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Hep Express Issue 23

ABBREVIATIONS: ACIP, Advisory Committee on Immunization Practices; CDC, Centers for Disease Control and Prevention; DVH, Division of Viral Hepatitis; HAV, hepatitis A virus; HBV, hepatitis B virus; HCV, hepatitis C virus; IAC, Immunization Action Coalition; IDU, injection drug user; MMWR, Morbidity and Mortality Weekly Report; MSM, men who have sex with men; STD, sexually transmitted disease; VIS, Vaccine Information Statement; WHO, World Health Organization.

(1 of 9)
November 18, 2004

[The following is cross posted from the Immunization Action Coalition's "IAC EXPRESS" electronic newsletter, 11/8/04.]

CDC published "Acute Hepatitis B Among Children and Adolescents--United States, 1990-2002" in the November 5 issue of MMWR. The article is reprinted below in its entirety, excluding references, two figures, and a table.


Since the 1991 adoption of a comprehensive strategy to eliminate hepatitis B virus (HBV) transmission in the United States, the incidence of acute hepatitis B cases has declined steadily. Declines have been greatest among children born after the 1991 recommendations for universal infant hepatitis B vaccination were implemented. In 1995, the elimination strategy was expanded to include routine vaccination of all adolescents aged 11-12 years and, in 1999, to include children aged <18 years who had not been vaccinated previously. To describe the epidemiology of acute hepatitis B in children and adolescents in the United States, CDC analyzed notifiable disease surveillance data collected during 1990-2002 and data collected during 2001-2002 through enhanced surveillance of reported cases of acute hepatitis B in children born after 1990. This report summarizes the results of that analysis, which indicated that the rate of acute hepatitis B in children and adolescents decreased 89% during 1990-2002 and that racial disparities in hepatitis B incidence have narrowed. Many confirmed cases in persons born after 1990 occurred among international adoptees and other children born outside the United States. Continued implementation of the hepatitis B elimination strategy and accurate surveillance data to monitor the impact of vaccination are necessary to sustain the decline of acute hepatitis B among children.

Cases of acute hepatitis B were reported weekly to CDC by all 50 states and the District of Columbia. Acute hepatitis B rates were calculated per 100,000 population by using population denominators from the U.S. Census Bureau. Acute hepatitis B was defined as an acute illness with (1) discrete onset of symptoms and jaundice or elevated serum aminotransferase levels and (2) laboratory evidence of either IgM antibody to hepatitis B core antigen (IgM anti-HBc) or hepatitis B surface antigen (HBsAg). Since March 2001, CDC has conducted enhanced hepatitis B surveillance, contacting states to confirm all reported cases of acute hepatitis B in persons born after 1990. State surveillance staff members were asked to verify each of the items in the case definition and provide information regarding vaccination history and country of birth. If errors were identified during this process, states were asked to correct the information in an updated submission to CDC.

National Surveillance
During 1990-2002, a total of 13,829 cases of acute hepatitis B were reported in the United States among persons aged <=19 years. The incidence of reported cases declined steadily during this period, from 3.03 per 100,000 population in 1990 to 0.34 in 2002, representing a decline of 89%. The incidence among adolescents aged 15-19 years was consistently higher than the incidence among younger age groups, ranging from 8.69 per 100,000 population in 1990 to 1.13 in 2002. Children and adolescents in all age groups experienced steep declines in incidence during 1990-2002; incidence declined 94% among children aged 0-4 years, 92% among children aged 5-9 years, 93% among those aged 10-14 years, and 87% among adolescents aged 15-19 years.

Among children and adolescents aged <=19 years in 1990, incidence per 100,000 population was highest among Asian/Pacific Islanders (A/PIs) (6.74) and blacks (4.29); whites had the lowest race-specific incidence (1.39). Differences in incidence between whites and A/PIs and between whites and blacks were 5.34 and 2.90, respectively. From 1990 to 2002, rates declined 92% among A/PIs, 88% among whites, 88% among blacks, and 84% among American Indians/Alaskan Natives (AI/ANs). In 2002, the highest incidence per 100,000 population was among A/PIs (0.55), followed by blacks (0.51), AI/ANs (0.43), and whites (0.16); since 1990, differences in incidence between whites and A/PIs and whites and blacks declined by 93% and 88%, respectively.

