Infant and Adolescent Hepatitis B Vaccination and Use of Combination Vaccines United States

1
Infant and Adolescent Hepatitis B Vaccination
and Use of Combination Vaccines United States
2

Elimination of Hepatitis B Virus Transmission
United States
Strategy

• Prevent perinatal HBV transmission
  (1984 - selective 1988 universal)
• Routine infant vaccination (1991)
• Catch-up vaccination
• 11-12 year-old children (1995)
• All children lt19 years of age (1997)
  
• Adults in high risk groups (1982)

3
Key Elements of Perinatal Hepatitis B Prevention
Program, United States

• Testing all pregnant women for HBsAg
• Reporting of HBsAg-seropositive women
• Case-management and tracking to assure
• HBIG and hepatitis B vaccine at birth
• completion of vaccine series by age 6 months
• post-vaccination serologic testing
• identification and vaccination of susceptible
  HH/sex contacts

4
Evaluations of HBsAg Screening
of Pregnant Women, 1991-2001
Births Reviewed, No.
Mothers Screened, ()
Study
Year
New York

1991
607
(96)
Kansas
1992
412
(84)
National
1993
3,982
(84)
Washington
1994
4,031
(96)
Ohio
1994
394
(96)
Illinois
1994-5
1,361
(91)
California
1995
5,414
(96)
Florida
1995
365
(88)
North Carolina
1997-98
4726
(92)
Delaware
1999
N/A
(91)
8 states (EID sites)
2001
5135
(96.5)
5
Identified and Expected Births to HBsAg-Positive
Mothers United States, 1993-1999
19042
19250
19252
19617
19919
20254
20861
Expected
7874
8403
8002
8687
8841
8730
9503
Identified
6
HBsAg Seroprevalence among Pregnant Women by
Prenatal Screening Status, Philadelphia, 1991
Prenatal
No. of Women
HBsAg-positive
Screening
Tested
No. ()
Yes
1555
12 (0.8)
No
208
14 (6.7)
Source JAMA 19912662852-5
7

Elimination of Hepatitis B Virus Transmission
United States
Strategy

• Prevent perinatal HBV transmission
  (1984 - selective 1988 universal)
• Routine infant vaccination (1991)
• Catch-up vaccination
• 11-12 year-old children (1995)
• All children lt19 years of age (1997)
  
• Adults in high risk groups (1982)

8
HepB3, DTP3, and Hib3 Coverage, Among 19-35
Month-Old Children, 1992-2000
DTP3
Routine HepB vaccination recommended
Hib3
HepB3
9
Reported Cases of Acute Hepatitis B in
ChildrenUnited States, 1985-2000
5-9 years
Routine HepB vaccination recommended
1-4 years
10
Estimated Non-Perinatal HBV Infections Among
Children lt10 Years of Age United States, 1991
Source Armstrong, et al. Pediatrics 2001 in
press
11
Age of Acquisition for Persons with Chronic HBV
Infection, United States
Newborn, 18
Children, 18
Adult, 59
Adolescent, 6
12

Elimination of Hepatitis B Virus Transmission
United States
Strategy

• Prevent perinatal HBV transmission
  (1984 - selective 1988 universal)
• Routine infant vaccination (1991)
• Catch-up vaccination
• 11-12 year-old children (1995)
• All children lt19 years of age (1997)
  
• Adults in high risk groups (1982)

13
National vaccination coverage levels of
adolescents 13-15 years of age, NHIS
14
States Requiring Hepatitis B Vaccination Before
Middle School Entry, 2001
WASHINGTON
MAINE
NORTH
MONTANA
MINNESOTA
DAKOTA
OREGON
VT
NH
WISCONSIN
IDAHO
SOUTH
MA
NEW
DAKOTA
YORK
CT
MICHIGAN
WYOMING
RI
IOWA
PENNSYLVANIA
NEBRASKA
NEVADA
NJ
OHIO
IN
DE
UTAH
ILLINOIS
DC
MD
COLORADO
WV
VIRGINIA
MISSOURI
KANSAS
KENTUCKY
CALIFORNIA
NO.
CAROLINA
TENNESSEE
31 of 50 States have HepB immunization
requirements
OKLAHOMA
ARIZONA
SO.
ARKANSAS
NEW
CAROLINA
MEXICO
MS
GEORGIA
ALABAMA
LA
TEXAS
ALASKA
FL
HAWAII
15
Reported cases of acute hepatitis B among 15-18
year olds United States, 1990-2000
16
Hepatitis B vaccine doses distributed in public
sector United States, 1990-2000
Total
Monovalent HepB
Millions of doses
Hib-HepB
18.3
14.6
8.5
0.4
17
(No Transcript)
18
Thimerosal Changes in Hepatitis B Vaccine
Recommendations, July 1999

• Joint PHS-AAP Statement
• Clinicians and parents can take advantage of the
  flexibility within the existing scheduleto
  postpone the first dose of hepatitis B vaccine
  from birth until 2 to 6 months of age
• AAP
• If thimerosol-free vaccine is not available,
  hepatitis B virus vaccination should be initiated
  at 6 months of age

19
Week
20
Vaccine coverage among infants born to unscreened
women, Oregon, 1999-2000
July 11, 1999 CDC/AAP announcement to defer
vaccination of infants born to HBsAg neg women
No change in recs for unscreened women August 28,
1999 Resume previous policies
21
Why Should Birth Dose Be Given to All Infants?

• Safety net If all get birth dose, eliminates
  missed immunoprophylaxis for infants born to
  HBsAg-positive mothers (a medical error)
• Assures immunoprophylaxis for infants born to
  unscreened women (10x more likely to be
  HBsAg-positive)
• May reduce number of doses that need to be given
  simultaneously with other vaccines
• May increase likelihood that the Hep B series
  will be given on schedule
• Conveys the importance of vaccination to parents

22
Hepatitis B Combination VaccinesConcerns

• Requires use of 4 dose schedule to prevent
  perinatal HBV transmission
• Potential to decrease use of birth dose
• Increased cost/cost-effectiveness data?
• Safety data?
• Need to assure adequate immunogenicity of all
  vaccine components in schedules used in developed
  and developing countries (w/ and w/o birth dose)
• Increased vaccine cost per dose
• requires increased attention to vaccine wastage
• smaller vaccine vials increased need for cold
  chain capacity
• Could displace local DTP production

23
(No Transcript)