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May 2, 2007
IT'S HEPATITIS AWARENESS MONTH: JOURNAL OF INFECTIOUS DISEASES PUBLISHES ARTICLE ABOUT HBV TRANSMISSION BETWEEN PATIENTS IN DENTAL PRACTICE: ACCOMPANYING EDITORIAL ADVOCATES HEPATITIS B VACCINATION FOR ALL PERSONS UP TO AGE 40 YEARS

The May 1 issue of the Journal of Infectious Diseases includes an article about patient-to-patient transmission of HBV in an oral surgeon's office where investigators found no deficiencies in infection control practices. The issue also features an accompanying editorial written by preventive medicine experts Ban Mishu Allos, MD, and William Schaffner, MD, who advocate universal hepatitis B vaccination of all adults up to age 40 years. The University of Chicago Press and the authors of the editorial graciously allowed IAC to reprint the editorial in Hep Express and to post it online.

The following is the citation for the article about patient-to-patient HBV transmission in the oral surgeon's office.

"Patient-to-Patient Transmission of Hepatitis B Virus Associated with Oral Surgery"
Authors: Redd JT, Baumbach J, et al.
Source: J Infect Dis, May 1, 2007, Vol. 195(9):1311-4
Click here for abstract

The following is the text of the editorial "Transmission of hepatitis B in the health care setting: the elephant in the room... or the mouse?" by Ban Mishu Allos and William Schaffner from the May 1, 2007, issue of The Journal of Infectious Diseases, University of Chicago Press. Copyright 2007 by the Infectious Diseases Society of America. All rights reserved.

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Most infections with hepatitis B virus in the United States occur as a result of specific high-risk behaviors. Most, but not all. Approximately 1.2 million people living in the United States have chronic hepatitis B virus infection [1]. Each year, another 8000 acute infections--mostly in adults--are reported to the Centers for Disease Control and Prevention (CDC) [1]. Many of these infections are the result of sexual activity (both heterosexual and homosexual) or intravenous drug use; however, up to one-third report no risk factors for infection [2]. Although it is likely that a large number of these risk-deniers simply are unwilling to acknowledge behaviors they may view as socially stigmatizing, it also is possible that some have acquired their hepatitis B infection in nonclassical ways. The blunt epidemiologic tools used in recent decades to assess risks of transmission have been important and useful. Nevertheless, finer implements may be needed to tease out smaller but perhaps substantial risk factors.

This need is illustrated in the report published in this issue of the Journal by Redd et al. [3]. They describe a 60-year-old, white, non-Hispanic woman who was not sexually active, did not use intravenous drugs, and who had no contacts with persons with hepatitis B virus infection. She went to her dentist in October 2001 for routine tooth extractions. There, despite the oral surgeon's adherence to standard infection control precautions, she was infected with hepatitis B virus. The oral surgeon and all the office staff were tested, and none had serologic evidence of infection with hepatitis B virus. How did this happen? The meticulous investigation that ensued demonstrated that this unfortunate woman's virus was identical to virus isolated from an hepatitis B surface antigen–positive 36-year-old woman who had hepatitis B infection dating back to at least 1999. The chronically infected woman had visited the same oral surgeon on the same day and had had 3 teeth extracted just 161 min before the index patient had a similar procedure.

The authors conclude that patient-to-patient transmission of hepatitis B infection occurred in the dentist's office and also state that such transmission appears to be rare. How certain should we be that events similar to this are, indeed, rare? Ought we to be confident that the magnitude of the problem is small (the proverbial mouse), or might we be dealing with a hidden elephant? We suggest that the current burden of health care–acquired bloodborne infection is largely unknown because  only modest efforts have been made to identify such cases and quantify the risk. A series of circumstances in this particular case led to the investigation that identified the source of the 60-year-old woman's infection. The New Mexico Department of Health (DOH) did what some local and state health departments would have done--they conducted a routine investigation of the index patient's newly diagnosed hepatitis B infection. In similar circumstances, if no traditional risk factors are found, the investigation typically stops. However, for reasons that are not entirely clear, when the DOH and the CDC could find no traditional risk factors to account for this infection, they looked further. They began by searching the state's registry of patients with hepatitis B to identify the epidemiologic link between the source and index patient. Subsequent genotyping of viruses obtained from both women established that the younger woman was the source of the older woman's infection. Thus, the investigators coupled traditional "shoe leather" epidemiology to newer molecular techniques to create an even more powerful scientific tool--a tool that hopefully may one day be used by most public health investigators.

