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Hep Express Issue 75

Issue Number 75, September 16, 2008
 
Contents of this Issue
1. 2006 NIS data indicate 50 percent of newborns born between January 2003-June 2005 received the hepatitis B birthdose by age 3 days
2. CDC corrects an "Ask the Experts" answer that appeared in recent issues of Needle Tips, Vaccinate Adults, and Vaccinate Women
3. CDC launches online forum for exchanging ideas about HIV, hepatitis, STD, and TB prevention
4. IAC updates eight pieces related to hepatitis B or general immunization
5. Two of IAC's revised viral-hepatitis screening questionnaires are now available in Spanish
6. FDA approves use of the HIV drug Viread for treatment of chronic hepatitis B virus infection in adults
7. CDC presents infection-control requirements for dialysis facilities and gives guidance on parenteral medication vials
8. CDC issues recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C virus, or HIV virus and tetanus in persons wounded during bombings and other mass-casualty events
9. Viet Hep B Free Project offers culturally appropriate information on its website
10. Reminder: NIH Consensus Development Conference on the Management of Hepatitis B to be held October 20-22 in Bethesda
11. Journal articles you may have missed

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.
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September 16, 2008
2006 NIS DATA INDICATE 50 PERCENT OF NEWBORNS BORN BETWEEN JANUARY 2003-JUNE 2005 RECEIVED THE HEPATITIS B BIRTHDOSE BY AGE 3 DAYS

[The following is cross posted from the Immunization Action Coalition's "IAC Express" electronic newsletter, 8/4/08.]

CDC published "Newborn Hepatitis B Vaccination Coverage Among Children Born January 2003-June 2005--United States" in the August 1 issue of MMWR. It is reprinted below in its entirety, excluding one table and references.

IAC Express editor's note: We have included links to several relevant resources at the end of this IAC Express article.

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Hepatitis B vaccine was first recommended for administration to all infants in 1991 by the Advisory Committee on Immunization Practices (ACIP) as the primary focus of a strategy to eliminate hepatitis B virus (HBV) transmission in the United States. The recommended timing of administration of the first dose of hepatitis B vaccine to infants has evolved since then to optimize prevention of perinatal and early childhood HBV infections. In 1991, the first dose was recommended to be administered at birth before hospital discharge or at age 1-2 months. In 2002, ACIP indicated a preference for the first dose to be administered to newborns before hospital discharge. In December 2005, ACIP issued revised recommendations specifying that all medically stable newborns who weigh >=2,000 g (4.4 lbs) receive their first dose of hepatitis B vaccine before hospital discharge. To measure hepatitis B vaccination coverage during the neonatal period, CDC analyzed data from the 2006 National Immunization Survey (NIS). This report summarizes the results of this analysis and provides national, state, and local data on vaccination coverage for infants who received the hepatitis B vaccine during the first days of life. The findings reveal that, during January 2003-June 2005, before implementation of the 2005 ACIP hepatitis B vaccine recommendation, the national newborn hepatitis B vaccination coverage estimate was 42.8% at age 1 day and 50.1% at age 3 days, with substantial variation by states and local areas. To comply with ACIP recommendations and increase coverage, delivery hospitals should provide hepatitis B vaccination of newborns as a standard of care.

NIS provides estimates of vaccination coverage among noninstitutionalized children aged 19-35 months for each of the 50 states and selected local areas. To collect vaccination data, NIS conducts a random-digit-dialed telephone survey of households and a mail survey of children's vaccination providers identified by household respondents. Data are weighted to adjust for households with multiple telephone lines, household nonresponse, and exclusion of households without landline telephones. Infant age at vaccination was calculated by subtracting birth date from vaccination date. Children included in the 2006 NIS were born during January 2003-June 2005.

Household response rate for the survey was 64.5%, based on Council of American Survey and Research Organizations guidelines (CASRO); 21,044 children with provider-verified vaccination records were included in this report and represent 70.4% of all children with completed household interviews. National newborn hepatitis B vaccination coverage was 42.8% at age 1 day, 48.5% at 2 days, 50.1% at 3 days, 51.1% at 4 days, 51.8% at 5 days, and 52.5% at 6 days. State and local area rates showed substantial variability, with hepatitis B vaccination coverage at age 1 day ranging from 8.2% in Fresno County, California, to 77.5% in Detroit, Michigan. Among all states and local areas surveyed, the median coverage estimate was 50.3% at age 1 day and 58.7% at 3 days.

