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Challenges in Management of Hepatitis A Virus Epidemiological Transition in Mexico
Jorge L. Trujillo-Ochoa*,**,*, Oliver Viera-Segura*,***, Nora A. Fierro
,***
* Immunovirology Unit, Molecular Biology Service, Civil Hospital of Guadalajara “Fray Antonio Alcalde”, Guadalajara, Jalisco, Mexico
** Biological and Agricultural Sciences Center, University of Guadalajara, Mexico
*** Health Sciences Center, University of Guadalajara, Mexico
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          "en" => "<p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Prevalence of HAVinfections in the states from Mexico &#40;1994 vs&#46; 2017&#41;&#46; Total HAV infections data from the National System for Epidemiological Surveilleance &#40;SUIVE&#41; by the SSA in 1994 and 2017 were collected and classified in HAV-infections by each state from Mexico&#44; <span class="elsevierStyleBold">A</span>&#46; Represents HAV infection distribution by state in 1994&#59; a total of 9700 HAV cases were reported&#46; <span class="elsevierStyleBold">B</span>&#46; Represents HAV infection distribution by state in 2017&#59; a total of 4636 HAV cases were reported&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015">Introduction</span><p id="p0010" class="elsevierStylePara elsevierViewall">Hepatitis A virus &#40;HAV&#41;&#44; first identified in 1973&#44; is a small&#44; positive-strand RNA virus and is the causative agent of acute hepatitis in humans&#46; It affects approximately 10 million people annually worldwide&#46; Currently&#44; three HAV-genotypes &#40;I&#44; II&#44; III&#41; with two subtypes &#40;A and B&#41;&#44; and one serotype have been known to infect humans&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> HAV belongs to the <span class="elsevierStyleItalic">Picornaviridae</span> family&#44; is mainly transmitted via the fecal-oral route by contaminated drinking water and is endemic in many countries&#44; particularly those with poor sanitation&#46; HAV is also considered a foodborne pathogen<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">2</span></a> based on the documented outbreaks of infection caused by the consumption of frozen fruits in developed and developing countries&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">3</span></a></p><p id="p0015" class="elsevierStylePara elsevierViewall">The clinical manifestations of HAV range from asymptomatic infections to acute liver failure &#40;ALF&#41;&#44; but infection does not progress to chronic disease&#46;However&#44; some patients may show atypical manifestations including prolonged cholestasis&#44; relapsing hepatitis&#44; extrahepatic manifestations or ALF associated with autoimmune hepatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">4</span></a> It has been accepted that clinical outcomes vary with age&#44; and older individuals are prone to develop more severe forms of the disease&#46; While HAV-induced ALF is not common&#44; ALF development results in intensive care and requires a decision regarding liver transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">5</span></a> Acute HAV infection resolves spontaneously in &#62; 99&#37; of infected individuals&#44; and relapsing hepatitis A with subsequent complete resolution has been reported in 3-20&#37; of patients with clinical hepatitis&#46; Fulminant hepatitis is rare&#44; with a wide range of estimated rates in immunocompetent individuals&#46; However&#44; reports from Korea and South-America&#44; including Mexico&#44; have raised concern that the current incidence of fulminant hepatitis A may be rising&#46; Immune-suppressed patients and patients with chronic liver disease are at an increased risk of developing severe hepatitis A&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">6</span></a>&#8217;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">7</span></a></p><p id="p0020" class="elsevierStylePara elsevierViewall">Acute hepatitis A is diagnosed by serologic testing to detect HAV-specific IgM antibodies&#46; The presence of anti-HAV IgG antibodies in the serum denotes previous infection&#46; Furthermore&#8217; viral detection through molecular methods is not common for diagnosis&#46; Prior to 1960&#44; the seroprevalence of IgG antibodies against the virus approached 100&#37; worldwide&#44; indicating that almost every person in the world was infected with HAV at that time&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">8</span></a> Since then&#44; improved hygiene and vaccination have reduced the infection rate by approximately 5&#37;-10&#37; in industrialized countries&#44; and universal mass vaccination &#40;UMV&#41; for children aged &#62; 1 year has been shown to be beneficial in developing countries in Latin America in terms of declining endemicity&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">9</span></a> In