Housing characteristics and indoor air quality in households of Alaska Native children with chronic lung conditions

Alaska Native children experience high rates of respiratory infections and conditions. Household crowding, indoor smoke, lack of piped water, and poverty have been associated with respiratory infections. We describe the baseline household characteristics of children with severe or chronic lung disease participating in a 2012-2015 indoor air study. We monitored indoor PM2.5, CO2 , relative humidity %, temperature, and VOCs and interviewed caregivers about children's respiratory symptoms. We evaluated the association between reported children's respiratory symptoms and indoor air quality indicators using multiple logistic regression analysis. Compared with general US households, study households were more likely overcrowded 73% (62%-82%) vs 3.2% (3.1%-3.3%); had higher woodstove use as primary heat source 16% (9%-25%) vs 2.1% (2.0%-2.2%); and higher proportion of children in a household with a smoker 49% (38%-60%) vs 26.2% (25.5%-26.8%). Median PM2.5 was 33 μg/m3 . Median CO2 was 1401 ppm. VOCs were detectable in all homes. VOCs, smoker, primary wood heat, and PM2.5>25 μg/m3 were associated with higher risk for cough between colds; VOCs were associated with higher risk for wheeze between colds and asthma diagnosis. High indoor air pollutant levels were associated with respiratory symptoms in household children, likely related to overcrowding, poor ventilation, woodstove use, and tobacco smoke.

Molecular epidemiology of serotype 19A Streptococcus pneumoniae among invasive isolates from Alaska, 1986-2010

Background

After the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7) in Alaska, the incidence of invasive pneumococcal disease (IPD) due to non-vaccine serotypes, particularly serotype 19A, increased. The aim of this study was to describe the molecular epidemiology of IPD due to serotype 19A in Alaska.

Methods

IPD data were collected from 1986 to 2010 through population-based laboratory surveillance. Isolates were serotyped by the Quellung reaction and MICs determined by broth microdilution. Genotypes were assessed by multilocus sequence typing.

Results

Among 3,294 cases of laboratory-confirmed IPD, 2,926 (89%) isolates were available for serotyping, of which 233 (8%) were serotype 19A. Across all ages, the proportion of IPD caused by serotype 19A increased from 3.5% (63/1823) pre-PCV7 (1986–2000) to 15.4% (170/1103) post-PCV7 (2001–2010) (p<0.001); among children <5 years of age, the proportion increased from 5.0% (39/776) to 33.0% (76/230) (p<0.001). The annual incidence rate of IPD due to serotype 19A (all ages) increased from 0.73 cases pre-PCV7 to 2.56 cases/100,000 persons post-PCV7 (p<0.001); rates among children <5 years of age increased from 4.84 cases to 14.1 cases/100,000 persons (p<0.001). Among all IPD isolates with reduced susceptibility to penicillin, 17.8% (32/180) were serotype 19A pre-PCV7 and 64% (121/189) were serotype 19A post-PCV7 (p<0.001). Eighteen different sequence types (STs) were identified; ST199 or single locus variants of ST199 (n=150) and ST172 (n=59) accounted for the majority of isolates. Multidrug-resistant isolates were clustered in ST199 and ST320.

Conclusion

While PCV13 should significantly reduce the burden of disease due to 19A, these data highlight the need to continue surveillance for IPD to monitor the effects of vaccination on the expansion and emergence of non-PCV strains.

Incidence of diabetes mellitus in a population-based cohort of persons with chronic hepatitis B virus infection

To investigate the effect of hepatitis B virus (HBV) infection on the development of diabetes mellitus (DM), we compared DM incidence and characteristics of Alaska Native persons with and without HBV infection. From 1990 to 2010, there were 52 incident DM cases among 1309 persons with infection vs 4557 DM cases among 85 698 persons without infection (log-rank test, P = 0.20). Compared to infected persons without DM, those with DM were significantly older (57.0 vs 47.4 years, P < 0.001) and had higher body mass index (34.5 vs 28.4 kg/m(2) , P < 0.001). Genotype, immune active disease and the presence of cirrhosis were not associated with DM. In this population-based cohort with over 20 years of follow-up, there was no effect of HBV infection on DM development.

