Hepatitis D outbreak among children in a hepatitis B hyper-endemic settlement in Greenland

Abstract

Hepatitis B virus (HBV) infection is endemic in Greenland with 5-10% of the population being HBsAg-positive (chronic carriers). Surprisingly, despite of the high prevalence of HBV infection, acute and chronic hepatitis B, liver cirrhosis and primary hepatocellular carcinoma appear much less frequently than expected. The reasons for the low frequencies are unknown, but as a consequence implementation of a childhood HBV vaccination programme, though debated for years, has never been instituted. We describe an outbreak of hepatitis D (HDV) infection among children in a hepatitis B hyper-endemic settlement of 133 inhabitants on the west coast of Greenland. In 2006 a total of 27% of the inhabitants were HBsAg-positive (chronic carriers) and 83% were HBcAb-positive (previously exposed). Forty-six percent of the HBsAg-positive persons were below 20 years of age. On follow-up 1 year later a total of 68% of the HBsAg-positive persons were HDV-IgG positive. Five children, who were HBsAg-positive in 2006, had HDV-seroconverted from 2006 to 2007, indicating a HDV-super-infection. Most of the HDV-IgG positive children had markedly elevated liver enzymes. In the multivariate analysis, among the HBV and HDV markers, presence of HDV-IgG was most strongly associated with elevation of liver enzymes. In conclusion, the HBV-HDV super-infection and presumed HDV outbreak in this settlement challenges the notion that HBV infection may not be as harmless in Greenland as previously anticipated. The findings strongly suggest that HBV vaccination should be included in the child-immunization program in Greenland.

Population-based comparative epidemiological survey of hepatitis B, D, and C among Inuit migrated to Denmark and in high endemic Greenland

“…This was further confirmed in direct comparisons of the frequencies of HBsAg, anti-HBs, and anti-HBc. The lower HBsAg frequency in West Greenland compared with previous findings (7%) by Langer [15] and (19%) by Børresen [20] may likely be due to differences in recruitment of participants. in one settlement on the west coast [20] and 29% in Ammassalik district in East Greenland [8] as discussed [8].…”

Serological and molecular epidemiological outcomes after two decades of universal infant hepatitis B virus (HBV) vaccination in Nunavut, Canada

“…Very recently, it has been reported that Greenland is still endemic for chronic HBV with a prevalence of 5-10% in 2011 [72]. However, even with a high endemic rate of HBV infection, incidence of HCC and cirrhosis were not substantially different from Denmark [73][74], which is not considered endemic due to an HBsAg prevalence of 0.1% [75]. Genotype D and B5 are predominant in Greenland, and a high incidence of B5 infection may explain the relatively low occurrence of HCC and cirrhosis [76][77].…”

Hepatitis D Virus: Introduction and Epidemiology

“…HDV continues to be an important health issue in the Brazilian Amazon despite the implementation of HBV vaccination in rural areas; in blood collected from HBsAg carriers along the banks of the Purus River in 2005 -2006, the prevalence of anti-HD was 41.9% (Braga et al 2012). Outbreaks of severe and fulminant hepatitis developing on a background of high-HBV endemicity have been reported in the last 20 years, also from Russia (Flodgren et al 2000), Greenland (Børresen et al 2010), and Mongolia (Tsatsralt-Od et al 2006).…”