(1 of 12)
October 25, 2007
NEW: CDC PUBLISHES UPDATED RECOMMENDATIONS FOR PREVENTION OF HEPATITIS A VIRUS INFECTION AFTER EXPOSURE AND BEFORE INTERNATIONAL TRAVEL

[The following is cross posted from the Immunization Action Coalition's "IAC EXPRESS" electronic newsletter, 10/22/07.]

CDC published "Update: Prevention of Hepatitis A After Exposure to Hepatitis A Virus and in International Travelers. Updated Recommendations of the Advisory Committee on Immunization Practices" in the October 19 issue of MMWR. Portions of the article are reprinted below.

In addition, on October 18, the CDC website posted a Q&A about the revised recommendations, and the New England Journal of Medicine (NEJM; issue dated 10/25/07) published a related article, "Hepatitis A Vaccine versus Immune Globulin for Postexposure Prophylaxis," and an editorial, "Another Success for Hepatitis A Vaccine." Links to the CDC Q&A and the NEJM article and editorial are given at the end of this IAC Express article.

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For decades, immune globulin (IG) has been recommended for prophylaxis after exposure to HAV. IG also has been recommended in addition to hepatitis A vaccine for preexposure prophylaxis for travelers to countries with high or intermediate hepatitis A endemicity who are scheduled to depart <4 weeks after receiving the initial vaccine dose. This report details updated recommendations, made by ACIP in June 2007, for prevention of hepatitis A after exposure to HAV and in departing international travelers and incorporates existing ACIP recommendations for prevention of hepatitis A. . . .

I. PREVENTION OF HEPATITIS A AFTER EXPOSURE TO HAV . . . .

Advantages of hepatitis A vaccine
The ability to use hepatitis A vaccine for postexposure prophylaxis provides numerous public health advantages, including the induction of active immunity and longer protection, greater ease of administration, higher acceptability and availability, and a cost per dose that is similar to IG. Also, the greater availability and ease of administration of hepatitis A vaccine might increase the number of persons at risk for infection who receive postexposure prophylaxis. . . .

Recommendations for postexposure prophylaxis with IG or hepatitis A vaccine
Persons who recently have been exposed to HAV and who previously have not received hepatitis A vaccine should be administered a single dose of single-antigen vaccine or IG (0.02 mL/kg) as soon as possible. Information about the relative efficacy of vaccine compared with IG postexposure is limited, and no data are available for persons aged >40 years or those with underlying medical conditions. Therefore, decisions to use vaccine or IG should take into account patient characteristics associated with more severe manifestations of hepatitis A, including older age and chronic liver disease.

For healthy persons aged 12 months-40 years, single-antigen hepatitis A vaccine at the age-appropriate dose is preferred to IG because of vaccine advantages that include long-term protection and ease of administration. For persons aged >40 years, IG is preferred because of the absence of information regarding vaccine performance and the more severe manifestations of hepatitis A in this age group; vaccine can be used if IG cannot be obtained. The magnitude of the risk for HAV transmission from the exposure should be considered in decisions to use IG or vaccine. IG should be used for children aged <12 months, immunocompromised persons, persons who have had chronic liver disease diagnosed, and persons for whom vaccine is contraindicated.

Persons administered IG for whom hepatitis A vaccine also is recommended for other reasons should receive a dose of vaccine simultaneously with IG. For persons who receive vaccine, the second dose should be administered according to the licensed schedule to complete the series. The efficacy of IG or vaccine when administered >2 weeks after exposure has not been established.

Close personal contact. Hepatitis A vaccine or IG should be administered to all previously unvaccinated household and sexual contacts of persons with serologically confirmed hepatitis A. In addition, persons who have shared illicit drugs with a person who has serologically confirmed hepatitis A should receive hepatitis A vaccine, or IG and hepatitis A vaccine simultaneously. Consideration also should be given to providing IG or hepatitis A vaccine to persons with other types of ongoing, close personal contact (e.g., regular babysitting) with a person with hepatitis A.

