Hepatitis A Vaccination Program Works, But Migration Complicates Impact

A new report from Turkey shows that the country’s efforts to boost vaccination rates against hepatitis A virus are working, but the report also highlights the ways in which migration of susceptible people from other countries is complicating those efforts.

The authors concluded that vigilant epidemiological monitoring and an expansion of vaccination efforts are required. The report was published in the Journal of Medicine and Palliative Care.

Corresponding author Benhur Sirvan Cetin, MD, of Turkey’s Erciyes University, said Turkey added hepatitis A vaccination to its national vaccine program in November 2012, hoping to curb the disease, which in some cases can lead to liver failure and death. Yet, that administrative change coincided with the Arab Spring movement, a series of uprisings in the Middle East that in some cases resulted in the overthrow of governments, but which in Syria has led to a protracted civil war and a massive migration crisis.

Many of those fleeing the violence in Syria have ended up in Turkey, and many of those refugees are not vaccinated against hepatitis A virus, since such vaccinations are not routine in Syria. Confounding the issue is the reality that many migrants are forced to live in crowded, unsanitary conditions, which could increase the risk of hepatitis A infection.

Cetin wanted to know how both the Turkish vaccination program and the inflow of Syrian migrants might be impacting Turkey’s efforts to limit the spread of hepatitis A infection.

To find out, Cetin retrospectively reviewed the charts of children (18 and under) who were diagnosed with viral hepatitis A between January 2013 and February 2018 at the Gaziantep Cengiz Gökçek Maternity and Children’s Hospital. He found a total of 1,039 cases, of whom 53% were male and the median age was 7.9 years. However, the number of infections declined over time from 321 and 360 cases in 2013 and 2014, respectively, to 119 and 73 cases in 2016 and 2017, respectively.

Overall, 14% percent of the hospital’s pediatric hepatitis A cases were Syrian refugees. However, their share of cases increased over time. In 2013, just 6.5% of cases were Syrian refugees, but by 2017, more than half of cases—52.1%—were Syrians.

“After the implementation of the HAV vaccine in the national program, case numbers are declining,” Cetin said. “However, there are still susceptible individuals, especially Syrian refugees.”

Cetin noted that there are an estimated 1.6 million Syrian children living in Turkey, and fully 10% of those children are believed to be in the city of Gaziantep, the location of the hospital that was the setting of the study. He said efforts have started locally to help more Syrian children get the hepatitis A vaccine.

“Prioritizing vaccination of this susceptible group started in the middle of 2017 in this region,” Cetin said. “We expect these infection rates to decrease in the future.”

Overall, about half of children diagnosed with hepatitis A infection were hospitalized. Cetin said that rate is concerning, even though hospitalized patients stayed for a relatively short length of time (a median of 4 days).

“While making a decision for hospitalization, non-compliance with guidelines or not trusting home care can increase the hospitalization rates improperly,” he said.

The average cost per stay was $246.80 per case, he reported.

Cetin said the data in the study affirm the importance of routine hepatitis A vaccination in Turkey, but they also call attention to the need to stay attentive to the risk.

“Continuous monitoring of epidemiological data and efforts to expand vaccine coverage are required for infection control,” he said. “In order to prevent unnecessary hospitalizations in managing the cases, it is necessary to review the patient management of the physicians in the field.”