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New ACIP Adult Hepatitis B Vaccine Recommendations

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Title: New ACIP Adult Hepatitis B Vaccine Recommendations


1
New ACIP Adult Hepatitis B Vaccine
Recommendations
Eric E. Mast M.D., M.P.H. Chief, Prevention
Branch, Division of Viral Hepatitis National
Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention, CDC Current Issues in Immunization
NetConference January 18, 2007
2
Outline
  • Background
  • Disease burden
  • Progress in implementing strategy to eliminate
    HBV transmission
  • Rationale for new recommendations
  • Overview of new recommendations

3
Hepatitis B Burden of DiseaseUnited States, 2005
  • New infections declining w/implementation of
    strategy to eliminate HBV transmission
  • 200,000-300,000 infections in 1980s
  • 51,000 new infections in 2005
  • Ongoing disease among persons infected in the
    past
  • 5 of persons (12.5 million) infected during
    their lifetime
  • 10 of infected persons (1.25 million) have
    chronic infection
  • 3-5000 deaths per year from hepatitis B-related
    chronic liver disease (cirrhosis, liver cancer)

4
ACIP Strategy to Eliminate HBV Transmission
  • Prevent perinatal HBV transmission
  • Universal infant vaccination, beginning at birth
  • Catch-up vaccination of all children and
    adolescents lt19 years
  • Vaccination of adults in risk groups

5
Estimated HepB Coverage, 19-35 Months of
AgeUnited States, 1992-2004
Routine infant vaccination recommended
Source National Immunization Survey, CDC
6
States With Elementary or Middle School
Hepatitis B Vaccination Requirements, 1994-2007
45
Elementary schools
37
Middle Schools
Source http//www.immunize.org/laws/hepb.htm
7
Reported Acute Hepatitis B Incidence By Age
Group United States, 1990-2005
20 years
96 decline
76 decline
12-19 years
Cases per 100,000
lt12 years
Year
Source National Notifiable Diseases Surveillance
System, CDC
8
Incidence of Acute Hepatitis B, by Age and Sex,
United States, 2005
0.0
0.0
Female
Male
0.0
0.0
0.0
0.0
0.5
0.6
1.7
2.4
4.3
3.0
2.9
4.2
2.9
4.5
4.5
2.3
2.2
3.4
1.7
3.0
2.2
1.3
0.6
1.1
Rate per 100,000
Source National Notifiable Diseases Surveillance
System, CDC
9
Reported Risk Characteristics Among Adults with
Acute Hepatitis B, United States, 2001-2005
Other Household contact, institutionalization,
hemodialysis, blood transfusion, occupational
exposure Source Sentinel Counties Study of Viral
Hepatitis, CDC
10
Reported HepB Coverage Among Adults Aged 18-49
Years, 2004
All adults
Adults at risk
Vaccine Coverage,
Source National Health Interview Survey, MMWR
2006 55(18)509-511
11
Rationale for New Recommendations
12
Rationale for New Recommendations
  • Since 1982, ACIP has recommended HepB vaccination
    for adults at risk for HBV infection
  • However, recommendations have not been
    effectively implemented
  • Many health care settings do not vaccinate
    adults at risk
  • A substantial number of adults at risk for
    HBV infection are not vaccinated
  • A substantial burden of new infections continues
    to occur among adults

13
Prior Opportunities For Vaccination Among
Patients With Acute Hepatitis B, 2001-2004
Source Sentinel Counties Study of Viral
Hepatitis (n760)
14
HepB Vaccination Demonstration Projects In
Settings Serving Adults At High Risk
  • 1st dose acceptance rates of 60-85
  • STD, drug abuse treatment/prevention, HIV
    testing/counseling, corrections
  • 3rd dose completion rates of
  • 20-30 in outpatient settings
  • 50-90 in correctional facilities (gt4 month
    incarceration)
  • Feasibility established of providing HepB as part
    of comprehensive STD, HIV/AIDs and hepatitis
    prevention services

15
Components Of Successful Adult Hepatitis B
Vaccination Programs
  • Institutional commitment
  • Trained and knowledgeable staff
  • Patients who are informed about hepatitis B and
    the benefits of vaccination
  • Infrastructure that ensures vaccine
    administration is accessible, convenient, and
    flexible for patients
  • Protocols and standing orders
  • Integrated delivery of vaccine with other
    services
  • Protected patient confidentiality
  • Funding for vaccine

16
Cost-Effectiveness Of Adult Hepatitis B
Vaccination In Settings Serving Adults At High
Risk
  • Sources
  • Vaccine 200221312-321
  • Am J Prev Med 200630498-506

17
Need For HepB Vaccination Strategies in Primary
Care/Specialty Medical Settings (I)
  • Not all adults with risk factors for HBV
    infection visit settings serving adults at high
    risk
  • e.g., estimated 80--95 of STDs are diagnosed in
    settings other than STD clinics
  • Risk-targeted vaccination is most efficient
  • 84 of persons w/acute hepatitis B report
    behaviors or characteristics placing them in
    group recommended for HepB
  • 15-20 of all adults report risk factors for HBV
    infection
  • Risk identification recommended to identify
    persons who need other prevention interventions
    e.g., HIV screening, STD screening, drug
    treatment)