Mexico&#44; previously considered a high endemic region for HAV infection&#44; UMV is not mandatory and sanitary improvements have resulted in a reduction in acute HAV cases&#46; Thus&#44; it has been proposed that Mexico is currently in transition for infection&#46; However&#44; diversity in environmental and economic conditions in distinct geographical regions of the country should be taken into account to better characterize HAV burden&#44; particularly in regions associated with the lowest levels of sanitation&#44; where poverty and a shortage in health services prevail&#46;</p><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Hav endemicity and risk groups</span><p id="p0025" class="elsevierStylePara elsevierViewall">The global spread of HAV infection has been assessed by monitoring overall and age-specific prevalence which enables an indirect measurement of incidence rates&#46; Overall prevalence has been classified as high &#40;&#62; 50&#37; of population&#41;&#44; intermediate &#40;15-50&#37;&#41; and low levels of endemicity &#40;&#60; 15&#37;&#41; based on the detection of anti-HAV IgG antibodies&#46; High endemicity of HAV is found in countries with poor sanitary and socioeconomic conditions&#44; where infection typically occurs early childhood&#46; Intermediate endemicity of HAV is typically found in countries transitioning from a low socioeconomic status to improved housing and hygienic conditions and in segments of the middle-class population&#46; In such countries&#44; the pediatric population may escape HAV infection in early childhood&#46; As a result&#44; older children and young adults become susceptible to HAV infections during outbreaks&#46; In countries with low HAV endemicity&#44; the risk of acquiring HAV infection is low&#46; Currently&#44; a new classification of endemicity is emerging worldwide based on the reported incidence of confirmed acute HAV cases&#46; Thus&#44; endemicity to HAV may also be classified as very low&#44; with an estimated incidence of 5 cases&#47;10<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">5</span></a>&#58; low&#44; 5-15 cases&#47;10<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">5</span></a>&#59; intermediate&#44; 15-150 cases&#47;10<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">5</span></a> and high &#62; 150 cases&#47;10<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">5</span></a>&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">10</span></a></p><p id="p0030" class="elsevierStylePara elsevierViewall">Epidemiological risk groups include populations of low socioeconomic status living under crowed conditions&#59; households that come into contact with infected individuals&#59; children visiting daycare centers&#59; men who have sex with men &#40;MSM&#41;&#59; intravenous drugs users&#59; patients with liver disease&#59; food handlers&#59; and patients with bloodclotting disorders&#46; However&#44; the source of HAV infection remains unidentified in &#62; 50&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">11</span></a> International travel from countries with low endemicity to areas with intermediate or high endemicity has been extensively documented as a risk factor for infection&#46; For instance&#44; a higher frequency of HAV cases documented in the United States &#40;USA&#41; has been found in those states that are adjacent to Mexico&#46; From 2000 to 2009&#44; a total of 1&#44;437 cases of acute hepatitis A were reported from sites on the border between Mexico and USA&#44; and cross-border travel during the incubation period is common among acute viral hepatitis cases in both countries&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">12</span></a></p></span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">HAV burden in Mexico&#58; comparison between government and public sources</span><p id="p0035" class="elsevierStylePara elsevierViewall">In contrast to the potential for developing a chronic disease from hepatitis B and C viral infections &#40;HBV&#44; HCV&#41;&#44; HAV infections are self-limiting in nature&#46; Over the past three decades&#44; progress in the study of HAV infection has been scarce&#46; This is illustrated by the limited number of HAV-related scientific reports regarding to the number of HBV and HCV studies in Mexico &#40;<a class="elsevierStyleCrossRef" href="#f0010">Figure 1</a>&#41;&#46; The first scientific HAV-related description in Mexico was published in 1982 and revealed a high seroprevalence of antibodies anti-HAV in samples from children from the 1970&#8217;s&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">13</span></a> Since then&#44; information about the epidemiological status of HAV in Mexico from a scientific perspective has been limited&#46; Notably&#44; the increased number of HAV-related reports found during 2011 to 2015 