The East Jakarta Project: surveillance for highly pathogenic avian influenza A(H5N1) and seasonal influenza viruses in patients seeking care for respiratory disease, Jakarta, Indonesia, October 2011-September 2012.

Indonesia has reported the most human infections with highly pathogenic avian influenza (HPAI) A(H5N1) virus worldwide. We implemented enhanced surveillance in four outpatient clinics and six hospitals for HPAI H5N1 and seasonal influenza viruses in East Jakarta district to assess the public health impact of influenza in Indonesia. Epidemiological and clinical data were collected from outpatients with influenza-like illness (ILI) and hospitalized patients with severe acute respiratory infection (SARI); respiratory specimens were obtained for influenza testing by real-time reverse transcription-polymerase chain reaction. During October 2011-September 2012, 1131/3278 specimens from ILI cases (34·5%) and 276/1787 specimens from SARI cases (15·4%) tested positive for seasonal influenza viruses. The prevalence of influenza virus infections was highest during December-May and the proportion testing positive was 76% for ILI and 36% for SARI during their respective weeks of peak activity. No HPAI H5N1 virus infections were identified, including hundreds of ILI and SARI patients with recent poultry exposures, whereas seasonal influenza was an important contributor to acute respiratory disease in East Jakarta. Overall, 668 (47%) of influenza viruses were influenza B, 384 (27%) were A(H1N1)pdm09, and 359 (25%) were H3. While additional data over multiple years are needed, our findings suggest that seasonal influenza prevention efforts, including influenza vaccination, should target the months preceding the rainy season.

Sentinel surveillance for patients with acute hepatitis in Egypt, 2001-04.

Viral hepatitis is a major problem in Egypt. To define the epidemiology of the disease, sentinel surveillance was established in 5 hospitals in diverse areas of the country in 2001. Data were completed for patients meeting the case definition for viral hepatitis. Of a total of 5909 patients evaluated, 4189 (70.9%) showed positive antibody markers for hepatitis. Out of those, 40.2% had evidence of hepatitis A virus (HAV) infection, 30.0% hepatitis B virus (HBV) and 29.8% hepatitis C virus (HCV) infection. This surveillance system was useful in identifying the variable endemicity of acute HAV infection in different regions and for better understanding the epidemiology of HBV and HCV infection.

Case-control study to evaluate risk factors for acute hepatitis B virus infection in Egypt.

Hepatitis B virus (HBV) infection is a significant health problem in Egypt. To better define risk factors associated with HBV transmission, we conducted a case-control study among patients admitted with acute hepatitis to an infectious disease hospital in Cairo. A total of 60 cases and 120 controls were interviewed about various exposures within 6 months prior to admission. Univariate analysis revealed HBV case-patients were more likely to report providing injections to relatives or friends, injecting drug use, exposure to a household contact with hepatitis, exposure to invasive medical procedures and being in the military. Efforts should be made to implement strict infection control standards in Egypt.

Sentinel surveillance for patients with acute hepatitis in Egypt, 2001-04

Viral hepatitis is a major problem in Egypt. To define the epidemiology of the disease, sentinel surveillance was established in 5 hospitals in diverse areas of the country in 2001. Data were completed for patients meeting the case definition for viral hepatitis. Of a total of 5909 patients evaluated, 4189 [70.9%] showed positive antibody markers for hepatitis. Out of those, 40.2% had evidence of hepatitis A virus [HAV] infection, 30.0% hepatitis B virus [HBV] and 29.8% hepatitis C virus [HCV] infection. This surveillance system was useful in identifying the variable endemicity of acute HAV infection in different regions and for better understanding the epidemiology of HBV and HCV infection

Case-control study to evaluate risk factors for acute hepatitis B virus infection in Egypt

Hepatitis B virus [HBV] infection is a significant health problem in Egypt. To better define risk factors associated with HBV transmission, we conducted a case-control study among patients admitted with acute hepatitis to an infectious disease hospital in Cairo. A total of 60 cases and 120 controls were interviewed about various exposures within 6 months prior to admission. Univariate analysis revealed HBV case-patients were more likely to report providing injections to relatives or friends, injecting drug use, exposure to a household contact with hepatitis, exposure to invasive medical procedures and being in the military. Efforts should be made to implement strict infection control standards in Egypt

Establishment of public health security in Saudi Arabia for the 2009 Hajj in response to pandemic influenza A H1N1.

