1. Implementing New ACIP Adult Hepatitis B Vaccine Recommendations Eric E
Implementing New ACIP Adult Hepatitis B Vaccine Recommendations Eric E. Mast, MD, MPH Division of Viral Hepatitis National Immunization Conference Kansas City, MO March 6, 2007

2. Outline
Progress in implementing strategy to eliminate HBV transmission
Rationale for new ACIP adult hepatitis B vaccine recommendations
Overview of CDC guidance to increase support for adult hepatitis B vaccination

3. Hepatitis B: Burden of Disease United States, 2005
New infections declining w/implementation of strategy to eliminate HBV transmission
~51,000 new infections in 2005
decline from 200, ,000 infections in 1980s
>95% of new infections among adults
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
~ deaths per year from hepatitis B-related chronic liver disease (cirrhosis, liver cancer)
Although substantial progress has been made in implementing hepatitis B vaccination programs, hepatitis B continues to be a major public health problem in the United States.
In estimated
According to data from NHANES

4. Newborn 18% Adult 59% Children 18% Adolescent 6%
Estimated Age at Infection of
Persons With Chronic HBV Infection
Before Childhood Vaccination, United States
Newborn 18%
Adult 59%
Children 18%
Because most of the morbidity and mortality associated with HBV infection occurs in persons who develop chronic infection, the primary goal of hepatitis B immunization is to prevent chronic infection.
This slide illustrates the estimated age at infection for persons with chronic infection before childhood vaccination programs.
Adolescent 6%
Sources: National Health and Nutrition Examination Survey III
N Engl J Med 1989;321:1301-5
Pediatrics 1992;89:269-73
Pediatrics 1995;96:1113-6

5. Advisory Committee on Immunization Practices
Strategy to Eliminate HBV Transmission
Prevent perinatal HBV transmission
Universal infant vaccination, beginning at birth
Catch-up vaccination of all children and adolescents <19 years
Vaccination of adults in high risk groups
Because a large burden of disease was occurring as a result of HBV transmission in all age groups, in 1991, ACIP recommeded a comprehensive immunization stratgy that was designed to eliminate transmission in all age groups. This strategy includes:

6. Estimated Hepatitis B Vaccination Coverage 19-35 Months of Age United States, 1992-2005
Routine infant
vaccination
recommended
Source: National Immunization Survey, CDC

7. States With Elementary or Middle School Hepatitis B Vaccination Requirements, 1994-200745
Elementary Schools 37
Middle Schools
Source:

8. 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
<12 years
Year
Source: National Notifiable Diseases Surveillance System, CDC

9. 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
0.6
0.5
1.7
2.4
4.3
3.0
2.9
4.2
2.9
4.5
2.3
4.5
2.2
3.4
1.7
3.0
1.3
2.2
0.6
1.1
Rate per 100,000
Source: National Notifiable Diseases Surveillance System, CDC

10. 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

11. Reported HepB Coverage Among Adults at Increased Risk for HBV Infection, 2004
Vaccine Coverage, %
Source: National Health Interview Survey, MMWR 2006; 55(18);

12. Why is there a need for renewed emphasis on adult hepatitis B vaccination?

14. HP 2010 Objective 14.3: Reduce Hepatitis B Among Adults
25-39 yrs
19-24 yrs
40+ yrs

15. New ACIP Hepatitis B Vaccine Recommendations for Adults
HepB vaccine recommended for:
all unvaccinated adults at risk
all adults seeking protection (acknowledgment of specific risk factor not required)
Vaccination strategies appropriate for practice setting to ensure all at risk adults offered HepB:
Settings w/high proportion of at risk adults
Primary care/specialty medical settings
Occupational health settings

16. Source: Sentinel Counties Study of Viral Hepatitis (n=760)
Prior Opportunities For Vaccination Among Patients With Acute Hepatitis B,
Prior Opportunity for Vaccination %
History of incarceration
40%
History of STD treatment
39%
History of drug treatment
22%
Any of the above
61%
Source: Sentinel Counties Study of Viral Hepatitis (n=760)

17. Adult 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% in jails (>4 month incarceration)
>90% in prisons (>4 month incarceration)
Feasibility established of providing HepB as part of comprehensive STD, HIV/AIDs and hepatitis prevention services

18. 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
Staff who recommend vaccination
Integrated delivery of vaccine with other services
Protected patient confidentiality
Funding for vaccine

19. ACIP Recommendations
Implemention of HepB Vaccination in Settings Where The Vaccine Series Might Not Be Completed
Concerns about completion of the vaccine series should not preclude starting the series
Each dose confers some protection
30%-55% after 1st dose
75% after 2nd dose
>90% after 3rd dose
Subsequent doses can be given outside recommended schedule because vaccine immunogenicity is not decreased by lengthened intervals between doses

