Knowledge, Attitudes, and Practices of European Healthcare Professionals towards Hepatitis A and Hepatitis B Vaccination in at-Risk Adults

Despite the occurrence of several hepatitis A (hepA) and hepatitis B (hepB) outbreaks in Europe in the last few decades, not all European countries have implemented hepA and hepB vaccinations in their national immunization programs, especially for adults at risk for hepA and/or hepB infection, such as men who have sex with men or patients with chronic liver disease. Currently, little is known on the attitudes of European healthcare professionals (HCPs) towards hepA and hepB vaccinations for at-risk adults. We conducted an online survey among HCPs in Germany, Spain, and the United Kingdom to assess their awareness of and adherence to their national hepA and hepB vaccination guidelines for at-risk adults. Among the 698 HCPs who took the survey, most (91.1%) were familiar with their national vaccination recommendations and always followed them or followed them most of the time when advising or prescribing hepA or hepB vaccines. Major and moderate barriers for recommending or administering such vaccines were the non-disclosure of risk factors by the patient (53.0-57.6%) and the patient's lack of motivation or knowledge about the risk of the disease (50.3-52.9%). These results may help inform strategies to improve and accelerate hepA and hepB vaccination in European at-risk adults.

Hepatitis A occurrence and outbreaks in Europe over the past two decades: A systematic review

Hepatitis A (HA) is a vaccine-preventable liver disease with >170 million new cases occurring yearly. In recent outbreaks in the USA, hospitalization and case-fatality ratios were >60% and ~1%, respectively. In Europe, endemicity persists and outbreaks continue to occur. We performed a systematic literature review to understand the changes in HA occurrence in Europe over the past two decades. PubMed and Embase were systematically searched for peer-reviewed articles published between 1 January 2001 and 14 April 2021 using terms covering HA, 11 selected European countries, outbreaks, outcomes and HA virus circulation. Here, we focus on HA occurrence and outbreaks in the five countries with the largest population and the most comprehensive vaccination recommendations: France, Germany, Italy, Spain and the UK; 118 reports included data for these five European countries. Notification rates (≤9.7/100,000 population) and percentages of men among cases (≤83.0%) peaked in 2017. The number of person-to-person-transmitted cases and outbreaks decreased in children but increased in other risk groups, such as men who have sex with men (MSM). Sexually transmitted outbreaks in MSM clustered around 2017. Travel-related outbreaks were few; the proportion of travel-related cases decreased during the past two decades, while the number of domestic cases increased. Despite the existing risk-based vaccination recommendations, HA transmission shifted in proportions from travelers and children to other risk groups, such as MSM and older age groups. Because a substantial proportion of the European population is susceptible to HA, adherence to existing recommendations should be monitored more closely, and enhanced vaccination strategies should be considered.

Use of expanded Neisseria meningitidis serogroup B panels with the serum bactericidal antibody assay for the evaluation of meningococcal B vaccine effectiveness

INTRODUCTION

Neisseria meningitidis serogroup B (NmB) antigens are inherently diverse with variable expression among strains. Prediction of meningococcal B (MenB) vaccine effectiveness therefore requires an assay suitable for use against large panels of epidemiologically representative disease-causing NmB strains. Traditional serum bactericidal antibody assay using exogenous human complement (hSBA) is limited to the quantification of MenB vaccine immunogenicity on a small number of indicator strains.

AREAS COVERED

Additional and complementary methods for assessing strain coverage developed previously include the Meningococcal Antigen Typing System (MATS), Meningococcal Antigen Surface Expression (MEASURE) assay, and genotyping approaches, but these do not estimate vaccine effectiveness. We provide a narrative review of these methods, highlighting a more recent approach involving the hSBA assay in conjunction with expanded NmB strain panels: hSBA assay using endogenous complement in each vaccinated person's serum (enc-hSBA) against a 110-strain NmB panel and the traditional hSBA assay against 14 (4 + 10) NmB strains.

EXPERT OPINION

The enc-hSBA is a highly standardized, robust method that can be used in clinical trials to measure the immunological effectiveness of MenB vaccines under conditions that mimic real-world settings as closely as possible, through the use of endogenous complement and a diverse, epidemiologically representative panel of NmB strains.

1239. Hepatitis A Epidemiology in Europe: A Systematic Literature Review of the Last 20 Years

Background

Hepatitis A (HepA) global burden is estimated to be > 100 million new cases/year. HepA is vaccine-preventable, but outbreaks still occur in regions with low endemicity such as Europe. Guidelines for HepA vaccination in adult risk groups are available in European countries, but adherence to vaccination recommendations is not systematically documented. Here we review European data on HepA infection outcomes, we discuss the HepA risk in the population in order to assess the adequacy of HepA vaccination strategies.

