EFFECT OF HIV PREVENTION AND TREATMENT PROGRAM ON HIV AND HCV TRANSMISSION AND HIV MORTALITY AT AN INDONESIAN NARCOTIC PRISON.

Validated data regarding HIV-transmission in prisons in developing countries is scarce. We examined sexual and injecting drug use behavior and HIV and HCV transmission in an Indonesian narcotic prison during the implementation of an HIV prevention and treatment program during 2004-2007 when the Banceuy Narcotic Prison in Indonesia conducted an HIV transmission prevention program to provide 1) HIV education, 2) voluntary HIV testing and counseling, 3) condom supply, 4) prevention of rape and sexual violence, 5) antiretroviral treatment for HIV-positive prisoners and 6) methadone maintenance treatment. During a first survey that was conducted between 2007 and 2009, new prisoners entered Banceuy Narcotics Prison were voluntary tested for HIV and HCV-infection after written informed consent was obtained. Information regarding sexual and injecting risk behavior and physical status were also recorded at admission to the prison. Participants who tested negative for both HIV and HCV during the first survey were included in a second survey conducted during 2008-2011. During both surveys, data on mortality among HIV-seropositive patients were also recorded. All HIV-seropositive participants receive treatment for HIV. HIV/ AIDS-related deaths decreased: 43% in 2006, 18% in 2007, 9% in 2008 and 0% in 2009. No HIV and HCV seroconversion inside Banceuy Narcotic Prison were found after a median of 23 months imprisonment (maximum follow-up: 38 months). Total of 484.8 person-years observation was done. Participants reported HIV transmission risk-behavior in Banceuy Prison during the second survey was low. After implementation of HIV prevention and treatment program, no new HIV or HCV cases were detected and HIV-related mortality decreased.

European survey of hepatitis B vaccination policies for healthcare workers.

BACKGROUND: The risk of transmission of hepatitis B virus (HBV) to healthcare workers (HCWs) is well known. Under current European Union (EU) legislation, all employers should perform a risk assessment to identify those exposed to HBV and offer vaccination. Immunization should happen early after the start of their career to avoid infection and development of carrier status. METHODS: Cross-sectional survey of country representatives, to find out how policies are put into practice in European countries. RESULTS: Answers were received from 17 countries, representing 89% of the population and 90% of HCWs in the EU-25. HBV vaccination was mandatory for medical, and nursing and other paramedical staff in five countries, and recommended in all other countries. It was mandatory for medical students and student nurses in five countries and recommended in nine other. Pre-vaccination serotesting was done in six countries. The vaccination schedule most often used was 0, 1, 6 months. Combined vaccine (hepatitis A virus /HBV) was used in 10 countries. Post-vaccination serotesting was done in 14 countries. Data on HBV vaccination coverage were available in 11 countries and published in five of them. Coverage was 85-93%. CONCLUSION: These results show the variation as to how EU legislation is translated into practice in European countries. More consultation between key actors at EU level could help to optimize the way this matter is dealt with. A battery of measures and interventions-including introduction of immunization programmes against HBV infection and increasing immunization coverage in HCWs-can contribute to further reducing HBV transmission to HCWs.

Human immunodeficiency virus, hepatitis B and hepatitis C in an Indonesian prison: prevalence, risk factors and implications of HIV screening.

OBJECTIVE: To determine the prevalence and behavioural correlates of HIV, HBV and HCV infections among Indonesian prisoners and to examine the impact of voluntary counselling and testing for all incoming prisoners on access to antiretroviral treatment (ART). METHODS: In a non-anonymous survey in an Indonesian prison for drug-related offences, all incoming prisoners and symptomatic resident prisoners were counselled and offered testing for HIV, hepatitis B and C. RESULTS: Screening was performed in 679 incoming prisoners, of whom 639 (94.1%) agreed to be tested, revealing a seroprevalence of 7.2% (95% CI 5.2-9.2) for HIV, 5.8% (95% CI 3.9-7.6) for HBsAg and 18.6% (95% CI 15.5-21.6) for HCV. Of 57 resident prisoners tested, 29.8% were HIV-positive. HIV infection was strongly associated with injecting drug use (IDU; P < 0.001), but not with a history of unsafe sex. Screening of incoming prisoners was responsible for diagnosing and treating HIV in 73.0%, respectively, and 68.0% of HIV-positive individuals. CONCLUSIONS: HIV and HCV are highly prevalent among incoming Indonesian prisoners and almost entirely explained by IDU. Our study is the first to show that voluntary HIV counselling and testing during the intake process in prison may greatly improve access to ART in a developing country.

