Published Date: 2013-05-26 01:42:39 Subject: PRO/EDR> Hepatitis A - Bosnia & Herzegovina (RS) Archive Number: 20130526.1737233
HEPATITIS A - BOSNIA AND HERZEGOVINA (RS) ****************************************** A ProMED-mail post http://www.promedmail.org ProMED-mail is a program of the International Society for Infectious Diseases http://www.isid.org
Hepatitis A outbreak in Bijeljina, Bosnia and Herzegovina, August 2012 - April 2013 ----------------------------------------------------------------------------------- [From:Institute for Public Health Federation of Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina. By: Dakic Z, Musa S. Hepatitis A outbreak in Bijeljina, Bosnia and Herzegovina, August 2012 - April 2013]
Summary ------- From August 2012-April 2013, an outbreak of hepatitis A with 28 laboratory-confirmed cases occurred in Bijeljina, Bosnia & Herzegovina. The index case was in a 7-year-old child from the local Roma [gypsy] community. Cases were 7-70 years old, and 7-15 year-olds (9 cases) were the most affected age group. The event highlights the susceptibility of the population due to reduced hepatitis A virus circulation with consecutive lower immunity in the population in the past years.
In January 2013, the local health authorities in Bijeljina informed the national authorities about an ongoing outbreak of hepatitis A. The 1st case had been notified in August 2012 and by mid-January  the case count had risen to 20. Here we describe the outbreak investigation and control measures taken by the local health authorities.
Background ---------- Bijeljina is a town and municipality with about 120 000 inhabitants, located in the north-east of Bosnia & Herzegovina. It is the 5th largest city in Bosnia & Herzegovina and 2nd largest in the Republic of Srpska, which is one of the 2 main political entities of Bosnia & Herzegovina. Bijeljina municipality shares borders with Croatia and Serbia. It is a significant agricultural, trade and transit area with a high population density.
During the past 21 years, the epidemiological situation of reported intestinal infectious diseases in Bijeljina municipality was stable. Only sporadic cases of salmonellosis and a few family outbreaks of trichinellosis were notified. In the Republic of Srpska, hepatitis A is a notifiable disease in accordance with the law on protection of the population against infectious diseases. Infectious disease reporting is regulated by respective rules which do not define the criteria for reporting in detail. Despite numerous challenges, such as the Bosnian war from 1992 to 1995, migration of inhabitants elsewhere, poor socio-economic conditions and the unprecedented floods of the Drina river at the end of 2010, no hepatitis A cases were recorded before the current outbreak in Bijeljina for the past 21 years. There is a possibility, however, that cases of hepatitis A had occurred that were neither detected nor registered due to severe disruption of the surveillance of infectious diseases, especially during wartime. Before that period, from 1971 to 1991, a total of 3399 cases of hepatitis A, with an average of 154 cases per year, were registered. In the last 15 years, the overall incidence of hepatitis A in Bosnia and Herzegovina decreased. In the same period, declining hepatitis A incidence trends were also observed in many other European countries.
Outbreak investigation ---------------------- On 17 January 2013, the epidemiological service of the Bijeljina Health Center notified the the Republic of Srpska Institute of Public Health about a hepatitis A outbreak in Bijeljina, due to an increased number of hepatitis A cases since August 2012. The case definition for the investigation of the hepatitis A outbreak corresponds to the European Union case definition. Confirmed cases are only those with clinical symptoms and laboratory confirmation (IgM antibody to hepatitis A virus (anti-HAV IgM)) reported from 1 August 2012 in Bijeljina.
The index case was a 7-year-old child from the Roma population that resides in the area close to the Dasnica canal , to where untreated domestic sewage and wastewater of the entire city is disposed. The other cases were from the general population, mostly pupils (9 cases) and unemployed persons (13 cases).The youngest case was 7 years old and the oldest 70 years old (median 34 years). With 9 of the 28 cases, the most affected age group was that of 7-14 year-olds.
All 28 cases were hospitalised; 23 were treated at the general hospital in Bijeljina and 5 were transported to and hospitalised at the Clinic for Infectious Diseases in Banja Luka because of limited availability of hospital beds in Bijeljina. All patients had several of the following clinical findings: jaundice, fever, weakness, fatigue, abdominal pain, vomiting, diarrhoea, light colored stools and dark colored urine. The clinical course was favourable for all and there were no complications.
From all 28 patients serum samples were taken and analysed for the following hepatitis markers: hepatitis B surface antigen (HBsAg), antibodies to hepatitis E virus (anti-HEV IgM), antibodies to hepatitis C virus (anti-HCV IgM and IgG) and anti-HAV IgM. After an initial analysis at the general hospital in Bijeljina, all samples which were not reactive for HBsAg, anti-HEV and anti-HCV, were further tested for hepatitis A at the Clinical Center of Banja Luka. All reported cases were reactive.