Serologic and clinical outcomes of 1536 Alaska Natives chronically infected with hepatitis B virus

BACKGROUND

Knowledge of the outcome of chronic hepatitis B virus (HBV) infection is limited.

OBJECTIVE

To determine the incidence of and risk factors for adverse events (hepatocellular carcinoma and end-stage liver disease) and clearance of hepatitis B e antigen (HBeAg) and surface antigen (HBsAg) in carriers of HBV.

DESIGN

Population-based cohort study of hepatitis B carriers who were observed for a median of 12.3 years as part of an active surveillance program to detect carriers with hepatocellular carcinoma.

SETTING

126 communities in Alaska.

PATIENTS

1536 Alaska Natives with chronic hepatitis B.

MEASUREMENTS

Bivariate comparisons, multivariable models, and other statistical methods were used to examine the relationships of risk factors to outcomes and clearance of HBeAg and HBsAg.

RESULTS

1536 chronic HBV carriers were followed up for 19 430 person-years from their first HBsAg-positive test result. At the first serologic test, 641 were HBeAg positive and 893 were anti-HBe positive. Older carriers were more likely than younger carriers to clear HBeAg (P < 0.001). The observed probability of clearing HBeAg within 10 years of diagnosis was 72.5%. Clearance of HBsAg occurred in 106 (7%) of all carriers and was positively associated with older age and positive result on initial anti-HBe test. The incidence of adverse events was 2.3 per 1000 carrier-years, and the incidence of hepatocellular carcinoma was 1.9 per 1000 carrier-years (2.3 in men and 1.2 in women). Risk for hepatocellular carcinoma increased with age, among those of Yupik Eskimo ethnicity, and among carriers who reverted from anti-HBe to HBeAg.

CONCLUSION

In HBsAg-positive carriers, observed clearance of HBeAg was more than 70% during the first 10 years of follow-up.

High prevalence of Helicobacter pylori in the Alaska native population and association with low serum ferritin levels in young adults

Iron deficiency anemia is a common public health problem in the Alaska Native population. Yet, a clear etiology has eluded researchers for decades. Previous studies suggested a link between Helicobacter pylori infection, gastrointestinal blood loss due to hemorrhagic gastritis, and generalized iron deficiency anemia in adult Alaska Natives. Therefore, we examined the association between the prevalence of H. pylori-specific immunoglobulin G (IgG) and serum ferritin levels, a marker of iron deficiency. A random sample of 2,080 serum samples from Alaska Native residents drawn between 1980 and 1986 from residents in 13 regions was selected, and the samples were stratified by age, sex, and region. Overall, 75% were positive for H. pylori-specific IgG. The rate of H. pylori seropositivity increased with age; by age 14 years, 78% of the residents were positive. There were no gender differences in H. pylori seropositivity. However, marked regional differences were observed. Serum ferritin levels of <12 ng/ml were found most commonly among persons <20 years of age and among women of childbearing age. A significant association between low serum ferritin levels and prevalence of H. pylori-specific IgG was found, particularly for people aged less than 20 years. H. pylori may be a factor contributing to the iron deficiency anemia in the Alaska Native population.

Screening for hepatocellular carcinoma in Alaska natives infected with chronic hepatitis B: a 16-year population-based study

The benefits of screening hepatitis B surface antigen (HBsAg)-positive carriers for hepatocellular carcinoma (HCC) in terms of long-term survival have not been established. We conducted a prospective 16-year, population-based cohort study to determine the impact of screening for HCC in 1,487 HBsAg-positive Alaska native carriers with alpha-fetoprotein (AFP) determinations every 6 months. Men and nonpregnant women with an elevated AFP level were evaluated for the presence of HCC by ultrasound (US) examination. The long-term survival rate for patients whose HCC was detected by the screening program was compared with a historical control group of Alaska native patients with HCC from the same population who were clinically diagnosed with HCC between 1969 and October 1982, through a National Cancer Institute-sponsored Cancer Registry. Between October 1982 and December 1998, 26,752 AFP determinations in HBsAg carriers were performed. One or more AFP elevations were found in 61 men and 39 nonpregnant women. HCC was diagnosed in 32 patients (24 men and 8 women). HCC tumors less than 6 cm were found in 23 patients; 22 patients had resections, and 1 patient refused a resection. Compared with 12 patients with hepatitis B virus (HBV)-related HCC diagnosed from 1969 to October 1982, before this program, the 5- and 10-year survival rate for the 32 patients with HCC were 42% (P =.008) and 30% (P =.07), respectively. Five- and 10-year tumor-free survival rates for carriers who had a normal AFP level on initial screening and subsequently developed HCC were 29% (P =.004) and 24% (P =.024), respectively. Screening of HBsAg carriers with semiannual AFP was effective in detecting most HCC tumors at a resectable stage and significantly prolonged survival rates when compared with historical controls in this population.

