Hepatitis B vaccination coverage among United States children

Hepatitis B Virus Treatment in Children: Common Challenges and Management Options in a Case-Based Format

The management of hepatitis B virus (HBV) in pediatrics presents many challenges, given the potential sequelae of untreated infection including hepatic fibrosis, cirrhosis, and malignancy, and a lack of clear guidance on the timing of treatment initiation. The goal of this review is to feature common clinical scenarios that occur in the evaluation and treatment of HBV infection in children. Each vignette presents an opportunity to discuss guidelines and evidence-based practices as well as review landmark studies and evolving practices.

Low rates of transfusion-transmitted infection screening in chronically transfused adults with sickle cell disease

BACKGROUND

Adults with sickle cell disease (SCD) on chronic transfusion therapy are exposed to a large volume of blood products, thus increasing their risk of transfusion-associated human immunodeficiency virus (HIV), hepatitis C (HCV), and hepatitis B (HBV).

METHODS

We performed a systematic chart review of chronically transfused SCD subjects at the Johns Hopkins Sickle Cell Center for Adults between October 2014 and September 2019 to determine our Center's adherence to the 2014 National Heart, Lung and Blood Institute (NHLBI) SCD guidelines for annual screening for Transfusion Transmitted infections (TTI) and assessed HBV immunity and HBV vaccination rates.

RESULTS

The study included 85 subjects with a median age of 34 years (23-63); 52% were female. No subject received annual screening; 68 subjects (80%) were screened for HIV, 60 subjects (71%) for HCV and 53 subjects (62%) for HBV infections at least once in the study period. Of those screened, one patient was newly diagnosed with HCV infection, and none with HIV or HBV infection. Among 31 subjects tested for anti-Hepatitis B surface antibody, 16 subjects (52%) tested negative. Nineteen (20%) subjects had HBV vaccination documented.

CONCLUSIONS

Low adherence to the NHLBI TTI screening guidelines, especially for HBV, highlights the resource intensiveness of this patient population. The low rates of anti-Hepatitis B surface antibody positivity highlight the need to confirm vaccination, provide boosters as indicated, and investigate the adults with SCD's immune response to HBV vaccination.

Computational modeling of interventions and protective thresholds to prevent disease transmission in deploying populations

Military personnel are deployed abroad for missions ranging from humanitarian relief efforts to combat actions; delay or interruption in these activities due to disease transmission can cause operational disruptions, significant economic loss, and stressed or exceeded military medical resources. Deployed troops function in environments favorable to the rapid and efficient transmission of many viruses particularly when levels of protection are suboptimal. When immunity among deployed military populations is low, the risk of vaccine-preventable disease outbreaks increases, impacting troop readiness and achievement of mission objectives. However, targeted vaccination and the optimization of preexisting immunity among deployed populations can decrease the threat of outbreaks among deployed troops. Here we describe methods for the computational modeling of disease transmission to explore how preexisting immunity compares with vaccination at the time of deployment as a means of preventing outbreaks and protecting troops and mission objectives during extended military deployment actions. These methods are illustrated with five modeling case studies for separate diseases common in many parts of the world, to show different approaches required in varying epidemiological settings.

Factors influencing administration of hepatitis B vaccine to community-dwelling teenagers aged 12-18 with an intellectual disability

The study aims to determine hepatitis B vaccination coverage rates among community-dwelling teenagers with an intellectual disability in Taiwan and to identify the possible influencing factors of their vaccination. The present paper was part of the results of the "2007 National Survey on Healthy Behaviors and Preventive Health Utilizations of People with Intellectual Disabilities in Taiwan," which was a cross-sectional survey of 1111 intellectually disabled (ID) teenagers ranging from 12 to 18 years of age. The results showed that the completed hepatitis B vaccination rate was 72.9%, a rate lower than that in the general population of Taiwan considering the same age group. There was no gender difference between each age group in the vaccination rate in this population. Multilevel logistic regression analyses revealed that those ID individuals whose primary caregivers were parents or siblings (OR = 2.45, 95% CI = 1.29-4.64), whose household monthly income was 20,000-59,999 NTD vs. less than 20,000 NTD (OR = 2.47, 95% CI = 1.00-6.12), and who had ever undergone an oral health exam (OR = 2.29, 95% CI = 1.24-4.01) were more likely to receive a complete hepatitis B vaccination than their counterparts. The study highlighted that most teenagers had received complete hepatitis B vaccination. Nonetheless, better public health strategies may be needed to deliver the hepatitis B vaccine to those who do not comply with the vaccination schedule in the community.

