often at first observation (incident cases 34.2 vs. 13.3 %). HBeAg-positives were more frequent among migrants (27.5 vs. 14 %). Genotype D, found in 87.8 % of Italian carriers, was present in only 40 % of migrants, who were more frequently inactive HBV carriers, with a lower prevalence of chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC). Only 27.1 % of migrants received antiviral treatment compared to 50.3 % of Italians.

CONCLUSIONS

Twenty-five percent of all HBV carriers examined at Italian centers was composed of immigrants with demographic, serological, and virological characteristics that differed from those of natives and appeared to have an inferior access to treatment.

Hepatitis B and immigrants: a SIMIT multicenter cross-sectional study

BACKGROUND

The continuing migration of individuals from geographic areas with high/medium endemicity has determined the arrival of new chronic hepatitis B virus (HBV) carriers in Italy. The magnitude of this phenomenon and clinical/virological features of HBsAg-positive migrants remain not very well defined.

AIMS

To evaluate the proportion of HBsAg-positive immigrants enrolled in this multicenter Società Italiana di Malattie Infettive e Tropicali (SIMIT) cross-sectional study and to compare the characteristics of chronic hepatitis B infection in migrants to those of Italian carriers.

METHODS

From February 1 to July 31 2008, anonymous data were obtained from all HBsAg-positive patients aged ≥ 18 years observed at 74 Italian centers of infectious diseases.

RESULTS

Of the 3,760 HBsAg-positive subjects enrolled, 932 (24.8 %) were immigrants, with a prevalent distribution in central to northern Italy. The areas of origin were: Far East (37.1 %), Eastern Europe (35.4 %), Sub-Saharan Africa (17.5 %), North Africa (5.5 %), and 4.5 % from various other sites. Compared to Italian carriers, migrants were significantly younger (median age 34 vs. 52 years), predominantly female (57.5 vs. 31 %), and most often at first observation (incident cases 34.2 vs. 13.3 %). HBeAg-positives were more frequent among migrants (27.5 vs. 14 %). Genotype D, found in 87.8 % of Italian carriers, was present in only 40 % of migrants, who were more frequently inactive HBV carriers, with a lower prevalence of chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC). Only 27.1 % of migrants received antiviral treatment compared to 50.3 % of Italians.

CONCLUSIONS

Twenty-five percent of all HBV carriers examined at Italian centers was composed of immigrants with demographic, serological, and virological characteristics that differed from those of natives and appeared to have an inferior access to treatment.

The impact of a vaccination campaign against hepatitis B on the further decrease of hepatitis B virus infection in a southern Italian town over 14 years

BACKGROUND

Hepatitis B virus infection has decreased in Italy. The aims of this study were to identify changes, if any, in the epidemiological pattern of HBV infection in a southern Italian town first surveyed in 1996 and to assess the effectiveness of vaccination campaign against hepatitis B.

METHODS

In 2010, subjects were selected from the census by a systematic 1:4 random sampling procedure. Hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B core antigen (anti-HBc) were detected by ELISA. Associations (odds ratios) linking exposure to hepatitis B virus infection to potential risk factors were estimated by univariate and multivariate analyses.

RESULTS

Of the 1100 eligible subjects, 1020 (92.0%) agreed to participate. The prevalences of HBsAg (0.6%) and anti-HBc (15.2%) were significantly lower than in 1996 (0.8% and 21.5%) (p<0.01). No subject below 30 years of age (those that had been targeted for compulsory immunization) had been exposed to HBV infection. At multiple logistic regression analysis, age>45 years (OR=9.8; 95% CI=5.1-18.7) and past use of glass syringes (OR=1.9; 95% CI=1.2-3.1) independently predicted the likelihood of anti-HBc positivity.

CONCLUSIONS

These results, albeit obtained in a small town and thus not generalizable, confirm the continuous decreasing trend of HBV infection and demonstrate the effectiveness of the Italian hepatitis B vaccination program.

