title: Considerations on the current universal vaccination policy against hepatitis A in Greece after recent outbreaks.
abstract: Greece is the only European Union member state that in 2008 included hepatitis A (HAV) vaccine in the routine national childhood immunization program (NCIP). Given that the resources allocated to public health have dramatically decreased since 2008 and that Greece is a low endemicity country for the disease, the benefit from universal vaccination has been questioned. The aim of this paper is to summarize the available epidemiological data of the disease for 1982-2013, and discuss the effects of universal vaccination on disease morbidity. Descriptive analysis, ARIMA modeling and time series intervention analysis were conducted using surveillance data of acute HAV. A decreasing trend of HAV notification rate over the years was identified (p<0.001). However, universal vaccination (~ 80% vaccine coverage of children) had no significant effect on the annual number of reported cases (p = 0.261) and has resulted to a progressive increase of the average age of infection in the general population. The mean age of cases before the inclusion of the vaccine to NCIP (24.1 years, SD = 1.5) was significantly lower than the mean age of cases after 2008 (31.7 years, SD = 2.1) (p<0.001). In the last decade, one third of all reported cases were Roma (a population accounting for 1.5% of the country's total population) and in 2013 three outbreaks with 16, 9 and 25 Roma cases respectively, were recorded, indicating the decreased effectiveness of the current immunization strategy in this group. Data suggest that universal vaccination may need to be re-considered. Probably a more cost effective approach would be to implement a program that will include: a) vaccination of high risk groups, b) universal vaccination of Roma children and improving conditions at Roma camps, c) education of the population and travel advice, and d) enhancement of the control measures to increase safety of shellfish and other foods.
authors.affiliation: Hellenic Centre for Disease Control and Prevention, Athens, Greece.
authors.forename: Kassiani
authors.initials: K
authors.lastname: Mellou
authors.affiliation: Hellenic Centre for Disease Control and Prevention, Athens, Greece.
authors.forename: Theologia
authors.initials: T
authors.lastname: Sideroglou
authors.affiliation: Third Department of Pediatrics, University of Athens, General University Hospital "ATTIKON", Chaidari, Athens, Greece.
authors.forename: Vassiliki
authors.initials: V
authors.lastname: Papaevangelou
authors.affiliation: Department of hygiene and epidemiology, Medical Faculty, University of Thessaly, Larissa, Greece.
authors.forename: Anna
authors.initials: A
authors.lastname: Katsiaflaka
authors.affiliation: Department of hygiene and epidemiology, Medical Faculty, University of Thessaly, Larissa, Greece.
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Bitsolas
authors.affiliation: Department of hygiene and epidemiology, Medical Faculty, University of Thessaly, Larissa, Greece.
authors.forename: Eleni
authors.initials: E
authors.lastname: Verykouki
authors.affiliation: Hellenic Centre for Disease Control and Prevention, Athens, Greece.
authors.forename: Eleni
authors.initials: E
authors.lastname: Triantafillou
authors.affiliation: Hellenic Centre for Disease Control and Prevention, Athens, Greece.
authors.forename: Agoritsa
authors.initials: A
authors.lastname: Baka
authors.affiliation: Hellenic Centre for Disease Control and Prevention, Athens, Greece.
authors.forename: Theano
authors.initials: T
authors.lastname: Georgakopoulou
authors.affiliation: Hellenic Centre for Disease Control and Prevention, Athens, Greece; Department of hygiene and epidemiology, Medical Faculty, University of Thessaly, Larissa, Greece.
authors.forename: Christos
authors.initials: C
authors.lastname: Hadjichristodoulou
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D003362:Cost-Benefit Analysis / Q000331:legislation & jurisprudence; D004196:Disease Outbreaks / Q000517:prevention & control*; D006115:Greece / Q000453:epidemiology; D006506:Hepatitis A / Q000453:epidemiology* / Q000276:immunology*; D022362:Hepatitis A Vaccines / Q000276:immunology*; D006801:Humans; D009017:Morbidity; D011159:Population Surveillance; D014611:Vaccination / Q000331:legislation & jurisprudence*; D055815:Young Adult
chemical_list: D022362:Hepatitis A Vaccines