Hepatitis B vaccination policies for student healthcare workers in Europe.

Student healthcare workers represent a particular risk group for hepatitis B virus (HBV) transmission and should be vaccinated as early as possible after the start of their career. An overview of specific HBV policies in European Union countries was conducted through a cross-sectional survey. Answers were received from 17 countries. HBV vaccination was mandatory for medical students and student nurses in five countries and recommended in nine. Pre-vaccination testing was done in five countries and serotesting after vaccination in 12 countries. Policies to ensure student healthcare workers' immunity against HBV should be diverse due to different policies regarding universal HBV vaccination.

Evaluation of mid-level management training in immunisation in the African region.

OBJECTIVE: The Mid-Level Management (MLM) training course provides managers of immunisation programmes with new, advanced skills in planning, management, monitoring and evaluation. An evaluation was conducted of the MLM training courses held between 2000 and 2004 in the African Region, in order to assess its effectiveness and impact, and its contribution to the management of the Extended Programme on Immunisation (EPI) at country level. METHODS: Evaluation methods included: a desk review of the MLM course reports, WHO/AFRO MLM modules and reference documents; interviews with MLM course participants, facilitators, supervisors, Ministry of Health officials and country-based partners; focus group discussions; and questionnaires. RESULTS: During 2000-2004, eleven MLM courses were held and 642 participants were trained. Of the 151 course participants interviewed, 85% rated the course as very useful and 15% as useful. Modules on new vaccines, immunisation safety, cold chain and vaccine management, communication and problem solving were most appreciated. According to supervisors, the MLM training has contributed to significant improvements in the performance of the staff after attending the MLM course. Using DTP3 as an indicator, immunisation coverage in the African Region increased from 49% in 1991 to 53% in 2001 and 69% in 2004. CONCLUSIONS: The MLM training has increased the performance of the trained staff and therefore contributed to the improvement of EPI coverage in the African Region. However, MLM training remains a predominantly vertical event and should be harmonised with other health training programmes for various levels of the health system.

A trial of the validity of genital smears and cultures with gonococcal vaccine provocation in diagnosing genital gonorrhoea in women.

In Russia the diagnosis of gonorrhoea in women relied on microscopy, justified by the hypothesis that sensitivity increases using 'provocation' techniques. The aim was to test the value of Gonovaccine as provocation in women who would have received it normally. Cervical specimens from 204 women were tested by culture and a ligase chain reaction (LCR) assay before the women were randomized to receive provocation or not. Further cervical specimens were obtained 24, 48 and 72 hours later for microscopy, culture and LCR tests. In both provocation and non-provocation arms, 24 women were positive for gonorrhoea by the LCR assay. Test-by-test, sensitivity of microscopy was 30% in the provocation arm and 13% in the control arm (P = 0.0407, Fisher's exact test). Patient-by-patient, sensitivity of microscopy was 50% in the provocation arm, but only 25% in the control arm (P = 0.0675, Fisher's exact test). The cost per case was greater ($214) using provocation with microscopy than culture and microscopy at the first visit ($150). Thus, although Gonovaccine provocation doubled the sensitivity of microscopy in detecting gonococci, the internationally recommended protocol of microscopy and culture at first visit should be adopted as routine practice in Russia. The findings raise questions about the pathogenesis and natural history of gonorrhoea.

Performance of direct fluorescent antibody tests for routine diagnosis of Chlamydia trachomatis in Russian sexually transmitted disease clinics.

SUMMARY: Testing for Chlamydia trachomatis in Russia is usually done by microscopic examination of genital smears stained with fluorescent antibody provided in locally produced kits. The aim was to assess the sensitivity and specificity of such direct fluorescent antibody (DFA) tests compared with a nucleic acid amplification test (NAAT) (ligase chain reaction) to detect C. trachomatis in 171 cervical smears and 201 urethral smears from men. The patients were at high risk of chlamydial infection and had been recruited at three sexually transmitted disease clinics in Moscow. Among women, DFA test sensitivity was 6% (95% CI 0-14) and the specificity was 92% (95% CI 88-97). Among men, the sensitivity was 9% (95% CI 2-16) and the specificity was 90% (95% CI 83-94). Poor DFA test performance was probably due to poor antibody quality and such tests are not adequate for routine examination of populations with either low or high chlamydial prevalence. As there may remain a place for DFA testing where few patients are seen, the Russian Ministry of Health should enforce registration of diagnostic tests, and Russian manufacturers should seek ways of improving DFA test performance. However, the mainstay of testing should depend on NAATs.

Increased exposure to hepatitis B virus infection in HIV-positive South African antenatal women.

