Hepatitis A Virus Genotype IB Outbreak among Internally Displaced Persons, Syria

Inactivation of Aerosolized Hepatitis A Viral Droplets on Food Contact Surfaces by Ultraviolet-Light-Emitting Diodes at 255 nm and 279 nm

Hepatitis A viral outbreaks continue to occur. It can be transmitted through aerosolized droplets and thus can contaminate surfaces and the environment. Ultraviolet light emitting diode (UV-C LED) systems are used for inactivation of microbes, though research is needed to determine optimal doses for aerosolized HAV inactivation. This study evaluates the UV-C LED doses for the inactivation of aerosolized hepatitis A virus (HAV) deposited on stainless-steel and glass discs. HAV was aseptically deposited onto stainless-steel or glass discs (1.27 cm diameter) using a nebulizer within a chamber followed by treatments for up to 1.5 min with 255 nm (surface dose = 0-76.5 mJ/cm2) or 279 nm (surface dose = 0-8.1 mJ/cm2) UV-C LED. Plaque assays were used to enumerate infectious titers of recovered viruses and data from three replicates were statistically analyzed. The calculated linear D10-value (UV-C dose for a 1-log reduction in aerosolized deposits) for HAV by 255 nm UV-C LED was 47.39 ± 7.40 and 40.0 ± 2.94 mJ/cm2 (R2 = 0.94 and 0.91) and using 279 nm UV-C LED were 6.60 ± 0.27 and 5.57 ± 0.74 mJ/cm2 (R2 = 0.98 and 0.94) on stainless-steel and glass discs, respectively. The non-linear Weibull model showed δ (dose needed for a 1-log reduction in aerosolized HAV deposits) values for HAV of 29.69 ± 5.49 and 35.25 ± 15.01 mJ/cm2 by 255 nm UV-C LED (R2 = 0.99 and 0.92) and 6.67 ± 0.63 and 5.21 ± 1.25 mJ/cm2 by 279 nm UV-C LED (R2 = 0.98 and 0.95) on stainless-steel and glass discs, respectively. These data indicate that 279 nm UV-C LED showed higher efficiency for HAV inactivation than 255 nm UV-C LED, and that Weibull models were a better fit when tailing was observed. This study provides the inactivation data needed to aid in designing UV-C LED systems for delivering doses required to inactivate bio-aerosolized HAV deposits on stainless-steel and glass.

Acute hepatitis A-associated aplastic anemia in a pediatric: a case report from Syria

Introduction and importance

Hepatitis A virus is typically an acute infection that is often asymptomatic, especially in children. In Syria, hepatitis A virus infections are not uncommon. However, the emergence of extrahepatic manifestations, such as aplastic anemia, following hepatitis A infection is unpredictable and challenging to manage, with the connection between these conditions remaining poorly understood. This paper aims to highlight this rare manifestation of aplastic anemia linked to hepatitis A infection in children.

Case presentation

We report a rare case of hepatitis-associated aplastic anemia in a 3-year-old Syrian boy who exhibited symptoms of fever, bruising, and mucosal bleeding 1 month after the onset of acute hepatitis. The diagnosis was confirmed via bone marrow examination, and he was treated with immunosuppressives, resulting in full recovery after a year of follow-up with no need for bone marrow transplantation.

Clinical discussion

Hepatitis A infection associated with aplastic anemia is an extremely rare condition. Its etiology might be related to the immune system, and its diagnosis is always confirmed with bone marrow biopsy. Treatment includes hematopoietic cell transplantation if the immunosuppressive therapy is not effective. Further research is essential to understand the mechanisms and optimize treatment options.

Conclusion

Awareness of the potential association between hepatitis A and aplastic anemia is essential for early diagnosis and effective management. More studies are required to enhance our understanding of the condition and improve therapeutic approaches.

Vaccination coverage and access among children and adult migrants and refugees in the Middle East and North African region: a systematic review and meta-analysis

Background

The Middle East and North African (MENA) region is a major global hotspot for migration with more than 40 million migrants, who may be an under-vaccinated group because of barriers to vaccination within countries of origin, transit, and destination. We systematically synthesised the evidence on coverage, acceptance, drivers of uptake, and policies pertaining to vaccination for children and adult migrants in the region, in order to explore tailored interventions for these groups.