An estimation of the occupational risk of HBV, HCV and HIV infection among Indonesian health-care workers.

AIM: to estimate the occupational risk of HBV, HCV and HIV infections among Indonesian HCWs. METHODS: the model developed by WHO was used to calculate the risk. The input parameters were selected from the best available evidence in Indonesia through a literature review. RESULTS: in 2005, sharps injuries led to an estimated 1445 infections with HBV, 399 with HCV and 18 with HIV among health-care workers (HCWs) in Indonesia. The attributable fractions of these infections due to sharps injuries among HCWs in Indonesia were estimated to be approximately 44%, 47%, and 11% for HBV, HCV and HIV, respectively. CONCLUSION: those data show that HCWs in Indonesia may face significant occupational risks of contracting viral hepatitis due to sharps injuries. In order to produce better estimates prospective studies in different health care settings are urgently needed.

Routine or targeted HIV screening of Indonesian prisoners.

PURPOSE: Routine HIV screening of prisoners is generally recommended, but rarely implemented in low-resource settings. Targeted screening can be used as an alternative. Both strategies may provide an opportunity to start HIV treatment but no formal comparisons have been done of these two strategies. The paper aims to discuss these issues. DESIGN/METHODOLOGY/APPROACH: The authors compared yield and costs of routine and targeted screening in a narcotic prison in Indonesia. Routine HIV screening was done for all incoming prisoners from August 2007-February 2009, after it was switched for budgetary reasons to targeted ("opt-out") HIV screening of inmates classified as people who inject drugs (PWIDs), and "opt-in" HIV testing for all non-PWIDs. FINDINGS: During routine screening 662 inmates were included. All 115 PWIDs and 93.2 percent of non-PWIDs agreed to be tested, 37.4 percent and 0.4 percent respectively were HIV-positive. During targeted screening (March 2009-October 2010), of 888 inmates who entered prison, 107 reported injecting drug use and were offered HIV testing, of whom 31 (29 percent) chose not to be tested and 25.0 percent of those tested were HIV-positive. Of 781 non-PWIDs, 187 (24 percent) came for testing (opt-in), and 2.1 percent were infected. During targeted screening fewer people admitted drug use (12.0 vs 17.4 percent). Routine screening yielded twice as many HIV-infected subjects (45 vs 23). The estimated cost per detected HIV infection was 338 USD for routine and 263 USD for targeted screening. ORIGINALITY/VALUE: In a resource limited setting like Indonesia, routine HIV screening in prison is feasible and more effective than targeted screening, which may be stigmatizing. HIV infections that remain unrecognized can fuel ongoing transmission in prison and lead to unnecessary disease progression and deaths.

Vaccine safety controversies and the future of vaccination programs.

In the years following the hepatitis B vaccination/multiple sclerosis controversy, a number of new issues regarding vaccine safety have been raised, in some cases leading to more debate and confusion. Against this background, an international group of experts was convened to review the current points of view concerning the use of thimerosal as a preservative and its potential risks; the suggested link between thimerosal-containing vaccines and acute lymphoblastic leukemia; the alleged association between aluminum-containing vaccines/macrophagic myofasciitis and general systemic complaints; a possible link between vaccination and autoimmune pathology; and a hypothetical link between measles-mumps-rubella vaccination and autism. At present, there are no data to conclude that childhood vaccines, and in particular hepatitis B vaccine, pose a serious health risk or justify a change in current immunization practice. However, vaccine "scares" continue to have an international impact on immunization coverage. Creating a positive environment for immunization can be achieved by repositioning the value of vaccines and vaccination, supported by evidence-based information. The role of international organizations, the media, and the industry in the implementation of communication strategies was discussed and the impact of litigation issues on vaccination was evaluated. The Viral Hepatitis Prevention Board confirms its commitment to current recommendations for universal and risk group hepatitis B vaccination and further encourages the conduct of vaccine safety studies and the dissemination of their results.