The prevalence of markers for hepatitis B virus (HBV) exposure and active infection in HIV-positive (n=710) and HIV-negative (n=710) pregnant South African women was investigated. The following statistically significant increases in the HIV-positive group were found: anti-hepatitis B core antigen (anti-HBc) (37.3% versus 28.6%; odds ratio [OR]: 1.49); anti-hepatitis B surface antigen (anti-HBs) (29.5% versus 20.1%; OR: 1.66); exposure based on hepatitis B surface antigen (HBsAg) and anti-HBc (39.2% versus 30.1%; OR: 1.49); and exposure based on anti-HBs, anti-HBc and HBsAg (37.1% versus 24.5%; OR: 1.82). However, there was no increase in active HBV infections, with 2.4% of the HIV positives and 2.2% of the HIV negatives being HBV DNA positive. Although the impact that HIV has had on the prevalence of HBV in this population group is not as pronounced as that found in areas of low endemicity (where up to seven-fold increases have been reported), there is a statistically significant increased exposure to HBV.

Clinical, epidemiological and cost aspects of contact lens related infectious keratitis in Belgium: results of a seven-year retrospective study.

AIM: Evaluation of the clinical, epidemiological and cost aspects of contact lens related infectious corneal ulcers requiring hospitalisation. METHODS: A retrospective analysis was performed on the files of patients hospitalised for contact lens induced corneal ulcer in the eight Belgian University Hospitals over a seven-year period (January 1997 until December 2003). For all hospitalised patients registration of the diagnosis is compulsory using the International Code of Diagnostics (ICD-9). RESULTS: 107 patients with contact lens related corneal ulcer were included. The great majority, 99 subjects, used soft contact lenses, of which 9 were disposables, 73 planned replacement and 17 conventional lenses. Only 6 patients were night and day wearers. 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 localised centrally which resulted in an average visual loss of 4 lines. In 16 patients a corneal graft was performed and one eye had to be eviscerated. CONCLUSION: Despite important technological improvements in contact lens materials and care systems, the problem of infectious ulceration has all but disappeared. On the contrary, during the study period, the number of patients hospitalised increased from 5 in 1997 to 22 in 2003, which is only partially explained by the increasing prevalence of lens wearers: 3,5% of the Belgian population in 1995 and 6,5% in 2003.

Hepatitis B virus and human immunodeficiency virus co-infection in sub-Saharan Africa: a call for further investigation.

A growing body of evidence indicates that human immunodeficiency virus (HIV)-positive individuals are more likely to be infected with hepatitis B virus (HBV) than HIV-negative individuals, possibly as a result of shared risk factors. There is also evidence that HIV-positive individuals who are subsequently infected with HBV are more likely to become HBV chronic carriers, have a high HBV replication rate, and remain hepatitis Be antigen positive for a much longer period. In addition, it is evident that immunosuppression brought about by HIV infection may cause reactivation or reinfection in those previously exposed to HBV. Furthermore, HIV infection exacerbates liver disease in HBV co-infected individuals, and there is an even greater risk of liver disease when HIV and HBV co-infected patients are treated with highly active anti-retroviral therapy (HAART). Complicating matters further, there have been several reports linking HIV infection to 'sero-silent' HBV infections, which presents serious problems for diagnosis, prevention, and control. In sub-Saharan Africa, where both HIV and HBV are endemic, little is known about the burden of co-infection and the interaction between these two viruses. This paper reviews studies that have investigated HIV and HBV co-infection in sub-Saharan Africa, against a backdrop of what is currently known about the interactions between these two viruses.

Prevention of hepatitis C virus infection.

In spite of advances made in our understanding of the biology of the hepatitis C virus (HCV), the epidemiology and natural history of HCV infection, and the treatment of chronic hepatitis C, the development and worldwide implementation of a comprehensive prevention and control strategy remains necessary. A World Health Organization informal consultation with the Viral Hepatitis Prevention Board was convened and met in Geneva, Switzerland, 13-14 May 2002, to review epidemiological and public health aspects of HCV infection, and the various prevention and control strategies that are currently in place. Based on the presentations and discussions, a number of specific recommendations were made, which should be considered in conjunction with previously published recommendations.

Hepatitis B surface antigenaemia following vaccination with a combined vaccine against hepatitis A and B.

We report a case of transient hepatitis B surface antigenaemia (HBsAg) following vaccination with a combined vaccine against hepatitis A and B in healthy adults. This phenomenon has been observed following administration of recombinant hepatitis B (monovalent) vaccine, mainly in newborns or dialysis patients. Reports on healthy adults are much less frequent and mostly concern blood donors. The frequency of its occurrence is largely unknown but its duration does not exceed 28 days. It is not detected by all available assays. It is caused by a passive transfer of antigen by vaccination, and not by viral replication; hence there is no risk for vaccination-induced infection. An important implication resulting from our findings is that the results of HBsAg assays should be interpreted according to the time elapsed since the last administration of a recombinant monovalent vaccine against hepatitis B or a combined vaccine against hepatitis A and B.

Chlamydial infection: an accurate model for opportunistic screening in general practice.