Methods

A systematic search in PubMed and Embase was performed from January 2001 to April 2021. Relevant data from ECDC, ProMED, ESCAIDE and national public health websites was also reviewed. We included articles in all languages, covering all ages and data published on 11 countries (Denmark, France, Germany, Greece, Hungary, Italy, the Netherlands, Spain, Sweden, Switzerland and the United Kingdom [UK]). Studies on seroprevalence and risk factors for HepA virus (HAV) were excluded.

Results

Overall, 134 articles and 85 grey literature reports were included in our review. In Europe, in the last 20 years, HepA infections were reported in all ages. Annual hospitalization rates exceeded 50% in 8 of the surveyed countries during 2016–2019. HAV complications were reported by 28 publications (ps): 8 liver transplantation cases in 6 ps ; liver failures in 0%–25% of HepA patients reported by 23 ps and hemorrhagic complications in 0%–51% of HepA patients reported by 8 ps. Fatality rates, reported by 12 ps for Italy, Hungary, Denmark, Germany and Spain were 0.05%–0.26%, mostly in adults/older adults.

Conclusion

In Europe, HepA infections are recorded in all ages despite not being consistently reported. Although the fatality rate is low, the hospitalization rates and the morbidity are high in adults/older adults. Considering the current epidemiological situation and HepA-related costs, authorities should raise awareness on HepA risk and adapt or improve compliance with the vaccination recommendations. Adherence to the existing recommendations should be monitored more closely. Universal HepA vaccination may be considered, similarly to the strategy adopted in the United States after widespread and ongoing HepA outbreaks.

Funding

GlaxoSmithKline Biologicals SA

Disclosures

Anar Andani, BSc, Medical director, GSK group of companies: Employee|GSK group of companies: Stocks/Bonds Eveline Bunge, PhD, GSK group of companies: My institution received grants and payment for developing studies Jennifer Eeuwijk, MSc, GSK group of companies: My institution received grants and payment for developing studies George Kassianos, MD (Hons), FRCGP, FESC, FBGTHA, FFTM RCPS(Glasg), FBHS, FHEA, FAcadMEd, DRCOG, LRCP (Edin.), LRCS (Edin.), LRCP&S (Glas.), DMedAcup., DMedHypn., DFP, AstraZeneca: Advisor/Consultant|British Global and Travel Health Association: President|European Scientific Working Group on Influenza (ESWI): Board Member|European Scientific Working Group on Influenza (ESWI): Lectures|MSD: Advisor/Consultant|Northern European Conference on Travel Medicine: Lectures|Novavax: Advisor/Consultant|Pfizer: Advisor/Consultant|RAISE Pan-European Committee on Influenza: Chair|Royal College of General Practitioners: National Immunisation Lead|Sanofi Vaccines: Advisor/Consultant|Seqirus: Advisor/Consultant|UK National Health Service: Lectures|Valneva: Advisor/Consultant Robert Steffen, MD, GSK group of companies: Advisor/Consultant|GSK group of companies: Honoraria.

Burden of disease and associated complications of hepatitis a in children and adults in Mexico: A retrospective database study

BACKGROUND

Hepatitis A virus (HAV) infection is a leading cause of viral hepatitis in children, yet the HAV vaccine is not included in the national immunization program (NIP) in Mexico. This study addresses an identified evidence gap of the burden of hepatitis A disease, complications, and associated costs in Mexico by analyzing surveillance and healthcare data. Data review included disease morbidity (incidence and hospitalization), mortality, and healthcare resource utilization costs.

METHODS

In this observational, retrospective database study, we conducted a systematic screening, extraction, and analysis of outcome data from the national surveillance system in Mexico from January 2000 to December 2019.

RESULTS

During the analysis period (2000-2019), the average incidence rate/year of HAV cases was 14.7 (5.4-21.5) per 100,000 inhabitants. Children 1-9 years of age (YoA) had the highest average incidence rate/year with 47.8 (14.7-74.5). The average hospitalization rate/year due to HAV infection was 5.8% (2.9-9.6%). Although the highest burden of HAV continued to be in children (1-9 YoA), an increase in incidence and hospitalizations (with complications) in older age groups (≥ 10-64 YoA) was observed. The annual average fatality rate was estimated to be 0.44% (0.26-0.83%) of which 28.8% of deaths were concentrated in adults ≥ 65 YoA. The total direct costs of medical attention due to HAV and related complications were estimated at $382 million Mexican pesos.