denotes interest in the study of the immune-pathogenesis associated with the infection &#40;<a class="elsevierStyleCrossRef" href="#f0010">Figure 1</a>&#41;&#46; However&#44; information relative to risk groups&#44; viral transmission and HAV current burden is still scarce&#46;</p><elsevierMultimedia ident="f0010"></elsevierMultimedia><p id="p0040" class="elsevierStylePara elsevierViewall">The local government health agency &#40;Secretarfa de Salud&#44; SSA in Spanish&#41;&#44; the agency responsible for statistics of infectious disease in Mexico started to report cases of hepatitis associated with HAV infection in 1994 &#40;<a class="elsevierStyleCrossRef" href="#f0015">Figure 2</a>&#41;&#46; According to the National System for Epidemiological Surveilleance &#40;Sistema Unico para la Investigation Epidemiologica&#44; SUIVE in Spanish&#41; by the SSA&#44; from 1994 to 2017 a total of483&#44;907 viral hepatitis cases were registered&#46; From those&#44; a 78&#46;4&#37; &#40;379&#44;261 cases&#41; corresponded to HAV infection&#44; followed by 6&#46;5&#37; &#40;31&#44;370 cases&#41; HCV infections&#44; 3&#46;7&#37; &#40;17 857 cases&#41; HBV infections and 11&#46;4&#37; &#40;55&#44;419 cases&#41; viral hepatitis without etiology detected<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">14&#44;15</span></a> &#40;<a class="elsevierStyleCrossRef" href="#f0015">Figure 2</a>&#41;&#46; In the early 1980&#8217;s&#44; according to the frequency of HAV infection reported by scientific publications&#44; Mexico was considered a region of high endemicity for type A viral hepatitis&#46; In Mexico&#44; 90&#37; of children between 1-5 years old were positive for anti-HAV IgG antibodies&#44; indicating high exposure to the virus early on&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">13</span></a> This is in agreement with a study in 2000&#44; where a seroepidemiological analysis conducted in five countries &#40;Venezuela&#44; Mexico&#44; Dominican Republic&#44; Chile and Brazil&#41; from Latin America revealed that the seroprevalence of antibodies to HAV was highest in Mexico and the Dominican Republic&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">16</span></a> However&#44; a reduction in the seroprevalence in children at age of 8 years old was reported in Mexico in 2008 showing 51&#37; of IgG and 13&#37; IgM antibodies anti-HAV&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">17</span></a>-<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">18</span></a></p><elsevierMultimedia ident="f0015"></elsevierMultimedia><p id="p0045" class="elsevierStylePara elsevierViewall">Although data from the SSA reveal that HAV epidemiology varies through the years&#46; For instance a high incidence of HAV was found in 1997 and 2005 probably as a consequence of Pauline and Wilma hurricanes&#46; In general&#44; a reduction in the incidence of hepatitis related to type A hepatitis virus has been reported by the SSA from 1994 to 2017 &#40;<a class="elsevierStyleCrossRef" href="#f0015">Figure 2</a>&#41;&#46; Moreover&#44; the SSA data reveal a trend towards a reduction in HAV incidence and infection as a cause of hepatitis in younger individuals&#46; However&#44; the data indicate that the pediatric population in Mexico is still the most prone to be infected with this virus &#40;<a class="elsevierStyleCrossRef" href="#f0020">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="f0020"></elsevierMultimedia><p id="p0050" class="elsevierStylePara elsevierViewall">The analysis of the SSA data conducted on the basis of distinct geographic regions in Mexico contradicts the documented relationship between the highest prevalence of HAV-infection and the lowest socio-economic status&#46; In 1994 and 2017&#44; most of the reported HAV-cases by the SSA were found in highly industrialized states in Mexico&#44; including Mexico state and Mexico City in 1994 and Nuevo Leon and Jalisco in 2017&#46; In contrast&#44; those regions associated with low economic status&#44; including Oaxaca and Chiapas located in south Mexico&#44; showed the lowest frequency of hepatitis related to HAV infection &#40;<a class="elsevierStyleCrossRef" href="#f0025">Figure 4</a>&#41;&#46; Despite the lower number of HAV cases found in the most marginalized states of Mexico&#44; as denoted in <a class="elsevierStyleCrossRef" href="#f0030">figure 5</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">14</span></a>&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">15</span></a>&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">19</span></a> it is plausible that deficient health services still prevail in these regions&#46; This may be a limitation in terms of detection and notification of HAV cases&#46; Additionally&#44; is important to take into account that many infected children are asymptomatic and usually do not have jaundice&#46; Thus&#44; they