Child care centers. Hepatitis A vaccine or IG should be administered to all previously unvaccinated staff members and attendees of child care centers or homes if (1) one or more cases of hepatitis A are recognized in children or employees or (2) cases are recognized in two or more households of center attendees. In centers that do not provide care to children who wear diapers, hepatitis A vaccine or IG need be administered only to classroom contacts of the index patient. When an outbreak occurs (i.e., hepatitis A cases in three or more families), hepatitis A vaccine or IG also should be considered for members of households that have children (center attendees) in diapers.

Common-source exposure. If a food handler receives a diagnosis of hepatitis A, vaccine or IG should be administered to other food handlers at the same establishment. Because common-source transmission to patrons is unlikely, hepatitis A vaccine or IG administration to patrons typically is not indicated but may be considered if (1) during the time when the food handler was likely to be infectious, the food handler both directly handled uncooked or cooked foods and had diarrhea or poor hygienic practices and (2) patrons can be identified and treated <=2 weeks after the exposure. In settings in which repeated exposures to HAV might have occurred (e.g., institutional cafeterias), stronger consideration of hepatitis A vaccine or IG use could be warranted. In the event of a common-source outbreak, postexposure prophylaxis should not be provided to exposed persons after cases have begun to occur because the 2-week period after exposure during which IG or hepatitis A vaccine is known to be effective will have been exceeded.

Schools, hospitals, and work settings. Hepatitis A postexposure prophylaxis is not routinely indicated when a single case occurs in an elementary or secondary school or an office or other work setting, and the source of infection is outside the school or work setting. Similarly, when a person who has hepatitis A is admitted to a hospital, staff members should not routinely be administered hepatitis A postexposure prophylaxis; instead, careful hygienic practices should be emphasized. Hepatitis A vaccine or IG should be administered to persons who have close contact with index patients if an epidemiologic investigation indicates HAV transmission has occurred among students in a school or among patients or between patients and staff members in a hospital.

II. PREVENTION OF HEPATITIS A BEFORE INTERNATIONAL TRAVEL . . . .

The following recommendation updates recommendations for prevention of hepatitis A among travelers departing in <4 weeks to areas where prophylaxis is recommended and consolidates other recommendations for prevention of hepatitis A among international travelers. These recommendations replace previous ACIP recommendations for preexposure protection against hepatitis A for travelers.

Recommendations for preexposure protection against hepatitis A for travelers
All susceptible persons traveling to or working in countries that have high or intermediate hepatitis A endemicity are at increased risk for HAV infection and should be vaccinated or receive IG before departure. Hepatitis A vaccination at the age-appropriate dose is preferred to IG. Data are not available regarding the risk for hepatitis A for persons traveling to certain areas of the Caribbean, although prophylaxis should be considered if travel to areas with questionable sanitation is anticipated. Travelers to Australia, Canada, western Europe, Japan, or New Zealand (i.e., countries in which endemicity is low) are at no greater risk for infection than [are] persons living or traveling in the United States.

The first dose of hepatitis A vaccine should be administered as soon as travel is considered. Based on limited data indicating equivalent postexposure efficacy of IG and vaccine among healthy persons aged <=40 years, 1 dose of single-antigen hepatitis A vaccine administered at any time before departure can provide adequate protection for most healthy persons. However, no data are available for other populations or other hepatitis A vaccine formulations (e.g., Twinrix). For optimal protection, older adults, immunocompromised persons, and persons with chronic liver disease, or other chronic medical conditions planning to depart to an area in <=2 weeks should receive the initial dose of vaccine and also simultaneously can be administered IG (0.02 mL/kg) at a separate anatomic injection site. Completion of the vaccine series according to the licensed schedule is necessary for long-term protection.

