1. Impact of Childhood Hepatitis A Vaccination: New York City Vikki Papadouka, PhD, MPH Jane R. Zucker, MD, MSc Sharon Balter, MD Vasudha Reddy, MPH Kristen Moore, MPH Amy Metroka, MSW New York City Department of Health and Mental Hygiene March 7, 2007

2. Overview of Presentation Hepatitis A: background, epidemiology, effect of vaccine recommendation prior to 2005 Implementation of universal vaccine recommendation in NYC –Data on vaccine uptake through the Citywide Immunization Registry (CIR) –Data on the effect of vaccination on hepatitis A cases reported

3. Hepatitis A Symptoms: fever, malaise, nausea, abdominal discomfort, jaundice –Up to 70% of infected children < 6 are asymptomatic Transmission: fecal-oral Pre-vaccine era (<1996) : 22,000-36,000 cases/year, representing an estimated 271,000 infections in the US annually 100 deaths/year from acute liver failure Mortality 0.3-0.6% among infected; can reach 1.8% among adults > 50 years of age

5. Distribution of Reported Hepatitis A Cases by State Vaccination Recommendations* 1990-1997 average N=~27,500 2004 average N=~6,000 *CDC data

6. Hepatitis A Rates among Children, 2004 Rate > 5/100,000 Rate 2-5/100,000 Rate <2/100,000

7. Hepatitis A Vaccine Recommendation In October 2005, ACIP recommended universal vaccination for children 12-23 months Catch up for older children 2 dose schedule, 6 months minimum interval In NYC: in December 2005 providers notified through CIR CIR used to measure uptake

8. CIR Profile NYC Health Code requires reporting to CIR by all immunizing providers: –1997: children < 8 years of age –2005: children and adolescents < 19 years of age > 1700 pediatric provider facilities and offices in NYC –~ 76% report regularly –> 85% of immunizations given Reporting method: –Electronic files: 55% of immunizations –On-line: 14% of immunizations –Paper: 31% of immunizations –Birth certificates loaded weekly

9. Hepatitis A Vaccine Doses Administered

10. Hepatitis A Vaccine Coverage by Age: Method Used To calculate coverage rate for each age group per month, divided # of children vaccinated in that month by monthly birth cohort In NYC birth cohort/month is ~ 10,000 children. –For 12-23 month olds, the denominator was 10,000 –For 24-59 month olds (3 cohorts), the denominator was 3 x 10,000

11. Hepatitis A Vaccination by Age

12. Hepatitis A Vaccine Coverage Rate per CIR: 2006 12-23 month olds –1 dose: ~28% –2 doses: ~7% 24-59 month olds –1 dose: ~ 17% –2 doses: ~4.5%

13. Hepatitis A Surveillance, New York City Prior to universal vaccine recommendation, approximately 300 acute cases/year Before July 2005, investigations only for case- reports received ≤ 10 days of diagnosis After July 2005 more timely reporting and additional funding: ALL case-reports investigated Allowed for the collection of better risk factors data and the identification of disproportionately affected neighborhoods

14. Highest Rates of Hepatitis A cases per 100,000 population: 2005, NYC NeighborhoodOverall Rate< 5 years Downtown Heights - Slope7.531.7 East New York5.219.5 Kingsbridge/ Riverdale6.719.4 Flushing-Clearview4.314.0 West Queens4.69.6 Fordham-Bronx Park5.28.9 Hunts Point-Mott Haven4.98.8 Long Island City-Astoria3.27.7 High Bridge – Morrisania5.85.5 Washington Heights- Inwood3.75.4 Crotona-Tremont5.0

16. Targeting High Rate Neighborhoods In May 2006, DOHMH recommended catch- up for children in neighborhoods where the infection rates where > 5/100,000 –Providers notified through CIR –Outreach to parents through schools based on zip code Tracked adoption of recommendations in CIR

17. Uptake of Hepatitis A Vaccine in Targeted Neighborhoods vs. NYC Letter to targeted neighborhoods

18. Coverage Rates in Targeted Neighborhoods: 2006 Coverage rates in targeted neighborhoods were higher than the city overall –38%* for 12-23 month olds (vs. 29%** for NYC) –23%* for 24-59 month olds (vs. 16%** for NYC) *p <.001 **Rates are slightly different than overall rates- they only include children with a valid NYC address