Mass gatherings of people challenge public health capacities at host locations and the visitors' places of origin. Hajj--the yearly pilgrimage by Muslims to Saudi Arabia--is one of the largest, most culturally and geographically diverse mass gatherings in the world. With the 2009 pandemic influenza A H1N1 and upcoming Hajj, the Saudi Arabian Ministry of Health (MoH) convened a preparedness consultation in June, 2009. Consultants from global public health agencies met in their official capacities with their Saudi Arabian counterparts. The MoH aimed to pool and share public health knowledge about mass gatherings, and review the country's preparedness plans, focusing on the prevention and control of pandemic influenza. This process resulted in several practical recommendations, many to be put into practice before the start of Hajj and the rest during Hajj. These preparedness plans should ensure the optimum provision of health services for pilgrims to Saudi Arabia, and minimum disease transmission on their return home. Review of the implementation of these recommendations and their effect will not only inform future mass gatherings in Saudi Arabia, but will also strengthen preparedness efforts in other settings.

Injection prescribing patterns in public health care facilities in Egypt.

This study assessed the frequency of and rationale for use of injections at health care facilities in Egypt based on WHO core drug use indicators. We reviewed 1406 prescriptions in 43 randomly selected hospitals and primary health care clinics in 2 governorates in Upper and Lower Egypt in 2001. Patients received an injection at 18.1% of encounters. The most frequently prescribed parenteral drugs were anti-infectives (56.9% of injections) and analgesics (13.7%). Injections were more often prescribed in hospitals than in primary health care clinics and in rural than in urban settings. Most injections (94.7%) could have been replaced by a suitable oral preparation. Further efforts are needed to enforce the essential medicines programme in Egypt to improve rational drug prescribing.

Injection prescribing patterns in public health care facilities in Egypt

This study assessed the frequency of and rationale for use of injections at health care facilities in Egypt based on WHO core drug use indicators. We reviewed 1406 prescriptions in 43 randomly selected hospitals and primary health care clinics in 2 governorates in Upper and Lower Egypt in 2001. Patients received an injection at 18.1% of encounters. The most frequently prescribed parenteral drugs were anti-infectives [56.9% of injections] and analgesics [13.7%]. Injections were more often prescribed in hospitals than in primary health care clinics and in rural than in urban settings. Most injections [94.7%] could have been replaced by a suitable oral preparation. Further efforts are needed to enforce the essential medicines programme in Egypt to improve rational drug prescribing

Laboratory-based surveillance of patients with bacterial meningitis in Egypt (1998-2004).

Laboratory-based surveillance for bacterial meningitis was conducted in a network of infectious disease hospitals in Egypt to better understand the epidemiology of this infection. Healthcare and laboratory personnel were trained in basic surveillance and microbiologic processing of cerebrospinal fluid (CSF) specimens. All bacterial isolates from CSF were confirmed and tested for antimicrobial susceptibility. PCR testing was performed on a random subset of purulent, culture-negative CSF specimens. Of 11,070 patients who met criteria for the case definition, 843 (8%) were culture positive (42% positive for Streptococcus pneumoniae, 20% for Haemophilus influenzae serotype b, 17% for each of Neisseria meningitidis and Mycobacterium tuberculosis, and 6% for other bacteria). Of 1,784 (46%) CSF specimens tested by PCR, 232 (13%) were positive for the first three major pathogens. Of N. meningitidis isolates, 52% belonged to serogroup A, 35% to serogroup B, and 4% to serogroup W135. S. pneumoniae isolates comprised 46 different serotypes, of which 6B, 1, 19A, 23F, and 6A were the most predominant. The overall case-fatality rate for culture-positive cases was 26% and was highest among patients with M. tuberculosis (47%). Factors significantly associated with death (p < 0.05) included admission to rural hospitals, long prodromal period, referral from other hospitals, antibiotic treatment prior to admission, and clear CSF (<100 cells/mm3). Susceptibility to ampicillin and ceftriaxone was observed in 44 and 100% of H. influenzae serotype b isolates and in 52 and 94% of S. pneumoniae isolates, respectively. This surveillance highlights the significant mortality and morbidity associated with bacterial meningitis in Egypt. Decision makers need to review current treatment guidelines and introduce appropriate vaccines for prevention and control of the disease.