Travelers who elect not to receive vaccine, are aged <12 months, or are allergic to a vaccine component should receive a single dose of IG (0.02 mL/kg), which provides effective protection against hepatitis A for up to 3 months. Such travelers whose travel period is expected to be >2 months should be administered IG at 0.06 mL/kg; administration must be repeated if the travel period is >5 months. The full statement containing licensed vaccination schedule and recommended dose of IG and vaccine has been published previously.

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To access a web-text (HTML) version of the complete article, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641a3.htm

To access a ready-to-print (PDF) version of this issue of MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5641.pdf

CDC Q&A: To access the CDC's Q&A on the revised recommendations, go to:
http://www.cdc.gov/ncidod/diseases/hepatitis/a/faqa_PEP.htm

NEJM ARTICLE: To access the full text of the article, go to:
http://content.nejm.org/cgi/content/full/NEJMoa070546

NEJM EDITORIAL: To access the full text of the editorial, go to:
http://content.nejm.org/cgi/content/full/NEJMe078189
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(2 of 12)
October 25, 2007
CDC POSTS HEPATITIS A Q&AS FOR HEALTHCARE PROFESSIONALS

CDC's Division of Viral Hepatitis recently developed a web page for healthcare professionals titled "Hepatitis A: Frequently Asked Questions," which includes information about the new recommendations for postexposure protection and international travel, as well as other topics.

To access this new resource, go to:
http://www.cdc.gov/ncidod/diseases/hepatitis/a/faqa.htm
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(3 of 12)
October 25, 2007
MMWR ANNOUNCES FDA'S MARCH 28 APPROVAL OF ALTERNATIVE DOSING SCHEDULE FOR TWINRIX COMBINED HEPATITIS A AND B VACCINE

[The following is cross posted from the Immunization Action Coalition's "IAC EXPRESS" electronic newsletter, 10/15/07.]

CDC published "Notice to Readers: FDA Approval of an Alternative Dosing Schedule for a Combined Hepatitis A and B Vaccine (Twinrix)" in the October 12 issue of MMWR. The notice is reprinted below in its entirety.

[IAC Express editor's note: FDA approved the alternative schedule on March 28, 2007. The alternative schedule could benefit individuals traveling to high-risk areas; emergency responders, especially those being deployed to disaster areas overseas; and others who are at risk for hepatitis A and B infection.]

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In April 2007, GlaxoSmithKline Vaccine Division (GlaxoSmithKline Biologicals, King of Prussia, Pennsylvania) received approval from the Food and Drug Administration (FDA) for an alternate schedule for Twinrix, a combined hepatitis A and hepatitis B vaccine. Twinrix was first licensed by FDA in 2001 on a 3-dose schedule (0, 1, and 6 months) for vaccination of persons aged >=18 years. Using the newly licensed, alternate 4-dose schedule, Twinrix doses can be administered at 0, 7, and 21-30 days, followed by a dose at 12 months.

In immunogenicity studies among adults aged >=18 years, the first 3 doses of the alternate schedule provided equivalent protection to the first 2 doses in the standard 3-dose Twinrix series. The first 3 doses of the alternate schedule also have proven effective in providing protection equivalent to a single dose of monovalent hepatitis A vaccine and to 2 doses of monovalent hepatitis B vaccine, administered using the licensed schedules for the monovalent vaccines. Thus, the alternate 4-dose schedule can be useful if vaccination with Twinrix has been initiated and travel or other potential exposure is anticipated before the second dose of Twinrix (or monovalent hepatitis B vaccine) is due, according to the standard 3-dose schedule (i.e., 1 month after the first dose). Additional information is available from the manufacturer's package insert [http://www.fda.gov/cber/label/hahbgsk032807lb.pdf] and GlaxoSmithKline Vaccines, telephone (800) 366-8900.

