Recurring hepatitis A outbreaks in the EU/EEA: summary of the recommendationsJohanna Takkinen, EPIET alumnus 1999 (cohort 5)European Centre for Disease Prevention and ControlESCAIDE, Stockholm, 12 November 2015

Hepatitis A – acute illness and virus characteristics Faecal-oral transmission Relapses in about 15% of patients

=> prolonged disease course up to 6-9 months

Asymptomatic or subclinical infection mostly in children < 5 years

Case-fatality low, < 0.5%

"HAV Infection" by GrahamColm at English Wikipedia. Licensed under CC BY-SA 3.0 via Commons - https://commons.wikimedia.org/wiki/File:HAV_Infection.png#/media/File:HAV_Infection.png

RNA virus in the family Picornaviridae

High environmental persistence One serotype, genotypes I, II and

III of human origin Highly conserved => slow

replication pace High genetic diversity

ECDC 1st Annual Epidemiological Report, covering data for 1995 - 2005

EU/EEA trend in 1995 – 2004:

Available at: http://ecdc.europa.eu/en/publications/surveillance_reports/annual_epidemiological_report/Pages/2007_epi_report.aspx

Hepatitis A notifications in EU/EEA, 2010 – 2014*

*Unpublished data for 2014

Main risk groups:- Intravenous drug users- Homeless people- Men having sex with

men- Travelling communities

Average EU/EEA notification rate 2.7 / 100 000 in 2010-2014

”Cluster” of alerts in Epidemic Intelligence Information System (EPIS) in 2013

Norway, 17 April 2013:

Germany, 8 May 2013:

Denmark, 1 March 2013:

Hepatitis A (IB, two strains) in Denmark, Finland, Norway and Sweden, October 2012 – June 2013 (N=103)

Severi et al .The Lancet Infectious Diseases 2015 15, 632-634DOI: (10.1016/S1473-3099(15)00021-3)

Vehicles of infection from Egypt or Morocco:

EPIS & EWRS

ECDC-EFSA ROA*

*ROA = Rapid Outbreak Assessment

Hepatitis A (IB) in travellers returning from Egypt, November 2012 – April 2013 (N=107, 14 countries)

mOR 10.1 (95%CI 1.1-93)

mOR 21 (95%CI 1.1-409)

fresh, in smoothies, pastries and fruit sauce

Vehicles of infection:

EPIS & EWRS week 16

RRA* week 17

*RRA = Rapid Risk Assessment

No vaccination in travellers!

Multi-state hepatitis A (IA) outbreak, due to contaminated berries and travel to IT, January 2013 – June 2014 (9 countries, finally 13 countries)

Source: EFSA report, Tracing food items in connection to hepatitis A, 2014

Vehicles of infection:Mixed frozen berriesEPIS &

EWRS ECDC-EFSA ROA 1st update of ECDC-EFSA

ROA

2nd update of ECDC-EFSA ROA

Hepatitis A: seroprevalence in EU/EEA 1975 – 2014*

*ECDC: Hepatitis A virus in the EU/EEA, 1975-2014: a systematic review of seroprevalence and incidence comprising European Surveillance data and national vaccination recommendations, expected publication in early 2016

1975 - 1989 1990 - 1999 2000 - 2013

WHO classification1:I = IntermediateL = LowVL = Very low

1World Health Organization. WHO position paper on hepatitis A vaccine-June 2012. WER 2012; 28-29: 261-276. Available at: http://www.who.int/wer/2012/wer8728_29.pdf?ua=1

24 countries in EU/EEA have very low seroprevalence profiles (based on seroprevalence estimates at 15 and 30 years)

Hepatitis A: susceptibility profilesin EU/EEA 2000 – 2014*

*ECDC: Hepatitis A virus in the EU/EEA, 1975-2014: a systematic review of seroprevalence and incidence comprising European Surveillance data and national vaccination recommendations, expected publication in early 2016

Conclusions Sequencing of HAV strains crucial for outbreak detection and

investigation Centralised collection of sequences essential for hypothesis

generation HAV sequencing practices vary by countries => comparison

difficult Population at risk shifted from risk groups to EU general

population – Large variations in susceptibility by countries and regions– Vaccine recommended for risk groups (e.g. travellers)

Lack of vaccination in European travellers => risk perception low when staying in luxury hotels even in endemic countries

Collaboration worked well between national food safety and public health authorities

EFSA-ECDC (risk assessors) and Commission (risk manager) worked too much in silos – Delay in the start of an EU-wide trace-back investigation

Invaluable support to all investigations received from EPIET/EUPHEM fellows in the field– EPIET/EUPHEM vision fulfilled; a network of

epidemiologists/microbiologists using common language and tools

Recommendations and actions (to be) taken A common sequencing protocol prepared in RIVM by

HAVNET Promotion of centralised sequence data collection is

needed=>HAVNET is a recommended centralised database for HAV sequences in Europe

A review of seroprevalence and susceptibility of EU populations by countries is needed to assist countries in their assessment on appropriateness of vaccination practices

=>Prepared by ECDC and expert panel, report to be published in early 2016

Increasing importance of berries as vehicle of HAV infection

EU-wide trace-back investigation should be initiated faster

=> Regular communication between Commission and ECDC-EFSA is needed in a multi-state foodborne outbreak event

Acknowledgements

Ettore

Severi

Jussi Sane

Julita Gil Cuesta

Emily MacDon

ald

Sofie Gillesberg Lassen

Pieter Smit

Max Gertler

Anneke Steens

Michael Edelstei

n

Line VoldBernardo

Guzman-Herrador

Bolette Søborg

Ruska Rimhanen-Finne

Martina Escher

Margot Einöder-Moreno

Heidi Lange

Margaret Fitzgeral

d

Justina Rogalska

Rita da Sousa

• Jussi Sane (EPIET) and Rita de Sousa (EUPHEM)

• All epidemiologists and virologists in affected countries that participated in investigations

• Harry Vennema /HAVNET/RIVM

• ECDC staff• Ettore Severi• Lara Tavoschi• Celine Gossner• Pier Luigi Lopalco• Paloma Carrillo-Santisteve• Marion Muehlen• Aftab Jasir• Yvan Huitin• Denis Coloumbier

• EFSA staff• Jane Richardson• Olaf Mosbach-Schulz• Pia Mäkelä

• Commission• Klaus Kostenzer

19 fellows involved!

Multi-state hepatitis A outbreak due to contaminated berries and travel to IT, January 2013 – June 2014 (9 countries, finally 13 countries)

Source: EFSA report, Tracing food items in connection to hepatitis A, 2014

Vehicles of infection:Mixed frozen berriesEPIS &

EWRS ECDC-EFSA ROA 1st update of ECDC-EFSA

ROA

2nd update of ECDC-EFSA ROA

ECDC-EFSA-MS-EC TC

Thank you for your attention!

Contact ECDC FWD team: fwd@ecdc.europa.eu ECDC website: www.ecdc.europa.eu