What would happen if all persons who are infected with bloodborne pathogens and who do not fit the classical epidemiologic paradigm were thoroughly investigated as was done in this case? Sixty-year-old women who are not sexually active and do not use intravenous drugs ought not to be getting infected with hepatitis B or other bloodborne viruses. In similar circumstances, other health departments also must be curious and motivated and have sufficient infrastructure to track down the source of infection. Special efforts should be made to identify potential exposures in medical, surgical, or dental settings.

Fear of transmission of bloodborne viruses in the health care setting reached almost hysterical levels in the early 1990s when a 19-year-old woman and 5 other persons were shown to have been infected with HIV by their dentist during routine dental procedures [4]. In 3 other published reports, epidemiologic studies and DNA analysis confirmed that an HIV-positive physician or nurse had transmitted HIV to a patient [5–8]. For a period of time, a flurry of "look-back" investigations of patients of HIV-infected health care workers was done and did not identify additional cases of transmission [9, 10]. Nosocomial transmission of hepatitis B virus is 100-fold more efficient than transmission of HIV [11] and once was a commonly reported event. Surgeon-to-patient and dentist-to-patient transmissions of hepatitis B were essentially eliminated when vaccination of health care workers became routine. Nevertheless, in the past 10 years, 91 cases of health care worker–to-patient transmission of hepatitis B virus occurred in settings where no breaches in infection control practices could be identified; 38 cases of health care worker–to-patient transmission of hepatitis C transmission have been reported [5].

To prevent future hepatitis B virus transmissions between patients in medical settings, the authors encourage strict adherence to standard infection control practices in dental settings. Although we also are strongly in favor of meticulous maintenance of bloodborne pathogen infection control standards in all medical settings, it is apparent that such practices were inadequate in blocking the movement of hepatitis B virus from the source to the index patient in the Redd et al. report. There and in other instances [12, 13] investigators have been unable to explain how the virus traveled from person A to person B--and that is troubling. It is troubling because it suggests that there are aspects of transmission of bloodborne disease that remain poorly understood. It also illuminates the insufficiency of the prevention message to this oral surgeon. If the oral surgeon could go back in time and reenact the day of transmission, one cannot make specific suggestions that anything should have been done differently because no infection control deviations were found.

Redd et al. report that they contacted and tested 25 patients who had procedures done at the oral surgery center during the same week but after the source patient's procedure. Only 16 (64%) had been previously vaccinated for hepatitis B. It is not surprising that the rate of vaccination among persons <25 years of age (93%) greatly exceeded that of persons >=25 years of age (20%) (P<.001). We advocate adoption of another prevention strategy: universal hepatitis B virus vaccination of all adults up to 40 years of age. Sadly, but not surprisingly, the current risk-based vaccination recommendations endorsed by the Advisory Committee on Immunization Practices have resulted in meager vaccination rates for persons in high-risk groups. Fewer than 10% of young adults with high-risk behaviors (intravenous drug users, persons with multiple sex partners, and men who have sex with men) have received hepatitis B virus vaccine [14, 15].

In the United States, the majority of new cases of hepatitis B infections occur in adults [16]. Universal hepatitis B vaccination policies produced dramatic declines in the incidence of acute hepatitis B infection in children [16]. In contrast, despite the availability of an effective and safe vaccine for adults, rates of acute hepatitis B virus infection in many adult age groups have plateaued or continue to increase [1]. Universal age-based recommendations might have prevented both the source patient's infection and subsequent transmission to the index patient in the oral surgeon's office.

