Report from Austin: Special Coverage of the 1998 National Hepatitis Coordinator Conference
Report from Austin:
Special Coverage of the 1998 National Hepatitis Coordinator Conference
Editor's Note: The annual CDC Hepatitis Coordinator Conference is the
largest meeting in the U.S. devoted to the control of viral hepatitis.
The1998 Conference was held on May 19-21 in Austin, Texas. Attendees
included hepatitis coordinators from all 50 states, health department
personnel, staff from the CDC Hepatitis Branch and National Immunization
Program, representatives from advocacy groups, and vaccine manufacturers.
The theme of this year's meeting was "Achieving the Goal of Hepatitis B
Elimination." Here are the highlights.
Failure to vaccinate high-risk adults blocks
hepatitis B elimination in U.S., says CDC
The vaccination of high-risk adults now stands as the biggest obstacle to
eliminating hepatitis B transmission in the United States, according to Dr.
Harold S. Margolis, Chief of the CDC Hepatitis Branch.
Margolis told attendees at the annual Hepatitis Coordinator Conference that
the nation is "doing well" in achieving three main components of the U.S.
Public Health Service (PHS) hepatitis B elimination plan: routine
vaccination of all newborns, catch-up vaccination of high-risk children, and
routine vaccination of adolescents. However, he said, the fourth component,
vaccination of high-risk adults, has been a frustrating "legacy of missed
The PHS hepatitis B elimination plan was developed by CDC in the late 1980s
and officially adopted by the Immunization Practices Advisory Committee (ACIP)
in November 1991 (MMWR 1991;40(RR-13):1-19).
Margolis's remarks reflect a growing frustration within CDC and state health
departments about the lack of progress in vaccinating adults at high risk
for hepatitis B, such as injecting drug users, men who have sex with men,
and household or sexual contacts of persons with chronic hepatitis B virus (HBV)
infection. Despite official recommendations dating back to 1982, vaccination
in these groups has been extremely slow.
Health care professionals miss many opportunities to vaccinate high-risk
adults. In a 1996 CDC survey of adult hepatitis B cases, 27% had been
treated for a sexually-transmitted disease (STD), 20% had been in prison,
10% had a history of sexual contact with a chronically infected patient, and
8% had a history of household contact with an HBV-infected person. In all,
58% of adult hepatitis B cases had histories that should have triggered
vaccination. If these missed opportunities could be eliminated, Margolis
said, a majority of the adult at-risk population could be immunized.
Another problem is bureaucratic tunnel vision. For example, in the late
1980s, researchers established a clear epidemiologic link between the risk
for STDs and the risk for hepatitis B. ACIP recommended vaccination for STD
patients in 1991. But, in a 1997 survey cited by Margolis, only 47% of
managers of federally-funded STD projects thought that hepatitis B
vaccination was the responsibility of their program, and only 24% offered
the vaccine (CDC, unpublished data).
Other barriers to high-risk adult vaccination include the cost of vaccine
and the lack of insurance coverage. Margolis pointed out that, of the "big
three" vaccine-preventable diseases of adults (influenza, pneumococcal
disease, and hepatitis B), only hepatitis B vaccine is not covered by public
or private insurance. Moreover, he said, when financial barriers are
removed, vaccination of adults does succeed. For example, 70% percent of
health care workers at occupational risk for hepatitis B have been been
vaccinated, largely because of the 1992 OSHA regulations requiring employers
to provide vaccine to this group (Mahoney FJ, et al. Progress towards the
elimination of hepatitis B virus transmission in the United States. Viral
Hepatitis 1997; 3: 105-19).
But vaccination rates for other high-risk adults remain low. In a California
survey, only 3% of homosexual men had evidence of hepatitis B vaccination (MMWR
1996;45:215-7), and successful vaccination programs for injecting drug users
are almost non-existent.
Margolis stressed that hepatitis B transmission cannot be eliminated, at
least in the near term, without effective vaccination of adult high-risk
groups. Adults transmit HBV directly to other adults. Immunizing children
and adolescents will eventually slow adult transmission (provided that
vaccine immunity does not wane too far), but it will take a generation for
this to occur.
Margolis does not want to wait that long. "Unless we can find a way to
vaccinate high-risk adults, countries such as Taiwan will eliminate HBV
transmission before the United States does," he said. "Yes, vaccinating
high-risk adults is complicated, but we must find a way to accomplish it."
CDC will launch quarterly reports in 1998
CDC and the states are continuing to discuss ways in which surveillance for
viral hepatitis can be improved, according to staff from the CDC Hepatitis
Branch and the Council of State and Territorial Epidemiologists (CSTE) (see
HCR, Summer 1997 issue). CSTE has contracted with an epidemiologist,
Dr. AnneMarie Wasley, to help the Branch devise a new hepatitis surveillance
system, one that will meet future public health needs.