Viral hepatitis: global goals for vaccination

In countries where hepatitis A is highly endemic, exposure to hepatitis A virus (HAV) is almost universal before the age of 10 years, and large-scale immunization efforts are not required. In contrast, in areas of intermediate endemicity or in transition from high to intermediate endemicity, where transmission occurs primarily from person to person in the general community (often with periodic outbreaks), control of hepatitis A may be achieved through widespread vaccination programmes. Hepatitis B virus (HBV) is one of the world's most widespread infectious agents and the cause of millions of infections each year. Between 500,000 and 700,000 people die each year from chronic infection-related cirrhosis, hepatocellular carcinoma (HCC) or from acute hepatitis B. Hepatitis B vaccine provides protection against infection and its complications including liver cirrhosis and HCC. It is therefore, the first vaccine against a cancer, the first vaccine protecting from a sexually transmitted infection, and the first vaccine against a chronic disease ever licensed. Control and significant reduction in incidence of new HBV infections as well as hepatocellular carcinoma has repeatedly been reported in countries in East Asia (i.e. Taiwan) and Africa (i.e. The Gambia). Two experimental vaccines against hepatitis E have been developed; one of them has been recently licensed but is not yet widely available. Attempts to develop a hepatitis C vaccine were so far unsuccessful.

Historical study of acute hepatitis B in subjects with or without hepatitis C infection

BACKGROUND

The epidemiological pattern of hepatitis B virus infection in Italy has greatly changed over the past decades. The aim of the study was to evaluate during time the epidemiological features of acute hepatitis B cases referred to an Infectious Disease Unit in North-East of Italy between 1978 and 1995.

PATIENTS AND METHODS

Stored sera of 183 cases were tested for HBV markers, HBV genotypes, anti-Delta and anti-HCV.

RESULTS

Anti-HBcIgM was positive in all cases. Mean age increased from 30.2 years in 1978 to 37.5 in 1995 (P<0.01). Significant increase was observed in proportion of cases reporting intravenous drug use from 11.5% to 29.6% (P<0.03). Chronicity rate was as low as 1.1%. Mean days of hospitalization significantly decreased. HBV genotype determination showed that majority of cases was infected by genotype D, but its prevalence decreased from 88.2% in 1978 to 75.0% in 1995. Delta coinfection was present in 8.2%. The prevalence of HCV in patients with acute HBV was 35.0%; it fluctuated from 26.2% to 44.2%, mostly related (53.1%) to intravenous drug use. Dual infection did not lead to a more severe course of disease.

CONCLUSIONS

From this retrospective study, remarkable fluctuations in the prevalence of dual HBV-HCV infection before the implementation of HBV vaccination were observed. Presence of anti-HCV did not affect the course of acute HBV.

Chronic hepatitis B infection

The management of chronic hepatitis B virus (HBV) infection requires understanding the natural history of the disease as well as the risks, benefits, and limitations of the therapeutic options. This article covers the principles governing when to start antiviral therapy, discusses recent advances using hepatitis B surface antigen quantification to better define various phases of infection, describes the use of HBV core, precore, and viral genotyping as well as host IL28B genotyping to predict response to interferon therapy, and reports on the management of HBV in 3 special populations (pregnancy, postliver transplantation, and in the setting of chemotherapy or immunosuppression).

Long-term immunogenicity of hepatitis B vaccination in children and adolescents in a southern Italian town

PURPOSE

Universal anti-hepatitis B vaccination of infants and of 12-year-old children became mandatory in Italy in 1991. The purpose of this study was to evaluate the persistence of anti-hepatitis B surface (HBs) antibodies several years after a primary course of vaccination.

METHODS

In 2010, anti-HBs titers were measured in all subjects aged between 5 and 25 years residing in a southern Italian town. Individuals with an anti-hepatitis B antibody concentration of 10 IU/ml or more were considered to be protected.

RESULTS

Of the 671 subjects evaluated, 149 (30%) lacked protective antibodies. Fifty-three (29.4%) of the subjects had been vaccinated ≤10 years earlier and 96 (30.3%) more than 10 years earlier (P = not significant). Subjects vaccinated in infancy were more likely to lack protective anti-HBs antibodies than subjects vaccinated at 12 years of age, regardless of the years elapsed since immunization.

CONCLUSIONS

Most subjects maintained protective antibodies for a considerable number of years after vaccination. Vaccination in adolescence results in more prolonged immunogenicity than vaccination in infancy.