Incidence and mortality rates of selected infection-related cancers in Puerto Rico and in the United States

BACKGROUND

In 2002, 17.8% of the global cancer burden was attributable to infections. This study assessed the age-standardized incidence and mortality rates of stomach, liver, and cervical cancer in Puerto Rico (PR) for the period 1992-2003 and compared them to those of Hispanics (USH), non-Hispanic Whites (NHW), and non-Hispanic Blacks (NHB) in the United States (US).

METHODS

Age-standardized rates [ASR(World)] were calculated based on cancer incidence and mortality data from the PR Cancer Central Registry and SEER, using the direct method and the world population as the standard. Annual percent changes (APC) were calculated using the Poisson regression model from 1992-2003.

RESULTS

The incidence and mortality rates from stomach, liver and cervical cancer were lower in NHW than PR; with the exception of mortality from cervical cancer which was similar in both populations. Meanwhile, the incidence rates of stomach, liver and cervical cancers were similar between NHB and PR; except for NHB women who had a lower incidence rate of liver cancer than women in PR. NHB had a lower mortality from liver cancer than persons in PR, and similar mortality from stomach cancer.

CONCLUSIONS

The burden of liver, stomach, and cervical cancer in PR compares to that of USH and NHB and continues to be a public health priority. Public health efforts are necessary to further decrease the burden of cancers associated to infections in these groups, the largest minority population groups in the US. Future studies need to identify factors that may prevent infections with cancer-related agents in these populations. Strategies to increase the use of preventive strategies, such as vaccination and screening, among minority populations should also be developed.

Global reduction of cervical cancer with human papillomavirus vaccines: insights from the hepatitis B virus vaccine experience

Background: Worldwide, prophylactic vaccines against two major human cancers are now commercially available: hepatitis B virus (HBV) vaccines (first licensed in 1982) against primary hepatocellular carcinoma and human papillomavirus (HPV) vaccines (first licensed 2006) against cervical cancer. Initial implementation strategies for HBV vaccination were not successful in preventing disease in the community: it took 15 years for significant global reduction in the burden of this disease. Methods: We compare and contrast HBV vaccine experiences to challenges for successful global HPV vaccination strategies, and make recommendations accordingly. Results: Lessons from HBV immunisation for successful outcomes with HPV immunisation showed that several factors need to be met: (i) the engagement of key stakeholders in all aspects of planning and delivery of HPV vaccine strategies; (ii) understanding the specific characteristics of targeted population groups; (iii) global cooperation and support with WHO recommendations; (iv) Government supported mass immunization programs and cooperation between public and private entities; (v) affordable HPV vaccines for some regions; (vi) culturally appropriate and diverse public education programs in targeted health promotion strategies; (vii) pro-active health providers and parents in encouraging adolescents to undertake HPV vaccination; and (vii) eventual immunisation of infants. Conclusions: The key to success will be affordable, readily deliverable HPV vaccines to young girls as universal campaigns.

Hepatitis B vaccines

Immunization is the most effective way to prevent transmission of HBV and, hence, the development of acute or chronic hepatitis B. The national strategy to eliminate transmission of the virus in the United States includes vaccination of all newborn infants, children, adolescents, and high-risk adults. Postexposure prophylaxis is also advocated, depending on the vaccination and anti-HBs status of the exposed person. Seroprotection after vaccination, defined as anti-HBs > or = 10 mIU/mL, is achieved in over 95% of all vaccinees. The hepatitis B vaccines are very well tolerated with usually minimal adverse effects. Predictors of non-response include increasing age, male gender, obesity, tobacco smoking, and immunocompromising chronic dis-ease. For those who remain nonresponders after the second series of vaccination, adjuvants such as GM-CSF may be considered, but their results are variable.