CONCLUSION

The overall results suggest an uptrend in HAV infections in adolescents/adults compared to children in Mexico. Therefore, as the overall incidence risk of HAV infection decreases, the mean age of infection increases. This consequently increases the risk of severity and complications in older age groups, thus increasing the demand for healthcare resources. Our findings provide evidence for including the inactivated HAV vaccine in the Mexican NIP.

What can Europe learn from HCP knowledge and attitudes towards hepatitis A vaccination in the US?

Background

An estimated >100 million new hepatitis A (hepA) infections occur annually worldwide. Centres for disease control and prevention reported 38795 hepA cases in the US since 2016, and 4475 outbreak-confirmed cases in Europe between 2016-2018. HepA outbreaks resulted mainly from person-to-person contact, especially among homeless, illegal drug users (IDU) and men who have sex with men (MSM). In 2020, we surveyed US health care providers (HCPs) to understand their knowledge and attitudes towards hepA vaccination in these populations at higher risk of infection and complications.

Methods

This was a cross-sectional, web-based survey of 400 HCPs (primary care providers, nurse practitioners, gastroenterologists, internal medicine and infectious disease specialists [IDs], emergency room physicians [ERs]) who had recommended and/or administered hepA vaccines to ≥ 19-year-olds.

Results

85% of 371 HCPs reported recommending hepA vaccine to homeless, 87% of 393 to IDU and 83% of 397 to MSM, although vaccination may not actually occur after recommendation. Results varied by specialty, 16% fewer ERs than IDs reported recommending the vaccine in these at-risk populations. Moreover, 64%, 75% and 71% of all (400) HCPs reported extremely important that homeless, IDU and MSM, respectively, get vaccinated for hepA, while 6%, 7% and 8% of all HCPs reported this as slightly, or not important. Reasons for not recommending hepA vaccine to homeless, IDU and MSM included uncertainty on guidelines (reported by 22/56, 24/50 and 29/66 HCPs, respectively) and low risk of infection (reported by 20/56, 30/50 and 27/66 HCPs, respectively).

Conclusions

Despite recent hepA outbreaks and strengthened recommendations for vaccination in at-risk populations, knowledge gaps persist among US HCPs. This survey may motivate European countries to reinforce national hepA vaccination recommendations and, in parallel, consider efforts to raise vaccination awareness.

Funding

GlaxoSmithKline Biologicals SA

Key messages

Education on hepatitis A vaccination recommendations in at-risk populations is needed. Health care providers’ vaccination knowledge plays a critical role to control the hepatitis A outbreak in the US and preventing hepatitis A in Europe.

Need for hepatitis A prevention in patients with chronic liver disease in the changing epidemiological setting of India

The burden of chronic liver disease (CLD) in India is high, particularly among middle-aged men, with nearly 220,000 deaths due to cirrhosis in 2017. CLD increases the risk of infection, severe disease (e.g. hepatitis A virus or HAV superinfection, acute-on-chronic liver failure, fulminant hepatic failure), and mortality. Hence, various countries recommend HAV vaccination for CLD patients. While historic Indian studies showed high seroprevalences of protective HAV antibodies among Indian adults with CLD, the most recent ones found that nearly 7% of CLD patients were susceptible to HAV infection. Studies in healthy individuals have shown that HAV infection in childhood is decreasing in India, resulting in an increasing population of adults susceptible to HAV infection. As patients with CLD are at increased risk of severe HAV infection, now may be the time to recommend HAV vaccination among people with CLD in India.

Endemicity change of hepatitis A infection necessitates vaccination in food handlers: An Indian perspective

In the last two decades, outbreaks due to the foodborne hepatitis A virus (HAV) have been frequently reported in India, with adolescents and adults primarily affected. In India, most food handlers are adolescents and young adults who might be exposed to unsatisfactory environmental conditions and poor water quality. This increases the risk of HAV infection and consequently compounds the risk of HAV transmission from food handlers to susceptible populations. Given the shift in hepatitis A endemicity from high to intermediate levels in India, implementing the vaccination of food handlers has become important as it can also contribute to the elimination of hepatitis A in India. This narrative review makes a case for hepatitis A immunization of food handlers in India considering the growing food industry, evolving food culture, and the substantial burden caused by hepatitis A outbreaks.

What is the context?

Hepatitis A disease is a common form of viral hepatitis and is transmitted through contaminated food and water or through close contact with an infected person. The virus with stands high temperature and can survive on surfaces for long periods of time.