Case Investigations
Follow-up investigations conducted by CDC and state and local health departments verified 19 case reports from 2001 and 2002 as cases of acute hepatitis B among children born after 1990. Of the verified case reports, 12 (60%) involved males, eight (42%) involved children aged <2 years, and 11 (58%) involved children born in the United States. Seven (37%) reported race as A/PI, five (26%) as white, four (21%) as black, and three (16%) as unknown. Eight (42%) cases were reported in children born outside the United States, including six international adoptees (32%). Receipt of >=1 dose of hepatitis B vaccine was confirmed in three (16%) cases. Vaccination status was unknown for 12 cases (63%).

Editorial Note:
The incidence of acute hepatitis B cases in U.S. children and adolescents decreased during the era of universal childhood vaccination. This decline coincided with an increase in hepatitis B vaccination coverage among children aged 19-35 months, from 16% in 1992 to 90% in 2002, and among adolescents aged 13-15, from nearly 0 in 1992 to 67% in 2002.

Declines in incidence were observed for children of all races, including A/PIs, whose rates historically have been higher than the national average. Because of the disproportionate burden of hepatitis B in A/PI communities, A/PI children were among the first groups for whom hepatitis B vaccination was recommended. The reduction of the disparity between A/PIs and other children is consistent with recent observations noting a decline in seroprevalence of HBV infection and successful implementation of routine hepatitis B vaccination among Asians who have recently immigrated to the United States. However, of the 11 verified cases during 2001-02 of acute hepatitis B among children born in the United States, three (27%) involved A/PIs. Although the national origins of these children's household members are unknown, the substantial proportion of A/PIs suggests that horizontal transmission of HBV among first-generation Asians might be a persistent problem.

The higher incidence among older adolescents (aged 15-19 years) likely is attributable to their having been born before universal infant hepatitis B vaccination was recommended in 1991. Incidence among older adolescents is expected to decline further as the vaccinated cohort ages and as 1999 recommendations to vaccinate all previously unvaccinated persons aged 0-18 years are fully implemented. The expected decline in rates among adolescents also might be augmented by laws in 32 states requiring proof of hepatitis B vaccination before entry into middle school.

Follow-up information obtained through surveillance of reported cases suggests that children born outside the United States, especially international adoptees, represent a substantial proportion of cases. Cases of acute hepatitis B among international adoptees might result from undervaccination and increased risk for exposure while living in areas with high prevalence of chronic HBV infection. International adoptees are exempt from U.S. regulations that bar entry to immigrants without documentation of hepatitis B vaccination. Studies have demonstrated that international adoptees exhibit low rates of protective titers of antibodies to vaccine-preventable diseases upon arrival in the United States, including adoptees with written evidence of age-appropriate vaccination provided by the birth country. Appropriate evaluation and remediation of the immunization status of international adoptees has been promoted through national guidelines; however, the extent to which these guidelines have been implemented is unknown.

Despite the decline in acute hepatitis B cases among children in the United States, the presence of confirmed cases highlights the importance of infant vaccination and timely completion of the 3-dose vaccination series. The vaccination series should be started at birth, preferably before the newborn is discharged from the hospital. Infants born to women who are HBsAg positive or who have not had prenatal HBsAg testing should receive the first dose of hepatitis B vaccine within 12 hours of birth. Beginning the vaccination series at birth decreases the risk for perinatal HBV transmission and predicts successful completion of the series.

Although enhanced surveillance data from verified case reports suggest that international adoptees and other children born outside the United States might particularly benefit from future prevention efforts, many case reports lacked risk factor information. As the incidence of acute hepatitis B among children and adolescents declines, accurate surveillance data become increasingly important to monitor the effect of immunization recommendations. Continued efforts of local, state, and national surveillance staff to improve data quality are critical to eliminating HBV transmission in the United States.


To access a web-text (HTML) version of the complete article, go to: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5343a4.htm

To access a ready-to-copy (PDF) version of this issue of MMWR, go to:

To receive a FREE electronic subscription to MMWR, go to:
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(2 of 9)
November 18, 2004

[The following is cross posted from the Immunization Action Coalition's "IAC EXPRESS" electronic newsletter, 11/1/04.]

