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slide1

Hepatitis BEliminating TransmissionPreventing Disease*John W. Ward, M.D.Division of Viral HepatitisCenters for Disease Control and Prevention *The findings and conclusion n this presentation have not been formally disseminated by CDC and should not be construed to represent CDC determination or policy

us disease burden of hepatitis b
US Disease Burden of Hepatitis B

Total HBV infection ~14 million (5%)

Chronic HBV 1-1.4 million

Other blood-borne infections

Chronic HCV 3 million

HIV 1 million

global disease burden of hepatitis b
Global Disease Burden of Hepatitis B

Total HBV infection 2 billion

Chronic HBV 370 million

Other blood-borne infections

Chronic HCV 130 million

HIV 40 million

immigrants admitted for permanent residence 1994 2003 by hbv endemicity 1
Immigrants Admitted For Permanent Residence, 1994-2003, by HBV Endemicity1

Estimated

HBsAg-positive3

Immigrants2

1. Country of birth

2. Yearbook of Immigration Statistics, Dept. of Homeland Security

3. Based on country-specific HBsAg prevalence estimates

modes of hbv transmission
Modes of HBV Transmission

Perinatal

    • Blood exposure during birth
    • Transmission risk depends on status of mother
      • HBeAg positive – 70-90% risk
      • HBeAg negative – 5-20% risk

Percutaneous and permucosal

    • Early childhood/horizontal
    • Injection drug use- >50% infected after 5 years
    • Health-care related (transfusion, unsafe injections)

Sexual

  • 16-40% of contacts infected
slide9

Advisory Committee on Immunization Practices

US Strategies to Eliminate HBV Transmission

  • Prevent perinatal HBV transmission (1984-88)
    • Maternal screening
    • Newborn vaccination
  • Recommend universal birth dose (2005)
  • Universal infant vaccination (1991)
  • Catch –up vaccination
    • adolescents 11-12 years (1995)
    • all persons <19 years (1999)
  • Adults at high risk (1982)
slide10

Hepatitis B Vaccine Coverage Among Children*United States, 1995-2003

Asian-Pacific Islander

HP 2010 target

Black

White

Hispanic

*Aged 19-35 months

Source: National Immunization Survey

effectiveness of hepatitis b immunization among api children hawaii and georgia
Effectiveness of Hepatitis B Immunization Among API Children, Hawaii and Georgia

Hawaii

Georgia

Before

vaccination

Before

vaccination

HBsAg

11.7%

4.5%

Anti-HBc

6.6%

99%

vaccine

coverage

98%

vaccine

coverage

1.6%

0.04%

0.2%

0.6%

0.6%

2001

(n=2470)

1989

(n=2701)

1986

(n=251)

2002

(n=157)

Sources: Pediatrics 1993, N Engl J Med 1989, CDC, GA Health Dept, HI Health Dept.

hepatitis b incidence among persons 19 yrs by race ethnicity 1990 2004
Hepatitis B Incidence Among Persons <19 Yrs By Race/Ethnicity, 1990-2004

Overall decline ~ 93%

Decline among API ~ 95%

Asian/Pacific Islander

Cases/100,000

Black

AI/AN

Hispanic

White

Year

hepatitis b incidence among persons 19 yrs by race ethnicity 1990 20041
Hepatitis B Incidence Among Persons ≥19 YrsBy Race/Ethnicity, 1990-2004

Black

Overall decline ~ 75%

Decline among API ~ 85%

Asian/Pacific Islander

AI/AN

Hispanic

White

who recommendation for hepatitis b vaccination
WHO Recommendation for Hepatitis B Vaccination
  • Recommendation made 1991
  • Integrate Hepatitis B vaccine into national childhood vaccination programs
  • By 2004, 153 of 192 (80%) WHO Member States had introduced
  • 48% of the world's children less than 1 year of age had received 3 doses of HepB
slide15

Global Status of Hepatitis B

Immunization Programs (2005)

Countries with hep B programs: ~80%

Global HepB3 coverage: ~40%

adult hepatitis b vaccine coverage united states 2002
Adult Hepatitis B Vaccine Coverage, United States,2002