Elimination of hepatocellular carcinoma and acute hepatitis B in children 25 years after a hepatitis B newborn and catch-up immunization program

Alaska Native people experience the highest rates of acute and chronic hepatitis B virus (HBV) infection and hepatocellular carcinoma (HCC) in the United States. We examined the effect of a universal newborn immunization with hepatitis B vaccine and mass population screening immunization program initiated in 1984 on rates of HBV and HCC in children 25 years later. During this time, the population of Alaska Native people grew from an estimated 75,000 to 130,000 persons. A surveillance system to detect acute HBV infection in Alaska Native facilities was established in 1981. Cases of HCC in children under 20 years of age were identified using a National Cancer Institute (NCI)-funded Cancer Registry established in 1969 coupled with an active surveillance program of screening persons with chronic HBV semiannually for alpha-fetoprotein since 1982. The incidence of acute symptomatic HBV infection in persons <20 years of age fell from cases 19/100,000 in 1981-1982 to 0/100,000 in 1993-1994. No cases of acute HBV have occurred in children since 1992. The incidence of HCC in persons <20 years decreased from 3/100,000 in 1984-1988 to zero in 1995-1999 and no cases have occurred since 1999. The number of identified hepatitis B surface antigen-positive children <20 years in the Alaska Native population declined from 657 in 1987 to two in 2008.

CONCLUSION

Universal newborn vaccination coupled with mass screening and immunization of susceptible Alaska Natives has eliminated HCC and acute symptomatic HBV infection among Alaska Native children and this approach is the best way to prevent HBV-related disease in children.

Trends in prevalence of hepatitis B virus infection among Albanian blood donors, 1999-2009

BACKGROUND

Hepatitis B virus (HBV) was among the first virus known to be transmitted by blood and blood productions. The objective of this study is to determine the trend of hepatitis B virus in blood donors.

MATERIALS AND METHODS

In this study 79274 blood donors were retrospectively evaluated for HBsAg. The donors were selected using personal questionnaire, physical examination and testing blood before donation. Blood banks records are used as source of information. The blood donors samples were analyzed for the presence of hepatitis B surface antigen (HBsAg) by commercial available kits ELISA method, third generation (from Abbott laboratory, Germany). A sample was considered as HBsAg positive when found twice repeatedly reactive. Reactive samples were not confirmed with addition tests.

RESULTS

In the evaluation data, we found out that from 79274 of the total healthy blood donors, 15983 were voluntary donors, 52876 were family replacement donors and 10424 commercial blood donors. The prevalence of HBsAg in blood donors was 7.9%. It was increased steadily from 5.9% in 1999 to 9.1% in 2006 and decreased in 7.9% in 2009. According to blood donors status the HBsAg prevalence was 10.5% in commercial blood donors, 8.1% in voluntary donors and 8.6% in family replacement donors. The prevalence of anti-HBc in blood donors was 59.1%.

CONCLUSION

The prevalence of HBsAg was lower in voluntary non remunerate blood donors than commercial donors and family replacement blood donors. In FDs the prevalence was higher than VDs but lower than CDs. So, it is important to encourage the voluntary blood donors to become regularly blood donors.

Relative decrease in the role played by hepatitis B virus infection in the aetiology of hepatocellular carcinoma during a 20-year period: a multicentre Italian study

BACKGROUND

Chronic hepatitis B virus (HBV) infection is one of the most frequent aetiological factors associated with the development of hepatocellular carcinoma (HCC).

AIM

This study evaluated the temporal trend in the aetiological role played by HBV infection alone in patients diagnosed with HCC during the last 20 years in Italy.

METHODS

Among the 2042 HCC patients included in the Italian Liver Cancer (ITA.LI.CA.) database, 346 had chronic HBV infection alone. We assessed the proportion of HCC patients with HBV infection in four quinquennia (1987-1991, 1992-1996, 1997-2001, 2002-2006) and evaluated their main clinical, virological and oncological characteristics across these periods.

RESULTS

Although the absolute number increased, the proportion of HBV-related HCC relatively decreased over time from 26.7% (47/176 patients) in 1987-1991 to 14.7% (127/862 patients) in 2002-2006 (P=0.0005). Patients' demographical, clinical and virological characteristics were similar across the four quinquennia. A greater proportion of patients was diagnosed with non-advanced HCC in more recent years (from 26% in 1987-1991 to 48% in 2002-2006, P=0.025), likely owing to a growing use of semiannual surveillance (from 63% in 1987-1991 to 80% in 2002-2006).

CONCLUSIONS

We observed a significant, relative decrease in the role played by chronic HBV infection alone in the determinism of HCC during the last 20 years. In recent years, more patients are diagnosed with non-advanced HCC probably owing to improvements in HCC detection.