Editorial Note:
The analysis in this report indicates that, for the January 2003-June 2005 birth cohort, 42.8% of newborns had received hepatitis B vaccine by age 1 day and 50.1% had received hepatitis B vaccine by age 3 days. These data provide a baseline for assessing implementation of the December 2005 ACIP recommendation to administer hepatitis B vaccine to all newborns before hospital discharge. The 2009 NIS will be the first to include all survey-eligible children who were born after the December 2005 recommendation was made. Therefore, that survey will be the first to provide full estimates of national newborn vaccination coverage to evaluate the effect of the 2005 ACIP recommendation.

Newborn hepatitis B vaccination coverage estimates varied substantially among and within states. Administration of hepatitis B vaccine to newborns is dependent on hospital policies and procedures and on provider and parent preferences.

Although NIS does not distinguish whether hepatitis B vaccine was given before or after hospital discharge, National Hospital Discharge Survey data indicate that the average length of hospital stay for all newborns in 2004 was 3.3 days, with an average stay of 2.1 days for well newborns and an average stay of 5.0 days for ill newborns; 85.6% of all newborns were discharged by age 3 days.

The findings in this report are subject to at least four limitations. First, NIS is a telephone survey; although results are statistically adjusted to account for nonresponse and households without telephones, some bias might remain. Second, vaccination coverage is confirmed using provider-verified records. Although clinic providers might not always have records of a hospital-administered hepatitis B vaccine dose, this does not appear to result in substantial under-ascertainment of vaccination. A 2004 study in eight locations matched provider-reported vaccination records for the children sampled in NIS to their vaccination histories reported by the state Immunization Information Systems (IIS). NIS data underestimated birth dose coverage by no more than 5% at any one location when compared with the combined NIS and IIS coverage among children who had vaccination histories from both sources (M Khare, CDC, personal communication, February 2008). Third, estimates from state and local areas should be interpreted with caution because of smaller sample size and wider confidence intervals compared with the national estimate. Finally, infants who were not recommended to receive hepatitis B vaccine until age 1 month or after hospital discharge because their birth weights were <2,000 g and they were born to HBsAg-negative mothers could not be excluded from the coverage estimates. Inclusion of those infants in the denominator might result in an underestimate of newborn coverage, but the effect should be minimal because infants at this birth weight account for only 3% of births.

Infants infected with HBV typically are asymptomatic and have a 90% likelihood of remaining chronically infected. Up to 25% of chronically infected children die prematurely of cirrhosis or liver cancer. Two primary modes of HBV transmission occur during infancy and early childhood: (1) from an infected mother to her infant during delivery, and (2) from infected household contacts to infant or child. Both modes of transmission can be prevented by immunization of newborn infants. For infants born to mothers identified as hepatitis B surface antigen (HBsAg)-positive (i.e., HBV-infected), administration of hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth is 85%-95% effective as postexposure prophylaxis in preventing HBV infection in the infant. In addition, hepatitis B vaccine alone is 70%-95% effective in preventing perinatal HBV transmission when the first dose is given within 24 hours of birth. Thus, administration of hepatitis B vaccine soon after birth provides timely postexposure prophylaxis to infants born to HBsAg-positive mothers who were not screened prenatally, or were not identified as HBsAg-positive because of testing errors or lapses in reporting or documentation of test results. Hepatitis B vaccination of all newborns also provides early preexposure protection to infants born to uninfected women during a period when the risk for developing chronic HBV infection is greatest.

