No 12 - 2018

Acute and chronic hepatitis C

In 2017, the Department of Infectious Epidemiology and Prevention received 12 notifications of acute hepatitis C; 11 of the cases were men. Furthermore, a total of 180 cases of chronic hepatitis C were notified, including 126 (70%) men and 54 (30%) women. For a detailed epidemiological account of the incidence in 2017.

The number of notified hepatitis C cases in 2017 is lower than the numbers observed in recent years. The annual “notification incidence” for chronic hepatitis C per 10⁵ decreased from 4.1 in 2016 to 3.1 in 2017. A decrease has been observed in the number of notifications since 2011.

Whether this decrease is due to poorer reporting, a decrease in the quality of testing quality or a real decrease in the hepatitis C incidence in Denmark cannot be established based on the data at hand. It is possible that the improved treatment has produced a decrease in infection pressure. It is, however, more likely that the decrease is observed because the majority of the persons who became infected in the 1970s and 1980s due to IV drug use have been diagnosed in the course of the subsequent period.

It is still mainly IV drug users who are notified with hepatitis C in Denmark. Therefore, former and current drug users are still recommended hepatitis C screening, not least owing to the improved treatment options. Additionally, persons from high-endemic countries, e.g. Egypt and China, should be tested for hepatitis C upon their arrival to Denmark.

The number of notified persons who are assessed as having been infected nosocomially (due to hospital treatment) is in line with the numbers reported in previous years. Among those who had become infected in Denmark, all except one were notified as having become infected by transfusion prior to the introduction of hepatitis C screening of donor blood.The final person was an immunosuppressed dialysis patient who had undergone two kidney transplants. The number of persons who have hepatitis C detected via blood donor screening is decreasing and has remained below 10 annual cases for the past 10 years. Seemingly, then, there is no basis for a recommendation of screening of specific generations of Danes.

All of the eight men who were notified as having become infected by homosexual contact (for both acute and chronic hepatitis C) were known HIV positives. Sexual practices that involve mucosal damage and which therefore carry an increased risk of bleeding seem to be associated with a higher risk of hepatitis C among HIV positives than among HIV negatives. It has been demonstrated that the hepatitis C risk of HIV negative men who have sex with men is equivalent to the risk recorded for the background population.

Ten persons were notified as heterosexually infected. IV drug use could be excluded in one case; five had engaged in sexual intercourse with persons who are known to be infected with hepatitis C.

No children in Denmark were notified as having become infected at birth in 2017. Hepatitis C does not form part of the screening of pregnant women, partly because of the extremely low risk of transmission of the virus to the child, partly because infection in connection with pregnancy and labour cannot be prevented as is the case for hepatitis B. Women who are known to have hepatitis C are not recommended to avoid either pregnancy or breastfeeding.

(M. Wessman, S. Cowan, Department of Infectious Epidemiology and Prevention)

Measles in Copenhagen

In week 11, a 6-month-old child living in Copenhagen had measles detected at Hvidovre Hospital. The child had not received MMR vaccination due to young age. The child had not stayed abroad, and no source of infection has been established so far. During the course of the disease prior to the diagnosis, the child spent time in a waiting room with other children and adults at the GP and at the Paediatric Reception (Børnemodtagelsen) at Hvidovre Hospital. The GP and Hvidovre Hospital in collaboration with the Danish Patient Safety Authority have ensured that patients who may have been exposed to infection have been informed of this.

Physicians in the Copenhagen area are encouraged to pay extra attention to the diagnosis in children and younger adults who present with measles symptoms. In case of clinically suspected measles, it is important to submit diagnostic tests; see below. It is important that any person who is suspected of having measles avoids being in waiting rooms with other patients as measles is extremely infectious. For further information about measles, please see the Measles theme (in Danish).

The diagnosis may be verified through detection of IgM antibodies in the blood. Rapid diagnostics of the virus using PCR is performed on throat swabs and urine (in some cases blood) at the Department of Clinical Microbiology (DCM), Hvidovre Hospital, and at the Department of Virology, Statens Serum Institut. When samples are submitted for testing on suspicion of current disease, it is expedient to contact the local DCM to ensure that the diagnosis is made as fast as possible. Laboratory-confirmed measles infection is notifiable on Form 1515.

Genotyping of virus isolated from the child from Copenhagen detected type D8, which is 100% identical to the genotyping from a current measles outbreak in Ireland and Great Britain, an outbreak which also counts some cases detected in France this year. As previously stated, it remains unknown how the Danish infant became infected. This stresses how infectious measles virus is, and that measles virus brought to Denmark following travels may continue to cause further infection even though Denmark has eliminated measles, EPI-NEWS 37/17. In this context, notably non-immune young adults and unvaccinated children below 15 months of age will be at increased risk of infection.

Vaccination against measles is covered by the MMR vaccine, which is offered to all children via the childhood vaccination programme. The vaccine may also be given to adults who have not previously been vaccinated.