can only be identified with viral detection and liver function tests&#46; Moreover&#44; we recently reported an unexpected high frequency of anti-HAV and anti-hepatitis E virus &#40;HEV&#41; IgM antibodies in children from west Mexico exhibiting acute hepatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">20</span></a> The detection rate of HEV-RNA was 17&#37; in coinfected samples&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">21</span></a> and supports the need to screen for type A and E viral content since hepatitis A is often indistinguishable from liver disease caused by HEV&#46;</p><elsevierMultimedia ident="f0025"></elsevierMultimedia><elsevierMultimedia ident="f0030"></elsevierMultimedia><p id="p0055" class="elsevierStylePara elsevierViewall">It has been accepted that because infection is mostly asymptomatic in children&#44; low-income areas with high incidence rates usually have a low burden of disease&#46; Thus&#44; HAV infection may be underestimated in the country&#46; This is in agreement with scientific reports showing a high frequency of HAV mainly in children&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">22-28</span></a> Furthermore&#44; a study of4907 sera to detect anti-HAV antibodies estimated that in 2007&#44; approximately 78&#46;7 million Mexicans were infected&#59; the risk factors associated with the infection in that time included childhood&#44; poverty associated with limited access to sanitary services &#40;clean water&#41; and living in rural communities of south Mexico&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">29</span></a> Since then&#44; sanitary improvements and vaccine campains are some of the strategies implemented to resist infection&#46; Unfortunately&#44; in the most marginalized areas of Mexico&#44; deficient sanity and limited health systems prevent efficient vaccine distribution&#46; Therefore&#44; the infection still prevails in these geographical areas&#46;</p><p id="p0060" class="elsevierStylePara elsevierViewall">Hepatitis A virus has been described as one of the water pollutants in coastal areas of Baja California&#44; Mexico&#44; and California&#44; USA&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">30</span></a> To date&#44; the only molecular characterization of HAV in Mexico &#40;genotype I&#41; resulted from its detection in contaminated water from Mazatlan and Altata&#44; Mexico&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">31</span></a> In spite of virus dissemination through water&#44; virus transmission has been modeled as a function of setting specific access to safe water&#44; and projections of HAV outcome in Mexico to 2050 have been conducted&#46; From this analysis&#44; assuming improvement in water quality and no introduction of a universal vaccination program over the project period&#44; Mexico is expected to experience a decrease in HAV incidence rates without a substantial decrease in the incidence of symptomatic HAV infections&#46; The prediction supports an increase in the mean age of HAV symptomatic cases that shift from childhood to early adulthood&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">32</span></a> This information should be taken into account in public health policies&#46;</p></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0030">Universal massive vaccination against HAV&#58; the results</span><p id="p0065" class="elsevierStylePara elsevierViewall">The vaccine against HAV was introduced in 1995 in the USA&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">33</span></a> Since then&#44; several HAV vaccines containing attenuated HAV have been developed&#44; and two types of HAV vaccines are currently used worldwide &#40;formalde-hyde-inactivated and live-attenuated HAV vaccines&#41; and result in a nearly 100&#37; of people develop protective levels of antibodies to the virus within 1 month after injection of a single dose of vaccine&#46; World Health Organization &#40;WHO&#41; recommends UMV against HAV in national immunization schedules for children aged &#62; 1 year&#44; if justified on the basis of acute HAV incidence&#44; declining endemicity from high to intermediate and cost-effectiveness&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">10</span></a></p><p id="p0070" class="elsevierStylePara elsevierViewall">The implementation of this WHO recommendation has resulted in a decline in acute hepatitis associated with HAV in several countries&#46; Studies in Argentina&#44; Belgium&#44; China&#44; Israel&#44; Panama and USA have provided data on the incidence of acute hepatitis A before the introduction of UMV showing percentages of reduction of HAV incidence from 88&#37; to 96&#37; and persistence of antibodies against the virus 5 years later&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">10</span></a> This reduction in viral incidence was