Epidemiology of hepatitis B and C viruses: a global overview

This article reviews the prevalence, disease burden, genotype distribution, and transmission patterns of hepatitis B virus (HBV) and hepatitis C virus in the 6 World Health Organization regions. The global epidemiology of hepatitis B and C demonstrates a predominantly declining prevalence of the diseases. Improvement in the control of hepatitis B has been largely achieved with implementation of a more universal HBV vaccine program, although a large gap still remains in the effort toward global prevention of hepatitis B. The transmission of hepatitis C has been greatly impacted by mandatory screening of blood donors in most countries in the world, although intravenous drug use continues to be a major source of infection. Public education regarding the risks of exposure to infected paraphernalia as well as household items such as razors is necessary in the continuing effort to curb this disease.

A significant proportion of patients with chronic hepatitis B who are candidates for antiviral treatment are untreated: A region-wide survey in Italy

BACKGROUND

Between 350 and 400 million people worldwide have chronic hepatitis B virus (HBV) infection, and in Italy this figure is 1% to 2% in the general population. In clinical practice, however, it is not known how many patients chronically infected by HBV and eligible for antiviral therapy are not treated.

AIM

To characterize the clinical picture of untreated HBV patients, and to assess whether current experts' recommendations for treatment are actually applied.

METHODS

We evaluated 362 patients chronically infected by HBV alone who were followed for at least 1 year at tertiary referral centers in Liguria region, Italy. Patients' data were evaluated on the basis of the Panel of Experts algorithm for the management of HBV [ie, HBV DNA levels > or =20,000 IU/mL in hepatitis B e antigen (HBeAg)-positive patients, HBV DNA levels > or =2000 IU/mL in HBeAg-negative patients, and evidence of biochemical and/or histologic activity of disease in both groups].

RESULTS

One-hundred and sixteen viremic chronic hepatitis B disease patients were not on antiviral therapy (33 HBeAg positive, 83 HBeAg negative). Serum HBV DNA was > or =20,000 IU/mL and > or =2000 IU/mL in 32 HBeAg-positive and 54 HBeAg-negative patients, respectively, and disease was present in 59 of these 86 patients. Treatment was not indicated in 10 of 59 patients, and had been planned in 8 (4 HBeAg positive), thus 84% potential treatment candidates (41 of 49 patients) were not treated.

CONCLUSIONS

Evaluation of a large series of patients chronically infected by HBV alone identified a significant proportion of patients who are actually untreated despite being potential candidates for antiviral therapy.

[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.

Chronic viral hepatitis as a public health issue in the world

This article will focus on the impact caused by chronic viral hepatitis B and C globally and will discuss public health measures that have to be implemented in order to prevent and control these diseases. Chronic viral hepatitis is a major global public health problem, an important cause of morbidity and mortality from sequelae which include chronic hepatitis, cirrhosis and primary liver cancer. Being a 'silent' disease, the contribution of chronic hepatitis to global morbidity and mortality is generally underestimated. Hepatitis B and C prevention and control should seek to reduce both the incidence of new infections and the risk of chronic liver disease. A comprehensive public health prevention programme should include the prevention and detection of HBV and HCV infections, the diagnosis and control of viral hepatitis related chronic liver disease, conducting surveillance and monitoring the effectiveness of prevention activities, and setting up a research agenda.

Long-term protection of hepatitis B vaccine 18 years after vaccination

INTRODUCTION

This is the third evaluation study of the hepatitis B virus (HBV) vaccination program, initiated in 1989 in Saudi Arabia.

AIMS

This study sought to assess the efficacy and long-term protection of the hepatitis B vaccine among Saudi adolescents.

METHODS

School students between the ages of 16 and 18 years were randomly chosen from high endemic (Aseer), intermediate endemic (Madinah), and low endemic (Al-Qaseem) areas of the country. Hepatitis B surface antigen (HBsAg), hepatitis B core IgG antibody (anti-HBc), and hepatitis B surface antibody (anti-HBs) were measured using standard techniques.

RESULTS

A total of 1355 students (689 males and 666 females) were selected randomly from the three areas. No cases of positive HBsAg or anti-HBc were detected among the study population. Five hundred and ten students (38%) showed protective anti-HBs titers (>/= 10mIU/ml), while 528 (39%) students had undetectable anti-HBs titers (<1 mIU/ml).

CONCLUSIONS

This study shows the excellent efficacy of the HBV vaccination program in Saudi Arabia 18 years after its launch. Based on this study and others, a booster dose for the adult population appears to be unnecessary.