In case of definite exposure of non-immune persons, MMR vaccination may be given within three days or immunoglobulin injection within six days to prevent or lessen the effects of the disease. For further information, see Measles post exposure prophylaxis (in Danish).

(L.K. Knudsen, P.H. Andersen, Department of Infectious Epidemiology and Prevention, T.K. Fischer, L.D. Rasmussen, Virology Surveillance and Research, A.L. Petri, the Danish Patient Safety Authority, Supervision and Guidance East)

Lack of hepatitis B vaccines

Just like for hepatitis A vaccines, EPI-NEWS 42-43/17, a number of hepatitis B-containing vaccines, primarily for adults, are now out of stock. Which products are currently on back order and when they are expected to be available again is presented on the Ordering module (Form 6) at Statens Serum Institut’s (SSI’s) website.

The supply shortage affects all of Europe and is due to production issues at the major producers, including discarded vaccine batches combined with a generally increased demand for the vaccines in recent years, e.g., for travels. Therefore, other wholesalers than Statens Serum Institut are also affected by the situation, including - to the best of our knowledge - e.g. the pharmacists’ wholesalers. Furthermore, the vaccine supply issue is widespread in Europe as the vaccine production is undertaken by fewer producers in an increasingly regulated market. The issue is therefore also being considered in the EU, among others, where the SSI is involved in discussions about various options that may ensure an improved supply of vaccines.

During supply shortages, it is the SSI’s main priority to ensure vaccines for special risk groups, and therefore the SSI has a robust safety stock of hepatitis A as well as hepatitis B vaccines that are dispensed on specific request from doctors. The SSI is not currently concerned about the prospective supply of hepatitis vaccines to those groups that have special medical needs.

It is important to stress that persons who are specifically exposed to infection, e.g. following sharps accidents and newborns to mothers who are chronically infected with hepatitis B, are given priority with respect to the mentioned safety stock. Ordinary travellers will normally not be covered by the safety stock. However, children below the age of 5 years who will be staying abroad and who are expected to come into close contact with local children are also vaccinated before initiating their travel, EPI-NEWS 6/11.

Below we describe general and specific advice to achieve the best possible protection of travellers against hepatitis B

Generally, the risk of becoming infected with hepatitis B is low for most travellers, and it may be further reduced by avoiding:

• unprotected sex
• tattooing, body piercing or acupuncture
• occupational exposure to blood or blood products (e.g. healthcare professionals)
• exposure to contaminated needles, either by IV drug use or in connection with medical or dental treatment (sterile needles and syringes may in some cases be brought from home)
• sharing shaving gear (razors) with others.

For adult travellers to countries with a high hepatitis B incidence (as defined based on the country-specific vaccination recommendation at the SSI’s travel website (in Danish)), and where a vaccination indication still exists before departure, immunocompetent adults may employ the following hierarchy of possibilities:

1. Adult dose of hepatitis B vaccine (Engerix B or HBVaxPRO) – currently backordered
2. Adult dose hepatitis A/B combo vaccine (Twinrix) – currently backordered
3. High-dose paediatric hepatitis A/B combo vaccine (Ambirix, corresponds to the Twinrix adult dose) – currently backordered
4. Paediatric Hep A/B combo vaccine (Twinrix ped.) – is currently in stock, but no immunogenicity data are available for its effect in adults when only one paediatric dose is given at each vaccination session. Alternatively, two paediatric doses of Twinrix ped. may be given on days 0, 30 and 180. This is mentioned as a possible vaccination schedule in English guidelines for patients with renal failure.

Patients who have initiated a vaccination series will have achieved some degree of protection.

Use of the rapid vaccination schedule (Days 0, 7, 21 and 360) is not recommended during the shortage situation as this schedule requires one dose more than when using the standard three-dose schedule.

(P.H. Andersen, Department of Infectious Epidemiology and Prevention, B. Neale, Vaccine Supply)

The temporary vaccination programme will conclude by the end of March

Due to production issues and by appointment with the Danish Health Authority and the Danish Ministry of Health, it was decided to introduce a new temporary childhood vaccination programme in mid February 2016, EPI-NEWS 5/16. Children who initiated vaccination under the programme after Week 7/8 received the hexavalent vaccine, Hexyon®, which in addition to the standard conditions also protects against hepatitis B.

In this connection, the Danish Health and Medicines Authority decided that all children who have received a minimum of one Hexyon® vaccination under the temporary vaccination programme, and who have therefore also initiated a vaccination schedule against hepatitis B, should be given the opportunity to conclude their hepatitis B vaccination. This offer to complete hepatitis B vaccination ends by the end of March 2018, EPI-NEWS 13/17. The affected children can, nevertheless, conclude their vaccination course at a later date, but their parents will need to defray the vaccination costs.

(L.K. Knudsen, P. Valentiner-Branth, Department of Infectious Disease Epidemiology and Prevention)

Link to previous issues of EPI-NEWS

21 March 2018