18
Cost-Effectiveness Of Adult Hepatitis B
Vaccination
Source Ann Intern Med 1993118298-306
19
Need For HepB Vaccination Strategies in Primary
Care/Specialty Medical Settings (II)
  • However, risk-targeted approaches can miss at
    risk persons
  • Patients might be reluctant to report risk
    behaviors, especially when not relevant to
    clinical encounter
  • lt50 of patients asked about sexual behaviors
  • All patients need to be educated about health
    benefits of HepB vaccination
  • Risk factors for infection
  • Importance of vaccination for persons w/risk
    behaviors
  • Might stimulate patients to request vaccination,
    without acknowledging a specific risk factor

20
New Recommendations
21
ACIP Recommendations for Hepatitis B Vaccination
of Adults
  • HepB is recommended for
  • All unvaccinated adults at risk for HBV infection
  • All adults seeking protection from HBV infection
  • Acknowledgment of specific risk factor not a
    requirement for vaccination
  • Vaccination strategies appropriate for the
    medical practice setting should be implemented
  • Ensure that all at risk adults are offered HepB

22
Unvaccinated Adults at Risk for HBV Infection
  • Persons at risk for sexual transmission
  • Persons at risk for transmission by
    percutaneous or mucosal exposure to blood
  • Others

23
Unvaccinated Adults at Risk for HBV Infection
  • Persons at risk for sexual transmission
  • Sex partners of HBsAg-positive persons
  • Sexually-active persons not in a long term,
    mutually monogamous relationship
    (e.g., gt1 partner
    in prior 6 mo)
  • Persons seeking evaluation/treatment for a STD
  • Men who have sex with men

24
Unvaccinated Adults at Risk for HBV Infection
  • Persons at risk for sexual transmission
  • Persons at risk for transmission by percutaneous
    or mucosal exposure to blood
  • Injection drug users
  • Household contacts of HBsAg-positive persons
  • Residents and staff of institutions for
    developmentally disabled persons
  • Health care and public safety workers
  • Dialysis patients, others w/end stage kidney
    disease

25
Unvaccinated Adults at Risk for HBV Infection
  • Persons at risk for sexual transmission
  • Persons at risk for transmission by
    percutaneous or mucosal exposure to blood
  • Others
  • International travelers to regions with HBsAg
    prevalence gt2
  • Persons with chronic liver disease
  • Persons with HIV infection
  • All others seeking protection from HBV infection

26
Implementation Recommendations
Setting-Specific Vaccination Strategies
  • Settings in which a high proportion of adults
    have risk factors for HBV infection
  • Primary-care and specialty medical settings
  • Occupational health settings

27
Implementation Recommendations
Settings In Which A High Proportion Of Persons
Have Risk Factors For HBV Infection
  • STD treatment facilities
  • HIV testing/treatment facilities
  • Drug abuse treatment/prevention facilities
  • Correctional facilities
  • Facilities targeting services to MSM/IDU
  • Chronic hemodialysis facilities and endstage
    renal disease programs
  • Institutions and nonresidential daycare
    facilities for developmentally disabled persons

28
Implementation Recommendations
Settings In Which A High Proportion Of Persons
Have Risk Factors For HBV Infection
  • Standing orders to administer HepB to all
    unvaccinated adults
  • Assume all unvaccinated adults are at risk
  • Provide HepB as a component of STD, HIV/AIDS, and
    other viral hepatitis prevention services
  • When feasible, provide HepB in outreach settings
  • (e.g., needle-exchange programs, HIV testing
    sites, homeless shelters)

29
Implementation Recommendations
Primary Care and Specialty Medical Settings
  • Standing orders to identify and vaccinate
    eligible adults
  • Provide information to all adults
  • Risk factors for HBV infection
  • Persons for whom HepB is recommended
  • Obtain risk history to help assess need for HepB
  • Risks for sexual transmission
  • Percutaneous or mucosal exposure to blood
  • Administer HepB to
  • All adults who report risks for HBV infection
  • All adults seeking protection from HBV infection
    (acknowledgement of a risk factor not required)

30
Occupational Health Programs
Implementation Recommendations
  • Identify all staff whose work-related activities
    involve exposure to blood or other potentially
    infectious body fluids
  • Provide education to staff to encourage
    vaccination
  • Implement active follow-up with reminders to
    track completion of the vaccine series

31
Adult Hepatitis B Vaccination - Summary
  • Substantial progress made in eliminating HBV
    transmission since 1991
  • childhood hepatitis B rates declined by gt95
  • adult hepatitis B rates declined by gt75
  • Substantial burden of new infections remains
  • 51,000 new infections in 2005 (gt95 among
    adults)
  • Elimination of HBV transmission can be
    accelerated by increasing HepB coverage among at
    risk adults
  • New recommendations provide
  • Adult groups who should receive HepB vaccine
  • setting-specific implementation strategies to
    ensure that all at risk adults are offered HepB

32
  • For More Information See http//www.cdc.gov/hepa
    titis
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