Prevention strategies tackling hepatitis B virus (HBV) in European Union (EU)/European Economic Area (EEA) countries are centred around universal or targeted vaccination programmes. Poster at ESCAIDE 2016, Stockholm

1. Impact of hepatitis B vaccination on acute hepatitis B
epidemiology in EU/EEA countries, 2006-2014
A Miglietta1, C Quinten1, P L Lopalco2, E F Duffell1
1. European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
2. Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa
Background
Prevention strategies tackling hepatitis B virus (HBV) in European
Union (EU)/European Economic Area (EEA) countries are centred
around universal or targeted vaccination programmes. National
differences exist in the type of strategy implemented and the
vaccine coverage achieved.
Our study aims to assess the impact of different HBV vaccination
strategies implemented by EU/EEA countries, vaccine coverage
levels and hepatitis B prevalence on the epidemiology of acute
hepatitis B, to help guide actions in countries towards the World
Health Organization’s goal of eliminating hepatitis B by 2030.
Corresponding author: Erika Duffell
www.ecdc.Europa.eu
Methods
In 2011 ECDC implemented a surveillance programme for HBV
across EU/EEA countries. Using a multi-level mixed-effects
multivariable Poisson regression model with repeated measures
(year) and country as cluster/random effect, we performed a
cross-sectional analysis of 2006-2014 acute HBV notification data
from countries with a universal vaccination programme. We
evaluated the impact of catch-up vaccination strategies, the year
universal vaccine was introduced, hepatitis B surface antigen
(HBsAg) prevalence and three dose vaccination coverage
(HepB3%), on acute notification rates. Results were expressed as
incidence rates ratios (IRR) [with 95% confidence intervals (CI)].
Results – Descriptive Epidemiology
During the period 2006-2014, 32,949 acute HBV cases were reported from 27 EU countries. The EU notification rate decreased by 56.3%,
from 1.6 per 100,000 population in 2006 to 0.7 in 2014. Countries with the highest average notification rate were Bulgaria, Latvia and
Romania (6.3, 5.1 and 2,7 per 100,000 respectively). Countries that started HBV vaccination programme before/in 1995 (panel B) had a
greater reduction in the acute HBV notification rate (-61.1%) compared to the group of countries that started after 1995 (-50%), as well as
the group of countries that implemented catch up HBV vaccination programme (-68.4% vs. -25%). Countries with HepB3%<95% had a stable
trend during 2006-2014 compared to the group of countries with HepB3%≥95%, that showed a marked decrease with -77%. A similar
pattern was observed for criteria 4, with a stable trend for the group of countries with HBsAg<1% and a marked decrease for those countries
with HBsAg≥1% (-79%).
Figure 1. Acute HBV notification rate (per 100,000 population) at EU level; and by group of countries and criteria. 2006-2014
Discussion:
• Notification rates of acute HBV infections reported to ECDC showed a marked decrease at the EU level between 2006 and 2014.
• Despite no statistically significant association being found, the descriptive epidemiology showed that countries that implemented a catch-up
immunization programme and that started their HBV vaccination programme before 1995 had a greater reduction in rates, as well as
countries with high vaccine coverage and HBV endemicity. The lack of any significant association may be due to various factors including the
timing of the analysis, the limited number of countries included and the design used (cross sectional analysis instead of trend analysis due
to missing data). The latter limitation outlines a need for trend analysis to further explore the associations.
• Among the group of countries that started their HBV vaccination programme before 1995 with a catch-up campaign, achieved vaccine
coverage of ≥95% and had HBsAg prevalence ≥1% are the countries with the highest acute HBV notification rates: Bulgaria, Latvia,
Romania. These are the countries that have received benefit from HBV vaccination as the great reduction in the acute notification rate for
countries with HBsAg≥1% shows .
• Finally, the analysis indicates that as vaccine coverage increase, acute HBV notification rates decrease, highlighting the importance of high
coverage in achieving the greatest impact.
Conclusion:
The results of this study suggest that universal and catch-up HBV vaccination strategies implemented with high coverage are likely to have
contributed towards the reduction in acute HBV notifications across the EU/EEA countries. Vaccination is central to national prevention efforts
for HBV and ending the transmission of HBV in Europe by 2030 will require high vaccine coverage delivered through universal programmes,
supported, where appropriate, by catch-up vaccination campaigns.
0.1
1.0
10.0 B - Criterion 1
≤1995 >1995
0.1
1.0
10.0 C - Criterion 2
Catch-up yes Catch-up no
0.1
1.0
10.0 D - Criterion 3
HepB3 <95% HepB3 ≥95%
0.1
1.0
10.0 E - Criterion 4
HBsAg ≥1% HBsAg <1%
LEGEND
Vertical axis: acute HBV notification rate per 100,000
population (logarithmic scale)
Horizontal Axis: Year
Criteria 1: Countries that started HBV vaccination programme
before/after 1995
Criteria 2: Countries with/without a catch up HBV vaccination
programme
Criteria 3: Countries with 3 doses HBV vaccine coverage ≥95% /
<95%
Criteria 4: Countries with HBsAg prevalence among general
population ≥1%/<1%
0.0
0.5
1.0
1.5
2.0 A - Europe
Results – Multivariable analysis
Multivariable analysis of the data found none of the criteria to have a statistically significant association with the acute HBV notification rate.
Finally (data not shown), the EU acute HBV IRR decreased by 11% for each 1% increase in vaccine coverage (IRR 0.89; 95%CI
0.85-0.92; p<0.01).