An assessment of the effect of hepatitis B vaccine in decreasing the amount of hepatitis B disease in Italy

Background

Hepatitis B (HBV) infection is an important cause of morbidity and mortality and it is associated to a higher risk of chronic evolution in infected children. In Italy the anti-HBV vaccination was introduced in 1991 for newborn and twelve years old children. Our study aims to evaluate time trends of HBV incidence rates in order to provide an assessment of compulsory vaccination health impact.

Method

Data concerning HBV incidence rates coming from Acute Viral Hepatitis Integrated Epidemiological System (SEIEVA) were collected from 1985 to 2006. SEIEVA is the Italian surveillance national system that registers acute hepatitis cases. Time trends were analysed by joinpoint regression using Joinpoint Regression Program 3.3.1 according to Kim's method. A joinpoint represents the time point when a significant trend change is detected. Time changes are expressed in terms of the Expected Annual Percent Change (EAPC) with 95% confidence interval (95% CI).

Results

The joinpoint analysis showed statistically significant decreasing trends in all age groups. For the age group 0–14 EAPC was -39.0 (95% CI: -59.3; -8.4), in the period up to 1987, and -12.6 (95% CI: -16.0; -9.2) thereafter. EAPCs were -17.9 (95% CI: -18.7; -17.1) and -6.7 (95% CI: -8.0; -5.4) for 15–24 and ≥25 age groups, respectively. Nevertheless no joinpoints were found for age groups 15–24 and ≥25, whereas a joinpoint at year 1987, before compulsory vaccination, was highlighted in 0–14 age group. No joinpoint was observed after 1991.

Discussion

Our results suggest that the introduction of compulsory vaccination could have contribute partly in decreasing HBV incidence rates. Compulsory vaccination health impact should be better investigated in future studies to evaluate the need for changes in current vaccination strategy.

Acute hepatitis B in patients with or without underlying chronic HCV infection

BACKGROUND AND AIM

Acute hepatitis B course may be significantly modified by underlying chronic hepatitis C. The aim of this study was to compare clinical and virological characteristics of acute hepatitis B in patients with or without chronic hepatitis C virus (HCV) infection.

MATERIALS AND METHODS

Twenty-seven patients with symptomatic acute hepatitis B were enrolled: 14 with underlying chronic HCV (Group A) and 13, matched by age and gender, with single hepatitis B (Group B). All patients were followed-up until HBsAg negativization.

RESULTS

Group A patients were HCV-RNA-negative on hospital admission and all but one remained negative during follow-up. HBeAg tested positive in 92.9% and 84.6% of Groups A and B patients, respectively. ALT, bilirubin, prothrombin time values and HBsAg titer were similar in both groups. Nevertheless, lower mean HBV-DNA levels (p=0.03), a shorter duration of HBsAg positivity (p<0.01) and of symptoms before ALT peak (p=0.014), and significantly lower peak ALT values (p=0.03) were observed in Group A compared to Group B patients.

CONCLUSIONS

Acute HBV infection suppressed HCV replication. Conversely, the underlying HCV infection exerted a modulatory effect on HBV replication which influenced the course, though not the outcome, of the acute disease. Although acute hepatitis B showed a mild clinical course in both groups of patients, HBV vaccination should be suggested to risk subjects.

Monitoring SCCA-IgM complexes in serum predicts liver disease progression in patients with chronic hepatitis

About 30% of the patients with chronic hepatitis develop a progressive liver disease and one of the most intriguing issues is the detection of noninvasive markers for fibrosis stage and disease progression. High levels of squamous cell carcinoma antigen (SCCA)-immunoglobulin M (IgM) are detectable in hepatocellular carcinoma and their increase in cirrhotic patients can predict tumour development. As SCCA-IgM can also be detectable at low percentages in patients with chronic hepatitis, the aim of this study was to assess SCCA-IgM complexes in relation to disease outcome in this group of patients. An ELISA assay was used to determine the presence of SCCA-IgM in 188 patients with chronic hepatitis and in 100 controls. An additional serum sample was available after a median period of 6 years in 57 untreated patients: these patients were subdivided in group A, including eight patients with a fibrosis score increase > or =2 in a second liver biopsy and group B, including 49 patients without fibrosis progression during a similar follow up. SCCA-IgM complexes were detectable in 63 of 188 (33%) patients but in none of the controls. A significant increase of SCCA-IgM levels over time was observed in patients with fibrosis progression (mean +/- SD: 117 +/- 200 U/mL/year), but not in those without histologic deterioration (mean +/- SD: -8.8 +/- 31 U/mL/year, P < 0.0001). In conclusion, monitoring SCCA-IgM levels over time appears a useful approach to identify patients with chronic hepatitis at higher risk for cirrhosis development.