The endemic treponematoses.

Treponemal diseases comprise venereal syphilis (Treponema pallidum subsp. pallidum) and the endemic (non-venereal) treponematoses, i.e. yaws (T. pallidum subsp. pertenue), endemic syphilis (T. pallidum subsp. endemicum) and pinta (T. carateum). Treponemal diseases are distinguished on the basis of epidemiological characteristics and clinical manifestations. They are at present indistinguishable by morphological, immunological or serological methods. Several minor genetic differences have been identified among the subspecies. The endemic treponematoses have not yet been eliminated and are currently thought to affect at least 2.5 million persons. Renewed action towards the elimination of these diseases should be undertaken.

An update after 16 years of hepatitis B vaccination in South Africa.

Hepatitis B (HB) virus (HBV) infection is highly endemic with at least 65 million chronic HB surface antigen (HBsAg) carriers in Africa, 25% of whom are expected to die from liver disease. Before the introduction of the HB vaccine, the prevalence of chronic carriage of HBV in black South Africans was 9.6%, with 76% having been previously exposed to HBV. The major transmission route in South Africa is unexplained horizontal transmission between toddlers, with most transmission occurring before the age of 5 years. During adolescence and early adulthood, sexual transmission becomes the dominant route, while healthcare workers (HCWs) are also at risk for parenteral/percutaneous transmission during occupational exposures. In 1995 the South African Department of Health (SADoH) incorporated the HB vaccine, administered as a monovalent, into the Expanded Programme on Immunisation (EPI) at 6, 10, and 14 weeks of age, and studies conducted thereafter have found it to be safe and highly effective. Catch-up vaccination for adolescents was not introduced and there is no schools-based vaccination programme. The SADoH recommends HB vaccination of HCWs, but this is not mandatory and there is no national policy, thus HB vaccination uptake in HCWs is sub-optimal. Since 1995, studies on children have found that the prevalence of chronic HBsAg carriage has decreased, as has the incidence of paediatric hepatocellular carcinoma and HBV-related membranous nephropathy. The SADoH should focus their efforts on attaining a high infant HB vaccine coverage, prepare for introducing a HB birth dose, and consider using a hexavalent vaccine (DTaP-IPV-Hib-HepB). The department may also want to consider including targeted HB vaccination for 12 year-olds, if their Road to Health Cards show they were not vaccinated as infants. A national policy is needed for HCWs to ensure that they are fully vaccinated and protected against HBV infection.

Addressing public questioning and concerns about vaccination in South Africa: a guide for healthcare workers.

Vaccination is one of the most cost-effective and successful public health interventions in the history of mankind. Anecdotal evidence, the media, and South African-based anti-vaccination websites and blogs point to the existence of anti-vaccination lobbies in South Africa, although the part played by these lobbies in sub-optimal vaccination coverage is unknown at present. This article discusses some of the claims made by South African anti-vaccination groups, including some drawn from anti-vaccination lobbyists based in highly resourced countries. While research is underway to better understand the scope and influence of anti-vaccine groups, it is important to build capacity among healthcare workers within the Expanded Programme on Immunisation of South Africa to enable them to deal empathically and effectively with parents and caregivers who have been exposed to anti-vaccination messages and who question the need to vaccinate their children. Claims that vaccines cause adverse effects need to be supported by valid and reliable scientific evidence. However, evidence alone that vaccines are safe and effective does not always result in parents being convinced to vaccinate their children. In addition to providing important evidence of vaccine safety, this paper discusses the important role of communication - especially dialogue - in building public trust in vaccination with the ultimate goal of increasing vaccination coverage and preventing future outbreaks of vaccine-preventable diseases.