Vaccination coverage in the South-East Anatolian Project (SEAP) region and factors influencing low coverage

OBJECTIVES

To determine the vaccination coverage of children living in the South-east Anatolian Project (SEAP) region; whether the vaccination coverage was similar to formal reports, other studies and other countries; and which factors influence vaccination, in order to indicate how vaccination coverage can be improved.

STUDY DESIGN

A descriptive cross-sectional study conducted in nine provinces of the SEAP region in order to determine public health problems and their causes.

METHODS

A population-based sample of 1150 houses was selected from rural and urban areas of the SEAP region and visited by the researchers. Questionnaires were applied in 2001 and 2002.

RESULTS

In the SEAP region, only 30% of children had received a complete set of vaccines. The vaccination coverage was 76.7% for Bacille Calmette-Guérin; 62.0% for the third doses of diphtheria, tetanus toxoid, pertussis and polio vaccine; 62.7% for measles; 44% for the third dose of hepatitis B vaccine in children aged 12-23 months; and 13.3% for the second dose of tetanus toxoid in women who gave birth in the last 5 years. In logistic regression analysis, residence type, number of siblings, birth interval, follow-up visits of midwives, and maternal level of education were found to influence whether children were completely vaccinated.

CONCLUSIONS

The findings of this study indicate that vaccination coverage is not acceptable in the SEAP region. Efforts must focus on family planning services, education of women, follow-up visits and strengthening health facilities, especially in rural regions, to improve vaccination.

Epidemiology of hepatitis B and hepatitis B virus infection in United States children

Before the era of routine hepatitis B vaccination, an estimated 24,000 children acquired hepatitis B virus (HBV) infection each year in the United States. Childhood hepatitis B immunization has led to significant declines in the incidence and prevalence of HBV infection in U.S. children. Because the greatest burden of hepatitis B is caused by complications of hepatocellular carcinoma and cirrhosis in adults who were infected with HBV as children, most of the benefits of vaccination have yet to be realized. Reaching the goal of eliminating HBV transmission to children likely will require increasing vaccination coverage, ensuring timely administration of postexposure immunoprophylaxis to prevent more perinatal infections, and continued evaluation of the impact of immunization recommendations.

Hepatitis B vaccines

Immunization is the most effective way to prevent transmission of HBV and, hence, the development of acute or chronic hepatitis B. The national strategy to eliminate transmission of the virus in the United States includes vaccination of all newborn infants, children, adolescents, and high-risk adults. Postexposure prophylaxis is also advocated, depending on the vaccination and anti-HBs status of the exposed person. Seroprotection after vaccination, defined as anti-HBs > or = 10 mIU/mL, is achieved in over 95% of all vaccinees. The hepatitis B vaccines are very well tolerated with usually minimal adverse effects. Predictors of non-response include increasing age, male gender, obesity, tobacco smoking, and immunocompromising chronic disease. For those who remain nonresponders after the second series of vaccination, adjuvants such as GM-CSF may be considered, but their results are variable.

Critical overview and outlook: pathogenesis, prevention, and treatment of hepatitis and hepatocarcinoma caused by hepatitis B virus

Viral hepatitis B is an enigmatic disease in which the host's own immune response to persistent viral infection may bring about host destruction through antiviral inflammatory responses which might otherwise present as a benign or inapparent disease. The simple solution to the hepatitis B problem is by immunoprophylaxis using the vaccine licensed in 1981, which prevents both infection and the late sequelae of liver cirrhosis and hepatocarcinoma. Immunotherapeutic vaccines against persistent hepatitis B infection have not been successful and new explorations are being directed to therapies which include antisense, ribozymes, gene silencing by RNA interference (RNAi) and aptamer approaches. Limited benefits from nucleoside therapy and limitations in opportunity for liver transplantation have left a large void of curative treatments. Findings with respect to e antigen tolerance provide a basis for exploration to determine whether passively administered e antigen might suppress cell-mediated immunity, creating a commensal state in which virus persists but without pathologic damage to the host. Therapy of hepatocarcinoma by conventional chemotherapy, radiation, or surgical resection and ablation gives little hope for restoration of health unless the tumor is detected very early. The large engagement of the world medical science community to develop therapeutic vaccines against cancer is now in major clinical trials to determine the hope and credibility for the immunization approach. Vaccines based on tumor peptides which are linked to heat shock proteins and directed to host dendritic cells give reason for excitement and may be the "best show in town". A new era of tumor therapy will need to be based on new discoveries in immune function which are required to pursue immunotherapy on a more rational basis. The many facets of current hepatitis B virology, pathogenesis, immunoprophylaxis, immunotherapeusis, chemotherapy, and tumor pathogenesis and therapy are discussed here, in depth, but in keeping with needed brevity.