The 2005 ACIP recommendation to administer the first dose of hepatitis B vaccine to all newborns before hospital discharge will increase hepatitis B vaccination coverage during the first days of life. Delivery hospitals play a key role in the national strategy to eliminate HBV transmission. The 2005 ACIP statement recommends that delivery hospitals have policies and procedures in place, including appropriate standing orders, to ensure (1) administration of hepatitis B vaccine to all newborns with birth weights >=2,000 g before hospital discharge and (2) identification of all infants born to HBsAg-positive mothers and infants born to mothers with unknown HBsAg status to allow initiation of postexposure prophylaxis within 12 hours of birth. State and local information on prevention of HBV infection in infants and children, including information on hospital-based policies and procedures to prevent HBV infection, is available through CDC-funded perinatal hepatitis B prevention coordinators based in state health departments. Contact information for those coordinators is available at
http://www.cdc.gov/vaccines/vpd-vac/hepb/perinatal-contacts.htm

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To access a web-text (HTML) version of the complete article, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5730a3.htm

To access a ready-to-print (PDF) version of this issue of MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5730.pdf

To receive a FREE electronic subscription to MMWR (which includes new ACIP recommendations), go to:
http://www.cdc.gov/mmwr/mmwrsubscribe.html

Relevant resources:
"A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Part 1: Immunization of Infants, Children and Adolescents":
http://www.cdc.gov/mmwr/PDF/rr/rr5416.pdf

"AAP Endorsed Policy Statement: A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States":
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;118/1/404

"Guidelines for Standing Orders in Labor & Delivery & Nursery Units to Prevent Hepatitis B (HBV) Transmission to Newborns":
http://www.immunize.org/catg.d/p2130.pdf

"Hepatitis B Shots Are Recommended for All New Babies":
http://www.immunize.org/catg.d/p4110.pdf

"States Report Hundreds of Medical Errors in Perinatal Hepatitis B Prevention":
http://www.immunize.org/catg.d/p2062.pdf

"Unprotected Babies: Two More Infants Chronically Infected with Hepatitis B Virus . . . the Medical Errors Continue":
http://www.immunize.org/catg.d/p2127.pdf

"Medical Errors Put Infants at Risk for Chronic Hepatitis B Virus Infection--Six Case Reports":
http://www.immunize.org/catg.d/p2128.pdf
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September 16, 2008
CDC CORRECTS AN "ASK THE EXPERTS" ANSWER THAT APPEARED IN RECENT ISSUES OF NEEDLE TIPS, VACCINATE ADULTS, AND VACCINATE WOMEN

[The following is cross posted from the Immunization Action Coalition's "IAC Express" electronic newsletter, 8/4/08.]

IAC was informed by a careful reader that an incorrect answer was published in "Ask the Experts" in Needle Tips (March 2008, page 22), Vaccinate Adults (March 2008, page 10), and Vaccinate Women (June 2008, page 10). The question concerned pre-exposure prophylaxis for travelers to protect them from hepatitis A virus infection. The question and its corrected answer follow.

QUESTION:
What are the new recommendations for vaccination of travelers to protect them from hepatitis A virus (HAV) infection?

ANSWER:
The new recommendations (www.cdc.gov/mmwr/preview/mmwrhtml/mm5641a3.htm) state that (1) hepatitis A vaccine is recommended for healthy susceptible persons ages 1 through 40 years who travel to or work in regions where hepatitis A is endemic and (2) hepatitis A vaccine should be given as soon as travel is considered, but it can be given any time prior to departure. For optimal protection, persons older than age 40 years, immunocompromised persons, and persons with diagnosed chronic liver disease or other chronic medical conditions, if departure will take place within two weeks, should also receive IG simultaneously with the first dose of hepatitis A vaccine but at a different anatomic injection site. For travelers younger than age 1 year, IG alone is recommended because hepatitis A vaccine is not licensed for use in this age group. Hepatitis A is endemic in all regions except the United States, Western Europe, New Zealand, Australia, Canada, and Japan.