Bloodborne viruses such as HIV, hepatitis B, and hepatitis C that may be transmitted in health care settings continue to present challenges to hospitals, physicians, dentists, and patients. The best efforts of well-meaning providers to eliminate these events will likely not completely succeed. However, strategies that may limit their number include meticulous infection control practices, postexposure prophylaxis administered promptly to those known or suspected of having been exposed to hepatitis B or HIV, and universal hepatitis B vaccination. A thorough search for nontraditional exposure sources for all patients with no recognized risk factors who are diagnosed with HIV, hepatitis B, or hepatitis C also may quantify the magnitude of the risk to patients in medical settings and perhaps shed light on mechanisms of transmission.

References
1. Incidence of acute hepatitis B--United States, 1990–2002. MMWR Morb Mortal Wkly Rep 2004; 52:1252–4.
2. Goldstein ST, Alter MJ, Williams IT, et al. Incidence and risk factors for acute hepatitis B in the United States, 1982–1998: implications for vaccination programs. J Infect Dis 2002; 185:713–9.
3. Redd JT, Baumbach J, Kohn W, Nainan O, Khristova M, Williams I. Patient-to-patient transmission of hepatitis B virus associated with oral surgery. J Infect Dis 2007; 195:1311–4 (in this issue).
4. Ciesielski C, Marianos D, Ou C, et al. Transmission of human immunodeficiency virus in a dental practice. Ann Intern Med 1992 116:798–805.
5. Perry JL, Pearson RD, Jagger J. Infected health care workers and patient safety: a double standard. Am J Infect Control 2006; 34:313–9.
6. Bosch X. Second case of doctor-to-patient HIV transmission. Lancet Infect Dis 2003; 3:261.
7. Astagneau P, Lot F, Bouvet E, et al. Lookback investigation of patients potentially exposed to HIV type 1 after a nurse-to-patient transmission. Am J Infect Control 2002; 30:242–5.
8. Lot F, Seguier J-C, Fegueux S, et al. Probable transmission of HIV from an orthopedic surgeon to a patient in France. Ann Intern Med 1999; 130:1–6.
9. Update: investigations of persons treated by HIV-infected health-care workers--United States. MMWR Morb Mortal Wkly Rep 1993; 42:329–31.
10. Mishu B, Schaffner W, Horan JM, Wood LH, Hutcheson RH, McNabb PC. A surgeon with AIDS: lack of evidence of transmission to patients. JAMA 1990; 264:467–70.
11. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone procedures. MMWR Recomm Rep 1991; 40:1–9.
12. Harpaz R, Von Seidlein L, Averhoff FM, et al. Transmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control. N Engl J Med 1996; 334:549–54.
13. McMenamin J, Cameron S, Morrison D, Armstrong G, Goldberg D. Hospital transmission of hepatitis B virus in the absence of exposure-prone procedures. Epidemiol Infect 2006; 134:259–63.
14. MacKellar DA, Valleroy LA, Secura GM, et al. Two decades after vaccine license: hepatitis B immunization and infection among young men who have sex with men. Am J Public Health 2001; 91:965–71.
15. Centers for Disease Control and Prevention. Hepatitis B vaccination among high-risk adolescents and adults--San Diego, California, 1998–2001. MMWR Morb Mortal Wkly Rep 2002; 51:618–21.
16. Mast EE, Margolis HS, Fiore AE, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. MMWR Recomm Rep 2005; 54:1–31.

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To read this article in PDF format, go to:
http://www.immunize.org/hepbhealthcaresetting.pdf
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(2 of 12)
May 2, 2007
IT'S HEPATITIS AWARENESS MONTH: IAC'S HEPATITIS PREVENTION WEBSITE FEATURES NEW AND REVISED PROGRAMS

In March 2001, IAC launched its hepatitis prevention website, http://www.hepprograms.org, as part of a cooperative agreement with CDC's Division of Viral Hepatitis. The site features programs successfully preventing hepatitis A, B, and/or C in individuals at risk of infection in the hope that public health and social service managers can use the information to start or improve hepatitis prevention programs. In addition, the site includes basic information about viral hepatitis for members of the public.

Currently, the site highlights 75 programs in 10 risk categories.