Recombinant hepatitis B vaccine (Engerix-B): a review of its immunogenicity and protective efficacy against hepatitis B

Engerix-B (Hep-B[Eng]) is a noninfectious recombinant DNA vaccine containing hepatitis B surface antigen (HBsAg). It is produced from genetically engineered yeast (Saccharomyces cerevisiae). Intramuscular Hep-B(Eng) [0-, 1-, 6-month schedule] has excellent immunogenicity in healthy neonates and infants, children, adolescents and adults, with seroprotection rates of 85-100% seen approximate, equals 1 month after the final dose of vaccine; seroprotection was defined as an antibody against HBsAg (anti-HBs) titre of > or =10 IU/L. The use of alternative Hep-B(Eng) immunisation schedules (e.g. a 0-, 1-, 2-, 12-month schedule in neonates and infants, 0-, 12-, 24-month or two-dose schedules in children and adolescents, and accelerated schedules in adults) have also been associated with high rates of seroprotection. Seroprotection rates were generally similar with Hep-B(Eng) and the recombinant vaccine Recombivax HB (Hep-B[Rax]) or plasma-derived vaccines (PDVs) approximate, equals 1 month after the final dose (although anti-HBs geometric mean titres were significantly higher with Hep-B[Eng] than with Hep-B[Rax]). One month after the final dose, adults had significantly higher seroprotection rates with the recombinant triple-antigen vaccine Bio-Hep-B (Hep-B[Bio]) than with Hep-B(Eng), although seroprotection rates in healthy infants were similar with Hep-B(Eng) and Hep-B(Bio). Hep-B(Eng) had excellent immunogenicity in several groups considered at high risk of acquiring hepatitis B (e.g. neonates born to hepatitis B carrier mothers and healthcare workers). The immunogenicity of Hep-B(Eng) was reduced in patients with conditions associated with impaired immune function (e.g. patients undergoing haemodialysis or being treated for malignancy), although it had good immunogenicity in patients with diabetes mellitus.Hep-B(Eng) had excellent protective efficacy against HBsAg carriage in healthy infants and children, and in neonates born to hepatitis B carrier mothers (protective efficacy of 95-99%). Hep-B(Eng) also demonstrated good protective efficacy in a number of other high-risk groups. Hep-B(Eng) is generally well tolerated with a tolerability profile similar to that of Hep-B(Rax), Hep-B(Bio) and PDVs. In conclusion, Hep-B(Eng) is a well established, highly immunogenic hepatitis B vaccine with good tolerability and excellent protective efficacy; it offers flexibility through a variety of immunisation schedules. In addition, it appears that Hep-B(Eng) confers immunity for at least 10 years. Hep-B(Eng) has an important role in mass vaccination campaigns against hepatitis B, as well as in groups considered at high risk of acquiring hepatitis B.

Cost-effectiveness of a potential vaccine for human papillomavirus

Human papillomavirus (HPV) infection, usually a sexually transmitted disease, is a risk factor for cervical cancer. Given the substantial disease and death associated with HPV and cervical cancer, development of a prophylactic HPV vaccine is a public health priority. We evaluated the cost-effectiveness of vaccinating adolescent girls for high-risk HPV infections relative to current practice. A vaccine with a 75% probability of immunity against high-risk HPV infection resulted in a life-expectancy gain of 2.8 days or 4.0 quality-adjusted life days at a cost of $246 relative to current practice (incremental cost effectiveness of $22,755/quality-adjusted life year [QALY]). If all 12-year-old girls currently living in the United States were vaccinated, >1,300 deaths from cervical cancer would be averted during their lifetimes. Vaccination of girls against high-risk HPV is relatively cost effective even when vaccine efficacy is low. If the vaccine efficacy rate is 35%, the cost effectiveness increases to $52,398/QALY. Although gains in life expectancy may be modest at the individual level, population benefits are substantial.