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To access a web-text (HTML) version of the complete article, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5640a5.htm

To access a ready-to-print (PDF) version of this issue of MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5640.pdf

To receive a FREE electronic subscription to MMWR (which includes new ACIP statements), go to:
http://www.cdc.gov/mmwr/mmwrsubscribe.html
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(4 of 12)
October 25, 2007
CDC RELEASES NATIONAL IMMUNIZATION SURVEY DATA ON THE HEPATITIS B BIRTH DOSE

CDC has posted 2006 National Immunization Survey (NIS) birth dose rates on its website at http://www.cdc.gov/vaccines/stats-surv/nis/tables/06/tab36_hepb_birth02_2006.xls This survey covers infants born January 2003 through June 2005.

The national rate for the birth dose of hepatitis B vaccine was 48.8%, with a state range of 14.2%-82.7%. The national average in the 2005 NIS survey was 47.9%.
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(5 of 12)
October 25, 2007
NEW: CDC PUBLISHES RECOMMENDED ADULT IMMUNIZATION SCHEDULE FOR OCTOBER 2007-SEPTEMBER 2008

CDC published "Recommended Adult Immunization Schedule--United States, October 2007-September 2008" (as an MMWR QuickGuide) in the October 19 MMWR.

To access a web-text (HTML) version of the complete article, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641a7.htm

To access a ready-to-print (PDF) version of this issue of MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5641.pdf

To directly access the schedule in English, go to:
http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm

Hep Express editor's note: the Spanish-language version will be available in 2008.
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(6 of 12)
October 25, 2007
OCTOBER 2007 ISSUES OF NEEDLE TIPS AND VACCINATE ADULTS NOW AVAILABLE ONLINE

IAC recently mailed the latest issues of Needle Tips and Vaccinate Adults to health professionals and others who work in the field of immunization. Both are packed with immunization and hepatitis resources for health professionals, patients, and parents, all of which can be downloaded from the Web. All articles and education pieces, except editorials, have been reviewed by immunization and hepatitis experts at CDC.

HOW TO ACCESS NEEDLE TIPS ON THE WEB
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:
http://www.immunize.org/nt

The PDF file of the entire issue, linked below, is large. For tips on downloading and printing PDF files, go to:
http://www.immunize.org/nslt.d/tips.htm

To download a ready-to-print (PDF) version of the entire October issue of Needle Tips, go to:
http://www.immunize.org/nslt.d/n37/n37.pdf

HOW TO ACCESS VACCINATE ADULTS ON THE WEB
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:
http://www.immunize.org/va

The PDF file of the entire issue, linked below, is large. For tips on downloading and printing PDF files, go to:
http://www.immunize.org/nslt.d/tips.htm

To download a ready-to-print (PDF) version of the entire October issue of Vaccinate Adults, go to:
http://www.immunize.org/va/va20.pdf
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(7 of 12)
October 25, 2007
IAC UPDATES THREE PRINT PIECES WITH INFORMATION ABOUT HEPATITIS A AND B VACCINES

IAC recently revised three of its print pieces containing information about hepatitis A and B vaccination as well as other routinely administered vaccines.

(1) "Summary of Recommendations for Childhood and Adolescent Immunization" (revised 10/07): The section on influenza vaccine was changed to indicate that LAIV vaccine may be given to healthy, non-pregnant persons age 2-49 years.

To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p2010.pdf

(2) "It's Federal Law! You must give your patients current Vaccine Information Statements (VISs)" (revised 9/07): The table that lists the most current VIS dates was updated to show that 8/16/07 is the most current date for the VIS for meningococcal vaccine.

To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p2027.pdf

(3) "If You Have HIV Infection, Which Vaccinations Do You Need?" (revised 10/07): Minor changes were made.

To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p4041.pdf
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(8 of 12)
October 25, 2007
LOOKING FOR A VACCINE-RELATED ARTICLE? CHECK OUT IAC'S REDESIGNED JOURNAL ARTICLES WEB SECTION

[The following is cross posted from the Immunization Action Coalition's "IAC EXPRESS" electronic newsletter, 10/15/07.]

IAC recently completed the redesign of its vast online collection of links to vaccine-related journal articles. IAC's selection of practical, clinical, and programmatic articles is now presented in a well-organized, easy-to-access format.

