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China CDC Weekly Outbreak Reports An Epidemic of Hepatitis A — Liaoning Province, 2020 Jing Sun1,&; Yuanqiu Li2,&; Xing Fang3,&; Yan Wang1; Yinan Han4; Yang Liu5; Jingyuan Cao6; Wenting Zhou6; Hui Zheng2,#; Wenqing Yao1,# sporadic, and cases were seen in nearly every township Summary of the two cities. Through an interview survey of HA What is already known about this topic? cases and a case-control study, we found that Hepatitis A (HA) is caused by acute hepatitis A virus consuming raw or undercooked seafood was (HAV) infection and was once very common in China. significantly associated with the increase in HA. Local Following the 2008 introduction of the HA vaccine governments have taken a series of measures including into the national Expanded Program on Immunization health education and restriction of the sale of seafood (EPI), the incidence of reported HA in China products in markets. During March 11–16, the China decreased markedly. However, HA epidemics still occur CDC, Liaoning Provincial CDC, and Dalian and in Liaoning Province every 3–5 years, although with far Dandong CDCs conducted a joint investigation and fewer cases than in the pre-HA-vaccination era. identified the consumption of raw seafood as the main What is added by this report? risk factors associated with the HA increase. We report Between January 1, 2020 and March 18, 2020, the results of the investigation and recommendations to number of reported cases of HA in Dalian and prevent similar epidemics. Dandong cities of Liaoning Province increased significantly compared with the same period in INVESTIGATION AND RESULTS previous years. All cases were sporadic, and cases were seen in nearly every township. The increase in HA All cases of hepatitis A were laboratory confirmed occurred one month after local fresh seafood became according to the Diagnostic Criteria of Viral Hepatitis A available with most cases being among adults. A case- (WS 298-2008) (1). Based on date of onset, 3,511 HA control study showed that consuming raw or cases were reported nationwide through NNDRS undercooked seafood, clams, snapping shrimp, and between January 1, 2020 and March 18, 2020, which oysters were significantly associated with the increase in was a decrease of 12.3% compared with the 4,003 HA. cases reported across the nation during the same period What are the implications for public health last year. In contrast, HA cases reported from Liaoning practices? Province in January 1 through March 18 increased Strengthening health education for residents to avoid from 700 in 2019 to 1,361 in 2020, accounting for consumption of raw seafood and encouraging HAV approximately one-third of all cases reported vaccination of adults aged 20 to 54 years are important nationwide. After integration of the HA vaccine into to prevent periodic HAV endemic outbreaks. Further the national Expanded Program on Immunization multisectoral cooperation must be emphasized on HA (EPI) in 2008, HA had occurred at relatively low levels surveillance in areas with a high prevalence of HA. in Liaoning with periodic increases in every 3–5 years, and the most recent increase was in 2014–2016. In 2020, the number of reported HA cases increased BACKGROUND markedly in the first 2 months of the year but began to decrease on March 4 (Figures 1 and 2). In February 2020 compared with February 2019, There were 426 and 586 cases reported from two there was a 138.2% increase of cases of hepatitis A coastal cities, Dalian and Dandong, which accounted (HA) reported to the National Notifiable Disease for 74.36% (1,012/1,361) of all cases reported from Report System (NNDRS) from Liaoning Province, Liaoning. Zhuanghe County of Dalian and Donggang and 77.6% of the cases in Liaoning were from two County of Dandong reported 262 (62.50%, 262/426) coastal cities — Dalian and Dandong. All cases were and 290 (49.49%, 290/586) cases, which was more 570 CCDC Weekly / Vol. 2 / No. 30 Chinese Center for Disease Control and Prevention China CDC Weekly 360 330 300 Liaoning Dandong Dalian 270 240 210 180 150 HA cases HA 120 90 60 30 0 4week 8week 1week 5week 8week 2week 6week 3week 7week 1week 5week 1week 15week 29week 43week 18week 32week 46week 22week 36week 50week 12week 26week 40week 15week 29week 43week 19week 33week 47week 22week 36week 50week 12week 26week 40week 16week 30week 44week 20week 34week 48week 10week 24week 38week 52week 14week 28week 42week 17week 31week 45week 21week 35week 49week 11week 25week 39week 15week 29week 43week 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 FIGURE 1. Weekly reported hepatitis A (HA) cases in Liaoning Province, 2004 through Week 11 of 2020. 