Getting Rid of Hepatitis B in the United States

Great Progress, Continued Efforts Mark Vaccine’s 20th Anniversary

By 1982, the reported incidence of hepatitis B virus (HBV) infections in the US had doubled in just ten years. “Health care workers lived in fear of needlestick injuries that could bring fatal hepatitis or slow death by cirrhosis,” remembers Seth Foldy, MD, Associate Clinical Professor of Family and Community Medicine at the Medical College of Wisconsin, and Milwaukee’s Health Commissioner. “Some infants were doomed to hepatitis and liver cancer from infections obtained at birth.” Silent carriers transmitted the infection without warning, similar to Human Immunodeficiency Virus (HIV) today. Preventing exposure was difficult, and the only post-exposure protection available was injection with hepatitis B immune globulin.

This year marks the 20th anniversary of the United States’ implementation of the world's first vaccine against hepatitis B virus. Before 1982, an estimated 200,000 - 300,000 people in the US were infected with HBV every year, including about 20,000 children. By 2001 this number had fallen to 78,000. Hepatitis B is spread through direct contact with the blood or body fluids of an infected person; for example, by having sex or sharing needles with an infected person. Infants can acquire hepatitis B from an infected mother during childbirth. Hepatitis B is not spread through food or water or by casual contact.

In addition to the initial, acute disease, people infected with HBV are at risk for chronic HBV infection, which in some cases can lead to cirrhosis or liver cancer. People who are infected with HBV and never recover fully from the infection carry the virus and can infect others for the rest of their lives. People with new HBV infections sometimes show no symptoms, or they might experience:

• Yellow eyes or skin
• Loss of appetite
• Nausea, vomiting, fever, stomach or joint pain
• Extreme fatigue, resulting in inability to work for weeks or months

In the United States there are about one million hepatitis B carriers. These people may have hepatitis B and be spreading the disease without knowing it; some people times with HBV infection has no symptoms at all. Only a blood test can tell for sure.

Who Should Be Vaccinated Against Hepatitis B?

• All children 0-18 years of age who have not been vaccinated
• People of any age whose behavior puts them at high risk for HBV infection
• People whose jobs expose them to human blood or body fluids

• Those who have sex with more than one partner
• Those who have had sexually transmitted infections (like gonorrhea or chlamydia)
• Men who have sex with men
• People living with or having sex with someone with recent or long-standing HBV infection
• Dialysis patients
• People who inject drugs
• People living or traveling in countries where the infection is common

“Universal vaccination of children will someday eliminate the threat of hepatitis B,” according to Geoffrey Swain, MD, Medical College of Wisconsin Associate Professor of Family and Community Medicine and Associate Medical Director at the Milwaukee Health Department. To speed the process, Milwaukee, like many cities, also offers Hepatitis B vaccination to patients at its sexually transmitted disease clinic.

Since 1982, substantial progress has been made toward eliminating the spread of HBV in children and reducing the risk for HBV infection in adults. During 1982 - 2002, an estimated 40 million infants and children and 30 million adults received hepatitis B vaccine. To stop the spread of HBV, high vaccine-coverage rates must be sustained among infants, children and adolescents, and programs to vaccinate adults at high risk for HBV infection must be expanded.

History
In June of 1982, the Advisory Committee on Immunization Practices (ACIP) published the first official recommendations on the use of hepatitis B vaccine. The ACIP initially recommended pre-exposure vaccination for groups with a high risk for HBV infection. However, by 1989, it became clear that members of high-risk groups (e.g., men who have sex with men, injection-drug users and heterosexuals with multiple partners) were not being vaccinated in substantial numbers. Many people did not recognize their risk for HBV infection, and others did not know about the vaccine or were unable to purchase it. In addition, health-care providers often did not identify candidates for vaccination. Evan though only 5% of acute hepatitis B cases occurred among health-care workers, they made up 80% of the approximately 2.5 million persons vaccinated during the 1980s.

In 1988, ACIP recommended that all pregnant women be screened routinely for evidence of past or present hepatitis B infection. Surveys conducted in 2000 showed that 96.5% of pregnant women had been screened. Of 10,192 infants born to hepatitis B-positive mothers, 90% received hepatitis B vaccine and hepatitis B immune globulin before hospital discharge. At age 6 - 8 months, 71% of these infants had completed the 3-dose hepatitis B vaccine series. On the basis of these coverage rates, CDC estimates that perinatal HBV infection in the United States declined 75% during 1987 - 2000.