At the Conference, Wasley said that the new system should be sensitive
enough to detect relatively small changes in hepatitis incidence. It should
also facilitate investigation of cases and provide useful data for directing
and evaluating prevention programs.
The current system does not fill those needs optimally, she said. Several
states do not even participate in CDC's most detailed surveillance system,
the Viral Hepatitis Surveillance Program (VHSP). In a recent survey of state
health departments, Wasley found that the main reason for low participation
in VHSP is lack of personnel. With only one or two people per state doing
hepatitis surveillance, there are not sufficient personnel to collect all
the data requested on the VHSP form.
To improve the quality and completeness of CDC surveillance, the agency is
revising the VHSP form and upgrading its system for recording incoming data,
both electronic and paper. To improve states' access to the information (at
this writing, the most recent CDC Hepatitis Surveillance Report was issued
in April 1996), the agency will launch a new quarterly surveillance report.
The first report, due out soon, will cover the first quarter of 1998.
Another important issue is
surveillance for chronic HBV
infection. Currently, CDC collects data only on the incidence of acute
disease, which are not very useful for assessing trends in chronic
infection. The NHANES
II and NHANES
surveys provided some trend data, most recently in 1988-94, but the samples
were too small to assess prevalence in high-risk groups and in smaller
geographic areas. The next survey,
IV, will be conducted in 1998-2000, but
believes that dedicated surveys in high-risk groups will be needed to truly
assess chronic infection in those groups.
CDC is also considering the establishment of a surveillance system dedicated
to perinatal hepatitis B. The agency will pilot such a system soon in
several states. The dedicated system will help answer some very important
questions, such as the rate of vaccine failures in infants, vaccine escape
mutants, and waning vaccine-induced immunity.
The State of Wisconsin piloted a registry for chronic HBV infections in
1996. Marjorie Hurie, a nurse with the Wisconsin Department of Health,
presented data from the pilot at the Conference. The registry received
reports from laboratories, private providers, blood and plasma centers, and
out-of-state sources, and attempted to follow up persons identified as
hepatitis B surface antigen (HBsAg) positive through questionnaires, chart
reviews and interviews. Follow-up was successful in 91% of positive HBsAg
tests overall and in 100% of such tests in pregnant women. The pilot
registry found that 72% of contacts of HBsAg-seropositive pregnant women
were properly vaccinated, versus 55% of contacts of non-pregnant persons.
"We have a two-tiered system of follow-up for hepatitis B," said Hurie.
"Follow up for pregnant women is much better, in part because it is funded.
There is no special funding for follow-up of non-pregnant people."
San Antonio hepatitis A vaccination program
cites low coverage rates
In February 1997, San Antonio, Texas became the first jurisdiction in the
U.S. to offer routine vaccination against hepatitis A to schoolchildren (see
HCR Winter 1996-97 issue). The program, a five-year demonstration
project led by San Antonio Health Director Dr. Fernando Guerra, has offered
hepatitis A vaccination for all children ages 3-9 in 46 schools and 31 day
care centers and Headstart centers located in the central city, where
hepatitis A rates have been high for many years (30-50 per 100,000
person-years). At the Conference, Linn Watson, hepatitis coordinator and
director of the San Antonio project, presented the results of the project to
The San Antonio program is purely voluntary in order for children to
receive the vaccine, parents must return a consent form distributed by
teachers in the targeted schools. Realizing that compliance with voluntary
vaccination programs is often low, Watson and her staff promoted the project
with parties, media coverage, and educational presentations for parents. The
project was developed in close consultation with medical staff from the
In the first year, the two-dose completion rate in elementary schools was
43%. In the second year, the one-dose completion rate was 38% (the second
dose was not yet due at the time of analysis). The one-dose completion rates
for Headstart and day care centers were somewhat higher, at 71% and 51%,
Watson said that it is too early to determine the impact of the vaccination
program on hepatitis A incidence in the targeted area (although preliminary
data show a decrease in hepatitis A incidence in the vaccinated group).
However, the coverage rates attained by the program are probably lower than
the rate needed to interrupt transmission. In a well-known study by McMahon
in Alaska, vaccine coverage of 79% was successful in stopping an outbreak,
but coverage of 49% was not (McMahon BJ, et al. Arch Pediatr Adolesc Med
1996;150:733-39.) Likewise, in the large hepatitis A vaccine
intervention in Memphis, Tennessee in 1995, a vaccine coverage rate of 54%
in high-incidence areas did not definitively affect transmission (Craig AS,
et al. Clinical Infectious Diseases , in press).
Watson pointed out that the low coverage rates attained by the program
occurred despite strong promotional and educational efforts by Health
District and school personnel.
ALL INFORMATION, DATA, AND
MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION
PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS
OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR
LEGAL ADVICE. THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND
COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH
YOUR HEALTH CARE PROVIDER.