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Foodborne outbreaks of hepatitis A virus (HAV) are most commonly associated with fresh and frozen produce and with various types of shellfish. Alcoholic beverage-borne outbreaks of hepatitis A are extremely rare. Here, we report an outbreak of hepatitis A associated with the consumption of a traditional wine at a funeral ceremony in the Sabah state of Malaysian Borneo. Confirmed cases were determined by serum anti-HAV immunoglobulin M and/or for fecal HAV by reverse transcription polymerase chain reaction (RT-PCR). The amplicons of RT-PCR were subjected to nucleotide sequencing followed by phylogenetic analysis. We conducted a 1:2 case–control study to identify the possible exposure that led to the outbreak. Sixteen patients met the case definition, they were 18 to 58 years old and 90% of them were males. The case–control study showed that the consumption of nipa palm wine during the ceremony was significantly associated (P = 0.0017) with hepatitis A infection (odds ratio, 5.44; 95% CI, 1.80–16.43). Untreated river water was used to dilute the traditional wine, which was assumed to be the source of the infection. Phylogenetically, these viruses belonged to genotype IA and formed an independent cluster with strains from Taiwan, Japan, and the Philippines. This strain might be an emerging HAV in Asian countries. Environmental assessments were performed and environmental samples were negative for HAV. The incidence of hepatitis A in Sabah was also determined and it was 0.795/100,000 population. Strict monitoring of traditional wine production should be implemented by the local authority to prevent future outbreaks.

Background: Vomiting is a common problem in children for which parents seek health care consultation. It has a varied etiology encompassing many organ systems, ranging from a benign physiological behavior to a life-threatening systemic disease. Most often, it is benign and self-limiting. Infections within and outside the gastrointestinal tract are the commonest causes. Objective: To evaluate the gastrointestinal and non-gastrointestinal causes of vomiting in children admitted to Al-Azhar University Hospital in Assiut from December 2019 to June 2020. Patients and Methods: This descriptive cross-sectional study included 105 children admitted to Al- Azhar University Hospital in Assiut during the period from December 2019 to June 2020 presenting with vomiting. Their ages varied from 2 to10 years old and included 64 males and 41 females. Results: Acute gastroenteritis was the leading cause of vomiting among all cases. It was observed that dehydration (86.0%) and weight loss (70.2%) were the most common clinical signs among GI causes of vomiting. Regarding laboratory results, anemia was presented in most of our cases, due to GI and non-GI causes of vomiting, representing (82.4%) and (70.8%) respectively. Abdominal U/S showed a high ability in diagnosing renal stones in (12.5%) of cases with non-GI causes of vomiting. Conclusion: The commonest GI cause of vomiting in children was gastroenteritis, followed by hepatitis A infection. The commonest non-GI cause of vomiting was lower respiratory tract infection. Weight loss was considered a golden standard in assessment of dehydration. Abdominal U/S was a useful tool for the diagnosis of renal stones.

In cases with a broad differential or atypical features, it is important to continually review the original diagnosis. Diagnosing SLE can be challenging due to its multisystem presentations; a multidisciplinary approach is beneficial.

Background: Infectious hepatitis can be caused by Hepatitis A and Hepatitis E viruses. Hepatitis E infection is a water-borne disease transmitted by faeco-oral route. It is a cause of major health problems in developing countries. Outbreaks can happen due to improper hygiene and poor sanitation. Hepatitis E infection shows similar mode of transmission and clinical features of Hepatitis A infection. Aim: This study was conducted to investigate the occurrence of Hepatitis E virus infection in patients screened for hepatitis A virus. Materials and Methods: This prospective surveillance study was conducted between March 2020 to March 2021 on 57 serum samples which is came for the screening of anti-Hepatitis A virus IgM by enhanced Chemiluminescence method. These samples were collected and tested for anti- Hepatitis E virus IgM by Enzyme linked immunosorbent assay. Results: Among 57 samples, 11 samples (19.3%) were positive for Hepatitis A Virus IgM, 13 samples (22.8%) were positive for Hepatitis E virus IgM, and 7 samples (12.3%) were positive for both. Conclusion: Hepatitis E virus infections were more than Hepatitis A virus. Hepatitis E and Hepatitis A virus co- infection was also observed. Screening of both viruses is suggested for infectious hepatitis. Keywords: Hepatitis A virus, Hepatitis E virus, IgM antibody.

Author(s): Laursen, Daniel; Krug, Jeffrey; Wolford, Robert | Abstract: Introduction: Acute inflammatory demyelinating polyneuropathy (AIDP) is characterized by progressive, mild sensory symptoms and progressive areflexic weakness. It typically follows a gastrointestinal or respiratory infection but has rarely been described after acute viral hepatitis.Case Report: This is the case of a 59-year-old male who presented to the emergency department after acutely developing progressive neurologic symptoms following a hospitalization for acute hepatitis A. Cerebrospinal fluid analysis revealed albuminocytologic dissociation, and cervical spine magnetic resonance imaging revealed nerve root enhancement.Discussion: The patient was diagnosed with AIDP, which is the most common subtype of Guillain-Barre syndrome in the United States and Europe. There have been few previously reported cases of AIDP following acute hepatitis A infection.