IAC regrets the confusion the initial Q&A may have caused readers of Needle Tips, Vaccinate Adults, and Vaccinate Women.
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September 16, 2008
CDC LAUNCHES ONLINE FORUM FOR EXCHANGING IDEAS ABOUT HIV, HEPATITIS, STD, AND TB PREVENTION

You are invited to exchange ideas on HIV/AIDS, viral hepatitis, STD, and TB prevention research and programs on Health Protection Perspectives, the new blog by Dr. Kevin Fenton, Director of CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

To access this new resource, go to http://www.cdc.gov/nchhstp/blog
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September 16, 2008
IAC UPDATES EIGHT PIECES RELATED TO HEPATITIS B OR GENERAL IMMUNIZATION

IAC made the following changes to eight of its educational pieces related to hepatitis B or general immunization:

(1) In the piece "Guide to Contraindications and Precautions to Commonly Used Vaccines," changes were made to the sections on rotavirus vaccine; diphtheria, tetanus, pertussis (DTaP) vaccine; tetanus, diphtheria (DT, Td) vaccines; and zoster vaccine.

To access this revised resource, go to:
http://www.immunize.org/catg.d/p3072a.pdf

(2) In the piece "It's Federal Law! You must give your patients current Vaccine Information Statements (VISs)," the issue dates were changed for the VISs for trivalent inactivated influenza vaccine (TIV; injectable) and live attenuated influenza vaccine (LAIV; nasal spray).

To access this revised resource, go to:
http://www.immunize.org/catg.d/p2027.pdf

NOTE: To access continually updated information on the issue dates for VISs, see the chart on IAC's Vaccine Information Statement web section at http://www.immunize.org/vis

(3) "Suggestions to Improve Your Immunization Services" was reviewed and minor revisions were made.

To access the revised "Suggestions to Improve Your Immunization Services," go to:
http://www.immunize.org/catg.d/p2045.pdf

(4) Newly licensed vaccines Pentacel, Kinrix, and Rotarix were added to "Notification of Vaccination Letter."

To access this revised resource, go to:
http://www.immunize.org/catg.d/p3060.pdf

(5) The title was changed, and Tdap, zoster, and HPV vaccines were added to "Before you vaccinate adults, consider their 'H-A-L-O!'"

To access this revised resource, go to:
http://www.immunize.org/catg.d/p3070.pdf

(6) National statistics were updated and other minor changes made to "Hepatitis B: Questions and Answers."

To access this revised resource, go to:
http://www.immunize.org/catg.d/p4205.pdf

Sarah Jane Schwarzenberg, MD, recently reviewed two of her print materials on childhood hepatitis B virus infection and revised one of them, as follows:

(7) "Brief Introduction to Hepatitis B for Parents of Adopted Children" was reviewed and found to be still accurate.

To access this resource, go to:
http://www.immunize.org/catg.d/p4150.pdf

(8) Minor changes were made to "What the Physician Can Do to Help the Child with Chronic Hepatitis B Virus Infection."

To access this revised resource, go to:
http://www.immunize.org/catg.d/p2170.pdf

IAC's Print Materials web section has more than 175 FREE, ready-to-print English-language resources for healthcare professionals and the public--as well as many in translation. To access all of IAC's print resources, go to: http://www.immunize.org/printmaterials
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September 16, 2008
TWO OF IAC'S REVISED VIRAL-HEPATITIS SCREENING QUESTIONNAIRES ARE NOW AVAILABLE IN SPANISH

[The following is cross posted from the Immunization Action Coalition's "IAC Express" electronic newsletter, 8/25/08.]

The screening questionnaires "Should You Be Vaccinated Against Hepatitis B? A screening questionnaire for adults" and "Should You Be Vaccinated Against Hepatitis A? A screening questionnaire for adults" were updated in June 2008. The updated versions are now available in Spanish.

To access the Spanish version of "Should You Be Vaccinated Against Hepatitis B? A screening questionnaire for adults," go to: http://www.immunize.org/catg.d/p2191-01.pdf

To access the English version of "Should You Be Vaccinated Against Hepatitis B? A screening questionnaire for adults," go
to: http://www.immunize.org/catg.d/p2191.pdf

To access the Spanish version of "Should You Be Vaccinated Against Hepatitis A? A screening questionnaire for adults," go
to: http://www.immunize.org/catg.d/p2190-01.pdf

To access the English version of "Should You Be Vaccinated Against Hepatitis A? A screening questionnaire for adults," go
to: http://www.immunize.org/catg.d/p2190.pdf
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September 16, 2008
FDA APPROVES USE OF THE HIV DRUG VIREAD FOR TREATMENT OF CHRONIC HEPATITIS B VIRUS INFECTION IN ADULTS

[The following is cross posted from the Immunization Action Coalition's "IAC Express" electronic newsletter, 8/18/08.]

