1. ‏Hepatitis B Eliminating Transmission Preventing Disease* John W. Ward, M.D. Division of Viral Hepatitis Centers 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

2. US Disease Burden of Hepatitis B Total HBV infection~14 million (5%) Chronic HBV 1-1.4 million Other blood-borne infections Chronic HCV3 million HIV 1 million

3. Global Disease Burden of Hepatitis B Total HBV infection2 billion Chronic HBV 370 million Other blood-borne infections Chronic HCV130 million HIV 40 million

4. Geographic Distribution of Chronic HBV Infection HBsAg Prevalence  8% - High 2-7% - Intermediate <2% - Low

5. Immigrants Admitted For Permanent Residence, 1994-2003, by HBV Endemicity 1 HBV Endemicity No.(%)No.(%) High (>8%) 2,364,561(26)270,400(67) Intermediate (2-7%) 3,044,963(33)107,264(26) Low (<2%) 3,779,779(41)28,879(7) Total9,189,303406,543 Immigrants2 Estimated HBsAg-positive 3 1. Country of birth 2. Yearbook of Immigration Statistics, Dept. of Homeland Security 3. Based on country-specific HBsAg prevalence estimates

6. Age-Adjusted HCC Mortality Rates Among Males, by Race and Year, 1990-2002; n=77,107

7. ‏Prevention of HBV Transmission

8. 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

9. 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) Advisory Committee on Immunization Practices US Strategies to Eliminate HBV Transmission

10. *Aged 19-35 months Source: National Immunization Survey HP 2010 target Hepatitis B Vaccine Coverage Among Children* United States, 1995-2003 White Black Hispanic Asian-Pacific Islander

11. Effectiveness of Hepatitis B Immunization Among API Children, Hawaii and Georgia HBsAg Anti-HBc Sources: Pediatrics 1993, N Engl J Med 1989, CDC, GA Health Dept, HI Health Dept. Before vaccination 2001 (n=2470) 1989 (n=2701) 1.6% 0.04% 4.5% 0.2% 99% vaccine coverage 2002 (n=157) 1986 (n=251) 6.6% 0.6% 11.7% 0.6% Before vaccination 98% vaccine coverage Hawaii Georgia

12. Hepatitis B Incidence Among Persons <19 Yrs By Race/Ethnicity, 1990-2004 Asian/Pacific Islander Black AI/AN Hispanic White Overall decline ~ 93% Decline among API ~ 95% Year Cases/100,000

13. Hepatitis B Incidence Among Persons ≥19 Yrs By Race/Ethnicity, 1990-2004 Asian/Pacific Islander AI/AN Black Hispanic White Overall decline ~ 75% Decline among API ~ 85%

14. 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

15. Global Status of Hepatitis B Immunization Programs (2005) Countries with hep B programs: ~80% Global HepB3 coverage: ~40%

17. Adult Hepatitis B Vaccine Coverage, United States,2002 0 10 20 30 40 50 60 19-2021-2526-3031-4041-5051-6565+ National Health Interview Survey Age group, yrs Vaccine coverage, % Vaccination of 0-18 yrs recommended

18. Reported Acute Hepatitis B Incidence, By Age and Sex, United States, 2004 3.9 6.2 6.3 6.0 6.2 5.1 3.8 2.6 1.7 0.1 0.0 0.1 0.7 0.1 0.0 0.1 1.1 0.8 1.3 2.0 2.7 3.6 4.4 4.0 4.2 3.1 <5 10-14 20-24 30-34 40-44 50-54 60+ Age group Rate per 100,000 persons 5-9 15-19 25-29 35-39 45-49 55-59 MaleFemale

19. Reported Risk Factors for Acute Hepatitis B in the U.S. (2001-2004) 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) Heterosexual – contact w/ confirmed or suspected case (10%) IDU (13%) MSM (23%) Other 1 (5%) No Identified Risk (25%) Heterosexual – > 1 opposite sex partner in past 6 months (22.3%)

20. Estimated Hepatitis B Vaccine Coverage in Adults Risk Group Coverage Estimate (year, site) Occupationally- exposed workers 75% (2002-2003, national) Dialysis patients56% (2002, national) Men who have sex with men 16% (1998-2001, San Diego) Injection drug users STD clinic clients 6% (1998-2001, San Diego) 10% (1998-2001, San Diego)

21. 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

22. Chronic HBV Infection

23. 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 Burden of Chronic HBV Infection United States

24. FDA Approved Therapies for Chronic Hepatitis B Interferon alpha-2b (Intron A) Adefovir (Hepsera) Epivir-HBV (Lamivudine) Entecavir (Baraclude) Others in clinical trials

25. Selected Characteristics of Chronic Hepatitis B Registries at Four Health Departments CharacteristicConnecticutMinnesotaMultnomah Cnty, OR New York State Year of inception1992198719932001 Number of cases entered2,87412,4442,3946423 Race White37%16%35%32% Black18%25%8%24% Asian/Pacific Islander44%57%56%39% Behavioral risk factors History of IDU12%4%10%--- Sexual7%5%7%--- Foreign born55%86%72%--- Other26%12%36%---

26. Deaths from Hepatitis B Vital records Reported Deaths are level by year –Year 2000 1458 deaths –Year 2001 1370 deaths –Year 2002 1350 deaths

27. Vital Records Do Not Capture All HBV-related Deaths 121 27 215

28. 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

29. 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

30. 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

31. 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