We investigated an outbreak of hepatitis A infection among children in an urban settlement of Vellore, South India. A total of 58 cases of jaundice were reported between April and August 2019. Sera from children who presented with jaundice were tested for hepatitis A virus (HAV) IgM. HAV IgM was positive in 18 (94.7%) of the 19 cases tested. These children also received a blood culture at the same time, as a part of the ongoing Surveillance for Enteric Fever in India (SEFI). Blood cultures from three children with confirmed hepatitis A infection grew Salmonella sp.: two with Salmonella Typhi and one with Salmonella Poona. Salmonella Poona is being reported for the first time from India. The overall hospitalization rate during the outbreak was 21%. Outbreaks of hepatitis A continue to occur with substantial morbidity in children from endemic settings, with notable emergence of other concurrent enteric infections, thereby warranting continued surveillance.

Background Hepatitis A infection is common in children and often presents with mild hepatic disease. The clinical manifestations of hepatitis A virus are usually related to liver damage but sometimes extrahepatic manifestations may occur. Case presentation We present a case of four-year- and eight-month-old male child with anicteric hepatitis A infection associated with a pleural effusion. The patient presented with abdominal pain, low-grade fever, loss of appetite, and vomiting of ten days duration. On examination, there was dullness and decreased air entry on the lower third of the lung field bilaterally and hepatomegaly of 6 cm below the costal margin. Ultrasonography revealed mild ascites, hepatosplenomegaly, and small bilateral pleural effusion. Immunoglobulin M anti-hepatitis A virus serology was positive. He was managed with supportive treatment and fully recovered after a month of follow-up. This case is reported to emphasize that hepatitis A infection should be considered in the differential diagnosis of pleural effusion in a patient with acute hepatitis even in the absence of jaundice. This is the first case of anicteric hepatitis A infection complicated with pleural effusion in children. Conclusion This report suggests that pleural effusion can be associated with anicteric hepatitis A infection and should be included in the differential diagnosis of pleural effusion.

Background: Hepatitis A virus infection (HAV) has generated about half of the total infection of hepatitis in the world. Poor envi­ronmental sanitation and unhealthy behavior of the society can increase the risk of Hepatitis A transmission. This study aimed to analyze the contextual effect of the village on biopsycho­social determinants of Hepatitis A. Subjects and Method: This was an analytic observational study with a case-control ap­proach. This study was conducted from Janu­ary to February 2020. This study used fixed disease sampling. The sample of this study was 200 patients consisted of 50 Hepatitis A pati­ents and 150 non-Hepatitis A patients in villages in Pacitan Regency. The dependent variable was Hepatitis A. The independent vari­ables were age, education, income, history of Hepatitis A vaccination, handwashing behavior, food consumption, availability of clean water, and availability of latrines. This study used questionnaires to collect the data. The data were analyzed by multilevel multiple logistic regression using Stata 13. Results: The risk of Hepatitis A infection decreased with age ≥40 years (OR= 0.06; 95% CI= 0.01 to 0.27; p

BACKGROUND This study aimed to investigate the prevalence of the disease and testing and vaccination status of healthcare workers in terms of hepatitis A infection as well as their awareness. This study is a multicenter descriptive study performed with healthcare workers. MATERIAL AND METHODS Testing status for hepatitis A, awareness of the results and vaccination status of healthcare workers were compared. RESULTS Of the 12,476 healthcare workers participating in the study, only 65% (8,115 healthcare workers) had awareness of hepatitis A test results. Of the participants, 6,481 (66.3 %) stated that they were not vaccinated against hepatitis A. Vaccination rates against hepatitis A decreased with increasing age (P < .01). The rates of vaccination in all departments where participants worked were above 60% (P < .05). While the rate of protection among those working in departments creating a risk for hepatitis A virus infection was higher, no difference among vaccination rates was observed compared with the other departments. CONCLUSION Vaccination of seronegative individuals is the safest way for hepatitis A, which can progress to fulminant hepatitis at advanced ages. It must be aimed primarily to increase the awareness of healthcare professionals and to increase the vaccination rates for hepatitis B and hepatitis A for the prevention of viral hepatitis. In our study, the awareness level was found to be above 50%, and the vaccination level was 35%, which is a rate that must be increased.

Hepatitis A virus infection is one of the major causes for acute viral hepatitis in children. Many extra-hepatic manifestations have been described in the literature. Only three cases of cardiovascular involvement in Hepatitis A in children have been reported till now. We here report two pediatric case of Hepatitis A infection with bradycardia.

