Factors Associated With Hepatitis A Mortality During Person‐to‐Person Outbreaks: A Matched Case–Control Study—United States, 2016‐2019

Abstract

Background and Aims During 2016‐2020, the United States experienced person‐to‐person hepatitis A outbreaks that are unprecedented in the vaccine era, during which case–fatality ratios reported by some jurisdictions exceeded those historically associated with hepatitis A. Approach and Results To identify factors associated with hepatitis A–related mortality, we performed a matched case–control study (matched on age [±5 years] and county of residence in a 1:4 ratio) using data collected from health department and hospital medical records of outbreak‐associated patients in Kentucky, Michigan, and West Virginia. Controls were hepatitis A outbreak–associated patients who did not die. There were 110 cases (mean age 53.6 years) and 414 matched controls (mean age 51.9 years); most cases (68.2%) and controls (63.8%) were male. Significantly (P < 0.05) higher odds of mortality were associated with preexisting nonviral liver disease (adjusted odds ratio [aOR], 5.2), history of hepatitis B (aOR, 2.4), diabetes (aOR, 2.2), and cardiovascular disease (aOR, 2.2), as well as initial Model for End‐Stage Liver Disease (MELD) score ≥ 30 (aOR, 10.0), aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio > 2 (aOR, 10.3), and platelet count < 150,000/μL (aOR, 3.7) among hepatitis A outbreak–associated patients in the independent multivariable conditional logistic regression analyses (each model adjusted for sex). Conclusions Preexisting liver disease, diabetes, cardiovascular disease, and initial MELD score ≥ 30, AST/ALT ratio ≥ 1, and platelet count < 150,000/μL among hepatitis A patients were independently associated with higher odds of mortality. Providers should be vigilant for such features and have a low threshold to escalate care and consider consultation for liver transplantation. Our findings support the recommendation of the Advisory Committee on Immunization Practices to vaccinate persons with chronic liver disease, though future recommendations to include adults with diabetes and cardiovascular disease should be considered.

The AST/ALT Ratio (De Ritis Ratio) Represents an Unfavorable Prognosis in Patients in Early-Stage SFTS: An Observational Cohort Study

“…Furthermore, we also found a new prospective relationship between the De Ritis ratio and different clinical parameters for SFTS, De Ritis ratio was inversely associated with PLT, previous studies highlighted that platelets are essential cells that contribute to cellular inflammation and are used in the scoring system for hepatic fibrosis. Megan G. Hofmeister et al found that an elevated De Ritis ratio and low platelet counts were associated with higher odds of hepatitis A-related mortality events (Hofmeister et al, 2020), moreover, low platelet counts were also associated with cirrhosis and progression to hepatic decompensation among patients with chronic hepatitis C (Xu et al, 2016). SFTS patients with a high De Ritis ratio and decreased platelet counts may indicate a progression of liver injury.…”

“…Megan G. Hofmeister et al. found that an elevated De Ritis ratio and low platelet counts were associated with higher odds of hepatitis A-related mortality events ( Hofmeister et al., 2020 ), moreover, low platelet counts were also associated with cirrhosis and progression to hepatic decompensation among patients with chronic hepatitis C ( Xu et al., 2016 ). SFTS patients with a high De Ritis ratio and decreased platelet counts may indicate a progression of liver injury.…”

Hepatitis A: Epidemiology, High-Risk Groups, Prevention and Research on Antiviral Treatment

“…Several studies have reported that disease severity and fatality rates due to an HAV infection are elevated among people with underlying chronic liver disease, including hepatitis B or C virus coinfection [89], alcoholic cirrhosis, and fatty liver disease [90]. Chronic liver diseases are also frequent in patients with HIV due to coinfections with HBV or HCV, antiviral drug damage, or alcoholic liver diseases.…”

Predictors associated with a better response to the Japanese aluminum‐free hepatitis A vaccine, Aimmugen®, for people living with HIV

“…3 On the other hand, Hofmeister et al recently reported that older age, preexisting nonviral liver disease, history of hepatitis B, diabetes, and cardiovascular diseases were significantly associated with mortality in acute hepatitis A. 26 Because of these findings, vaccination of relatively elderly PLWHIV or those with such comorbidities should be strongly recommended. When we started the vaccination, we recommended almost all MSM-LWHIV, but we may have to consider these conditions when trying to vaccinate MSM-LWHIV who have not been vaccinated or have low titers anti-HA-IgG.…”