Epidemiology of hepatitis A in Greece in the last decade: management of reported cases and outbreaks and lessons learned

Abstract

Hepatitis A is a mandatory notifiable disease in Greece. Here, we present the epidemiological data for 2009–2018 and the results of outbreak investigations performed, and discuss future public health priorities. Overall, 1193 cases were reported; 320 migrants/refugees, 240 Roma, 112 travellers and 521 from the general population. The median age of the affected general population (37 years) had an increasing trend (from 30.8 years in 2009 to 40.5 in 2018, P < 0.001) and was significantly higher than that among Roma and migrants (7 and 8 years, respectively, P < 0.001). Twenty-two cases (2.2%) were unvaccinated patients with a chronic liver disease. Fifty clusters with 2–12 cases each were recorded; 44 were attributed to person-to-person transmission and six to food consumption. Three outbreaks accounting for 32.3% of the total number of recorded cases were identified; in 2013 among Roma (112 cases), in 2016 among refugees (188 cases) and in 2017 among men having sex with men (96 cases; 33 of them (34.4%) HIV-positive). The epidemiological data depict that improving living conditions and vaccination coverage of deprived populations, and informing adults on the disease focusing at faecal–oral transmission during sexual intercourse and travel should be the future public health priorities.

Migration and Outbreaks of Vaccine-Preventable Disease in Europe: A Systematic Review

“…Germany (n=9) (16, 29, 32, 34, 37, 52, 56, 59, 62), Spain (n=8) (43-45, 48, 61, 63-65), Italy (n=6) (33, 36, 40, 46, 47, 58, 60) and Greece (n=5) (28, 42, 50, 51, 54, 55) were the countries that most frequently reported outbreaks involving migrants between 2000 and 2020. Two thirds (n=6) of included outbreaks in Germany affected refugee or asylum-seeking populations, mostly in temporary camps, 78% (n=7) were measles outbreaks and all but one were reported in 2010 or later.…”

Hepatotropic viruses: Is Roma population at risk?

“…Roma people are recognized as a high-risk group for HAV infection, in addition to migrants, travelers to endemic countries, and men who have sex with other men[ 19 , 20 ]. In Slovakia and Greece, the countries with a significant number of Roma residents, several hepatitis A outbreaks were reported over the last 15 years[ 16 , 19 , 21 ]. In the period between 2009 and 2018, 1193 cases of HAV infection were reported in Greece.…”

“…In the period between 2009 and 2018, 1193 cases of HAV infection were reported in Greece. Roma people accounted for approximately 20% of all infections, with 80.7% of cases affecting Roma children under 15 years old, whereas in the non-Roma population, the percentage of children was significantly lower (5.3%)[ 19 ]. Even though the HAV vaccine is mandatory for all children in Greece since 2008, the study from 2013 showed that only 22.6% of Roma children were vaccinated against HAV[ 22 ].…”

“…In the Roma population, both genders were equally affected, whereas in the non-Roma population, infection predominantly occurred in males. Almost half of HAV clusters (2009-2018) were reported in the Roma population, which accounts for the minority of the Greek population[ 19 ]. The study on the HAV outbreak in south-eastern Greece (2007) demonstrated that Roma are susceptible to HAV infection, which appears at an earlier age than in non-Roma[ 16 , 20 ].…”

“…HAV infection in Roma differs from the non-Roma population in terms of the lower age of infection and equal distribution among genders[ 16 , 19 ]. The high prevalence is mainly due to poor socioeconomic factors, inadequate sanitary conditions, and sewage systems, contributing to easier transmission of the disease.…”