Acute hepatitis B 14 years after the implementation of universal vaccination in Italy: areas of improvement and emerging challenges

BACKGROUND

Italy had intermediate-level endemicity for hepatitis B virus (HBV) infection in the 1970s and 1980s. In 1991, vaccination of infants and adolescents became mandatory. We report the impact of universal vaccination 14 years after its beginning.

METHODS

We performed a case-control study within a population-based surveillance for acute viral hepatitis. The incidence of acute hepatitis B (AHB) was estimated for the time since 1991, and the association between AHB and the considered risk factors was analyzed for the period 2001-2005.

RESULTS

The incidence of AHB progressively decreased from 1991 to 2005, mainly for persons in the age groups targeted by the universal vaccination campaign: there was a 24-fold and 50-fold decrease in the 15-24-year and 0-14-year age groups, respectively; for the > or =25-year age group, the incidence halved. Owing to the persons' ages, approximately 3% of total AHB cases should have been the target of vaccination campaign. In 2004-2005, foreigners accounted for 14% of total cases and for 57% of persons who should have been targets for vaccination. Missed opportunities for immunization were documented for approximately 50% of patients with AHB who reported cohabitation with HBV carriers and for 70% of those who reported injection drug use. The strongest associations with AHB were found for blood transfusion (adjusted odds ratio [OR(adj)], 8.4; 95% confidence interval [CI], 2.7-26), cohabitation with HBV carriers (OR(adj), 5.3; 95% CI, 3.6-7.7), injection drug use (OR(adj), 3.8; 95% CI, 2.5-5.8), and unsafe sexual practices (OR(adj), 2.8; 95% CI, 1.9-4.2).

CONCLUSION

Universal vaccination has contributed to a decreasing AHB incidence in Italy, especially by reducing the risk of infection among persons aged 15-24 years. Most infections occur in persons aged > or =25 years in association with injection drug use, unsafe sexual activity, percutaneous treatment, and iatrogenic exposure. Improvement of vaccine coverage in high-risk groups and adherence to infection control measures during surgery and percutaneous treatment are needed. The high risk still associated with blood transfusion needs to be further investigated, with consideration of occult HBV infection in blood donors. The potential spread of HBV infection from the immigrant population deserves adequate health policy prevention programs.

[Current data on the treatment of chronic hepatitis B]

Despite the development of new therapeutic options, treatment of chronic hepatitis B remains a clinical challenge because of the need for long-term treatment in most patients. Treatment with pegylated interferon is the only option that allows a defined duration of treatment. Nonetheless, approximately 70% of the patients treated do not have a prolonged treatment response. A variety of nucleoside analog viral polymerase (reverse transcriptase) inhibitors have been developed (lamivudine, adefovir dipivoxil, entecavir, telbivudine); they can be administered orally and are well tolerated. These antiviral agents effectively induce viral suppression, which is accompanied by an improvement in transaminases and hepatic histology. Nonetheless, the rates of HBe and HBs seroconversion remain low with nucleoside analogs, and the absence of these immunologic events necessitates prolonged antiretroviral treatment. Treatment with nucleoside analogs leads to selection of resistant mutant viruses. They therefore require close clinical and virologic follow-up to enable early screening for resistance and adaptation of treatment before the liver disease worsens. The development of these different treatment options has made possible very significant improvements in the management of patients with chronic hepatitis B, by preventing aggravation of liver disease in most of them.

Emerging drugs for hepatitis B

Chronic hepatitis B remains a treatment challenge despite the availability of new nucleoside analogs. This is due to the persistence of viral infection during therapy, which exposes the patient to the risk of developing antiviral drug resistance. Therefore, new polymerase inhibitors are needed to manage resistance to existing drugs and new trials of combination therapy are required to delay drug resistance. In the future, antiviral agents targeting other steps of the viral life cycle will be needed to achieve antiviral synergy and prevent antiviral drug resistance. Immune modulators are also expected to enhance antiviral response and to achieve sustained response. Discovery of new antiviral drugs and design of new treatment strategies are, therefore, needed to manage this disease, which is still the main cause of cirrhosis and hepatocellular carcinoma worldwide.