Severe respiratory syncytial virus disease in Alaska native children. RSV Alaska Study Group

Hospitalization rates for respiratory syncytial virus (RSV) infection range from 1 to 20/1000 infants. To determine the rate and severity of RSV infections requiring hospitalization for infants in the Yukon-Kuskokwim (YK) Delta of Alaska, a 3-year prospective surveillance study was conducted. The annual rate of RSV hospitalization for YK Delta infants <1 year of age was 53-249/1000. RSV infection was the most frequent cause of infant hospitalization. RSV disease severity did not differ among non-high-risk infants in the YK Delta and at Johns Hopkins Hospital (JHH). On average, 1/125 infants born in the YK Delta required mechanical ventilation for RSV infection. During the peak season, approximately $1034/child <3 years of age was spent on RSV hospitalization in the YK Delta. In YK Delta infants </=6 months old, RSV microneutralizing antibody titers <1200 were associated with severe disease (odds ratio=6.2, P=.03). In the YK Delta and at JHH, newborns may be at greater risk for severe RSV illness than previously thought.

Bacterial pathogens in chronic otitis media with effusion in Alaska Native children

This study examined the bacterial pathogens and the presence of possible risk factors for the development of chronic otitis media with effusion (OME) in a group of Alaska Native children. Middle ear aspirates were collected from 128 children < 6 years of age requiring tympanocentesis between 1987 and 1989. Bacterial pathogens were cultured from 40% of 209 fluids. Predominant isolates, after contamination of the outer ear was controlled for, were Haemophilus influenzae (21%; 84% of these were nontypeable), Streptococcus pneumoniae (8.1%; serotypes 6B, 10A, 11A, 14, 18B, 18C, 19A, and 23F), Staphylococcus epidermidis (3.8%), and Moraxella (Brahmanella) catarrhalis (2.9%). Pneumococcal-C-polysaccharide (PnC) was detectable in 3 of 135 (2.2%) aspirates that did not grow Streptococcus pneumoniae. Combining culture and PnC assay results evidence of pneumococcal infection was found in almost 10% of aspirates tested. There was not a significant difference in the number of episodes of acute otitis media after the first year of life based on the age at the first episode (< 6 mo, > or = 6 mo). However, 88% of infants in the study had their first acute otitis media episode before 1 year of age.

Immunogenicity of a combined hepatitis B and Haemophilus influenzae type b conjugate vaccine in Alaska Native infants

Hepatitis B and Haemophilus influenzae b (Hib), prevalent diseases in Alaska Native infants, have been reduced 95% following universal vaccination. Therefore, we were interested in studying a new combined Hib and hepatitis B vaccine in this population.

METHOD

Healthy Alaska Native infants free from Hib and hepatitis B exposure were randomized into four groups, three with different lots of bivalent Hib and hepatitis B vaccine, and one with Hib and hepatitis B monovalent controls. The Hib component had 7.5 micrograms of polyribosylribitol phosphate polysaccharide (PRP) bound to 125 micrograms of Neisseria meningitidis outer membrane protein complex (OMP); the hepatitis B component was 5 micrograms of recombinant hepatitis B surface antigen. The vaccines were given at 2 months, 4 months, and 12-15 months of age.

RESULTS

There were no differences in the responses to the bivalent compared to the monovalent controls except for a lower Hib anti-PRP level at 12-15 months in the bivalent recipients; this did not persist after the booster.