Dated 8/4/04, the current version of the VIS for hepatitis A vaccine is now available on the IAC website in eight additional languages: Arabic, Armenian, Cambodian, Farsi, Haitian Creole, Hmong, Korean, and Vietnamese. IAC gratefully acknowledges the Massachusetts Department of Public Health for the Haitian Creole translation and the California Department of Health Services for the remaining translations.

PLEASE NOTE: When hepatitis A vaccine is added to the Vaccine Injury Compensation Program's injury table, presumably later in 2004, another hepatitis A vaccine VIS will be issued. To avoid large printing expenses, print off only as many of the 8/4/04 VISs as you anticipate needing for the next several months.

To obtain a ready-to-copy (PDF) version of the VIS for hepatitis A vaccine in ARABIC, go to:

To obtain it in ARMENIAN, go to:

To obtain it in CAMBODIAN, go to:

To obtain it in FARSI, go to:

To obtain it in HAITIAN CREOLE, go to:

To obtain it in HMONG, go to:

To obtain it in KOREAN, go to:

To obtain it in VIETNAMESE, go to:

To obtain it in ENGLISH, go to:

For information about the use of VISs, and for VISs in a total of 32 languages, visit IAC's VIS web section at http://www.immunize.org/vis
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(3 of 9)
November 18, 2004

CDC's Division of Viral Hepatitis has developed a three-part slide set for high school students, designed to give adolescents basic information and raise awareness about HAV, HBV, and HCV. The set can be used as a resource for science or health projects, as an outline for a teaching tool, or as reference material to inform others (e.g., family, friends).

Click here to view or download this resource.
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(4 of 9)
November 18, 2004

The Hepatitis B Birth Dose Program is an initiative of the New York State Department of Health (NYSDOH) that provides free hepatitis B vaccine to any birthing hospital in New York State that agrees to adopt a universal hepatitis B birth dose policy. Since October 2003, the program has enrolled 50 (out of 113) upstate and 25 (out of 45) New York City birthing hospitals.

Hospitals may participate in the program by submitting a brief application, along with their birth dose policy, to NYSDOH for review. The policy must clearly show that all newborns will be routinely vaccinated against hepatitis B at birth regardless of maternal hepatitis B surface antigen status, infant's insurance status, or individual physician preference.

The provision of hepatitis B vaccine to all infants at birth provides a safety net to high-risk infants who do not receive appropriate prophylactic treatment against HBV transmission at birth, and to infants who are exposed to HBV postnatally from another family member or caregiver.

In a 2002 survey of New York State birthing hospitals, cost of vaccine was identified as a barrier to vaccinating infants at birth by many hospitals. Through this new program, NYSDOH hopes to eliminate additional hospital costs for vaccine purchase while improving hospital compliance with recommended standards of care.

Questions regarding the program can be directed to Perinatal Hepatitis B Program Manager Elizabeth Herlihy, RN, MS, at (518) 473-4437 or EJH04@health.state.ny.us
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(5 of 9)
November 18, 2004

The Illinois Chapter of the American Academy of Pediatrics (AAP) and the Illinois Department of Public Health collaborated on a study titled: "Report of Illinois Birthing Hospital Practices with Respect to the Administration of the Hepatitis B Birth Dose Vaccine and Hospital Participation in the Vaccines for Children-Plus Program."

The first four study objectives were

  1. Assess Illinois birthing hospital practices and policies with respect to administration of the hepatitis B vaccine to newborns prior to hospital discharge.
  2. Identify strategies to increase the hepatitis B birth dose vaccination rate in Illinois.
  3. Determine how many Illinois birthing hospitals are currently enrolled in the Vaccines for Children-Plus (VFC-Plus) program. [VFC-Plus provides hospitals with vaccines, such as that for hepatitis B, for children who do not have insurance or for whom private insurance will not pay.]
  4. Identify factors impacting enrollment/non-enrollment into the VFC-Plus program.

The study found that the establishment of hospital policies, and more importantly, written standing orders for administration of the hepatitis B birth dose correlated with significantly higher hepatitis B birth dose administration rates. Hospitals enrolled in the Illinois VFC-Plus program demonstrated significantly higher hepatitis B birth dose vaccination rates when compared with non-enrolled hospitals.