19. Impact of Vaccination on Hepatitis A Case Reports in NYC

20. Symptomatic Hepatitis A Cases: 2005 vs. 2006 2005 – prior to universal recommendation 2006 – after universal recommendation Age groupNRate per 100,000* N < 5 years 122.240.7 5 – 18 years 453.2271.9 > 18 years 731.2380.6 All ages 1301.6690.9 *Rates are calculated for July through December

21. Summary Hepatitis A vaccination successful, good uptake in the first year of recommendation Surveillance showed a 47% reduction in cases for all ages and a 67% reduction for children < 5 Consistent with literature: with moderate vaccine coverage rates in children, large reductions in hepatitis A cases among all ages A registry can help monitor uptake and identify differences in vaccination practices –Allows a timely assessment of vaccine recommendation adoption

22. Future work Will continue monitoring uptake though the CIR in the second year of recommendation to ensure that rates continue to improve Will notify providers of their good work in immunizing children against hepatitis A – encourage them to improve Analyze this year’s surveillance data for risk factors; outreach to the groups where most of the cases come from

23. Thank you!

24. Hepatitis A Rates, from July through December

25. Proportion of Children from Targeted Neighborhoods with a Hepatitis A Letter to targeted neighborhoods

26. Proportion of Children from a Targeted Neighborhood with a Hepatitis A and MMR

27. Demographics of Confirmed/Probable Cases, 7/05- 7/06 (N = 179)—older data N%NYC rate/100,000 0-4 years169%3.0 5-9 years2514%4.5 10-19 years3821%3.6 20-44 years7140%2.2 45-59 years169%1.2  60 years 116%0.9

28. Demographics of Confirmed/Probable Cases, 7/05- 7/06 (N = 179)—older data N% NYC rate/100,000 National rate/100,000 Hispanic8648%4.02.8 White NH4022%1.4 Black NH84%0.41.0 Asian/Pac Islander 2111%2.72.8 Unknown2413%

29. Hepatitis A Cases, New York City, 2005 Ethnicity of acute cases (N=286) –Hispanic: 112 (39%); rate 5.2/100,000 –White, NH: 51 (18%); rate 1.4/100,000 Cases under 18 reporting international travel: 59/101 (58%) –Of these, 59% reported travel to the Dominican Republic, Mexico, Ecuador –Of these, 56% were diagnosed in Sept & Oct which resulted from infection during summer travel

30. Characteristics of Hepatitis A Cases in High Rate Neighborhoods: NYC, 2005 Similar to national data, rate of disease was higher among Hispanic populations –Hispanic: 5.2/100,000 (n=112; 39%) –All cases: 3.6/100,000 (n=286) –The 11 high rate neighborhoods accounted for 42% of all cases (121/286)

31. International Travel among Hepatitis A Cases: NYC, July 2005 to July 2006 54% (99/185) of cases reported international travel 71% (54/76) of cases <18 years of age reported international travel –Most frequently visited countries were the Dominican Republic, Mexico, Ecuador –Overall, 55% of children <18 years of age were diagnosed in September and October which resulted from infection during summer travel

32. Symptomatic Hepatitis A Cases: by ethnicity 2005 – prior to universal recommendation 2006 – after universal recommendation Race/EthnicityN (%)Rate per 100,000 N Hispanic73 (56%)3.437 (54%)1.7 White Non- Hispanic 27 (21%)1.05 (7%)0.2 Asian4 (3%)13 (19%) Pacific Islander 4 (3%)0 Unknown1512 Total13069

33. Importance of Vaccinating Children 1-5 years of Age 70% of children in this age range may be asymptomatic Between 25-50% of adults with no clear risk factor have contact with asymptomatic child Recent evidence suggests that asymptomatic pediatric travelers are a factor in silent transmission in the US

34. 0 5 10 15 20 25 199019911992199319941995199619971998199920002001200220032004 cases per 100,000 population <2 yr 2 - 18 19+ yrs Hepatitis A Incidence by Age, 1990-2004

35. Drop from ~35,000 cases reported prior to 1999, to ~6,000 cases in 2004 Non Hispanic Hispanic