Hepatitis B vaccination coverage in healthcare workers in Gauteng Province, South Africa.

Hepatitis B (HB) virus (HBV) is highly endemic and HBV infection is a major public health problem in sub-Saharan Africa. Percutaneous/parenteral transmission is an important mode of spread of HBV in the healthcare setting, thus healthcare workers (HCWs) and their patients are at risk for acquiring HBV infections. This study was conducted on three HCW populations in Gauteng Province during 2009, in order to (1) determine HB vaccination coverage of HCWs, and (2) investigate demographic predictors of vaccination uptake. Being a doctor was a statistically significant predictor of vaccination uptake (odds ratio [OR]: 3.2; 95% confidence interval [CI]: 1.48-6.72; p-value: 0.003), while working in the private sector was also statistically significantly associated with vaccination uptake (OR: 1.73; 95% CI: 1.01-2.98; chi-square p-value: 0.035). The majority (67.9% [491/723]) of HCWs had received at least 1 dose of vaccine, but where data on number of doses was available, only 19.9% (94/472) were fully vaccinated. In conclusion, there is a need to increase HB vaccination uptake in Gauteng HCWs through a policy that is properly implemented and routinely monitored and evaluated, and this policy must ensure that all three doses of vaccine are administered.

Reduced detection and levels of protective antibodies to hepatitis B vaccine in under 2-year-old HIV positive South African children at a paediatric outpatient clinic.

The study evaluated and compared the prevalence of anti-HBs and exposure to hepatitis B virus (HBV) in vaccinated South African babies aged between 5 and 24 months from the Expanded Programme on Immunisation clinic [EPI group] and paediatric outpatient clinic [OPD group], and results were stratified by HIV status. A total of 303 (243 EPI group and 60 OPD group) babies were studied. All sera were tested for anti-HBs, HBsAg and anti-HBc, while IgM anti-HBc and HBV DNA were only tested in samples positive for HBsAg and/or anti-HBc. Overall, there was a gross difference in the prevalence of anti-HBs marker between the EPI and OPD groups. The EPI group demonstrated higher levels of seroconversion (89.3% vs. 81.7%; p=0.105) and seroprotection rates (86.0% vs. 75.0%; p=0.038), compared to the OPD babies. When the overall results were stratified by HIV status, seroprotection was 85.7% for the HIV-negatives and 78.1% for the HIV-positives, although this was not statistically significant (p=0.125). The seroprotection rates were almost comparable between the HIV-positives (84.3%; n=51) and the HIV-negatives (86.5%; n=192) (p=0.695) in the EPI group. In contrast, reduced seroprotection rates were observed between the HIV-positives (63.6%; n=22) and HIV-negatives (81.6%; n=38) in the OPD group, although this was not statistically significant (p=0.123). Interestingly, no HBsAg or anti-HBc marker was detected in the OPD group, compared to total exposure rate of 4.9% (HBsAg carriage was 1.2%) in the EPI group.

Contact lens-related corneal ulcers requiring hospitalization: a 7-year retrospective study in Belgium.

PURPOSE: To evaluate the clinical and epidemiological aspects of contact lens-related infectious corneal ulcers requiring hospitalization. METHODS: A retrospective analysis was performed on the files of patients hospitalized for contact lens-induced corneal ulcer in the eight Belgian university hospitals over a 7-year period (January 1997 to December 2003). Diagnoses for all hospitalized patients are obligatorily registered using the ICD-9 code. RESULTS: A total of 107 patients with contact lens-related corneal ulcers were documented: the number increased from five in 1997 to 22 in 2003. A total of 99 subjects used soft contact lenses, of whom nine used disposables, 73 planned replacement and 17 conventional lenses. Only six patients used extended wear lenses. Three patients used daily disposable lenses. The most frequently cultured organisms were Pseudomonas and other Gram-negative germs (70%) and Acanthamoeba (16%). The majority (77%) of the corneal ulcerations were centrally located and resulted in an average visual loss of four lines. CONCLUSION: During the study period, the number of patients hospitalized rose, which is only partially explained by the increasing prevalence of lens wearers: 3.5% and 6.5% of the Belgian population used lenses in 1995 and 2003, respectively. These factual data highlight the need for improvements in patient education.