Investigation into a cluster of infant deaths following immunization: evidence for methanol intoxication.

A cluster of infant deaths due to severe metabolic acidosis following immunization was reported in a prosperous farming village in Egypt. Fears that more deaths might occur, and of a deleterious effect on national immunization programs prompted an urgent investigation by national and international partners. The deaths, and other previously unrecognized illness following immunization, were associated with excessive topical application of methanol. Methanol was employed as an anti-pyretic and anti-inflammatory agent following injections. Fear of adverse reactions to vaccine had encouraged increasing use of methanol for these purposes. Local physicians and nurses were unaware of the toxicity of methanol and did not consider it in the differential diagnosis, and thus did not offer appropriate life-saving therapy. The interaction of traditional practices and modern medical interventions can have clinically important consequences, and should be considered when programs are introduced and as they are monitored.

Factors associated with student participation in a school-based hepatitis B immunization program.

This study examined the relationship between participation in a school-based hepatitis B immunization program and teacher attitudes toward school-based health care and student socioeconomic factors. A survey addressing teachers' attitudes was administered to all teachers participating in the program. Information regarding student participation in school lunch programs and scores on national standardized tests were collected. Of the 4,874 fifth-grade students targeted for the program, 3,483 (72%) consented to be vaccinated and 3,232 (93% of 3,483) received all three doses of vaccine. Socioeconomic factors were the most important predictors of student participation in this school-based immunization program. Participation was significantly lower among students in schools with a high proportion of students receiving free or reduced-price school lunch and with low test scores. The only teacher factor associated with student participation was whether the teacher had returned the questionnaire. Strategies to increase immunization coverage in school-based programs should target children of low socioeconomic status.

Hepatitis B vaccination in sexually transmitted disease (STD) clinics: a survey of STD programs.

BACKGROUND: Hepatitis B virus infection causes substantial morbidity and mortality in the United States. Sexual activity is the most commonly reported risk factor among persons with acute hepatitis B, yet hepatitis B vaccine coverage among adolescents and adults with high-risk sexual practices is low. Sexually transmitted disease (STD) clinics are potentially efficient settings for vaccine administration to persons with high-risk sexual practices; however, little is known about hepatitis B vaccination activities in these settings. GOAL: To gain information about policies and activities for vaccinating against hepatitis B in STD clinic settings. STUDY DESIGN: In April 1997, a questionnaire was sent to managers of 65 federally funded STD programs in state and local health departments. A similar survey was sent to 89 STD clinic managers in November 1997. RESULTS: The response rate among program managers was 97% (63/65). Forty-eight percent considered hepatitis B prevention a program responsibility; 21% had developed and distributed written policies to prevent hepatitis B through vaccination; and 27% had developed policies to encourage hepatitis B education activities. The response rate among clinic managers was 82% (73/89). Forty-five percent reported that their STD clinics had implemented policies recommending hepatitis B vaccination and health education activities. Program managers and clinic managers reported that lack of funding to cover the cost of the vaccine, and lack of resources to provide prevaccination counseling, administer vaccine, and track clients for vaccine series completion were the primary barriers to the implementation of hepatitis B vaccination programs. CONCLUSIONS: To enhance hepatitis B vaccination in STD clinics, existing funding sources must be accessed more effectively. Supplemental funding mechanisms for the cost of vaccine and resources for implementing vaccination programs also need to be identified. Additionally, STD clinics and programs should continue to propose and implement hepatitis B vaccination policies.