CONCLUSION

A combined Hib and hepatitis B vaccine appears immunogenic. The recommended schedule for the Hib component (PRP-OMP) of 2 months, 4 months, and 12-15 months appears to promote an optimal response to the hepatitis B component as well.

Reemergence of invasive Haemophilus influenzae type b disease in a well-vaccinated population in remote Alaska

Before vaccination, Alaska Natives experienced very high rates of invasive Haemophilus influenzae type b (Hib) disease and carriage. Vaccination with Hib conjugate vaccine PRP-OMP (polyribosylribitol phosphate Neisseria meningitidis outer membrane protein) began in 1991 and resulted in a sharp decline in cases. In 1996, after switching to a different Hib conjugate vaccine, DTP-HbOC (which combines diphtheria-tetanus-whole cell pertussis vaccines with HbOC [Hib oligosaccharide CRM197]), cases of invasive Hib disease increased, suggesting ongoing Hib transmission despite widespread vaccination. To determine the prevalence of and risk factors for carriage, a cross-sectional study of oropharyngeal Hib carriage was conducted among Alaska Native children aged 1-5 years in remote southwestern Alaska. Of 496 children with swabs taken, 46 (9.3%) were colonized with Hib. Carriage rates varied by village from 2.2% to 13.2% and by age from 6.1% in 1-year-olds to 14.7% in 5-year-olds. Crowding was associated with Hib carriage. Widespread vaccination with PRP-OMP Hib conjugate vaccine did not eliminate carriage in this population of Alaska Natives, and ongoing carriage contributed to disease resurgence.

Immune responses of prematurely born infants to hepatitis B vaccination: results through three years of age

BACKGROUND

Hepatitis B vaccine is effective in infants. Preterm infants also respond but information on long term immunogenicity is limited.

PURPOSE OF STUDY

To compare response of premature and full term infants to hepatitis B vaccine.

METHODS

Sixty-nine prematurely born Alaska Native infants received three doses of hepatitis B vaccine beginning at discharge. Thirty-seven infants had paired serum samples drawn at approximately 1 and 3 years of life which were tested for antibody to hepatitis B surface antigen. One hundred eight infants born at full term enrolled in a separate study were used for comparison.

RESULTS

Both early and late blood sample antibody to hepatitis B surface antigen titers were lower in preterm than in term infants (23.1 mIU/ml vs. 56.8 mIU/ml, early blood sample; and 0.7 mIU/ml vs. 1.32 mIU/ml, late blood sample); however, these values were not statistically different. The drop in titer over time, however, was significant in both groups as was the decrease in the percent of infants with titers > or = 10 mIU/ml (preterm infants 75.7% early specimen and 8.1% late specimen compared with term infants 87% early specimen and 15% late specimen). Both prematurity and longer interval between third vaccination and blood sample were associated with a decreased antibody titer. No infant had evidence of hepatitis B viral infection by developing antibody to hepatitis B core antigen.

CONCLUSIONS

Preterm and term infants have a similar decline in antibody titers during the first 3 years, but preterm infants generally have a lower titer. The immunogenicity of the vaccine beyond 3 years and the need for revaccination in these populations requires further study.

Iron deficiency anemia among Alaska Natives may be due to fecal loss rather than inadequate intake

To define more fully the nature of a persistently high prevalence of iron deficiency anemia observed among Alaska Native children, we examined dietary iron intake, hemoglobin concentrations, and storage iron (serum ferritin) based on multiple cross-sectional surveys of Alaska Natives between 1983 and 1989. Approximately 30 to 50% of the children studied < 12 y of age had depleted iron stores. Anemia and depleted iron stores also were prevalent among adult men and women, about twice as prevalent as in the U.S. population based on the Second National Health and Nutrition Examination Survey (NHANES II). The higher rate of iron deficiency, occurring even when the dietary assessment found Alaska Native iron intake to be higher than the U.S. average with an ample intake of food high in bioavailable iron, suggests blood loss as a possible cause of the unusual pattern of iron deficiency observed. In a pilot study of stool blood loss in two villages, 65% of the samples had a significantly elevated stool heme concentration. Further investigation of iron deficiency due to gastrointestinal blood loss for the Alaska Native is warranted.