In India, the burden of hepatitis A has shifted from children to adolescents and adults who are more culnerable to infection. They present a high risk of complications, often requiring hopitalization.

The prevention of the disease has often bee neglected, inadequate safety measures for the preparation of food (via food handlers) is a known risk factor for the transmission of hepatitis A.

What is new?

Our review highlights the relationship between food handling and hepatitis A infection among adolescents and adults in Inida.

The lack of knowledge of food safety regulations and hygiene measures among food handlers and the organizations that guide them may contribute to the spread of hepatitis A.

What is the impact?

Sanitation efforts, awareness and educational programs for food are needed to help reduce the transmission of hepatitis A virus and disease, yet these measures alone may not be sufficient.

Vaccination among high-risk populations such as food handlers can prevent hepatitis A infection and its complications as well as transmission.

One or two doses of hepatitis A vaccine in universal vaccination programs in children in 2020: A systematic review

BACKGROUND

Hepatitis A virus (HAV) is a global health concern as outbreaks continue to occur. Since 1999, several countries have introduced universal vaccination (UV) of children against HAV according to approved two-dose schedules. Other countries have implemented one-dose UV programs since 2005; the long-term impact of this schedule is not yet known.

METHODS

We conducted a systematic literature search in four electronic databases for data published between January 2000 and July 2019 to assess evidence for one-dose and two-dose UV of children with non-live HAV vaccines and describe their global impact on incidence, mortality, and severity of hepatitis A, vaccine effectiveness, vaccine efficacy, and antibody persistence.

RESULTS

Of 3739 records screened, 33 peer-reviewed articles and one conference abstract were included. Rapid declines in incidence of hepatitis A and related outcomes were observed in all age groups post-introduction of UV programs, which persisted for at least 14 years for two-dose and six years for one-dose programs according to respective study durations. Vaccine effectiveness was ≥95% over 3-5 years for two-dose programs. Vaccine efficacy was >98% over 0.1-7.5 years for one-dose vaccination. Antibody persistence in vaccinated individuals was documented for up to 15 years (≥90%) and ten years (≥74%) for two-dose and one-dose schedules, respectively.

CONCLUSION

Experience with two-dose UV of children against HAV is extensive, demonstrating an impact on the incidence of hepatitis A and antibody persistence for at least 15 years in many countries globally. Because evidence is more limited for one-dose UV, we were unable to draw conclusions on immune response persistence beyond ten years or the need for booster doses later in life. Ongoing epidemiological monitoring is essential in countries implementing one-dose UV against HAV. Based on current evidence, two doses of non-live HAV vaccines are needed to ensure long-term protection.

34. Impact of Universal Mass Vaccination Programs of Children Against Hepatitis a with 2-dose and 1-dose Schedules: A Systematic Literature Review

Background

With more than 100 million new hepatitis A (HepA) virus (HAV) infections estimated each year, HepA is a serious health concern worldwide. Several countries implemented 2- or 1-dose universal mass vaccination (UMV) programs of children with HAV vaccines. Here we present the first systematic review describing the impact of 2- and 1-dose UMV programs on HepA incidence and related health outcomes.

Methods

We systematically searched several databases for data published between Jan 2000–Jul 2019 (Figure 1). We assessed available evidence for 2- and 1-dose UMV programs with inactivated HAV vaccine in children worldwide, in terms of impact on HepA incidence, disease severity and mortality, vaccine efficacy, vaccine effectiveness and antibody persistence.

Figure 1. PRISMA flowchart

Results

3739 articles were screened and 34 studies were included in our analysis (Figure 1). 18 real-world studies in 9 countries showed that HepA incidence declined in all ages following introduction of 2-dose and 1-dose UMV programs and persisted for at least 14 years (2-dose) and at least 6 years (1-dose) (Figure 2). Evidence for 1-dose schedule was limited to only 3 studies. HAV related outcomes (disease severity, mortality) decreased after UMV with either 2-dose or 1-dose schedule. Vaccine effectiveness for the 2-dose schedules was ≥ 95% over 3–5 years. Vaccine efficacy for the 1-dose schedule was > 98% over 0.1–7.5 years. Anti-HAV antibody persistence in vaccinated children was documented up to 15 years with ≥ 90% seropositivity rates for the 2-dose schedule and up to 10 years with ≥ 74.3% seropositivity rates for the 1-dose schedule. Anti-HAV antibody GMC data is presented in Table 1.