The following programs have been added since the last article about the website in Hep Express.

Injection Drug User (IDU) HIV Counseling and Testing Utilizing Hepatitis C Virus (HCV) Screening High-Risk Initiative (CA)
http://www.hepprograms.org/std/std21.asp

Ortho Clinical Diagnostics
http://www.hepprograms.org/other/other15.asp

Shots for Tots (Louisiana)
http://www.hepprograms.org/other/other16.asp

The following projects have updated their program information:

AID Atlanta's Men's STD Clinic
http://www.hepprograms.org/msm/msm4.asp

The American Liver Foundation's Latino Community Outreach Program
http://www.hepprograms.org/other/other14.asp

Arizona Department of Health Services
http://www.hepprograms.org/other/other1.asp

B-Empowered (Bucks County, PA)
http://www.hepprograms.org/other/other9.asp

Callen-Lorde Health Center (New York, NY)
http://www.hepprograms.org/msm/msm8.asp

County Jail Hepatitis Vaccination Program, New York State Department of Health
http://www.hepprograms.org/adult/adult12.asp

Denver Health/Denver Public Schools Adolescent Immunization Program
http://www.hepprograms.org/school/school7.asp

Hartford Gay and Lesbian Health Collective
http://www.hepprograms.org/msm/msm5.asp

HepTalk Project, Migrant Clinician's Network and Community Health Education Concepts
http://www.hepprograms.org/other/other8.asp

Howard Brown Health Center
http://www.hepprograms.org/msm/msm3.asp

Integrating Hepatitis A, B, and C into HIV Prevention Messages (New Jersey)
http://www.hepprograms.org/other/other11.asp

Mid America Immunization Coalition (Kansas City, MO)
http://www.hepprograms.org/school/school1.asp

Multnomah County Health Department (Oregon)
http://www.hepprograms.org/msm/msm12.asp

New York State Health Department
http://www.hepprograms.org/std/std1.asp

Prince George's County Health Department (Maryland)
http://www.hepprograms.org/std/std2.asp

"Protect Yourself" Education and Immunization Outreach Project
http://www.hepprograms.org/msm/msm20.asp

In addition to program descriptions, the website also offers support group information, hepatitis A and hepatitis B FAQs, case histories, photos, and video clips. Much of the support group information has also been updated--check the support group sections for updated information for your geographic area.

As always, we need your input! If you have a model program to share, go to: http://www.hepprograms.org/tellus.htm If you know of additional HBV or HCV support groups, have viral hepatitis resources to share (including brochures, manuals, slide sets, photos, or videos), write admin@hepprograms.org
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(3 of 12)
May 2, 2007
IT'S HEPATITIS AWARENESS MONTH: SYMPOSIUM ON HIV AND HEPATITIS B VACCINES PLANNED FOR MAY 10 IN WASHINGTON, DC

[The following is cross posted from the Immunization Action Coalition's "IAC EXPRESS" electronic newsletter, 4/23/07.]

Combating HIV and Hepatitis B, a symposium on the development of HIV and hepatitis B vaccines, is scheduled for May 10 to coincide with World AIDS Vaccine Day on May 18 and Hepatitis Awareness Week, May 7-11.

The program will begin at 9AM in Room 119 of the Thomas Jefferson Building, 10 First St. S.E., Washington, DC. The event is free and open to the public; tickets are not required.

The symposium will be cybercast live at http://www.loc.gov After May 10, the webcast will be available at http://www.loc.gov/today/cyberlc

The Library of Congress's Kluge Center is holding the symposium in partnership with the International AIDS Vaccine Initiative (IAVI) and the Hepatitis B Foundation (HBF), with support from the Dana Foundation.
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(4 of 12)
May 2, 2007
IT'S HEPATITIS AWARENESS MONTH: CONGRESSIONAL BRIEFING ON ASIAN AMERICAN AND PACIFIC ISLANDER HEALTH SCHEDULED FOR MAY 11

The Association for Asian Pacific Community Health Organizations (AAPCHO) and the Asian and Pacific Islander American Health Forum (APIAHF) are holding a congressional briefing to discuss and highlight some of the major health issues experienced by these communities in the United States. The impact of chronic HBV infection will be one of the issues discussed.