OBJECTIVES: To estimate the prevalence of Chlamydia trachomatis in women in general practice and to assess risk factors associated with infection. METHODS: The study was carried out in 2001-2 in different general practices in Antwerp, Belgium. Sexually active women, visiting their general practitioner for routine gynaecological care (mostly pill prescription or PAP smear), were offered opportunistic screening for chlamydia. 787 participants aged 15-40 delivered a self taken vaginal sample and filled in a questionnaire which included questions on demographic variables, urogenital symptoms, sexual history, and sexual behaviour. Samples were tested for presence of chlamydial DNA by means of a ligase chain reaction (LCR) assay, and positives were confirmed by two other amplification assays (PCR and SDA). RESULTS: Overall prevalence was 5.0% (95% CI: 3.5 to 6.5). Determinants of infection in logistic regression analysis were age 18-27 years, >1 partner in the past year, no use of contraceptives, frequent postcoital bleeding, having a symptomatic partner, painful micturition, and living in the inner city. The area under the ROC curve in the full model was 0.88. Selective screening based on a combination of the five first determinants detects 92.3% of infections in this sample; 37.5% of the population would need to be screened. CONCLUSION: Targeted screening for chlamydial infection is possible, even in a heterogeneous group of general practice attendants. Implementing this model would require considerable communication skills from healthcare providers.

Performance of the recommendations of a British advisory group for screening for chlamydia in a sample of women in general practice.

In this study the performance of the guidelines produced by the British Chief Medical Officer's expert advisory group for selective screening for Chlamydia trachomatis was evaluated. The guidelines were applied to a sample of 777 women in general practice in Antwerp, Belgium. The accuracy of the screening/testing recommendations was suboptimal. The model detected 90% of infections but failed to identify a high-risk population; the population to be screened was reduced by only 21%. The focus on young age as the most important determinant for screening was not appropriate. More attention should be paid to risky sexual behaviour.

The difficult quest for data on "vanishing" vaccine-preventable infections in Europe: the case of measles in Flanders (Belgium).

We aimed to describe the impact of vaccination on the epidemiology of measles infection in Flanders (Belgium), to document probable vaccination coverage based on this evidence, compare these epidemiological data with those generated by a mathematical model and estimate the costs of morbidity from measles. In contrast to previous analyses, we included the costs of long-term care for sequelae due to encephalitis and subacute sclerosing panencephalitis (SSPE). We estimated the direct health care costs per average measles case at 227, 212, 210, 200 and 194 for the age groups of 0-4, 5-9, 10-14, 15-19 and > or=20 years, respectively. Excluding long-term care lowers these estimates by 22-51%, depending on the age group. By including indirect time costs, we arrive at total costs per measles case of 320, 305, 210, 200 and 625, respectively. In addition to registering vaccination coverage more rigorously in the future, it seems necessary to undertake seroprevalence studies to document the age-specific immunity to measles. By using such information, current vaccination strategies can be adapted to prevent future outbreaks and to help eliminate measles from Europe in an efficient way. We noted throughout that many of the data sources are flawed. Better and accessible data bases are required to improve the reliability of similar studies in the future.

Pros and cons of an illicit drug users' registration system by means of judicial data in Flanders (Belgium).

The main objective of this study was to evaluate the advantages and shortcomings of a new kind of registration of illicit drug users in Flanders, Belgium. Data about the profile of drug users who have come into contact with the law were collected by examining the records kept by the District Courts. On the one hand, published data on illicit drug users in Flanders are scarce. On the other hand, a lot of unused judicial information is available. All District Courts in Flanders (n=13) and Brussels (n=1) participated in the study. The data show that a simple registration of verbalised drug users with a short questionnaire can provide useful information for prevention campaigns and police investigation and shows the importance of prevention programmes starting at school. Notwithstanding some shortcomings, the illicit drug users' registration system by means of judicial data in Flanders forms a solid basis upon which an integrated registration of illicit drug use can be built.

Teenagers' lifestyle and the risk of exposure to hepatitis B virus.

Prevention of lifestyle-related diseases and promotion of physical and mental well-being in adolescents require an understanding of how life situations place adolescents at risk. The most important risk factors for hepatitis B virus (HBV) infection are sexual activity with more than one partner and injecting drug use. Sexual transmission is particularly important in areas of low endemicity, but is increasingly important in areas of high endemicity as young people adopt a 'Western' lifestyle. HBV infection in general is associated with indicators of sexual activity, e.g. number of sexual partners, years of sexual activity and the occurrence of other sexually transmitted diseases (STDs). Risk behaviours are often associated: adolescents who have frequent sexual intercourse also drink more alcohol, smoke more cigarettes, use marijuana more often and wear seat-belts less often when driving than adolescents who have little or no sexual activity. Health education and health promotion are important activities aimed at preventing HBV infection, but the major strategy should be providing immunity from infection before risk-taking behaviour. As for other STDs, this is best achieved by universal vaccination of young adolescents or infants or both.