Figure 2. Impact of vaccination on hepatitis A incidence in countries implementing 2-dose or 1-dose schedules (data from studies presenting ‘all ages’ incidence data)

Table 1. Anti-HAV antibody GMCs following vaccination with 2-dose and 1-dose schedules, data from studies included in our review

Conclusion

The implementation of 2- and 1-dose UMV programs against HAV induced decreases in disease incidence and related outcomes. Experience with 2-dose schedule is extensive, with wide geographical use, while evidence beyond 10 years for the 1-dose schedule has not yet been demonstrated. Continued and robust surveillance is needed to monitor the epidemiology, vaccine effectiveness, antibody persistence and protection (particularly in the absence of natural boosting) in order to have a strong, scientifically sound basis for decision makers when concluding on HepA prevention strategies in their countries.

Funding: GlaxoSmithKline Biologicals SA

Disclosures

Anar Andani, BSc, GSK group of companies (Employee, Shareholder) Eveline M. Bunge, PhD, GSK group of companies (Research Grant or Support) Fernanda Salgado, MD, MSc, GSK group of companies (Employee) Rosa C. van Hoorn, MSc, GSK group of companies (Research Grant or Support) Bernard Hoet, MD, FFPM, GSK group of companies (Shareholder)

Hepatitis A epidemiology in Latin American countries: a 2020 view from a systematic literature review

INTRODUCTION

The World Health Organization recommends vaccination against hepatitis A virus (HAV) for children aged 1 year and older in areas where endemicity has shifted from high to intermediate. There are no recent comprehensive reviews of the epidemiology of HAV infection in Latin America, but seroprevalence and socioeconomic data suggest that, with improved clean water and sanitation systems, countries are transitioning to intermediate endemicity.

AREAS COVERED

We conducted a systematic literature review of the epidemiology of HAV infection in 25 countries in the Latin American region, which included gray literature. We compiled data on HAV incidence and prevalence, including the identification of epidemiological changes observed in countries that established pediatric HAV vaccination programs.

EXPERT OPINION

We identified 59 relevant articles, including 34 peer-reviewed seroprevalence studies (12 recent studies from Brazil), three incidence studies, and six vaccine impact studies (three from Argentina). Based on the estimated age at midpoint of population immunity in each country, most have a high-intermediate, intermediate, or low-intermediate level of HAV endemicity, suggesting that national childhood immunization may be an appropriate disease prevention strategy. However, recent data were lacking for most countries. Improved data quality and continued epidemiological surveillance are required for this region.

Long-Term Persistence of Antibody Response with Two Doses of Inactivated Hepatitis A Vaccine in Children

INTRODUCTION

Hepatitis A virus infection is more severe in adults than children. Although vaccination can protect adults, current childhood programs cover a large population more successfully. Childhood vaccination is, therefore, a solution to protecting adults if it induces lasting immunity. Fifteen-year protection has been demonstrated in children, but longer-term data are only available for adults. We aimed to predict long term persistence of antibody in children beyond 15 years and assess if immunological mechanisms triggered by vaccination support longer-term protection.

METHODS

Long-term clinical studies using hepatitis A (HAV) or A/B vaccines (HAB) containing 720 or 1440 Enzyme-linked immunosorbent assay Units (EU) of hepatitis A virus antigen were identified. Duration of persistence of antibodies and possible protection was determined by descriptively comparing antibody geometric mean concentration (GMC) kinetics, as well as GMC (95% confidence interval) at 15 years post-vaccination across studies. Immunological mechanism studies describing hepatitis A vaccination were identified.

RESULTS

One study in children 12-15 years (2-dose HAB 720) and four in adults (2-dose HAV 1440 and 3-dose HAB 720) showed comparable GMC kinetics and per year rates of change up to 15 years. At 15 years, the GMC in children [414.7 mEU/ml (336.9; 510.5)] was in the same range as in adults [range 282.6 (217.6; 367.0) to 550.1 (416.0; 727.4)]. Based on these data, mathematical model predictions from adult studies (showing > 85% protected at 50 years) were deemed likely to also apply to children. Studies identified, both humoral and cell-mediated responses are induced following vaccination.

CONCLUSION

Based on comparable antibody data in adults and children up to 15 years, similar longer-term antibody persistence is expected in children with 2-dose inactivated hepatitis A 720 containing vaccine at least up to 50 years. Accordingly, improving routine childhood hepatitis A vaccination coverage could protect against more severe disease in adulthood. Fig. 1 Plain language summary TRIAL REGISTRATION: ClinicalTrials.gov identifiers, NCT00875485, NCT01000324, NCT01037114, NCT00289757, NCT00291876.