There are rare instances where patients with acute hepatitis A virus infection subsequently developed autoimmune hepatitis. The diagnosis of autoimmune hepatitis in this setting is challenging. Furthermore, information on treatment with steroids or other immune suppressants, duration of therapy and possibility of treatment discontinuation is currently unclear. Here we report a case series of four patients with histology proven autoimmune hepatitis after hepatitis A virus infection. We describe the presenting features, diagnosis, treatment and long-term outcomes of these cases. This case series provides a insight into the clinical presentation and treatment of autoimmune hepatitis after hepatitis A infection with interesting take home points for clinical hepatologists.

During 1995-2011, the overall incidence of hepatitis A decreased by 95% in the United States from 12 cases per 100,000 population during 1995 to 0.4 cases per 100,000 population during 2011, and then plateaued during 2012─2015. The incidence increased by 294% during 2016-2018 compared with the incidence during 2013-2015, with most cases occurring among populations at high risk for hepatitis A infection, including persons who use illicit drugs (injection and noninjection), persons who experience homelessness, and men who have sex with men (MSM) (1-3). Previous outbreaks among persons who use illicit drugs and MSM led to recommendations issued in 1996 by the Advisory Committee on Immunization Practices (ACIP) for routine hepatitis A vaccination of persons in these populations (4). Despite these long-standing recommendations, vaccination coverage rates among MSM remain low (5). In 2017, the New York City Department of Health and Mental Hygiene contacted CDC after public health officials noted an increase in hepatitis A infections among MSM. Laboratory testing* of clinical specimens identified strains of the hepatitis A virus (HAV) that subsequently matched strains recovered from MSM in other states. During January 1, 2017-October 31, 2018, CDC received reports of 260 cases of hepatitis A among MSM from health departments in eight states, a substantial increase from the 16 cases reported from all 50 states during 2013-2015. Forty-eight percent (124 of 258) of MSM patients were hospitalized for a median of 3 days. No deaths were reported. In response to these cases, CDC supported state and local health departments with public health intervention efforts to decrease HAV transmission among MSM populations. These efforts included organizing multistate calls among health departments to share information, providing guidance on developing targeted outreach and managing supplies for vaccine campaigns, and conducting laboratory testing of clinical specimens. Targeted outreach for MSM to increase awareness about hepatitis A infection and improve access to vaccination services, such as providing convenient locations for vaccination, are needed to prevent outbreaks among MSM.

Hepatitis E virus (HEV) is one of the main causes of viral hepatitis infection worldwide. Sources of contamination can vary greatly according to geographical regions and HEV genotypes. HEV is endemic and responsible for large waterborne epidemics involving human HEV-1 or HEV-2 genotypes in regions with limited sanitation, in contrast to industrialized countries, where HEV is mainly a foodborne zoonosis involving HEV-3 and HEV-4 zoonotic genotypes. Limited data on HEV source attribution are available, and all possible sources and transmission pathways of HEV are not fully identified. A systematic review and a meta-analysis of case-control and cohort studies (including transversal studies) were performed to determine the main risk factors associated with sporadic hepatitis E infection. Suitable scientific articles were identified through a systematic literature search and subjected to a methodological quality assessment. From each study, odds-ratio (OR) measures were extracted/calculated, as well as study characteristics such as population type, design, and risk factor hierarchy. Mixed-effects meta-analyses models were adjusted by population type to appropriate data partitions. Seventy-seven cohort and case-control studies conducted between 1986 and 2016 and investigating risk factors in mixed population, susceptible population, and pregnant women, were included in this meta-analysis. Hepatitis E cases were defined with serological exams and differentiated whenever the serological exam is associated or not with symptoms. This meta-analysis identified the parenteral pathway (blood transfusion, tattooing or IV injection, dialysis or hemodialysis), and routes of infection related to contaminated water, animal contact (occupational exposure) and consumption of foods as relevant risk factors for hepatitis E infection. With regards to the role of food, as suspected and sometimes proven in several studies, pig meat, pork sausages, and game meat are identified as significant risk factors for HEV, in particular undercooked pig meat, or meat preparations containing pig liver. In addition, consumption of shellfish (oysters and mussels), in which HEV can accumulate when water is environmentally contaminated (from animal or human origin), is also associated with the detection of anti-HEV antibodies. The results of this meta-analysis show that symptomatic and infected cases share the most explainable risk factors, and are in agreement with recent studies conducted in Europe. This meta-analysis reveals that some sources such as consumption of insufficiently treated water, shellfish, or vegetables are under-investigated. Future case-control studies should include population at risk but under-investigated, such as transplant recipients, pregnant women and children, and investigate other potential sources of HEV. The authors would like to thank ANSES staff and the members of the ANSES Working Group on Source Attribution of Foodborne Diseases: Moez Sanaa, Laurence Watier, Jean Christophe Augustin, Frédéric Carlin, Julie David, Philippe Fravalo, Laurent Guillier, Nathalie Jourdan-Da Silva, Alexandre Leclercq, Lapo Mughini-Gras, Isabelle Villena. The authors are also grateful to the reviewers for their help in improving the manuscript quality. U. Gonzales-Barron and V. Cadavez are grateful to the Foundation for Science and Technology (FCT, Portugal) for financial support through national funds FCT/MCTES to CIMO (UIDB/00690/2020). U. Gonzales-Barron also thanks FCT, P.I., for the institutional scientific employment program. info:eu-repo/semantics/publishedVersion