20. Cost-Effectiveness Of Adult Hepatitis B Vaccination
Vaccination Strategy
Cost-effectiveness
Prison inmates1
Cost saving
Clients of STD clinics2
$3,500/life year saved
Clients of HIV testing sites2
$4,400/life year saved
Sources:
Vaccine 2002;21:
Am J Prev Med 2006;30:

21. Cost-Effectiveness Of Adult Hepatitis B Vaccination
Vaccination Strategy
Cost-effectiveness
All high-risk adults
Cost saving
All adults
$257,000/life year saved
Source: Ann Intern Med 1993;118:

22. Need For HepB Vaccination Strategies in Primary Care and 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
~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

23. Need For HepB Vaccination Strategies in Primary Care and 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
providers might not ask about risk behaviors
physician surveys conducted indicated that <50% of patients were 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

24. Fenton/Schuchat ‘Program Manager’ Letter October 10, 2006

25. Verb of the Day: Encourage
State/local health agencies are encouraged to:
“Increase their support for adult hepatitis B vaccination”
“…consider using sec. 317 funds to purchase adult hepatitis B vaccine to help public health settings implement adult hepatitis B immunization as recommended by ACIP”
Dear Colleague Letter: October 10, 2006
ACIP: Advisory Committee on Immunization Practices

26. Adult Hepatitis B Vaccine Provided By CDC Immunization Program Grantees, 2005
No. of Doses Distributed
Setting
No. (%) of grantees distributing to setting
HepB Vaccine
HepA/HepB Vaccine
STD clinics
30 (59)
27,298
15,813
HIV CTS
16 (31)
1,050
2,890
Correctional facilities
23 (45)
9,790
6,350
Needle/syringe exchange
10 (20)
322 15
Substance abuse treatment
11 (22)
262
3,030
Primary care
18 (35)
3,269
1,044
Local Health Dept
26 (51)
69,515
39,620
Other
12 (24)
2,403
278
Total
40 (78)
113,909
69,040
Source: Hepatitis C coordinator survey, 2006 (51/52 responded)

27. Source: CDC Vaccines for Adults at High Risk Survey, 2001
Estimated Annual Client Visits in Settings with High Proportion of At Risk Adults
Venue
Annual clients visits
STD clinics
1,538,547
HIV CTS
949,012
Substance abuse treatment
216,000
Prison (admissions only)
630,000
Jails
6,164,837
Total
~9.5 million
Source: CDC Vaccines for Adults at High Risk Survey, 2001

28. CCID Divisions Support for Adult Hepatitis B Vaccination*
Immunization Services Division
provide funding for adult HepB vaccine (317 grant program)
provide technical assistance:
implementation of adult HepB vaccination services
immunization registries for adults
program evaluation
Division of Viral Hepatitis
identifying at-risk populations and appropriate vaccination settings
integrating viral hepatitis prevention into other public heath services
identifying educational materials and training resources
*NCIRD/NCHHSTP Dear Colleague Letter: October 10, 2006

29. CCID Divisions Support for Adult Hepatitis B Vaccination*
Division of HIV Prevention
incorporate HepB vaccination messages into:
HIV counselor training
educational materials for MSM, IDU, HRH
promote HepB vaccination as an essential part of comprehensive prevention services in collaboration w/:
health departments
community planning groups
community-based organizations
promote routine referral for HepB vaccination in settings where direct provision of services is not feasible
*NCIRD/NCHHSTP Dear Colleague Letter: October 10, 2006
Good language from DHAP – not only incorporate hepatitis prevention but also STD prevention services

30. CCID Divisions Support for Adult Hepatitis B Vaccination*
Division of STD Prevention
integrate HepB vaccination into Prevention Training Center training activities
include HepB vaccination messages in STD prevention efforts targeting populations recommended to receive HepB vaccine
where feasible, encourage STD prevention programs to implement HepB vaccination in STD clinics
*NCIRD/NCHHSTP Dear Colleague Letter: October 10, 2006

32. Adult Hepatitis B Vaccination - Summary
Substantial progress has been made in eliminating HBV transmission; since 1990:
hepatitis B rates in children declined >95%
hepatitis B rates in adults declined >75%
Substantial burden of new infections remains
~51,000 new infections in 2005 (>95% among adults)
>85% among persons with risk characteristics
There is a time limited opportunity to accelerate elimination of HBV transmission by increasing HepB vaccine coverage among at risk adults