The section's homepage offers users an alphabetical listing of 18 vaccine-preventable diseases. Click on a disease, and you will be taken to a chronological catalog of links to recently published (2004-2007) journal articles pertinent to the disease or topic. Each article listed offers users a live link to the article's abstract and/or full text.

Articles published before 2004 are available in archives organized chronologically by disease.

To access the Vaccine-Related Journal Articles web section, go to:
http://www.immunize.org/journalarticles
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(9 of 12)
October 25, 2007
CDC WEBSITE POSTS INFORMATION ON PRODUCTION DELAYS FOR VAQTA PEDIATRIC AND ADULT HEPATITIS A VACCINE

[The following is cross posted from the Immunization Action Coalition's "IAC EXPRESS" electronic newsletter, 10/8/07.]

On September 28, NCIRD updated its website with information about a current production delay for Vaqta hepatitis A vaccine; the delay applies to both the pediatric and adult formulations of Vaqta. The vaccine delay information is reprinted below in its entirety.

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Merck & Co., Inc., are experiencing production delays for Pediatric and Adult hepatitis A vaccine (Pediatric & Adult VAQTA), resulting in backorders for these products. Merck has temporarily discontinued accepting orders for Pediatric VAQTA and Adult VAQTA in the vial formulation. Based on current information, it is estimated that VAQTA will be available in late first-quarter 2008, but actual timing will be confirmed when more is known. GSK [GlaxoSmithKline] production and supply of their Pediatric and Adult hepatitis A vaccine (Pediatric & Adult Havrix) and their Adult hepatitis A/hepatitis B combination vaccine (Twinrix) are currently in good supply to meet demand. GSK has initiated plans to increase production of Havrix and Twinrix, to help ensure uninterrupted supply for the U.S. market.

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To access the information from the NCIRD website, go to: http://www.cdc.gov/vaccines/vac-gen/shortages and scroll down the section titled Chart of Vaccines in Delay or Shortage.
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(10 of 12)
October 25, 2007
NEW: SPANISH-LANGUAGE VERSION OF THE CURRENT RECOMMENDED CHILDHOOD AND ADOLESCENT IMMUNIZATION SCHEDULE NOW ONLINE

[The following is cross posted from the Immunization Action Coalition's "IAC EXPRESS" electronic newsletter, 10/8/07.]

The 2007 Recommended Childhood, Adolescent, and Catch-up Immunization Schedule is now available in Spanish and can be printed from the CDC website. The schedule, which was released in English in January 2007, has been approved by the Advisory Committee on Immunization Practices (ACIP), American Academy of Pediatrics (AAP), and American Academy of Family Physicians (AAFP).

To access the Spanish-language schedule, click here.
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(11 of 12)
October 25, 2007
HBF POSTS FALL 2007 ISSUE OF "B INFORMED" NEWSLETTER ON ITS WEBSITE

The Fall 2007 issue of "B Informed," the newsletter of the Hepatitis B Foundation (HBF), is now available online. This issue includes an article about underestimation of chronic hepatitis B in the United States, an article about chronic HBV infection and offspring gender, participant reports about the June B Informed Patient Conference, and regular features.

The current issue of "B Informed" can be accessed at http://www.hepb.org/pdf/hepbnews50.pdf

To receive "B Informed" through the U.S. mail, please send your name and full address to info@hepb.org and HBF will add your name to its confidential mailing list.

The HBF website offers many other resources, including the continually updated "HBF Drug Watch." To access the home page go to: http://www.hepb.org
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(12 of 12)
October 25, 2007
JOURNAL ARTICLES YOU MAY HAVE MISSED

The following recent journal articles present research related to viral hepatitis prevention or treatment.

"Underestimation of Chronic Hepatitis B Virus Infection in the United States of America"
Authors: Cohen C, Evans AA, London WT, Block J, Conti M, Block T
Source: J Viral Hepat, August 6, 2007, published online
Click here for abstract.