Background. Hepatitis A virus (HAV) is the most common cause of viral hepatitis worldwide. Hepatitis A vaccine is not included in the Expanded Programme on Immunisation in South Africa (EPI-SA), as the country is considered to be highly endemic for hepatitis A. Objectives. To determine the seroprevalence of hepatitis A infection in Western Cape Province (WCP), South Africa. Methods. We conducted a cross-sectional seroprevalence study in the 1 - 7-year age group in WCP. Our samples ( N =482) were blood specimens left over after laboratory testing obtained from referral hospitals between August and October 2015. A Siemens enzyme immunoassay was used to test for total hepatitis A antibodies. We also analysed hepatitis A immunoglobulin G antibody results from the National Health Laboratory Service (NHLS) Disa*Lab database at Groote Schuur Hospital from 2009 to 2014, and included 2009 - 2014 acute hepatitis A (immunoglobulin M-positive) surveillance data from the National Institute for Communicable Diseases to look at trends in notified acute infections over the same period. Results. Our cross-sectional study showed 44.1% seroprevalence in the 1 - 7-year age group. Hepatitis A data from the NHLS database indicated a seroprevalence of

Hepatitis A incidence has declined in most countries through a combination of prevention measures, augmented through the use of a highly effective vaccine. In Australia, the proportion of the population susceptible to hepatitis A infection has declined over time due to high rates of opportunistic vaccination as well as the sustained inflow of seropositive immigrants from high-endemicity countries. These factors have contributed to a rapid decline in incidence. An age-structured hepatitis A transmission model incorporating demographic changes was fitted to seroprevalence and disease notification data and used to project incidence trends and transmission potential for hepatitis A in the general population. Robustness of findings was assessed through worst-case scenarios regarding vaccine uptake, migration and the duration of immunity. The decline in age-specific seroprevalence until the introduction of hepatitis A vaccine in 1994 was well explained through a declining basic reproduction number (R0 ) that remained >1. Accounting for existing immunity, we estimated that the effective reproduction number (Reff )

Background Hepatitis A is one of the most common infectious causes of acute hepatitis, and currently, a neglected global public health problem necessitating an urgent response in Somalia. Hepatitis A infection and its rare complication of acute liver failure in children are largely based on very limited data. The aim of the study was therefore to investigate the Hepatitis A infection and its rare complication of acute liver failure in children in Somalia. Methods This retrospective study was conducted on children aged 0–18 years who were admitted to the pediatric departments of the Somalia Mogadishu-Turkey Training and Research Hospital, Somali, from June 2019 and December 2019. Patients who were tested for hepatitis A infection during the study period and had complete data were included. Children with chronic disease, primary or secondary immunodeficiency, blood transfusion history, and missing data were excluded. Abstracted data including patients' demographics, clinical presentation, laboratory results, ultrasonographic findings, length of hospital stay, clinical course and outcome were retrieved from the hospital database system. Results Of the 13,047 children, 219 were analyzed. Of the 219 Hepatitis A cases, 25 (11%) were diagnosed with pediatric acute liver failure (PALF). The mean age of children with Hepatitis A was 6.7 years. The majority of cases were reported in the 5–9 (39.7%) year age range. Hepatic encephalopathy, length of hospital stay, levels of albumin, and values of PT, aPPT, and INR were significantly higher in children with acute live failure. The presence of cholecystitis and cholecystitis with ascites in the sonographic evaluation were poor prognostic markers for acute liver failure. Conclusions This study revealed hepatitis A virus infection and its related acute liver failure among hospitalized children in Somalia of which 11% had PALF. Hence, the introduction of Hepatitis A vaccination, which is the main public health tool, into the national immunization program, the improvement of hygiene conditions, raising awareness of the disease, and increasing health literacy are necessary to prevent the consequence of the Hepatitis A virus in children.