The briefing is scheduled for May 11, 12:00-1:30 pm, in Room HC-5 of the U.S. Capitol. For more information, contact Rose Valenzuela at (510) 272-9536, ext. 118 or rvalenzuela@aapcho.org from AAPCHO; or Mona Bormet at (202) 466-7772 or mbornet@apiahf.org from APIAHF.
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(5 of 12)
May 2, 2007
IT'S HEPATITIS AWARENESS MONTH: ASIAN HEALTH COALITION SPONSORING MEDIA CONFERENCE AT THE UNIVERSITY OF ILLINOIS, MAY 8

The Asian Health Coalition is sponsoring a media conference at the University of Illinois campus in Chicago. The organization recently screened 1,585 Asian Americans for HBV infection and found that well over 10 percent of the participants were chronically infected. At the media conference, expert speakers will discuss the results of the study and ways to increase vaccinations and improve treatment for Asian Americans.

The conference is scheduled for May 8, 11:00 am-12:00 noon. For more information, call Anita Banerji at (773) 841-1064 or Veena Iyer at (773) 633-7406.
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(6 of 12)
May 2, 2007
IT'S HEPATITIS AWARENESS MONTH: SEATTLE STD/HIV PREVENTION TRAINING CENTER AND UNIVERSITY OF WASHINGTON DEVELOP ONLINE STUDY SITE

The Seattle STD/HIV Prevention Training Center and the University of Washington announced the release of Hepatitis Web Study, a website designed for healthcare workers who provide clinical care to persons with viral hepatitis. This project was funded by CDC's Division of Viral Hepatitis.

The website features

• Fourteen interactive, clinically-relevant case studies that highlight and illustrate key recommendations from national guidelines;
   
• Free continuing education credits, including an easy way to print CME/CNE documentation and an electronic CE tracker;
   
• Numerous high-quality figures that the user can easily download into PowerPoint slides;
   
• Reference linked to Pub Med abstracts, federal guidelines sites, and/or CDC MMWR documents.

The site will be maintained and updated on an ongoing basis and will continue to be expanded. Please visit the site and share the address with your colleagues! To access this valuable resource, go to: http://www.hepwebstudy.org

Bruce Maeder, program manager for this Viral Hepatitis Education and Training Project, welcomes your feedback at (206) 543-1562 or maeder@u.washington.edu
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May 2, 2007
IT'S HEPATITIS AWARENESS MONTH: SAN FRANCISCO STARTS HEP B FREE CAMPAIGN TO TEST AND VACCINATE ASIAN PACIFIC ISLANDERS

The city of San Francisco in cooperation with more than 50 healthcare and Asian Pacific Islander (API) organizations is launching the SF Hep B Free campaign, an attempt to test and vaccinate all API in San Francisco for hepatitis B.

San Francisco's API residents comprise 34% of the city's population and bear a disproportionate burden of liver cancer and undetected HBV infection. San Francisco has the highest liver cancer rate in the nation. It is estimated that one in 10 people in the API community have an undiagnosed HBV infection. APIs are up to 100 times more likely to suffer from chronic HBV infection and four times more likely to die from liver cancer compared with the general population.

The SF Hep B Free campaign started spreading its message of "B Sure, B Tested, B Free" through Asian and mainstream media outlets on April 25. Low-cost screening and vaccination services will be offered at various locations throughout the city.

The SF Hep B Free steering committee is made up of the San Francisco Department of Public Health, the Asian Liver Center at Stanford University, and Asian Week Foundation.

For more information, go to: http://www.SFHepBFree.org
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May 2, 2007
IT'S HEPATITIS AWARENESS MONTH: HBF SPONSORS WEBCAST ABOUT THE CHANGING EPIDEMIOLOGY OF HBV

On May 9, at 12:00 pm CT, the Hepatitis B Foundation (HBF) will sponsor a webcast titled "The Changing Epidemiology of the Hepatitis B Virus." The speaker, Stanley Martin Cohen, MD, will cover the epidemiology of HBV worldwide and in the U.S. and review how the changing epidemiology of HBV affects the prevalence of HBV genotypes and mutants and screening recommendations.