Progress in coverage with hepatitis B vaccine among US children, 1994-1997.

OBJECTIVES: This study was done to assess progress in hepatitis B vaccination of children from 1994 through 1997. METHODS: We used data from the National Immunization Survey (NIS), a random-digit-dialed telephone survey that includes a mail survey to verify vaccination providers' records. The NIS is conducted in 78 geographic areas (50 states and 28 selected urban areas) in the United States. RESULTS: A total of 32,433 household interviews were completed in the 1997 NIS. An estimated 83.7% of children aged 19 to 35 months received 3 or more doses of hepatitis B vaccine. Coverage with 3 doses was greater (86.7%) among children in states that had day care entry requirements for hepatitis B vaccination than among children in states without such requirements (83.0%) and was greater among children from families with incomes at or above the poverty level (85.0%) than among children below the poverty level (80.6%). Hepatitis B vaccination of children increased from 1994 through 1996, from 41% to 84%, but coverage reached a constant level of 84% to 85% in 1996/97. CONCLUSION: Although substantial progress has been made in fully vaccinating children against hepatitis B, greater efforts are needed to ensure that all infants receive 3 doses of hepatitis B vaccine.

Update on diagnosis, management, and prevention of hepatitis B virus infection.

Acute and chronic hepatitis B virus (HBV) infection is a leading cause of liver disease worldwide. It is estimated that approximately 350 million people worldwide have chronic HBV infection and that 1 million persons die each year from HBV-related chronic liver disease. In the past decade, significant progress in the understanding of the molecular virology and pathogenesis of HBV infection has been made. In addition, effective treatment modalities have been developed for persons with chronic infection. Worldwide, prevention of HBV transmission has become a high priority. In 1992, the Global Advisory Group to the World Health Organization recommended that all countries integrate hepatitis B vaccine into national immunization programs by 1997. Currently, 80 countries have done so and several others are planning to. Many countries have reported dramatic reductions in the prevalence of chronic HBV infection among children born since the hepatitis B vaccine was introduced into infant immunization schedules. Recent reports from Taiwan indicate a reduction in the incidence of liver cancer among children as a result of widespread hepatitis B vaccination programs.

Hepatitis B vaccination of premature infants: a reassessment of current recommendations for delayed immunization.

