New ACIP Adult Hepatitis B Vaccine Recommendations

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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
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Outline

• Background
• Disease burden
• Progress in implementing strategy to eliminate
  HBV transmission
• Rationale for new recommendations
• Overview of new recommendations

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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)

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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

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Estimated HepB Coverage, 19-35 Months of
AgeUnited States, 1992-2004
Routine infant vaccination recommended
Source National Immunization Survey, CDC
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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
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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
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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
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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
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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
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Rationale for New Recommendations
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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

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Prior Opportunities For Vaccination Among
Patients With Acute Hepatitis B, 2001-2004
Source Sentinel Counties Study of Viral
Hepatitis (n760)
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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

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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

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Cost-Effectiveness Of Adult Hepatitis B
Vaccination In Settings Serving Adults At High
Risk

• Sources
• Vaccine 200221312-321
• Am J Prev Med 200630498-506

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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)

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Cost-Effectiveness Of Adult Hepatitis B
Vaccination
Source Ann Intern Med 1993118298-306
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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

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New Recommendations
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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

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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

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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

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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

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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

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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

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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

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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)

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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)

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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

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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

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