Vaccination of 0-18 yrs recommended

60

50

40

30

Vaccine coverage, %

20

10

0

19-20

21-25

26-30

31-40

41-50

51-65

65+

Age group, yrs

National Health Interview Survey

reported acute hepatitis b incidence by age and sex united states 2004
Reported Acute Hepatitis B Incidence, By Age and Sex, United States, 2004

<5

0.1

0.1

Female

Male

0.0

5-9

0.0

0.1

0.1

10-14

15-19

1.1

0.7

20-24

3.1

3.9

4.2

6.2

25-29

30-34

4.0

6.3

Age group

35-39

4.4

6.0

40-44

3.6

6.2

45-49

2.7

5.1

50-54

2.0

3.8

1.3

2.6

55-59

60+

0.8

1.7

Rate per 100,000 persons

reported risk factors for acute hepatitis b in the u s 2001 2004
Reported Risk Factors for AcuteHepatitis B in the U.S. (2001-2004)

No Identified Risk (25%)

IDU (13%)

Other1 (5%)

Heterosexual –

contact w/ confirmed or

suspected case (10%)

Heterosexual –

> 1 opposite sex partner

in past 6 months (22.3%)

MSM (23%)

1 Other: Household contact, institutionalization, hemodialysis, blood transfusion, occupational exposure,

admits to a risk factor but does not specify which one

Source: Sentinel Counties Study of Acute Viral Hepatitis, CDC (n = 591)

revised acip recommendations for adult hepatitis b vaccination
Revised ACIP Recommendations for Adult Hepatitis B Vaccination
  • Settings with high HBV prevalence
    • Conduct universal vaccination
    • Settings with high prevalence settings (e.g. STD/ HIV, corrections Routinely inform patients of the potential value of HBV vaccination
  • Vaccinate all persons seeking protection
  • To assure high risk persons receive vaccination
    • Offer to all patients in high prevalence settings ()
    • In Primary care settings
    • Risk based
    • Age-based
slide23

Burden of Chronic HBV Infection

United States

  • 1.0-1.25 million have chronic HBV infection
  • ~45,000 new cases of chronic HBV infection
    • ~40,000 (90%) are foreign born
    • >50% are Asian-Americans
    • Limited studies suggest most are unaware of infection
  • Improved therapies for chronic hepatitis B increase potential benefit of counseling and testing programs
fda approved therapies for chronic hepatitis b
FDA Approved Therapies for Chronic Hepatitis B
  • Interferon alpha-2b (Intron A)
  • Adefovir (Hepsera)
  • Epivir-HBV (Lamivudine)
  • Entecavir (Baraclude)
  • Others in clinical trials
deaths from hepatitis b vital records
Deaths from Hepatitis B Vital records
  • Reported Deaths are level by year
    • Year 2000 1458 deaths
    • Year 2001 1370 deaths
    • Year 2002 1350 deaths
purposes of hepatitis b screening
Purposes of Hepatitis B Screening
  • Prevent transmission
      • Transfusion/transplantation
      • Perinatal
      • Close contacts
  • Efficient delivery of vaccine
  • Begin medical management of chronic disease
    • Early diagnosis
    • Evaluation and treatment
screening recommendations for pregnant woman
Screening Recommendations for Pregnant Woman
  • Shift focus to include needs of HBV infected mothers
  • Prevention case management model
    • Vaccination of contacts
    • Referral for care
  • Particular focus on foreign born persons from high endemic areas
public health programs for chronic hepatitis b
Public Health Programs for Chronic Hepatitis B
  • Represents a change in division orientation
    • New research questions
    • New surveillance practices
      • Chronic disease registries
      • Program indicators
  • New public health infrastructure
strategic imperatives
Strategic Imperatives
  • Sustain child/adolescent immunization programs
  • Increase vaccine coverage among at risk adults
  • Develop chronic HBV infection programs
    • Screening programs for Asian and other populations
    • Build services for immigrants and refugees
    • Conduct prevention case management
      • Facilitate access to medical care
      • Vaccinate close contacts of infected persons
  • Assist prevention efforts in Asia countries
  • Obtain data for program planning/evaluation