OBJECTIVE: Current American Academy of Pediatrics and United States Public Health Service Immunization Practices Advisory Committee recommendations for hepatitis B immunization in premature infants weighing <2 kg at birth born to hepatitis B surface antigen (HBSAg)-negative mothers are to delay the initiation of vaccination until such infants reach 2 kg or until 2 months of age. This proposal to delay vaccination at birth in these low-risk infants was based on limited studies not conducted in the United States. We sought to reassess current recommendations to delay administration of hepatitis B vaccine in low-risk premature infants by determining the immunogenicity of early hepatitis B vaccination in a US population and identifying variables associated with poor immunogenicity. METHODS: A total of 148 infants <37 weeks' gestation born to mothers negative for HBSAg were recruited at birth and stratified to three birth weight groups: <1000 g, 1000 to 1500 g, and >1500 g. Recombinant hepatitis B vaccine was administered within the first week of life, at 1 to 2 months of age, and at 6 to 7 months of age. Serum obtained at birth and after the second and third doses of vaccine was tested for antibody to HBSAg. Variables associated with poor response were sought prospectively by collecting demographic and clinical data. RESULTS: A total of 118 subjects (83%) completed the study. Postsecond dose sera were available for 117 infants and postthird dose sera were available for 112 infants. The seroprotection rate (attaining >/=10 mIU/mL HBS antibody) after two doses was low (25%) regardless of birth weight; infants weighing <1000 g at birth had the poorest response (11%). The seroprotection response rate after three doses of vaccine increased with birth weight; infants weighing 1500 g at birth (group 3; 84% response rate). The seroprotection response rate of group 3 infants after three doses of vaccine, although low, could not be differentiated from the response rates reported for full-term infants using 95% confidence intervals. Of all infants who did not achieve protective levels of antibody after three doses of vaccine, 96% (26/27) weighed <1700 g at birth. The geometric mean HBS antibody levels in responders were 88 and 386 mIU/mL after two and three doses, respectively. Of 36 children with a birth weight >1500 g, 33 (91%) achieved levels of HBS antibody >100 mIU/mL after three doses of vaccine, compared with 25/35 (71%) of infants with birth weight <1500 g. Using logistic regression analysis, nonresponders were more likely than were responders to have been treated with steroids (26% vs 9%) and to have had a low birth weight (1037 g vs 1455 g). In addition, the seroresponse rate of black infants was more likely than that of white infants to be associated with poor weight gain (falling off 2 percentile ranks in weight) in the first 6 months of life: 22% of black and 60% of white children who failed to gain weight adequately responded to vaccination, compared with 92% of black and 70% of white children who were growing adequately. Of interest, the only infant with a birth weight of >1700 g who did not make protective levels of specific antibody after three doses of vaccine was 2300 g at birth, but had inadequate weight gain in the first 6 months of life. CONCLUSIONS: This study supports current recommendations of the American Academy of Pediatrics and the Centers for Disease Control and Prevention for delaying the initiation of hepatitis B immunization beyond the first week of life for premature infants at low risk for hepatitis B infection, particularly in newborns weighing <1700 g at birth. In addition, we have identified variables other than birth weight that were associated with an inadequate immune response to early hepatitis B vaccination in premature infants, such as poor weight gain in the first 6 months of life

Immunogenicity of hepatitis B Vaccines. Implications for persons at occupational risk of hepatitis B virus infection.

OBJECTIVE: To assess risk factors for decreased immunogenicity among adults vaccinated with hepatitis B vaccine and to determine the importance of differences in immunogenicity between vaccines among health care workers (HCWs). DESIGN: Randomized clinical trial and decision analysis. PARTICIPANTS: HCSw. MAIN OUTCOME MEASURES: Development of seroprotective levels of antibody to hepatitis B surface antigen (anti-HBs) and the number of expected chronic hepatitis B virus (HBV) infections associated with lack of protection. RESULTS: Overall, 88% of HCWs developed seroprotection. Risk factors associated with failure to develop seroprotection included increasing age, obesity, smoking and male gender (P < .05). Presence of a chronic disease was associated with lack of seroprotection only among persons > or = 40 years of age (P < .05). The two vaccines studied differed in their overall seroprotection rates (90% vs. 86%; P < .05), however, this difference was restricted to persons > or = 40 years of age (87% vs. 81%; P < .01). Among HCWs > or = 40 years of age, the decision analysis found 44 (0.34/100,000 person-years) excess chronic HBV infections over the working life of the cohort associated with use of the less immunogenic vaccine compared to the other. CONCLUSIONS: He patitis B vaccines are highly immunogenic, but have decreased immunogenicity associated with increasing age, obesity, smoking, and male gender; and among older adults, the presence of a chronic disease. One of the two available vaccines is more immunogenic among older adults; however, this finding has little clinical or public health importance. Hepatitis B vaccines should be administered to persons at occupational risk for HBV infection early in their career, preferably while they are still in their training.

Progress toward elimination of hepatitis B virus transmission in the United States.