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.PLAIN LANGUAGE SUMMARY

Annually, 1.5 million cases of hepatitis A infection occur worldwide. The United Arab Emirates (U.A.E.) has seen a decrease in infection rates and seroprevalence coupled with an increase in the average age of infection. This study aimed to assess the U.A.E. society’s hepatitis A knowledge, and attitudes and vaccination practices, with the applicability of its introduction into the local immunization schedule. A self-administered, 50-item questionnaire was used to collect data from the four most populous cities in the U.A.E., between January and March 2020. A total of 458 responses were collected and analysed using IBM-SPSS-26, R-4.0.0 and Matplotlib-v3.2.1. Females had better attitudes (P = 0.036), practices (P

Aim To determine the frequency of and identify risk factors associated with sexual practices leading to hepatitis A infection in the population of men who have sex with men in Spain. Background The increased incidence of hepatitis A as a result of sexual contact among this population is a public health concern and a challenge in controlling sexually transmitted infections. Methods This cross-sectional, online survey-based study included 881 men who have sex with men. Unprotected oro-anal and insertive-anal sex are considered to be unsafe sexual practices associated with hepatitis A infection. Results Of all respondents, 83.4% engaged in insertive-anal sex and 71.3% in unprotected oro-anal sex during the previous 12 months. An association was found with sociodemographic factors [living alone (OR = 2; 95%CI = 1.13-3.35)] and contextual factors of sexual behaviour [previous diagnosis of sexually transmitted infection(s) (OR = 1.74; 95%CI = 1.15-2.61) and participating in 'chemsex' (OR = 5.15; 95%CI = 1.05-25.15)]. Conclusion The frequency of unsafe sexual practices associated with hepatitis A among men who have sex with men in Spain is high. Interventions based on sociodemographic and contextual factors of sexual behaviour should be implemented. Implications for nursing management Nurse managers should update and incorporate the support needs of men who have sex with men and take advantage of the opportunity to implement harm reduction strategies.

Our study aimed to determine the prevalence of prior exposure to hepatitis A virus in Crohn’s disease patients, whose IgG antibody levels against hepatitis A virus were compared with age and sex-matched controls. All of the 41 cases with Crohn’s disease and 43 controls included in the study tested positive for IgG anti-hepatitis A virus antibody, with titres (38.8 IU/ml, 22–63.9; median, IQR) similar to those in controls (40.7 IU/ml, 17.3–66.7; p = 0.75). Environmental sanitation remains poor in India, despite reasonable economic gains as reflected by universal exposure to hepatitis A virus infection. Vaccination against hepatitis A may not be important in patients attending inflammatory bowel disease clinic, owing to natural immunity provided by prior infection. The observed rise in inflammatory bowel disease incidence seems to be increasing despite persistently poor environmental hygiene.

Background Hepatitis A often occurs in school among students in the form of an outbreak. The transmission was through fecal-oral (common source) provided that the epidemic curve is close to propagated. The aim of the current study was to analyze the determinants of Hepatitis A infection among students. Design and methods This study was a case-control study which was conducted at SMAN Plus with a sample size of 80 students chosen by using simple random sampling. The data obtained were then analyzed using logistic regression with 95% confidence level (α = 0.05), while the strength of the relationship between variables was identified using odds ratio (OR). Results Most of the students were at the age of 17 to 19 years old (65%) and male (57.5%). The average age in the case group was 17.1 years old, while in the control group was 16.75 years old. The habit of consuming raw foods (p=0.001) as well as eating and drink at the same time during an activity (p=0.000) had a significant influence on the outbreak of Hepatitis A in the curve epidemic of common source. Conclusion The outbreak is confirmed as a transmission occurs through fecal-oral which the common source epidemic curve. Risk factors that have been proven to be related to hepatitis A include consuming raw food, eating shared meals during an activity, and drinking with shared drinking utensils.

Hepatitis A virus (HAV) infection occasionally leads to a critical condition in patients with or without chronic liver diseases. Acute-on-chronic liver disease includes acute-on-chronic liver failure (ACLF) and non-ACLF. In this review, we searched the literature concerning the association between HAV infection and chronic liver diseases in PubMed. Chronic liver diseases, such as metabolic associated fatty liver disease and alcoholic liver disease, coinfection with other viruses, and host genetic factors may be associated with severe hepatitis A. It is important to understand these conditions and mechanisms. There may be no etiological correlation between liver failure and HAV infection, but there is an association between the level of chronic liver damage and the severity of acute-on-chronic liver disease. While the application of an HAV vaccination is important for preventing HAV infection, the development of antivirals against HAV may be important for preventing the development of ACLF with HAV infection as an acute insult. The latter is all the more urgent given that the lives of patients with HAV infection and a chronic liver disease of another etiology may be at immediate risk.