[Details of theLaboratory reports can be viewed by accessing the original text via the source URL above. - Mod.CP]
Control measures ---------------- Specific guidelines for case management of hepatitis A do not exist in the Republic of Srpska. We inspected schools and public buildings in Bijeljina. All cases and contacts were provided with general information about the nature of the disease, ways of transmission and how to prevent hepatitis A. The local health authorities disinfected houses (with chlorine granulates dissolved in water) and the immediate environment of patients as well as premises of kindergartens and pre-schools and local boarding school facilities and other collective accommodation buildings in Bijeljina. Monitoring of drinking water quality from the waterworks and affected households was intensified and showed that water was safe for drinking.
Vaccines and immunoglobulin against hepatitis A are not available in the Republic of Srpska.
Discussion --------- The surveillance system in Bosnia & Herzegovina dates back to the time of the former Socialist Republic of Yugoslavia and is a passive reporting system of infectious diseases. Reporting is done through paper forms and depends on cooperation of doctors who report diseases to the relevant epidemiological service in the public health authorities. Diagnosis is usually only clinical; microbiological confirmation of diseases is still quite limited. In the current hepatitis A outbreak the 1st case and 5 more cases occurring in September, October and November 2012, were reported in the Roma population living in the southern part of Bijeljina, in an area with significant infrastructure problems e.g. unregulated water supply system and sewage. During the past 20 years this area has been exposed to a large migration of the Roma population, many of whom left the town.
We assume that the infection transmission in the current outbreak, which started in the Roma community, reached the general community through transmission in schools. The age distribution of cases with the most affected age group being that of children between 7-14 years old, compared with cases in outbreaks in the Czech Republic, Latvia, Estonia and Slovakia, is most similar to that in Estonia. [See: ProMED-mail: Hepatitis A - Estonia (06): (VD) 20111123.3431]. These outbreaks confirm the susceptibility of the population due to a reduced HAV circulation with [consequently] lower immunity in the population in the past years.
Based on epidemiological data and results of analysis of drinking water, most probable routes of transmission are (mainly) indirect faecal-oral transmission contact via common use items: door handles, sanitary devices in school and public toilets etc. The last outbreak case was reported on 2 April 2013. The average incubation period of hepatitis A is 28-30 days (range 15-50 days). After the double maximum incubation period from the last notified hepatitis A case, we will announce the end of this outbreak most probably at the beginning of July this year  if no further cases occur.
A lesson learnt from this event is that in an increasingly susceptible population, unresolved problems in sanitary infrastructures can increase the risk of an outbreak of hepatitis A. There is an obvious need for greater involvement of institutions responsible for public health and for the educational sector to raise the awareness of the population, through the mass media and educational campaigns, about the need to improve hygiene. Also, cross-border collaboration is necessary because of the vicinity to other countries and the mobility of the local population. Hepatitis A is resurging in Europe at the moment with a number of food-related multi-country outbreak(s) and travel-related cases which show the challenge of increased susceptibility in the population.
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[Republika Srpska is one of 2 political entities that constitute Bosnia & Herzegovina, the other being the Federation of Bosnia and Herzegovina. The Constitution of Republika Srpska defines it as a territorially unified, indivisible and inalienable constitutional and legal entity of Bosnia and Herzegovina, that independently performs its constitutional, legislative, executive and judicial functions. The National Assembly and the Government of Republika Srpska are based in Banja Luka, although Sarajevo remains the official capital.
It is remarkable that despite the prolonged involvement of this region in protracted ethnic and civil strife that hepatitis A virus infection has remained so low and possibly mainly restricted to the residual Roma [population]. Continued investment in social infrastructure will be required to avoid a resurgence of hepatitis A virus infection. There is an effective vaccine, but control by vaccination is an expensive option. The virus is primarily spread when an uninfected (and unvaccinated) person ingests food or water that is contaminated with the faeces of an infected person. The disease is closely associated with a lack of safe water, inadequate sanitation and poor personal hygiene.
Unlike hepatitis B and C, hepatitis A infection does not cause chronic liver disease and is rarely fatal, but it can cause debilitating symptoms and fulminant hepatitis (acute liver failure), which is associated with high mortality. In developing countries, countries with transitional economies, and regions where sanitary conditions are variable, children often escape infection in early childhood. Ironically, these improved economic and sanitary conditions may lead to a higher susceptibility in older age groups and higher disease rates, as infections occur in adolescents and adults, and large outbreaks can occur.
There is no specific treatment for hepatitis A. Recovery from symptoms following infection may be slow and take several weeks or months. Therapy is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids that are lost from vomiting and diarrhoea.