On August 11, FDA issued a supplement to its approval of tenofovir disoproxil fumarate (Viread; Gilead). The drug is now indicated for use in treating chronic hepatitis B virus infection in adults. Previously, it was approved only for treating HIV infection.

To access the approval letter, go to:
http://www.fda.gov/cder/foi/appletter/2008/021356s025ltr.pdf

To access the package insert posted on the Gilead website, go to:
http://www.gileadhiv.com/pdf/VireadFPI.pdf
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September 16, 2008
CDC PRESENTS INFECTION-CONTROL REQUIREMENTS FOR DIALYSIS FACILITIES AND GIVES GUIDANCE ON PARENTERAL MEDICATION VIALS

[The following is cross posted from the Immunization Action Coalition's "IAC Express" electronic newsletter, 8/18/08.]

CDC published "Infection Control Requirements for Dialysis Facilities and Clarification Regarding Guidance on Parenteral Medication Vials" in the August 15 issue of MMWR. A summary made available to the press is reprinted below in its entirety.

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In dialysis and other healthcare settings, injected medications that are labeled for single-use should be used one time for one patient only. To avoid contamination and potential spread of infection in dialysis settings, medications and solutions must be handled using proper infection control precautions as described in CDC guidelines and now mandated through the new CMS Conditions for Coverage. This includes injection preparation using only new sterile needles/syringes in a clean area separate from patient treatment areas and contaminated items. Beginning in October 2008, outpatient dialysis facilities will be required by the Centers for Medicare and Medicaid Services (CMS) to follow CDC infection control guidelines that pertain to hemodialysis settings. These guidelines include recommendations for correct handling and use of injected medications. To prevent transmission of both bacteria and bloodborne viruses in hemodialysis settings, all injectable medications labeled as "single-use" should be used for one patient and be entered one time only. Medications packaged as multidose should be assigned to a single patient whenever possible. All parenteral medications should be prepared using sterile injection equipment in a clean area that is removed from the patient treatment area and separate from potentially contaminated items and surfaces.

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To access a web-text (HTML) version of the MMWR article, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5732a3.htm

To access a ready-to-print (PDF) version of this issue of MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5732.pdf

To receive a FREE electronic subscription to MMWR (which includes new ACIP recommendations), go to:
http://www.cdc.gov/mmwr/mmwrsubscribe.html
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September 16, 2008
CDC ISSUES RECOMMENDATIONS FOR POSTEXPOSURE INTERVENTIONS TO PREVENT INFECTION WITH HEPATITIS B VIRUS, HEPATITIS C VIRUS, OR HIV VIRUS AND TETANUS IN PERSONS WOUNDED DURING BOMBINGS AND OTHER MASS-CASUALTY EVENTS

[The following is cross posted from the Immunization Action Coalition's "IAC Express" electronic newsletter, 8/4/08.]

On August 1, CDC published "Recommendations for Postexposure Interventions to Prevent Infection with Hepatitis B Virus, Hepatitis C Virus, or Human Imunodeficiency Virus, and Tetanus in Persons Wounded During Bombings and Other Mass-Casualty Events--United States, 2008: Recommendations of the Centers for Disease Control and Prevention (CDC)" in MMWR Recommendations and Reports. The recommendations' Summary is reprinted below.

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Summary
This report outlines recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C virus, or human immunodeficiency virus, and tetanus in persons wounded during bombings or other events resulting in mass casualties. Persons wounded during such events or in conjunction with the resulting emergency response might be exposed to blood, body fluids, or tissue from other injured persons and thus be at risk for bloodborne infections. This report adapts existing general recommendations on the use of immunization and postexposure prophylaxis for tetanus and for occupational and nonoccupational exposures to bloodborne pathogens to the specific situation of a mass-casualty event. Decisions regarding the implementation of prophylaxis are complex, and drawing parallels from existing guidelines is difficult. For any prophylactic intervention to be implemented effectively, guidance must be simple, straightforward, and logistically undemanding. Critical review during development of this guidance was provided by representatives of the National Association of County and City Health Officials, the Council of State and Territorial Epidemiologists, and representatives of the acute injury care, trauma and emergency response medical communities participating in CDC's Terrorism Injuries: Information, Dissemination and Exchange (TIIDE) project. The recommendations contained in this report represent the consensus of U.S. federal public health officials and reflect the experience and input of public health officials at all levels of government and the acute injury response community. . . .