Methods

We searched six databases (including Medline, Embase) for peer-reviewed literature, and other websites (including WHO, IOM, ministries of health) for grey literature on coverage, acceptance, drivers of uptake and policies for any vaccination in migrants in the MENA region from between 2000 and 27 August 2024 in any language. We included studies reporting primary data on coverage, acceptance, and drivers of uptake, and any relevant articles on policies. We defined migrants as individuals who move away from their place of habitual residence, within or across international borders, temporarily or permanently. Studies without disaggregated migrant data were excluded. Primary outcomes were coverage (% individuals receiving ≥1 doses of any vaccine) and acceptance (% individuals accepting any vaccine). We separately synthesised data on children (<18 years) and adults (≥18). Estimates were pooled using a random-effects meta-analysis where possible or narratively synthesised, and drivers of uptake were synthesised using the WHO Behavioural and Social Drivers model. PROSPERO protocol: CRD42023401694.

Findings

We identified 6088 database and 282 grey literature records and included 55 studies and 1,906,975 migrants across 15 countries (including mostly refugees in the Middle East and expatriates in Gulf Cooperation Council countries). COVID-19 vaccination was reportedly provided free of charge to migrants in all countries whereas childhood vaccinations were reportedly provided to migrant children in seven countries. However, for adolescents and adults, there were wide variations across countries, and we found no policies relating to catch-up vaccination. Coverage for childhood vaccination amongst migrants was reportedly low, with only 36.0% of 589 migrant children fully vaccinated according to national schedules (95% CI 35.0%-43.0%, I 2 = 67%; data from migrants in Lebanon, Morocco, Sudan). Likewise, data on specific routine vaccines in children was generally low: measles containing vaccines (MCV): MCV dose 1 63.9%-66.9%; MCV dose 2 25.4%-85.6%; oral polio vaccine (OPV): OPV dose 3 65.1%-76.4%; diphtheria, tetanus and pertussis (DTP) containing vaccines: DTP dose 1 81.8%-86.7%; DTP dose 3 59.7%-76.6%). Drop-out rates across all routine vaccines for subsequent vaccine doses ranged from 12.4 to 38.5%, suggesting that migrants face a range of barriers to vaccine uptake beyond the first dose, that need to be better considered when designing interventions. For adults, we found eleven studies on coverage (including 9 on COVID-19) showing that COVID-19 vaccination coverage ranged 33.5-84.8% in migrants and 25.0-59.0% in host populations. Drivers of uptake of childhood vaccination in migrants included limited availability of vaccines and vaccination personnel, communication and administrative barriers, financial difficulties, lack of caregiver knowledge about services, and concerns expressed by caregivers around safety and benefits. For adults, drivers were mainly related to the COVID-19 vaccine and included concerns around safety, quality, side effects, and mistrust in vaccines and the systems that deliver them.

Interpretation

Migrants have unique risk factors for under-immunisation in the MENA region and have low vaccination coverage despite some level of entitlement to services. Data on vaccination coverage, drivers of uptake and policies for migrants in the MENA region is limited to small-scale studies among accessible groups, mostly focusing on COVID-19 compared to routine childhood and adult vaccination. There is an urgent need to strengthen data collection to better understand coverage across different migrant groups, ages, and MENA countries, especially on adult and catch-up vaccinations for routine immunisations, and develop innovative co-designed strategies to address specific drivers of vaccine uptake among this group.

Funding

La Caixa, LCF/PR/SP21/52930003.

Hepatitis A virus infection and seroprevalence, Istanbul, Turkey, 2020-2023

BACKGROUND

Hepatitis A infections continue to be a major global public health problem. The epidemiology and seroprevalence of hepatitis A virus (HAV) have important public health implications. This study aimed to retrospectively examine the hepatitis A cases and hepatitis A seroprevalence in our region in our hospital with the highest number of inpatient and outpatient cases in Istanbul.

OBJECTIVE

Determination of hepatitis A cases and seroprevalence.

DESIGN

Cross-sectional.

SETTING

Tertiary care.

PATIENTS AND METHODS

A total of 39 385 individuals who were tested for Anti-HAV IgM and Anti-HAV Total (IgM+IgG) antibodies between May 2020 and September 2023 and were included in this study. Hepatitis A specific IgM and Total (IgM+IgG) antibodies were determined using the enzyme-linked immunosorbent assay method.

MAIN OUTCOME MEASURE

Hepatitis A seroprevalence.

SAMPLE SIZE

46 721.