Background The epidemiological pattern of hepatitis A infection has shown dynamic changes in many parts of the world due to improved socio-economic conditions and the accumulation of seronegative subjects, which leads to possible outbreaks and increased morbidity rate. In Tunisia, the epidemiological status of hepatits A virus is currently unknown. However, over the past years higher numbers of symptomatic hepatitis A virus infection in school attendants and several outbreaks were reported to the Ministry of Health, especially from regions with the lowest socio-economic levels in the country. The aim of this study was to investigate the current seroprevalence of hepatitis A virus antibodies in central-west Tunisia and assess the impact of hepatitis A virus vaccination on hepatitis A epidemiology. Methods Serum samples from 1379 individuals, aged 5–75 years, were screened for hepatitis A virus antibodies. Adjusted seroprevalence, incidence and force of infection parameters were estimated by a linear age structured SEIR (Susceptible-Exposed-Infectious-Recovered) compartmental model. A vaccine model was then constructed to assess the impact on hepatitis A virus epidemiology of 3 scenarios of vaccination strategies: one dose at 12-months of age, one dose at 6-years and one dose at 12-months and another at 6-years of age during 6 years. Results A rapid increase in anti-hepatitis A virus seroprevalence was noted during infancy and adolescence: 47% of subjects under 10-years-old are infected; the prevalence increases to 77% at 15-years and reaches 97% in subjects aged 30-years. The force of infection is highest between 10 and 30-years of age and the incidence declines with increasing age. The vaccine model showed that the 3-scenarios lead to a significant reduction of the fraction of susceptibles. The two doses scenario gives the best results. Single-dose vaccination at 6-years of age provides more rapid decrease of disease burden in school-aged children, as compared to single-dose vaccination at 12-months, but keeps with a non-negligible fraction of susceptibles among children Conclusions Our study confirms the epidemiological switch from high to intermediate endemicity of hepatitis A virus in Tunisia and provides models that may help undertake best decisions in terms of vaccinations strategies.

Objectives: To report 2 children with acute hepatic myelopathy after hepatitis A infection who recovered completely after living donor liver transplantation. Methods: All the children admitted into liver intensive care unit (LICU) from November 1st 2018 to 31st October 2019, were evaluated for the neurological features. The data was collected from the admission register of the LICU unit in children below 15 years age. Medical records of these children were reviewed and data collected. Established clinical criteria were used to categorize the various grades of hepatic encephalopathy/myelopathy. Results: 37 children were seen over 1-year period between 6 months to 15 years age. There were 24 male(64.9%) and 13 females. Acute liver failure was seen in 19 (51.3%) and acute on chronic liver failure in 18 (48.7%). There were 10 cases of hepatitis A in acute liver failure group,10 of 19 cases (52.6%), while Wilson’s disease and undetermined etiology group formed the chronic group. 2 cases of hepatic myelopathy were seen in acute liver failure following hepatitis A infection. Both these children underwent live liver donor transplantation and recovered completely. Further in hepatitis A group,3 children had spontaneous recovery, 4 died and 1 child was discharged with end of life care. Overall out of all 37 children with liver failure,20 (54%) were discharged, 6 (16.2%) were advised end of life care and 11 (29.8%) died. Conclusion: Two cases (10.5%) of reversible hepatic myelopathy were seen in acute liver failure group of 19 cases. 18 out of 37 (48.6%) children had residual neurological features at discharge time.

Author(s): Kaigh, Caroline; Blome, Andrea; Schreyer, Kraftin E.; Healy, Megan | Abstract: Introduction: The Philadelphia Department of Public Health (PDPH) declared a public health emergency due to hepatitis A in August 2019.1 Our emergency department (ED) serves a population with many of the identified risk factors for hepatitis A transmission. This study examines the impact of an ED-based hepatitis A vaccination program, developed in partnership with the PDPH, on incidence of hepatitis A infection and hospital admission.Methods: We conducted a retrospective review of all ED visits in the 12-week period centered around the implementation of the ED-based hepatitis A vaccination program. All adult patients presenting to the ED were offered vaccination, with vaccines supplied free of charge by the PDPH. We compared the incidence of diagnosis and of hospital admission for treatment of hepatitis A before and after implementation of the program.Results: There were 10,033 total ED visits during the study period, with 5009 of them prior to the implementation of the vaccination program and 5024 after implementation. During the study period, 669 vaccines were administered. Before the vaccination program began, 73 patients were diagnosed with hepatitis A, of whom 67 were admitted. After implementation of the program, 38 patients were diagnosed with hepatitis A, of whom 31 were admitted.Conclusion: A partnership between an ED and the local public health department resulted in the vaccination of 669 patients in six weeks in the midst of an outbreak of a vaccine-preventable illness, with a corresponding drop in ED visits and hospital admission for acute hepatitis A.

Hepatitis A represents one of the major public health problems worldwide including India. Vaccination is the most effective way to prevent hepatitis A infection. Two types of hepatitis A vaccines-live attenuated (H2 strain) and inactivated (killed) are available for use in clinical practice in India with former having advantage of a single-dose compared to two-dose killed vaccine. One of the important characteristic of an ideal vaccine includes its ability to provide life-long protection. In this article we reviewed the available long-term (≥10 years follow-up) published data on live attenuated hepatitis A (H2 strain) vaccine. The data from country of origin of the vaccine (China) and India establish the long-term immunogenicity, protection, and tolerability. Based on the results of several clinical trials showing long-term protection, single dose of live attenuated hepatitis vaccine can be widely used to protect high-risk population against hepatitis A virus infection and related complications.