independent of the brand of the HAV vaccine used in the national programs&#44; the number of given doses and the target age at first vaccination&#46; In addition&#44; indirect effects of vaccine coverage including&#58; reduction in the number of cases of fulminant hepatitis&#44; declining in the number of outbreak-related acute hepatitis A cases reported&#44; reduction in the age-adjusted hepatitis A-mortality rate and reduction in the hospitalization rates associated with the infection were observed&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">9</span></a> In Argentina&#44; for instance&#44; no case of fulminant hepatitis associated with HAV infection was reported after UMV&#44; and a decline in acute hepatitis A incidence was seen in all age groups&#44; including in children too young to be vaccinated when the UMV programs were introduced in 2005&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">34</span></a></p><p id="p0075" class="elsevierStylePara elsevierViewall">The same decline was found in Panama after the introduction of a UMV national program in 2007&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">35</span></a> and similar reduction in hepatitis A-associated hospitalization rates was observed in nonvaccinated age groups in the USA&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">36</span></a> Moreover&#44; single-dose universal vaccination for children aged two years was introduced in Brazil in 2014&#44; which resulted in a high rate of anti-virus positivity in the short term&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">37</span></a></p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">HAV vaccination in Mexico</span><p id="p0080" class="elsevierStylePara elsevierViewall">In Mexico&#44; four HAV vaccines are available&#58; HAVRIX &#40;GlaxoSmithKline&#41;&#44; VAQTA &#40;Schering Plow&#41;&#44; AVAXIM &#40;Sanofi Aventis&#41; and TWINRIX &#40;GlaxoSmithKline&#41;&#46; They are approved by the Federal Commission for Protection Against Health Risks &#40;Comision Federal para la Proteccion contra Riesgos Sanitarios&#44; COFEPRIS in Spanish&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">38</span></a> However&#44; the HAV vaccine is only available in a few specialized vaccinations centers supported for the Mexican government to be administered for free or can be acquired in private consultations&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">39</span></a></p><p id="p0085" class="elsevierStylePara elsevierViewall">The HAV vaccine in Mexico was recommended to be used in risk populations in 2008&#59; however&#44; it was not until 2013 that single-dosage HAV vaccine was authorized to be used in children &#62; 1 year old in childcare centers&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">40</span></a> This action resulted in a decreased frequency of HAV infections in the following years &#40;<a class="elsevierStyleCrossRef" href="#f0015">Figure 2</a>&#41;&#46; Indeed&#44; this recommendation is in agreement with the WHO declaration that the vaccination against hepatitis A should be part of a comprehensive plan for the prevention and control of viral hepatitis and should be included in regular childhood immunizations programs&#46; However&#44; HAV vaccination is not mandatory in Mexico&#46;</p><p id="p0090" class="elsevierStylePara elsevierViewall">National immunization programs should consider the inclusion of HAV vaccines in the immunization schedules&#46; This option seems to be comparable in terms of prevention and effectiveness and is supported by a model study of dynamic transmission that estimated the potential impact of universal infant HAV vaccination in Mexico using two doses of HAVRIX on the incidence of all HAV infections &#40;symptomatic and asymptomatic&#41;&#46; The results of this model indicate that universal HAV vaccination in children reduces the cumulative incidence of all HAV cases over a 25-year time window compared with no vaccination and shows a 70&#37; first-dose coverage and 85&#37; second-dose coverage&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">41</span></a> It is important to take into account that a deficient UMV against HAV may also result in a growing number of susceptible adults as reported in the USA&#44; where outbreaks continue to occur as result of lower hepatitis A immunization rates than other vaccines&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">42</span></a> Thus&#44; health policies should ensure that no child outgrows the pediatric practice without being vaccinated&#46;</p><p id="p0095" class="elsevierStylePara elsevierViewall">The worldwide immunization efforts on HAV control have continued&#46; In June 2016&#44; 16 countries &#40;including 6 countries in the American region&#44; 3 in the eastern Mediterranean region&#44; 4 in the European region and 3 in the western Pacific