Chapter 14: HPV vaccine introduction in industrialized countries.

Introduction of a vaccine requires the achievement of three initial milestones. These are licensure by a national control authority that determines the vaccine is safe and effective, development of recommendations for use by expert advisory bodies on immunization, and obtaining funding for vaccination. Once these milestones have been achieved, a successful vaccination program requires that a number of interlinked programmatic components be brought together in a coordinated fashion. These include vaccine purchase and supply, vaccination service delivery, high coverage rates, surveillance of the vaccination program, immunization finance policies and practices, and political will. Human papillomavirus (HPV) vaccination provides unique challenges in all of these areas because of the many gaps in our knowledge.

Chapter 29: Knowledge gaps and priorities for research on prevention of HPV infection and cervical cancer.

The recognition that human papillomavirus (HPV) infection is the necessary cause of cervical cancer brought new prevention paradigms in screening and HPV immunization. We now face many questions about how to implement an ambitious evidence-based agenda for cervical cancer prevention. Much is known about the epidemiology and natural history of HPV infection but several key variables remain to be elucidated. Research on HPV transmission requires new study designs to provide useful insights into preventive strategies. HPV testing has carved a niche in clinical practice but to consolidate its role in screening still requires evidence of long-term benefit. The rapidly evolving field of HPV diagnostics has contributed useful information concerning the value of HPV typing. Other screening methods hold promise in specific settings. The decade-long process that brought HPV vaccines to the doorstep of public health application is over. Many questions remain concerning long-term efficacy, correlates of protection, age of vaccination, and delivery. As vaccination makes inroads as a cancer control strategy, screening practices must be reformulated to maximize the synergy between primary and secondary prevention. Research on how to achieve an efficient combination of these modalities is yet to begin, but mathematical models have provided a useful road map for field-testing of promising algorithms. Daunting questions loom large concerning delivery of vaccines to those populations that need it the most. The field of HPV and cervical cancer prevention has never been so multi-disciplinary. A new era has begun and the challenges are many.

Chapter 30: HPV vaccines and screening in the prevention of cervical cancer; conclusions from a 2006 workshop of international experts.

The finding that cervical cancer only occurs in women infected with specific, "high-risk" types of the human papillomavirus (HPV) has led to the development of novel, non-cytology-based cervical cancer prevention strategies. We now have sensitive molecular methods for detecting HPV that dramatically improve our ability to detect high-grade cervical cancer precursor lesions. Perhaps more importantly, prophylactic HPV vaccines have been developed that are protective against cervical cancer precursors caused by HPV 16 and 18. In the Spring of 2006, over 100 experts in HPV, cervical cancer screening, and vaccination worked together to define how best to incorporate HPV DNA testing and the HPV vaccines into cervical cancer prevention efforts. In this summary, we summarize the opinions of this expert group on how these advances can be introduced to provide the maximum benefit to women and to reduce the global burden of cervical cancer.

Long-term efficacy of hepatitis B vaccine, booster policy, and impact of hepatitis B virus mutants.

The long-term efficacy of hepatitis B vaccine, long-term effectiveness of hepatitis B immunisation programmes, immune memory induced by hepatitis B vaccine, current booster policies, and impact of hepatitis B virus mutants on immunisation programmes were reviewed at the Viral Hepatitis Prevention Board (VHPB) meeting in Sevilla, Spain, March 2004. The main focus was on universal vaccination programmes with data being presented from Italy, Saudi Arabia, Singapore, Spain, Taiwan, Thailand, The Gambia, and USA (Alaska).