An uncommon presentation of Hepatitis A Virus (HAV) Infection is cutaneous vasculitis. This report is about a seven-year-old male patient that came to the pediatric emergency with complaints of bilateral swelling of lower limbs and pain in right knee for the last three days. Patient had history of jaundice one month back. On examination, he was febrile and had swelling over right knee with decreased range of movements and multiple palpable purpura over lower extremities and buttocks. Laboratory evaluation showed deranged Liver Function Test (LFT) and positive HAV IgM antibodies. Histopathological examination of skin biopsy was suggestive of leukocytoclastic vasculitis and IgA deposition. Final diagnosis of Henoch Schonlein Purpura (HSP) was established based on clinical findings and skin biopsy findings which are usually sufficient for confirmed diagnosis. Patient was admitted and managed conservatively with oral analgesics. After a few days, patient was discharged in satisfactory condition.

Adult-onset Still's disease (AOSD) is a rare inflammatory disorder of unknown etiology. The varied clinical presentation of the disease mimicking many other diseases makes it difficult to diagnose. Various infectious triggers in a genetically susceptible host have been described in literature. We report a case of a 25-year-old female who presented with fever, rash, and arthralgia and diagnosed to be AOSD triggered by hepatitis A infection after excluding other differentials. She was managed with corticosteroids with dramatic response and continued to be in remission even after steroid withdrawal.

Hepatitis B infection has often been considered one of the most common sexually transmitted viral hepatitides. However, there have been several recent outbreak reports of sexual transmission of Hepatitis A and Hepatitis C infection in men who have sex with men, usually in the context of receptive anal intercourse and/or HIV co-infection. Testing for Hepatitis A, B or C infections relies on either serological diagnosis or nucleic acid testing. Since symptoms can be non-specific, a clinician will need to have a high level of suspicion to test for and diagnose these infections. Vaccination against hepatitis A and hepatitis B are routinely recommended for all newborns in the United States as well as for individuals with chronic liver disease or risk factors for viral hepatitis acquisition. While the management for hepatitis A infection is supportive, antiviral medications are available for treatment of Hepatitis B and C.

A 12-year-old girl presented with a one-week history of fever associated with jaundice, vomiting and skin rash on the fifth day of illness. She denied any abdominal pain, diarrhoea, history of recent shell-fish or traditional medication ingestion. On examination, she appeared jaundice, and there was sandpaper-like rash on the trunk and extremities (A). Laboratory investigations revealed severe transaminitis (AST 849 U/L, ALT of 1092 U/L) and predominantly direct hyperbilirubinaemia. Hepatitis A IgM was reactive whereas leptospirosis, hepatitis B and C serology were non-reactive. The antistreptolysin O titre and throat swab culture were negative. Ultrasound of the hepatobiliary system demonstrated normal liver parenchyma without sonographic evidence of biliary obstruction. She was admitted for intravenous fluid and symptomatic therapy. She remained well with improving transaminitis, and did not exhibit any signs of liver failure. She was discharged after 5 days of hospital stay. The rash disappeared and liver function test normalized during a followup review 2 weeks post-discharge. Many types of skin rashes can occur as a part of the serum sickness-like prodrome of acute viral hepatitis which is thought to be due to immune complex deposition. An evanescent rash was reported to be present in 14% of patients with acute hepatitis A. Cutaneous vasculitis associated with hepatitis A can appear as an erythematous maculopapular eruption affecting the buttocks and lower extremities. Scarlatiniform rash has not been reported previously in hepatitis A infection. Clinicians should be alert to this rare extrahepatic manifestation of hepatitis A infection when encountering patients with skin rash and severe transaminitis.

Objectives: there has been a global increase in the incidence of hepatitis A infection. The aim of this study was to examine the characteristics of the increase in our region and the degree of adherence to the recommended hygienic measures after discharge from hospital. Methods: demographic, clinical and biochemical variables were collected from patients with acute hepatitis A in our health area. The patients were grouped as follows: January 2010 to December 2016 (historical cohort) and January 2017 to October 2017 (recent cohort). A phylogenetic analysis was also performed in the recent cohort. One month after discharge, bacterial growth was evaluated by a culture of the dominant hand imprint and were compared with a control group. Results: a total of 110 cases were registered with a median age of 36.3 years (range 3-89) and 77.3 % were male. The incidence was 0.82/100,000 inhabitants/year and 22.75/100,000 inhabitants/year in the historical and recent cohorts, respectively. Patients in the recent cohort were more frequently male (52.6 % vs. 82.4 %, p = 0.008) and younger (51.7 [3-89] vs. 33.4 [4-74] years, p < 0.001). In addition, 63.8 % of the recent cohort were men who had sex with other men and had unsafe sexual practices (37.5 %). Phylogenetic analysis showed a predominance of genotype A and a high frequency of the VRD 521-2016 sequence. A higher growth of enterobacteria was observed in patients with hepatitis A compared to the control group (7.3 % vs. 1.2 %, p = 0.005), despite specific hygienic measures given at discharge. Conclusions: a recent outbreak of hepatitis A in our area was related with gender, younger age and sexual practices. Hepatitis A infected subjects showed a poor adherence to hygienic measures. Our data suggests the need for policies that encourage preventive actions, particularly vaccination in this high-risk group. This study was partially supported by grants from Fondos FEDER. Dr. M. Hernandez-Guerra is the recipient of a Grant from Instituto de Salud Carlos III (PI14/01243). Sí

