Take aim at eliminating spread of hepatitis B virus in U.S. population

Sexual activity is responsible for almost half of new HBV infections

When discussing prevention strategies against sexually transmitted diseases (STDs) with your patients, do you discuss immunization against hepatitis B? The message may not be getting through; 42% of 1,150 adults ages 18-35 participating in a 2004 national survey did not know they could protect themselves from hepatitis B virus (HBV) infection through vaccination.1

Sexual activity is responsible for almost 50% of new HBV infections.2 As Contraceptive Technology points out, latex or synthetic condom use reduces the risk of many bacterial and viral STDs, including those transmitted primarily through genital secretions, such as HBV.3 HBV continues to be among the most frequently reported vaccine-preventable diseases in the United States. In 2003, about 73,000 individuals were infected with HBV.4 About 1.2 million people in the United States have chronic HBV infection, and an estimated 5,000 people die each year from HBV-related liver disease.5

Get ready to implement new recommendations on adult HBV immunizations from the Advisory Committee on Immunization Practices (ACIP), which aids the federal government in designing the most effective means to prevent vaccine-preventable diseases. The committee met in October to review proposed changes, the first to be implemented since 1991. While the committee voted to accept the new recommendations, they remain provisional until they are released in the Morbidity and Mortality Weekly Report, published by the Centers for Disease Control and Prevention (CDC). Recommendations on immunizations for infants, children, and adolescents were published in December 2005.6 While publication of the adult immunization recommendations is expected in 2006, a release date has not yet been set, says Eric Mast, MD, MPH, chief of the prevention branch in CDC’s Division of Viral Hepatitis.

Review recommendations

Who should receive HBV vaccination? According to the provisional ACIP recommendations, candidates include:

All unvaccinated adults at risk for HBV infection and all adults seeking protection from HBV infection. Acknowledgment of a specific risk factor is not a requirement for vaccination. (See listing of risk groups.)

In settings where a high proportion of adults are likely to have risk factors for HBV infection, all unvaccinated adults should be assumed to be at risk and should receive hepatitis B vaccination. These settings include STD treatment facilities, HIV testing facilities, HIV treatment facilities, facilities providing drug abuse treatment and prevention, correctional facilities, health care settings serving men who have sex with men (MSM), chronic hemodialysis facilities and end-stage renal disease programs, and institutions and nonresidential day care facilities for developmentally disabled persons.

Standing orders should be implemented to identify and vaccinate eligible adults in primary care and specialty medical settings. If ascertainment of risk for HBV infection is a barrier to vaccination in these settings, providers may use alternative vaccination strategies such as offering hepatitis B vaccine to all unvaccinated adults in age groups with highest risk for infection, such as those younger than age 45.7

Some in the public health field had looked to ACIP to recommend an age-based, universal hepatitis B vaccination strategy for adults.8 Routinely immunizing adults against hepatitis B would only be needed for a limited period, since the program would serve as a "catch-up" to vaccinate those adults who have not yet benefited from child and adolescent vaccination programs.9

An age-based strategy was considered by ACIP, says Mast; however, the strategy that was approved by the committee emphasizes achieving high vaccine coverage among people at risk because approximately 85% of new hepatitis B cases occur in persons with well-defined risk characteristics.

The committee recommended that as part of routine services, all primary care and specialty medical settings (e.g., physicians’ offices, family planning clinics, community health centers, liver disease clinics, and travel clinics) should implement standing orders to identify at-risk adults who should be vaccinated and to administer hepatitis B vaccination to unvaccinated adults, Mast says. In addition, providers should help patients assess their need for hepatitis B vaccination by obtaining a history of risks for sexual transmission and percutaneous or mucosal exposure to blood. If ascertainment of risk for HBV infection is a barrier to hepatitis B vaccination, providers are encouraged to use other vaccination strategies, such as vaccinating all people younger than than 45 years of age, which is the age group with the highest risk of infection, explains Mast.

"The recommendations give flexibility to clinicians to implement age-based vaccination strategies if those are required to achieve high vaccine coverage among adults who need to be vaccinated, which is what we are trying to achieve," Mast says.

STD clinics have been increasingly implementing HBV vaccination programs, and the ACIP’s new recommendations will strengthen their efforts to routinely administer vaccine to adults, says Mast. However, substantial gains will need to be made if public health officials are to achieve the federal government’s Healthy People 2010 goal for 90% of STD clinics to routinely offer hepatitis B vaccines to all STD clients.10

Frequent barriers to integrating hepatitis B programs into STD clinic services are lack of funding, lack of resources to track patients, patient noncompliance, and lack of awareness about the hepatitis B vaccine, says Lisa Gilbert, PhD, director of research at the American Social Health Association (ASHA) in Research Triangle Park. Gilbert served as lead author of an ASHA study of STD clinic and program managers, designed to check the progress of implementing HBV prevention programs in STD treatment facilities.11 While researchers found that HBV policies and vaccination and education efforts in STD clinics have improved, hurdles are left to be cleared.

"To increase integration efforts, STD clinics need more resources including funds, vaccine, training, and educational materials for clients and health care providers," she notes.

References

  1. American Social Health Association. Hepatitis A & Hepatitis B: The Only Vaccine-Preventable STDs. Fact sheet. Accessed at: www.ashastd.org/pdfs/Surveygraphic.pdf
  2. Alter MJ. Epidemiology and prevention of hepatitis B. Semin Liver Dis 2003; 23:39-46.
  3. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology: 18th revised edition. New York City: Ardent Media; 2004.
  4. Centers for Disease Control and Prevention. Disease burden from viral hepatitis A, B, and C in the U.S. Accessed at: www.cdc.gov/ncidod/diseases/hepatitis/resource/dz_burden02.htm.
  5. Centers for Disease Control and Prevention. Hepatitis B virus: A comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991; 40:1-19.
  6. Mast EE, Margolis HS, Fiore AE, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part 1: Immunization of infants, children, and adolescents. MMWR 2005; 54(RR-16):1-31.
  7. Centers for Disease Control. Provisional Recommendations. Advisory Committee on Immunization Practices (ACIP) Voted to Approve the Following Recommendations — October 2005. Accessed at: www.cdc.gov/nip/recs/provisional_recs/hepB_adult.pdf.
  8. Landers SJ. Hepatitis B vaccine considered for all adults. AMNews 2005; accessed at: www.ama-assn.org/amednews/2005/09/26/hlsa0926.htm.
  9. Handsfield HH. Hepatitis A and B immunization in persons being evaluated for sexually transmitted diseases. Am J Med 2005; 118 Suppl 10A:69S-74S.
  10. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health, 2nd ed. Washington, DC: U.S. Government Printing Office; November 2000.
  11. Gilbert LK, Bulger J, Scanlon K, et al. Integrating hepatitis B prevention into sexually transmitted disease services: U.S. sexually transmitted disease program and clinic trends — 1997 and 2001. Sex Transm Dis 2005; 32:346-350.