The study is an excellent example of collaboration between a state public health department and the state AAP chapter and can be used to stimulate discussion and planning in other states.

To read the report online, go to:
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(6 of 9)
November 18, 2004

[The following is cross posted from the Immunization Action Coalition's "IAC EXPRESS" electronic newsletter, 11/1/04.]

CDC recently posted the following notice on the Viral Hepatitis section of the National Center for Infectious Diseases' (NCID) website.



BD and Abbott Diagnostics have initiated an investigation concerning the increased rate of initial and/or repeat reactive results for the AUSZYME Monoclonal test when using BD Vacutainer SST Plus tubes. As described in the AUSZYME package insert, reactive specimens should be repeated in duplicate. If either of the repeats is positive, the sample should then be tested with a licensed neutralizing confirmatory test, such as the HBsAg Confirmatory Assay. Only those specimens in which the HBsAg can be neutralized by the confirmatory test procedure may be designated as positive for HBsAg. All highly sensitive immunoassay systems have a potential for nonspecific reactions. The specificity of a repeatedly reactive specimen can be confirmed by neutralization tests.


To access the notice, go to: http://www.cdc.gov/ncidod/diseases/hepatitis/new.htm#top Click on the link titled "False positive HBsAg tests noted."

Click here for additional technical or product-related information or to read the BD technical bulletin.

If you have identified a cluster of infants born to false-positive HBsAg mothers, who because of the false-positive results, have been monitored as if they were born to HBsAg-positive mothers, please call Susan A. Wang, MD, MPH, at NCID at (404) 371-5953.
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(7 of 9)
November 18, 2004

IAC recently revised two of its long-standing hepatitis B education pieces.

"Hepatitis B Shots Are Recommended for All New Babies" is a brochure targeted at expectant or new parents who might question the need for, or timing of, infant vaccination against HBV.

To access a ready-to-copy (PDF) version of "Hepatitis B Shots Are Recommended for All New Babies," go to:

To access a web-text (HTML) version of it, go to:

"Hepatitis B Information for Asian and Pacific Islander Americans" was created to answer the questions of Asian and Pacific Islander Americans (APIA), including immigrants and refugees, as well as persons of APIA descent born in the United States. The revised version includes an updated list of related organizations that readers might wish to contact.

To access a ready-to-copy (PDF) version of "Hepatitis B Information for Asian and Pacific Islander Americans," go to:

To access a web-text (HTML) version of it, go to:
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(8 of 9)
November 18, 2004

IAC recently mailed the latest issue of "VACCINATE ADULTS" (October 2004) to 100,000 health professionals and others who work in the field of immunization. Packed with immunization resources for health professionals and patients, the 12-page issue is well worth downloading. All articles and education pieces, except editorials, have been thoroughly reviewed by immunization and hepatitis experts at CDC.

PLEASE NOTE: Current as of September 2004, the resources in the October "VACCINATE ADULTS" do not contain the most recent information on influenza vaccine and vaccine supply. On October 5, ACIP developed interim influenza vaccine recommendations in response to Chiron Corporation's announcement that its trivalent inactivated influenza vaccine will not be available in the United States for the 2004-05 influenza season. The information in the interim recommendations is not reflected in any of the influenza information published in the October "VACCINATE ADULTS."

You can view selected articles from the table of contents below or download the entire issue from the Web.

To view the table of contents with links to individual articles, go to:

The PDF file of the entire issue, linked below, is large at 608,197 bytes. Some printers cannot print such a large file. For tips on downloading and printing PDF files, go to: http://www.immunize.org/nslt.d/tips.htm

To download a ready-to-copy (PDF) version of the October issue, go to:
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(9 of 9)
November 18, 2004

The Viral Hepatitis Prevention Board (VHPB) website has been updated to include a new issue of the publication "Viral Hepatitis."

"Viral Hepatitis," Volume 13, Number 1, is prepared from material presented at the VHPB meeting on March 11-12, 2004, in Sevilla, Spain. The topic of this meeting was "Hepatitis B vaccine: long-term efficacy, booster policy, and impact of HBV mutants on hepatitis B vaccination programmes."

To access the ready-to-copy (PDF) versions of this issue, go to:

To access the home page of the VHPB website, go to:

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