"Cost-Effectiveness of Screening and Vaccinating Asian and Pacific Islander Adults for Hepatitis B"
Authors: Hutton DW, Tan D, So SK, Brandeau ML
Source: Ann Intern Med, October 2, 2007, Vol. 147(7):460-9
Click here for abstract.

"Hepatitis A 2004 Vaccination in Children: Methods and Findings of a Survey in Two States"
Authors: Fiore A, Baxter LC, Bell BP, Hershow R, et al.
Source: Am J Prev Med, October 2007, Vol. 33(4):346-52
Click here for abstract.

"Hepatitis A Outbreak Activity in the United States: Responding to a Vaccine-Preventable Disease"
Authors: Craig AS, Watson B, Zink TK, Davis JP, et al.
Source: Am J Med Sci, September 2007, Vol. 334(3):180-3
Click here for abstract.

"Physician Beliefs and Practices Regarding the Use of Hepatitis A Vaccine"
Authors: Sabnis S, Pomeranz AJ, Mao J
Source: WMJ, July 2007, Vol. 106(4):211-4
Click here for abstract.

"Deaths from Chronic Liver Disease and Viral Hepatitis, Multnomah County, Oregon, 2000"
Authors: Thomas AR, Zaman A, Bell BP
Source: J Clin Gastroenterol, October 2007, Vol. 41(9):859-862
Click here for abstract.

"Costs of Needlestick Injuries and Subsequent Hepatitis and HIV Infection"
Authors: Leigh JP, Gillen M, Franks P, et al.
Source: Curr Med Res Opin, September 2007, Vol. 23(9):2093-105
Click here for abstract.

"Occupational Exposures to Blood and Body Fluid: A Study of Medical Students and Health Professions Students in Virginia"
Author: Askew SM
Source: AAOHN J, September 2007, Vol. 55(9):361-71
Click here for abstract.

"Bacterial and Viral Contamination of Reusable Sharps Containers in a Community Hospital Setting"
Author: Runner JC
Source: Am J Infect Control, October 2007, Vol. 35(8):527-30
Click here for abstract.

"Hepatitis B Vaccination of Men Who Have Sex with Men Attending an Urban STD Clinic: Impact of an Ongoing Vaccination Program, 1998-2003"
Authors: Gunn RA, Murray PJ, Gilchick RA, Margolis HS
Source: Sex Transm Dis, September 2007, Vol. 34(9):663-8
Click here for abstract.

"School-Based Health Centers: Improving Access and Quality of Care for Low-Income Adolescents"
Authors: Allison MA, Crane LA, Beaty BL, Davidson AJ, et al.
Source: Pediatrics, October 2007, Vol. 120(4):e887-94
Click here for abstract.

"Integrating Multiple Programme and Policy Approaches to Hepatitis C Prevention and Care for Injection Drug Users: A Comprehensive Approach"
Authors: Birkhead GS, Klein SJ, Candelas AR, et al.
Source: Int J Drug Policy, October 2007, Vol. 18(5):417-25
Click here for abstract.

"A Peer-Education Intervention to Reduce Injection Risk Behaviors for HIV and Hepatitis C Virus Infection in Young Injection Drug Users"
Authors: Garfein RS, Golub ET, Greenberg AE, et al.
Source: AIDS, September 2007, Vol. 21(14):1923-1932
Click here for abstract.

"Vaccine Immunogenicity in Injecting Drug Users: A Systematic Review"
Authors: Baral S, Sherman SG, Millson P, Beyrer C
Source: Lancet Infectious Disease, October 7, 2007, Vol. 7(10):667-74
Click here for abstract.

"Infection Control in Jails and Prisons"
Author: Bick JA
Source: Clin Infect Dis, October 15, 2007, Vol. 45(8):1047-55
Click here for abstract.

"Blood-Borne Infections"
Authors: Pirozzolo JJ, LeMay DC
Source: Clin Sports Med, July 2007, Vol. 26(3):425-31
Click here for abstract.