The webcast is free and offers PACE/CEU credit, but individuals must register at http://registration.mshow.com/addelearning to participate.
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(9 of 12)
May 2, 2007
IT'S HEPATITIS AWARENESS MONTH: HBF PROMOTES PUBLIC AWARENESS OF CHRONIC HEPATITIS B INFECTION WITH "AIM FOR THE B" CAMPAIGN

"AIM for the B" (Awareness, Involvement, and Mobilization for Chronic Hepatitis B) is a public awareness program sponsored by the Hepatitis B Foundation (HBF). The goal is to engage the media in promoting hepatitis B as an urgent health priority. Activities are scheduled to complement National Hepatitis B Awareness Week (May 7-11, 2007).

"AIM for the B" is designed to illustrate the significant impact associated with chronic hepatitis B through testimonies from patients, physicians, and third-party organizations that are involved first-hand with the disease. HBF serves as host and moderator of the media roundtables, which are held across the country.

As part of the program, a series of local events will be held in cities where chronic hepatitis B prevalence is high, including San Francisco, Los Angeles, and New York City. Please go to http://www.hepb.org/advocacy/aim.htm for location and time details.
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(10 of 12)
May 2, 2007
IT'S HEPATITIS AWARENESS MONTH: ONE-MINUTE CONSULT FEATURE PROVIDES AN AUTHORITATIVE ANSWER TO THE #1 HEPATITIS QUESTION!

At IAC, we receive hundreds of questions via email and phone every month. Approximately half relate to hepatitis B vaccination, and many of these concern restarting an interrupted vaccination series.

CDC's Division of Viral Hepatitis has posted a One-Minute Consult published in the Cleveland Clinic Journal of Medicine and written by Miriam J. Alter, PhD. Titled "Do patients who fail to complete a hepatitis A or hepatitis B vaccination series have to restart it?" the one-page response answers this pesky question once and for all!

To access this document, go to:
http://www.cdc.gov/ncidod/diseases/hepatitis/a/quick_faq.pdf
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(11 of 12)
May 2, 2007
IT'S HEPATITIS AWARENESS MONTH: HEALTHY ROADS MEDIA SEEKS INPUT FROM HEP EXPRESS READERS

The website of Healthy Roads Media offers free health education materials in a number of languages and a variety of formats. IAC has previously promoted VISs that Healthy Roads Media makes available in enhanced formats--video, multimedia, and audio.

Now, Healthy Roads Media is asking for input from Hep Express readers. If you are a healthcare or social service professional who works with immigrant or refugee populations, here is your chance to shape future language/format choices. Please take a few minutes to share your experience working with these populations with Healthy Roads Media.

The process is simple: First, go to http://www.healthyroadsmedia.org/topics/immunization.htm to view the current VIS choices, including the languages and  formats available.

Then, click on the button at the top of the page titled: "Please take our short vaccine information survey!" You will be directed to a 10-question online survey.

The director of Healthy Roads Media, Mary Alice Gillispie, MD, thanks you for your help.
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(12 of 12)
May 2, 2007
IT'S HEPATITIS AWARENESS MONTH: WORLD GASTROENTEROLOGY ORGANISATION PROVIDES INFORMATION ABOUT WORLD DIGESTIVE HEALTH DAY

World Digestive Health Day is May 29. A total of 400 million people are chronically infected with hepatitis B virus, and about half that number are chronically infected with hepatitis C virus. Together, these viruses are responsible for the majority of hepatocellular carcinoma cases, the third leading cause of cancer death worldwide.

The World Gastroenterology Organisation has set up a working group to coordinate activities on viral hepatitis for World Digestive Health Day 2007. Information on planned activities and support material, including a sampling of World Digestive Health Day activities from around the globe, can be accessed at http://www.worldgastroenterology.org/wdhd/wdhd2007.html