recurring hepatitis a outbreaks in the eu/eea: summary of the recommendations, dr. johanna takkinen
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Recurring hepatitis A outbreaks in the EU/EEA: summary of the recommendationsJohanna Takkinen, EPIET alumnus 1999 (cohort 5)European Centre for Disease Prevention and ControlESCAIDE, Stockholm, 12 November 2015
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Hepatitis A – acute illness and virus characteristics Faecal-oral transmission Relapses in about 15% of patients
=> prolonged disease course up to 6-9 months
Asymptomatic or subclinical infection mostly in children < 5 years
Case-fatality low, < 0.5%
"HAV Infection" by GrahamColm at English Wikipedia. Licensed under CC BY-SA 3.0 via Commons - https://commons.wikimedia.org/wiki/File:HAV_Infection.png#/media/File:HAV_Infection.png
RNA virus in the family Picornaviridae
High environmental persistence One serotype, genotypes I, II and
III of human origin Highly conserved => slow
replication pace High genetic diversity
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ECDC 1st Annual Epidemiological Report, covering data for 1995 - 2005
EU/EEA trend in 1995 – 2004:
Available at: http://ecdc.europa.eu/en/publications/surveillance_reports/annual_epidemiological_report/Pages/2007_epi_report.aspx
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Hepatitis A notifications in EU/EEA, 2010 – 2014*
*Unpublished data for 2014
Main risk groups:- Intravenous drug users- Homeless people- Men having sex with
men- Travelling communities
Average EU/EEA notification rate 2.7 / 100 000 in 2010-2014
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”Cluster” of alerts in Epidemic Intelligence Information System (EPIS) in 2013
Norway, 17 April 2013:
Germany, 8 May 2013:
Denmark, 1 March 2013:
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Hepatitis A (IB, two strains) in Denmark, Finland, Norway and Sweden, October 2012 – June 2013 (N=103)
Severi et al .The Lancet Infectious Diseases 2015 15, 632-634DOI: (10.1016/S1473-3099(15)00021-3)
Vehicles of infection from Egypt or Morocco:
EPIS & EWRS
ECDC-EFSA ROA*
*ROA = Rapid Outbreak Assessment
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Hepatitis A (IB) in travellers returning from Egypt, November 2012 – April 2013 (N=107, 14 countries)
mOR 10.1 (95%CI 1.1-93)
mOR 21 (95%CI 1.1-409)
fresh, in smoothies, pastries and fruit sauce
Vehicles of infection:
EPIS & EWRS week 16
RRA* week 17
*RRA = Rapid Risk Assessment
No vaccination in travellers!
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Multi-state hepatitis A (IA) outbreak, due to contaminated berries and travel to IT, January 2013 – June 2014 (9 countries, finally 13 countries)
Source: EFSA report, Tracing food items in connection to hepatitis A, 2014
Vehicles of infection:Mixed frozen berriesEPIS &
EWRS ECDC-EFSA ROA 1st update of ECDC-EFSA
ROA
2nd update of ECDC-EFSA ROA
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Hepatitis A: seroprevalence in EU/EEA 1975 – 2014*
*ECDC: Hepatitis A virus in the EU/EEA, 1975-2014: a systematic review of seroprevalence and incidence comprising European Surveillance data and national vaccination recommendations, expected publication in early 2016
1975 - 1989 1990 - 1999 2000 - 2013
WHO classification1:I = IntermediateL = LowVL = Very low
1World Health Organization. WHO position paper on hepatitis A vaccine-June 2012. WER 2012; 28-29: 261-276. Available at: http://www.who.int/wer/2012/wer8728_29.pdf?ua=1
24 countries in EU/EEA have very low seroprevalence profiles (based on seroprevalence estimates at 15 and 30 years)
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Hepatitis A: susceptibility profilesin EU/EEA 2000 – 2014*
*ECDC: Hepatitis A virus in the EU/EEA, 1975-2014: a systematic review of seroprevalence and incidence comprising European Surveillance data and national vaccination recommendations, expected publication in early 2016
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Conclusions Sequencing of HAV strains crucial for outbreak detection and
investigation Centralised collection of sequences essential for hypothesis
generation HAV sequencing practices vary by countries => comparison
difficult Population at risk shifted from risk groups to EU general
population – Large variations in susceptibility by countries and regions– Vaccine recommended for risk groups (e.g. travellers)
Lack of vaccination in European travellers => risk perception low when staying in luxury hotels even in endemic countries
Collaboration worked well between national food safety and public health authorities
EFSA-ECDC (risk assessors) and Commission (risk manager) worked too much in silos – Delay in the start of an EU-wide trace-back investigation
Invaluable support to all investigations received from EPIET/EUPHEM fellows in the field– EPIET/EUPHEM vision fulfilled; a network of
epidemiologists/microbiologists using common language and tools
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Recommendations and actions (to be) taken A common sequencing protocol prepared in RIVM by
HAVNET Promotion of centralised sequence data collection is
needed=>HAVNET is a recommended centralised database for HAV sequences in Europe
A review of seroprevalence and susceptibility of EU populations by countries is needed to assist countries in their assessment on appropriateness of vaccination practices
=>Prepared by ECDC and expert panel, report to be published in early 2016
Increasing importance of berries as vehicle of HAV infection
EU-wide trace-back investigation should be initiated faster
=> Regular communication between Commission and ECDC-EFSA is needed in a multi-state foodborne outbreak event
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Acknowledgements
Ettore
Severi
Jussi Sane
Julita Gil Cuesta
Emily MacDon
ald
Sofie Gillesberg Lassen
Pieter Smit
Max Gertler
Anneke Steens
Michael Edelstei
n
Line VoldBernardo
Guzman-Herrador
Bolette Søborg
Ruska Rimhanen-Finne
Martina Escher
Margot Einöder-Moreno
Heidi Lange
Margaret Fitzgeral
d
Justina Rogalska
Rita da Sousa
• Jussi Sane (EPIET) and Rita de Sousa (EUPHEM)
• All epidemiologists and virologists in affected countries that participated in investigations
• Harry Vennema /HAVNET/RIVM
• ECDC staff• Ettore Severi• Lara Tavoschi• Celine Gossner• Pier Luigi Lopalco• Paloma Carrillo-Santisteve• Marion Muehlen• Aftab Jasir• Yvan Huitin• Denis Coloumbier
• EFSA staff• Jane Richardson• Olaf Mosbach-Schulz• Pia Mäkelä
• Commission• Klaus Kostenzer
19 fellows involved!
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Multi-state hepatitis A outbreak due to contaminated berries and travel to IT, January 2013 – June 2014 (9 countries, finally 13 countries)
Source: EFSA report, Tracing food items in connection to hepatitis A, 2014
Vehicles of infection:Mixed frozen berriesEPIS &
EWRS ECDC-EFSA ROA 1st update of ECDC-EFSA
ROA
2nd update of ECDC-EFSA ROA
ECDC-EFSA-MS-EC TC
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Thank you for your attention!
Contact ECDC FWD team: [email protected] ECDC website: www.ecdc.europa.eu