region&#41; included hepatitis A vaccine in the routine immunization of children&#46; Currently&#44; the WHO reports that 10 countries in the American region &#40;Argentina&#44; Brazil&#44; Chile&#44; Colombia&#44; Honduras&#44; Panama&#44; Paraguay&#44; Uruguay&#44; USA and Mexico&#41; use HAV vaccine in children and risk groups&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">43</span></a> However&#44; there are limited guidelines and regulatory mechanisms for the study of highly dynamic diseases that impact public health&#44; such as HAV&#46; The use of HAV vaccine in each country has special indications and standard guidelines should be implemented with the aim of standardizing vaccination globally&#46;</p></span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">Remarks</span><p id="p0100" class="elsevierStylePara elsevierViewall">The WHO recommends the eradication of hepatitis by 2030&#46; Thus&#44; joined efforts are required to assess and better understand the disease burden due to HAV&#44; particularly in those regions with the lowest sanitary conditions and where people are at a higher risk for infection&#46; With the mission of improving the diagnosis and general management of HAV infections in Mexico and the ultimate goal of limiting the spread of this virus&#44; the following recommendations can be followed&#58;</p><p id="p0105" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0010"><li class="elsevierStyleListItem" id="u0010"><span class="elsevierStyleLabel">&#8226;</span><p id="p0110" class="elsevierStylePara elsevierViewall">Serological diagnosis in identified high-risk populations for contracting the infection is priority&#46; Viral detection is needed and allows to discriminate acute cases related to HAV relative to those associated with other viruses &#40;for instance HEV&#41;&#46;</p></li><li class="elsevierStyleListItem" id="u0015"><span class="elsevierStyleLabel">&#8226;</span><p id="p0115" class="elsevierStylePara elsevierViewall">Careful scrutiny of the virus distribution is required to support handling strategies of the disease&#44; to define treatment and to prevent potential outbreaks&#46; A detailed guideline for following cases in endemic regions needs to be developed to contain the virus in emergency situations&#46;</p></li><li class="elsevierStyleListItem" id="u0020"><span class="elsevierStyleLabel">&#8226;</span><p id="p0120" class="elsevierStylePara elsevierViewall">The origin and transmission of HAV infections in Mexico need to be identified&#46; The systemic identification of risk represented by water&#44; particularly in areas considered to have poor health conditions and deficient treatment of water&#44; is required&#46; The consumption of contaminated fresh produce represents a risk of public health&#46; Appropriate surveillance systems are required to adopt risk management practices for reducing the likelihood of contamination&#46;</p></li><li class="elsevierStyleListItem" id="u0025"><span class="elsevierStyleLabel">&#8226;</span><p id="p0125" class="elsevierStylePara elsevierViewall">Close monitoring of the infection and periodically undertaking cost-effectiveness analyses of immunization strategies are required&#44; considering that the creation of a complete immunization schedule can reduce the medical and social costs in terms of new infections and outbreaks&#46;</p></li><li class="elsevierStyleListItem" id="u0030"><span class="elsevierStyleLabel">&#8226;</span><p id="p0130" class="elsevierStylePara elsevierViewall">It is imperative to increase awareness for HAV-associated diseases as part of health teaching programs for the general population&#44; particularly in those regions where the infection prevails&#46;</p></li></ul></p></span></span><span id="s0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Conclusions</span><p id="p0135" class="elsevierStylePara elsevierViewall">In Mexico&#44; HAV infection is the first causative agent for viral hepatitis&#46; Although improvement in health conditions in the country has reduced the incidence of HAV infection&#44; Mexico is a transitional region for this infection&#46; A detailed analysis of the HAV epidemiologic status&#44; particularly in those regions of the country with the highest levels of poverty and deficient access to public health services is required&#46;</p></span><span id="s0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Abbreviations</span><p id="p0140" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0015"><li class="elsevierStyleListItem" id="u0035"><span class="elsevierStyleLabel">&#8226;</span><p id="p0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">ALF</span>&#58; Acute liver failure&#46;</p></li><li class="elsevierStyleListItem" id="u0040"><span class="elsevierStyleLabel">&#8226;</span><p id="p0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">COFEPRIS</span>&#58; Comision