250 In Jan 2020, Liaoning seafood sales Dandong In mid-late increased 200 Dalian Nov, seasonal during Spring seafood was Festival 150 available in markets 100 50 Reported HA cases Reported HA 0 1.4−1.8 2.3−2.7 3.4−3.8 1.9−1.13 1.29−2.2 2.8−2.12 2.28−3.3 3.9−3.13 11.5−11.9 10.1−10.5 12.5−12.9 12.30−1.3 1.14−1.18 1.19−1.23 1.24−1.28 2.13−2.17 2.18−2.22 2.23−2.27 3.14−3.18 10.31−11.4 11.30−12.4 10.6−10.10 11.10−11.14 11.15−11.19 11.20−11.24 11.25−11.29 10.11−10.15 10.16−10.20 10.21−10.25 10.26−10.30 12.10−12.14 12.15−12.19 12.20−12.24 12.25−12.29 2019 2020 FIGURE 2. Seafood sales timeline and daily distribution of reported hepatitis A (HA) cases in Liaoning, October 1, 2019 to March 18, 2020. than any other county (Figure 3). in Dandong, the percent of HA cases with a history of Most cases were among adults that were aged 30–54 seafood consumption in 2020 was 84.7% (287/339), years in Dalian and aged 30–49 years in Dandong, which was higher than in 2018 (72.0%) and 2019 which represented 85.4% (364/426) and 82.6% (61.0%) (local, unpublished data). (484/586) of the cases in the two cities. There were 4 We compared sales of local seafood during the two (0.39%, 4/1,012) reported cases among children less months prior to the HA increase with sales during the than 15 years of age, and 3 of the 4 children had no HA epidemic. We found that HA case reports began to history of HAV vaccination. By occupation, 50.9% increase in December 2019, approximately one month (515/1,012) of HA cases were among farmers and after local seafood became available in November. 31.2% (316/1,012) were among household workers or Following a sharp increase of seafood sales during unemployed individuals. Spring Festival in January 2020, there was a peak of Local CDCs conducted routine epidemiological HA cases in February and early March (Figure 2). investigations of all reported and confirmed HA cases The case-control study was conducted by Dalian in face-to-face or telephone interviews (n=191). The CDC using face-to-face and telephone interviews. All interviews focused on five themes including eating 191 confirmed HA cases reported between January 1, habits, drinking water, types of seafood eaten, dining- 2020 and March 7, 2020 in Zhuanghe County were out behavior, and sources of food during their enrolled as the case group, and 277 healthy individuals incubation period. We analyzed data from case residing in the same county were recruited for the interviews conducted between January and early March control group. Controls were healthy adults living in in Zhuanghe County and found that 71.2% the same town as a case, with no history of HA, and (104/146), 36.9% (31/84), and 13.3% (2/15) of who had not received HAV vaccine. The questionnaire interview subjects who consumed oysters, snapping was designed, tested, and revised by Dalian CDC; all shrimp, or cockles ate them raw. During the same time data, including eating habits, types of drinking water, Chinese Center for Disease Control and Prevention CCDC Weekly / Vol. 2 / No. 30 571 China CDC Weekly A No. of reported cases 0− 4− 10− 25− 100− 1 Dot = 1 case B C FIGURE 3. Geographic distribution of Hepetitis A (HA) reports in Liaoning Province and two local areas, January 1, 2020 to March 18, 2020. (A) County level distribution of reported HA cases in Liaoning Province. (B) Township-level distribution in Zhuanghe County, Dalian City. (C) Township-level distribution in Donggang County, Dandong City. types of seafood eaten, food sources, and dining out RESPONSE behavior, were collected by trained, experienced local staff. HA risk factors were identified by univariate and Local governments took several measures in multivariate logistic regression analyses. We found that response to the HAV epidemic in Dalian and consumption of raw or undercooked seafood (OR= Dandong including educational, mass-media public 11.1, 95% CI: 6.0–20.6), eating clams (OR=2.5, 95% communications about the importance of avoiding CI: 1.6–5.9), eating snapping shrimp (OR=3.1, 95% consuming raw seafood and an encouragement of CI: 1.6–6.0), and eating oysters (OR=4.6, 95% CI: HA vaccination. By March 14, 4,418 adults in 2.6–8.1) were significantly associated with HAV Zhuanghe County of Dalian and 1,861 adults in infection (Table 1). Donggang County of Dandong were vaccinated.
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