The strategy to eliminate hepatitis B virus (HBV) transmission in the United States is comprised of the following components: (1) preventing perinatal transmission, (2) routine infant vaccination, (3) catch-up vaccination of children in high-risk groups at any age, (4) catch-up vaccination of all children at 11-12 years of age and (5) vaccination of adolescents and adults in high-risk groups. According to recent surveys, > 85% of pregnant women are screened for hepatitis B surface antigen (HBsAg). Of infants born to HBsAg-positive women identified in 1995, 93% received appropriate immunoprophylaxis at birth; however, only 69% were fully vaccinated by 6-8 months of age. From 1991 (when routine infant hepatitis B vaccination was first recommended) to 1996, the proportion of 19-35-month-old children who have received three doses of hepatitis B vaccine has increased from < 10 to 83%. During this time, rates of acute hepatitis B in children 7-10 years of age have declined by 27% and rates among children 3-6 years of age have declined by 62%. Implementation of programmes for catch-up vaccination of all adolescents at 11-12 years of age and for vaccination of adolescents and adults in high-risk groups have only recently begun and no data are available to assess the progress of these programmes. However, 26% (13/50) of states now have laws requiring adolescents to be vaccinated in order to enter school. Current data indicate that substantial progress has been made in implementing a strategy to eliminate HBV transmission in the United States. Future efforts need to be focused on improving complete immunoprophylaxis of infants of HBsAg-positive mothers, increasing vaccine coverage among 11-12 year old children and implementing programmes to vaccine adolescents and adults in high-risk groups.

Progress toward the elimination of hepatitis B virus transmission among health care workers in the United States.

BACKGROUND: Hepatitis B virus (HBV) infection is a well-recognized occupational risk for health care workers (HCWs). Vaccination coverage, disease trends, and the need for booster doses after hepatitis B vaccination of adults have been the subject of intense study during the 15 years of the vaccine's availability. METHODS: Vaccination coverage of HCWs was determined from a review of medical records on a sample of employees from 113 randomly selected hospitals. The number of HBV infections among HCWs and the general US population for 1983 through 1995 was estimated from national surveillance data. Studies on long-term protection after hepatitis B vaccination of adults were reviewed. RESULTS: A total of 2837 employee medical records were reviewed; 2532 employees (90%) were eligible to receive hepatitis B vaccine, and 66.5% of them (95% confidence interval, 61.9%-70.9%) had received 3 doses of hepatitis B vaccine. Vaccination coverage was highest (75%) for personnel with frequent exposure to infectious body fluids (phlebotomists, laboratory personnel, and nursing staff) and lowest (45%) for employees at low risk for exposure (dietary and clerical staff). The number of HBV infections among HCWs declined from 17,000 in 1983 to 400 in 1995. The 95% decline in incidence observed among HCWs is 1.5-fold greater than the reduction in incidence in the general US population. Studies on long-term protection demonstrate that vaccine-induced protection persists at least 11 years even when titers of antibody to hepatitis B surface antigen decline below detectable levels. CONCLUSIONS: Although a high percentage of HCWs have been fully vaccinated with hepatitis B vaccine, efforts need to be made to improve this coverage. There has been a dramatic decrease in the number of HBV infections among HCWs who are now at lower risk of HBV infection than the general US population. Vaccine-induced protection persists at least 11 years and booster doses are not needed at this time for adults who have responded to vaccination.

Prevention of hepatitis A virus infection.

Hepatitis A virus infection is major cause of acute hepatitis in the United States, accounting for approximately 75,000 cases of clinical illness each year. These infections occur among persons in every age group and are associated with a variety of exposures related to fecal-oral transmission. Recently, the U.S. Food and Drug Administration approved licensure of two inactivated hepatitis A vaccines. Both vaccines are highly immunogenic and have been licensed in pediatric and adult formulations. The prevention of hepatitis A virus infection is directly related to many aspects of family practice, and family physicians may see patients in a variety of settings that warrant administration of hepatitis A vaccine. Groups for whom vaccination is currently recommended include international travelers, children in communities with high rates of hepatitis A virus infection, men who have sex with men, Illicit drug users, patients with chronic liver disease and persons with clotting factor disorders.