Federal para la Protection contra Riesgos Sanitarios&#46;</p></li><li class="elsevierStyleListItem" id="u0045"><span class="elsevierStyleLabel">&#8226;</span><p id="p0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CONEVAL</span>&#58; Consej o Nacional de Evaluacion de la Polftica de Desarrollo Social&#46;</p></li><li class="elsevierStyleListItem" id="u0050"><span class="elsevierStyleLabel">&#8226;</span><p id="p0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HAV</span>&#58; Hepatitis A virus&#46;</p></li><li class="elsevierStyleListItem" id="u0055"><span class="elsevierStyleLabel">&#8226;</span><p id="p0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HBV</span>&#58; Hepatitis B virus&#46;</p></li><li class="elsevierStyleListItem" id="u0060"><span class="elsevierStyleLabel">&#8226;</span><p id="p0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HCV</span>&#58; Hepatitis C virus&#46;</p></li><li class="elsevierStyleListItem" id="u0065"><span class="elsevierStyleLabel">&#8226;</span><p id="p0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HEV</span>&#58; Hepatitis E virus&#46;</p></li><li class="elsevierStyleListItem" id="u0070"><span class="elsevierStyleLabel">&#8226;</span><p id="p0180" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">MSM</span>&#58; Men who have sex with men&#46;</p></li><li class="elsevierStyleListItem" id="u0075"><span class="elsevierStyleLabel">&#8226;</span><p id="p0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">SSA</span>&#58; Secretarfa de Salud&#46;</p></li><li class="elsevierStyleListItem" id="u0080"><span class="elsevierStyleLabel">&#8226;</span><p id="p0190" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">SUIVE</span>&#58; Sistema Unico para la Investigation Epidemiologica&#46;</p></li><li class="elsevierStyleListItem" id="u0085"><span class="elsevierStyleLabel">&#8226;</span><p id="p0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">UMV</span>&#58; Universal mass vaccination&#46;</p></li><li class="elsevierStyleListItem" id="u0090"><span class="elsevierStyleLabel">&#8226;</span><p id="p0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">USA</span>&#58; United States&#46;</p></li><li class="elsevierStyleListItem" id="u0095"><span class="elsevierStyleLabel">&#8226;</span><p id="p0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">WHO</span>&#58; World Health Organization&#46;</p></li></ul></p></span><span id="s0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0055">Conflict of Interest</span><p id="p0210" class="elsevierStylePara elsevierViewall">No competing financial interests exist&#46;</p></span><span id="s0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0060">Acknowledgements</span><p id="p0215" class="elsevierStylePara elsevierViewall">This work was funded by a grant from the Consejo Nacional de Ciencia y Tecnologfa &#40;CONACYT&#41; No&#46; 239470 to NAF&#46; OVS was supported by a Ph&#46;D&#46; Scholarship from the CONACYT&#46;</p></span></span>"
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          "titulo" => "Introduction"
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              "identificador" => "s0015"
              "titulo" => "Hav endemicity and risk groups"
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            1 => array:2 [
              "identificador" => "s0020"
              "titulo" => "HAV burden in Mexico&#58; comparison between government and public sources"
            ]
            2 => array:2 [
              "identificador" => "s0025"
              "titulo" => "Universal massive vaccination against HAV&#58; the results"
            ]
            3 => array:2 [
              "identificador" => "s0030"
              "titulo" => "HAV vaccination in Mexico"
            ]
            4 => array:2 [
              "identificador" => "s0035"
              "titulo" => "Remarks"
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          "titulo" => "Conclusions"
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          "identificador" => "s0045"
          "titulo" => "Abbreviations"
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        5 => array:2 [
          "identificador" => "s0050"
          "titulo" => "Conflict of Interest"
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          "identificador" => "s0055"
          "titulo" => "Acknowledgements"
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          "titulo" => "References"
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            0 => "Hepatitis A virus"
            1 => "Mexico"
            2 => "Risk groups"