Hepatitis A is a common viral infection with a benign course but in rare cases can progress to acute liver failure. It usually presents with abdominal pain, nausea, vomiting, diarrhea, jaundice, anorexia, or asymptomatically, but it can also present atypically with relapsing hepatitis and prolonged cholestasis. In addition, extrahepatic manifestations have been reported, including urticarial and maculopapular rash, acute kidney injury, autoimmune hemolytic anemia, aplastic anemia, acute pancreatitis, mononeuritis, reactive arthritis, glomerulonephritis, cryoglobulinemia, Guillain–Barre syndrome, and pleural or pericardial effusion. A rare manifestation of hepatitis A is acute myocarditis. We report a case of a young woman who presented with “flu-like symptoms” and was found to have severe elevation of liver enzymes due to acute hepatitis A infection. On her 3rd day of admission, the patient developed chest pain and nonspecific electrocardiographic changes. Her troponins rose to 16.4 ng/mL, and a transthoracic echocardiogram revealed global hypokinesis and a depressed ejection fraction at 30%. A CT angiography showed no evidence of significant coronary artery disease. The patient was managed supportively, and symptoms and laboratory findings slowly improved over the next 7 days. Her chest pain resolved and a follow-up echocardiogram showed improved ejection fraction to 45%.

In Taiwan, an outbreak of acute hepatitis A (AHA) infection has been identified since June 2015. Approximately half of the cases occurred in HIV-infected men who have sex with men (MSM). We used the Taiwan Centers for Disease Control (TCDC)-operated National Disease Surveillance Systems (NDSS) to identify the incidence of AHA during 2011-2016. Between June 2015 and December 2016, a total of 1268 AHA cases were documented, and 601 cases (47.4%) were co-infected with HIV; the majority of whom were MSM (98.4%). Each AHA case was matched to two HIV-infected controls without AHA reported in the NDSS on age (± 5 years), risk factor of HIV infection, HIV diagnosis date (± 30 days) and county/city of residence at HIV diagnosis. Three hundred forty-three HIV/AHA cases were matched to 686 controls. In multivariable conditional logistic regression analysis, a previous gonorrhoea (adjusted OR=1.77, 95% CI 1.16-2.70) and recent (aOR=6.77, 95% CI 4.34-10.55) or remote syphilis report (aOR=3.56, 95% CI 2.48-5.13) were independently associated with AHA. The epidemic persisted till December 2016, and the cases with a new diagnosis of HIV infection after AHA (28/301, 9.3%) increased after July 2016 (P = .001). HIV/AHA cases were centralized in northern and central metropolitan areas and HIV-infected MSM with a recent history of sexually transmitted diseases in Taiwan. We recommend surveillance of associated behavioural and virologic characteristics and HAV counselling and testing for HIV-infected men.

Acute hepatitis due to the hepatitis A virus usually has a short, benign and self-limited course, without causing chronic hepatitis. However, some cases have an atypical presentation, such as relapsing hepatitis, prolonged or persistent cholestasis, fulminant hepatic failure, or liver failure associated with autoimmune hepatitis. The typical clinical course of acute hepatitis A virus infection is spontaneous remission in 90% of the cases, but atypical cases have a prevalence that varies from less than 1 to 20%, depending on the manifestation (overall prevalence ∼7%). There is little information on the atypical clinical courses of hepatitis A virus infection and the lack of recognizing those presentations in clinical practice often results in carrying out numerous studies and treatments that not only are unnecessary, but can also be harmful. The aim of the present article was to describe 3 clinical cases of atypical hepatitis A infection and provide a literature review of such cases. Resumen: La hepatitis aguda por virus de hepatitis A usualmente sigue un curso corto, benigno y autolimitado sin ocasionar una hepatitis crónica, sin embargo en algunos casos puede manifestarse mediante formas atípicas como son hepatitis recurrente, colestasis prolongada o persistente, falla hepática fulminante o asociada a hepatitis autoinmune. El curso clínico típico de la infección aguda por el virus de hepatitis A es hacia una remisión espontánea en más del 90% de los casos, sin embargo los cursos atípicos presentan una prevalencia que varía de

Hepatitis A infection results in a spectrum of illness from asymptomatic disease to severe fulminant hepatitis. Since 2000, 1, outbreak control costs were in excess of €45 000. This outbreak illustrates the considerable adult morbidity that can occur in hepatitis A outbreaks, highlights the challenges in controlling a large CCF-associated outbreak and the importance of early recognition by clinicians of hepatitis A.