In 1991, recognizing the difficulty of vaccinating high-risk adults and the substantial burden of HBV-related disease acquired from infections in childhood, ACIP recommended a comprehensive strategy to eliminate HBV transmission in the United States. The strategy focused on universal childhood vaccination, prevention of HBV transmission during birth, vaccination of adolescents and adults in high-risk groups, and catch-up vaccinations for susceptible children in high-risk populations. Hepatitis B vaccine is now considered part of the routine childhood vaccination schedule.

In 1999, some universal hepatitis B vaccination programs for newborns were suspended due to concerns about the ingredient thimerosal (which contains mercury). All hepatitis B vaccine in the US is now thimerosal-free; unfortunately, many hospitals and physicians have not returned to “universal birth dosing” for newborns. According to the CDC (MMWR, Sept. 10, 1999;48:780-2), routine hepatitis B immunization for all newborn infants should be reintroduced immediately. This should be done even if future doses are planned using Hib-Hep B or other combination vaccines. Without universal birth dosing, completely preventable cases of and deaths from perinatal hepatitis B will continue to occur due to unrecognized maternal infection and to unrecognized horizontal transmission from an infected family member at home.

Challenges for the 21st Century
There have been substantial declines in the incidence of acute hepatitis B among highly vaccinated populations such as young children and health-care workers. During 1986 - 2000, the rate of acute hepatitis B among children aged 1 - 9 years declined by more than 80%. During 1983 - 1995, the rate of HBV infection in health-care workers declined 95% and is now lower than the rate for the general US population.

Despite progress in vaccinating American children and adults, approximately 1.2 million persons in the United States have chronic HBV infection, and an estimated 4,000 - 5,000 persons die each year from HBV-related liver diseases. The goal of eliminating the spread of HBV transmission in the United States can only be reached by maintaining a high level of immunity in all age groups. Adolescent vaccination will remain an important goal for the next decade, until the group of vaccinated infants reaches adolescence.

The greatest remaining challenge for hepatitis B prevention is the vaccination of high-risk adults. The rate of hepatitis B vaccination in this group has remained low, in part because of the difficulty in identifying candidates for vaccination before they become infected and limited public funding for adult vaccination. In testing of men aged 15 - 22 who had sex with other men, only 9% had serologic evidence of hepatitis B vaccination. Among intravenous drug users attending sexually transmitted disease clinics in San Diego from 1998 - 2001, only 6% reported previous hepatitis B vaccination.

The national health objectives for 2010 call for a reduction of 75% - 90% in acute hepatitis B cases among high-risk adults. To reach this goal, adults with behavioral risk factors for HBV infection must be vaccinated. Unfortunately, many opportunities to vaccinate high-risk adults are missed. For example, approximately 56% of adults with acute hepatitis B have received care previously in correctional facilities or STD treatment clinics, where vaccination could have been offered. The most effective approach to vaccinating high-risk adults is to integrate hepatitis B vaccination into programs that provide services to persons with risk factors for HBV infection (e.g., STD clinics, HIV counseling and testing sites, correctional facilities, and drug treatment clinics).

The CDC is working with state and local public health departments to integrate comprehensive hepatitis prevention measures, including hepatitis B vaccination, into programs providing services to persons at risk for HBV infection. In addition, the CDC has funded cooperative agreements at 18 sites around the country to identify the most effective ways to achieve integration of hepatitis B vaccination into these programs.

Unless efforts to vaccinate adults at increased risk for HBV infection are greatly expanded, we may not achieve our goal of complete elimination of HBV transmission in the United States. Conversely, attaining and sustaining high vaccine-coverage rates among infants, children, and adolescents will ensure that future generations are protected from HBV infection and its serious consequences, and that hepatitis B transmission will become a thing of the past.

This article includes information from:
Morbidity and Mortality Weekly Report, June 28, 2002
National Immunization Program
Division of Viral Hepatitis, National Center for Infectious Diseases, CDC

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.