            3 => "HAV-surveillance"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abs0010" class="elsevierStyleSection elsevierViewall"><p id="sp0035" class="elsevierStyleSimplePara elsevierViewall">Hepatitis A virus &#40;HAV&#41; is the most common cause of acute viral hepatitis worldwide&#46; The virus is mainly transmitted via the fecaloral route and&#44; the incidence of infection is closely related to low socioeconomic conditions and poor sanitation&#46; Mexico&#44; previously categorized an area of high endemicity for HAV infection&#44; is undergoing epidemiological transition&#46; However&#44; a limited number of HAV-related scientific reports regarding to virus burden is available&#46; According to the local government health agency &#40;Secretarla de Salud&#44; SSA in Spanish&#41;&#44; from 1994 to 2017 a reduction in the incidence of hepatitis related to HAV has been reported&#46; However&#44; HAV is still the most common cause of viral hepatitis in the country&#44; and the pediatric population is the most prone to be infected with this virus&#46; The analysis of the SSA data reveals that most of the reported cases from 1994 to 2017 were found in highly industrialized states&#46; This information contradicts the documented relationship between the highest prevalence of infection and the lowest socio-economic status&#44; and supports the necessity of viral detection and notification of HAV cases&#46; Moreover&#44; in spite that four HAV vaccines are available in Mexico and universal vaccination has been shown to be beneficial in developing countries in terms of declining endemicity&#44; HAV vaccination is not mandatory in Mexico&#46; In this review&#44; preventive strategies including appropriate diagnosis&#44; vaccination and public health policies on the basis of the epidemiologic status of HAV in Mexico are discussed&#46;</p></span>"
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          "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Timeline of the number of papers on HAV&#44; HBV and HCV in Mexico&#46; Based on references found on PubMed Central&#44; Scielo and Google Scholar when &#8220;hepatitis A virus and Mexico&#8221;&#44; &#8220;hepatitis B virus and Mexico&#8221; or &#8220;hepatitis C virus and Mexico&#8221; were used as search keywords&#46;</p>"
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          "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Viral hepatitis in the Mexican population &#40;1994-2017&#41;&#46; Data corresponding to viral hepatitis from the National System for Epidemiological Surveilleance &#40;SUIVE&#41; by the SSA between 1994 to 2017 were collected and classified by an ethology agent&#46;</p>"
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          "en" => "<p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">Viral hepatitis in the Mexican population &#40;1994 vs&#46; 2017&#41;&#58; age groups&#46; Total HAV infection data from the National System for Epidemiological Surveilleance &#40;SUIVE&#41; by the SSA&#44; between 1994 to 2017 were collected and classified by age group&#46; <span class="elsevierStyleBold">A</span>&#46; Represents HAV cases classified by age group in 1994&#46; <span class="elsevierStyleBold">B</span>&#46; Represents to HAV cases classified by age group in 2017&#46;</p>"
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          "en" => "<p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Prevalence of HAVinfections in the states from Mexico &#40;1994 vs&#46; 2017&#41;&#46; Total HAV infections data from the National System for Epidemiological Surveilleance &#40;SUIVE&#41; by the SSA in 1994 and 2017 were collected and classified in HAV-infections by each state from Mexico&#44; <span class="elsevierStyleBold">A</span>&#46; Represents HAV infection distribution by state in 1994&#59; a total of 9700 HAV cases were reported&#46; <span class="elsevierStyleBold">B</span>&#46; Represents HAV infection distribution by state in 2017&#59; a total of 4636 HAV cases were reported&#46;</p>"
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          "en" => "<p id="sp0030" class="elsevierStyleSimplePara elsevierViewall">Prevalence of HAV infections relative to poverty level in states from Mexico&#46; Iota&#33; HAV infections data from the National System for Epidemiological Surveilleance &#40;SUIVE&#41; by the SSA from 2008 to 2016 were collected and classified in HAV infections in each state from Mexico&#46; The bars represent the total average of HAV infections reported every two years from 2008 to 2016 by state&#46; The percentages of poverty from National Council for the Evaluation of Social Development Policy &#40;Consejo National de Evaluation de la Polftica de Desarrollo Social&#44; CONEVAL in Spanish&#41; by state&#44; taking into account the total population by state from 2008 to 2016&#44; were collected&#46; The line represents the percentage of poverty&#46;</p>"
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Article information
ISSN: 16652681
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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