RESULTS

The study included a total of 46 721 samples from 39 385 individuals who were tested for hepatitis A serology. The median age of the 39385 individuals included in the study was 28 (interquartile range [IQR]; 22-46), with 58.74% being female and 4.07% (n=1163) being foreign nationals. Reactivity was detected in 91 of the 25 442 patients tested for HAV-IgM. Among these patients, 33 (0.13%) had acute hepatitis A infection, while 58 (0.23%) were considered false positives. Of the acute hepatitis A patients, 13 (0.09%) were women, and 22 (0.80%) were children. Acute hepatitis A was most commonly observed in the 6-9 and 15-18 age groups, with 7 cases each. The seroprevalence rate of hepatitis A was 67.23% among 33 683 individuals. Of those tested for HAV-Total, 13 132 (64.92%) were women, and 2533 (64.88%) were children. The lowest seroprevalence rate among age groups (35.91%) was in the 15-18 age year range, while the highest seroprevalence (98.34%) was detected in individuals aged 60 years and above.

CONCLUSION

With a seroprevalence rate of 67.23%, our region is still considered a medium-endemic area for hepatitis A, and it is crucial to continue administering the HAV vaccine as currently included in the childhood vaccination schedule in our country. Additionally, the significantly low hepatitis A seropositivity, particularly in the 15-18 and 19-24 age groups, indicates the need to promote catch-up vaccination for young adults. Since our study covers a large population, it can serve as a guide regarding the serological status of hepatitis A in Istanbul.

LIMITATIONS

Since vaccination information for the study population was not available, it was not possible to distinguish between seropositivity due to vaccination or natural immunity. Despite being conducted in Istanbul, a cosmopolitan city, and in the largest city hospital, the results may not be representative of the entire country.

Seroprevalence of Hepatitis A, B and C Among a Sample of Refugees in Egypt: An Exploratory Survey

BACKGROUND

Estimating the prevalence of infectious diseases, including viral hepatitis, among refugees is important for evaluating their health needs and predicting the burden on the health system of the host country. This study aimed at estimating the seroprevalence of viral hepatitis among refugees in Egypt.

METHODS

This cross-sectional study involved a heterogeneous group of 501 refugees. Enzyme-linked immunosorbent assays were used to detect IgG antibodies against hepatitis A virus (HAV), B virus (HBV) surface antigen (anti-HBsAg), C virus (HCV), and HBV surface antigen (HBsAg).

RESULTS

Anti-HAV was the most prevalent marker (n = 482, 96.2%), followed by anti-HBs (n = 142, 28.3%) and HBsAg (n = 21, 4.2%), while only four refugees (0.8%) had positive anti-HCV IgG. Anti-HBs was higher in males (p < 0.05). Older refugees and non-working subjects had significantly higher seropositive rates of anti-HAV (p = 0.051 and p = 0.023, respectively), while students and those below 15 years of age had higher rates of anti-HBs (p < 0.05). Positive HBsAg results were associated with history of hepatitis (p < 0.001). Obese participants were more likely to be positive for HBsAg (p = 0.025) and anti-HBs (p < 0.05). Sudanese refugees had significantly higher rates of anti-HAV antibodies (p = 0.049), while Yemini refugees had significantly higher rates for HBsAg (p = 0.019) positivity. Residents of Dakahlia had significantly higher rates of anti-HAV (p = 0.008) and anti-HBs (p < 0.05). None of the studied risk factors was significantly associated with anti-HCV.

CONCLUSION

Refugees in Egypt have poor immunity against HBV with intermediate to high HBV and low HCV prevalence rates. Despite that 65% of refugees received the HAV vaccine, almost all had IgG anti-HAV, denoting previous infection.

Catch-22: War, Refugees, COVID-19, and the Scourge of Antimicrobial Resistance

Wars have hidden repercussions beyond the immediate losses of life, well-being, and prosperity. Those that flee wars and seek refuge in safer locations are not immune to the tragic impacts. Of particular concern is the susceptibility of the refugee populations to infectious diseases and antimicrobial-resistant pathogens. This poses a detrimental risk to these disenfranchised populations, who often have limited access to medical care, sanitation, and nutritious and safe food. Furthermore, antimicrobial-resistant pathogens in refugees can be both transmitted to and acquired from their hosting communities. The latter is particularly problematic when the host countries suffer from serious challenges such as limited resources, pollution, and widespread antimicrobial resistance (AMR). Here, we discuss AMR in refugees of the ongoing Syrian war, a conflict that resulted in the largest population displacement in recent history. We argue that Syrian refugees and their hosting communities are at an elevated risk of complicated and life-threatening AMR infections. We also call on the international community to address this grievous problem that threatens the disenfranchised refugee populations and can spill over across geographic borders to affect multiple countries.

Viral hepatitis in 2021: The challenges remaining and how we should tackle them

Viral hepatitis results in 1.4 million deaths annually. The World Health Organization (WHO) set an ambitious target to eliminate viral hepatitis by 2030, but significant challenges remain. These include inequalities in access to healthcare, reaching at risk populations and providing access to screening and effective treatment. Stigma around viral hepatitis persists and must be addressed. The WHO goal of global elimination by 2030 is a worthy aim, but remains ambitious and the coronavirus 2019 pandemic undoubtedly has set back progress. This review article will focus on hepatitis A to E, highlighting problems that have been resolved in the field over the past decade, those that remain to be resolved and suggest directions for future problem solving and research.