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To access a ready-to-print (PDF) version of the recommendations, go to:
http://www.cdc.gov/mmwr/PDF/rr/rr5706.pdf

To access a web-text (HTML) version of the recommendations, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5706a1.htm
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September 16, 2008
VIET HEP B FREE PROJECT OFFERS CULTURALLY APPROPRIATE INFORMATION ON ITS WEBSITE

The Vietnamese Community Health Promotion Project has launched a program called the Viet Hep B Free Project which aims to increase knowledge about hepatitis B and receipt of hepatitis B testing in the Vietnamese community in Northern California.

The Viet Hep B Free Project's website has information about hepatitis B testing, vaccination, and treatment in English and Vietnamese at http://www.suckhoelavang.org/VietHepB
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September 16, 2008
REMINDER: NIH CONSENSUS DEVELOPMENT CONFERENCE ON THE MANAGEMENT OF HEPATITIS B TO BE HELD OCTOBER 20-22 IN BETHESDA

[The following is cross posted from the Immunization Action Coalition's "IAC Express" electronic newsletter, 8/18/08.]

The National Institute of Health's (NIH) Consensus Development Conference on the Management of Hepatitis B will be held October 20-22, in Bethesda, MD. This conference is sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases and the Office of Medical Applications of Research.

Speakers and attendees at this conference will discuss issues related to the benefits and risks of current therapeutic options for HBV infection, including which persons should be treated, what measures are appropriate to monitor therapy and assess outcomes, and what the greatest needs are for future research.

For more information, including the preliminary agenda, go to:
http://consensus.nih.gov/2008/2008HepatitisBCDC120main.htm
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September 16, 2008
JOURNAL ARTICLES YOU MAY HAVE MISSED

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

"Hepatitis B and C among Veterans on a Psychiatric Ward"
Source: Dig Dis Sci, June 2008, Vol. 53(6):1693-8
Authors: Tabibian JH, Wirshing DA, Pierre JM, et al.
Click here.

"Excellent Response Rate to a Double Dose of the Combined Hepatitis A and B Vaccine in Previous Nonresponders to Hepatitis B Vaccine"
Source: The Journal of Infectious Diseases, September 1, 2008,
Vol. 198:299304
Authors: Cardell K, Akerlind B, Sallberg M, Fryden A
http://www.hivandhepatitis.com/hep_b/news/2008/082908_a.html

"Has the Time Come to Control Hepatitis A Globally? Matching Prevention to the Changing Epidemiology"
Source: Journal of Viral Hepatitis, August 27, 2008, Vol. 15 (Suppl2):1-15
Authors: Hendrickx G, Van Herck K, Vorsters A, et al.
http://www3.interscience.wiley.com/journal/121388614/abstract

"Characteristics of Persons and Jobs with Needlestick Injuries in a National Data Set"
Source: Am J Infect Control, August 2008, Vol. 36(6):414-20
Authors: Leigh JP, Wiatrowski WJ, Gillen M, Steenland NK
Click here.

"Greater Drug Injecting Risk for HIV, HBV, and HCV Infection in a City Where Syringe Exchange and Pharmacy Syringe Distribution Are Illegal"
Source: J Urban Health, May 2008, Vol. 85(3):309-22
Authors: Neaigus A, Zhao M, Gyarmathy VA, Cisek L, Friedman SR, Baxter RC
Click here.

"Injecting Drug Users' Understanding of Hepatitis C"
Source: Addict Behav, July 22, 2008 ePrint
Authors: O'Brien S, Day C, Black E, Dolan K
Click here.


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