Organizational learning, resilience and psychological empowerment as antecedents of work engagement during COVID-19

Purpose

This paper aims to explore the relationship between organizational learning (OL) and work engagement (WE) in the Middle East region amid the COVID-19 pandemic and to test the mediating role of employee resilience (ER) and psychological empowerment (PE) on this relationship.

Design/methodology/approach

The sample size was 208 respondents working in the Middle East area during COVID-19. Hypotheses were tested using regression analysis with bootstrapping.

Findings

The findings indicate a significant positive impact of OL on WE. Moreover, both constructs – ER and WE – were identified as mediators for this relationship.

Practical implications

Practical implications within this study call for organizations to focus on promoting a learning culture in order to adapt and respond effectively to unprecedented external challenges.

Originality/value

The current study extends previous research and strengthens the antecedents of WE, namely, OL, ER and PE in the Middle East region while controlling for COVID-19 perceptions.

Predictors of hepatitis A immunity in adults in California in order to better utilize hepatitis A vaccine

BACKGROUND

Hepatitis A vaccine recommendations now include homelessness, illegal drug use, and HIV, as well as traditional risk factors and travel to areas endemic for hepatitis A. We examined a large diverse population for predictors of Hepatitis A immunity in order to better utilize Hepatitis A vaccine.

METHODS

We performed a cross-sectional descriptive study of members of a large integrated health plan with a test for Hepatitis A Immunoglobulin G (IgG) between January 1st, 2007, and December 31st, 2017. Exclusion criteria included age <18 years, <6 months of continuous enrollment, and Hepatitis A vaccine prior to Hepatitis A test. Variables of interest were age, gender, primary language spoken, ethnicity/race, neighborhood household income, and history of travel or history of jaundice. Multivariable logistic regression was performed to evaluate the association of risk factors on Hepatitis A immunity.

RESULTS

Of the 318,170 persons ≥ 18 years tested for Hepatitis A immunity, 155, 842 persons had a reactive Hepatitis A IgG test (49%). The lowest prevalence was for Whites at 28.1% followed by Blacks at 35.8%. Hispanics and Asian/Pacific Islanders had prevalence rates of 63% and 68.2% respectively. In adjusted analyses, Asian/Pacific Islanders, Hispanics and Blacks were 5.17, 3.44 and 1.42 times more likely to have Hepatitis A immunity than Whites. Those that spoke Spanish or language other than English or Spanish as their primary preferred language were 6.11 and 3.27 time more likely to have immunity than English speakers. Known travel history conferred a 2.16 likelihood of Hepatitis A immunity.

CONCLUSIONS

Persons of Hispanic and Asian/Pacific Islander background as well as persons with a preferred spoken language other than English have a high prevalence of Hepatitis A immunity. Testing for Hepatitis A immunity prior to vaccination should be considered for these groups.

The excretion rate and stability of HAAg in human fecal samples after live attenuated hepatitis A vaccination

The live attenuated hepatitis A virus vaccine (HA-L) is in routine use in the Chinese national immunization program (NIP). The major disadvantages of HA-L include that theoretically, it may be possible for mutation shifts and secondary infections of the live vaccine viral strain. The aim of this study was to explore variation in the viral strain after vaccination with the HA-L. A total of 1297 fecal samples (including 470 for the 18 to 36-month-old age group, 527 for the 3 to 16-year-old group, and 300 for the 16 years and older group) were collected in the study, and the rate of hepatitis A virus (HAV) positivity in fecal samples was 11.36% (31/273), 11.44% (31/271), 9.70% (26/268), 8.47% (21/248), and 9.70% (23/237) on days 0, 7, 14, 21 and 28, respectively. A total of 77 HAV positive samples were randomly selected for VP1/2A (360 bp, 2218-2577) gene analysis. Phylogenetic trees were then constructed by the neighbor-joining method. Phylogenetic analyses showed that all the isolated HAV strains belonged to sub-genotype IB, which was the same as the vaccine strain. Compared with the vaccine strain, HM-175/7MK-5 (M16632.1), there were only two base mutations discovered, at 2291 and 2568. However, the amino acid mutation analysis showed that those base mutations were synonymous mutations. The isolated HAV strains were genetically stable. This study provides a reference for the safety concern regarding the routine and wide-range use in people older than 18 months.