A program to control an outbreak of hepatitis A in Alaska by using an inactivated hepatitis A vaccine

OBJECTIVE

To stop an epidemic of hepatitis A in rural Alaska by mass immunization of susceptible persons with 1 dose of an inactivated hepatitis A vaccine.

DESIGN

Nonrandomized, uncontrolled trial. Hepatitis A vaccine was offered to all persons in susceptible age groups in villages with documented cases of hepatitis A. Immune globulin was not offered at the time of vaccination.

SETTING

Twenty-five rural communities located in interior Alaska and along the northwest coast of the Bering Sea and Arctic Ocean.

PARTICIPANTS

Persons without a history of acute hepatitis A in age groups selected by applying results of a previous serosurvey conducted on serum collected before the epidemic.

INTERVENTION

One dose of a formalin-inactivated hepatitis A vaccine was given to each participant. Adults 20 years of age and older received 1440 enzyme-linked immunosorbent assay units and persons younger than 20 years received 720 enzyme-linked immunosorbent assay units. Prevaccination and postvaccination levels of antibody to hepatitis A IgG were obtained from 136 participants.

MAIN OUTCOME MEASURES

An active surveillance system was established to detect persons with symptomatic illnesses compatible with hepatitis A; persons who met the illness criteria were tested for antibody to hepatitis A IgM. One area (the Kotzebue region), where all communities were offered vaccine, was selected for intensive surveillance and analysis.

RESULTS

During the 12-month period before the vaccine trial, 529 cases of icteric hepatitis A were reported, and 443 were confirmed to be positive for antibody to hepatitis A IgM. Hepatitis A vaccine was administered to 4930 persons, 3517 of whom were younger than 20 years. After vaccination began, 237 persons positive for antibody to hepatitis A IgM were identified during a 60-week surveillance period; 46 were vaccines and 191 were unvaccinated susceptible persons. In the Kotzebue region, in communities in which more than 80% of persons considered susceptible were vaccinated, the outbreak ceased in 4 to 8 weeks, whereas in 1 large community in which less than 50% of susceptible persons were vaccinated, the outbreak continued for more than 50 weeks. More than 90% of seronegative persons developed antibody to hepatitis A IgG 3 to 4 weeks after vaccination.

CONCLUSION

This trial suggested that by providing both short-term and long-term protection, hepatitis A vaccine used without immune globulin halted an established epidemic of hepatitis A in rural Alaska.

Immunogenicity of an inactivated hepatitis A vaccine in Alaska Native children and Native and non-Native adults

The response to an inactivated hepatitis A vaccine was assessed in 307 persons: 163 Alaska Native children, ages 3-6 years, and 144 Native (84) and non-Native (60) adults. All adults received the same vaccine schedule (0, 1, and 12 months), whereas children were randomized to receive three different schedules (0, 1, and 6; 0, 1, and 2; or 0, 1, and 12 months). After one dose, 141 (96%) of 147 children and 129 (90%) of 143 adults responded with levels of antibody to hepatitis A virus > 20 mIU/mL. After three doses, all participants responded. The geometric mean titer (GMT) 1 month after the third dose was significantly higher in children who received the third dose 12 months after the first dose rather than 2 months after the first dose. While there were differences in the GMT of some blood samples by age, sex, and ethnicity, all participants responded to the vaccine.

Immunogenicity of the 23-valent pneumococcal polysaccharide vaccine in Alaska Native chronic alcoholics compared with nonalcoholic Native and non-Native controls

PURPOSE

This study was designed to evaluate the immunogenicity of the 23-valent pneumococcal polysaccharide vaccine in Alaska Native chronic alcoholics and compare these responses with those in age- and sex-matched nonalcoholic, Native and non-Native control subjects.

PATIENTS AND METHODS

Native alcoholic patients were recruited from the inpatient medical service and outpatient clinics. Healthy age- and sex-matched Alaska Native and non-Native nonalcoholics were recruited from hospital employees. At the initial visit, a standardized questionnaire, the Alcohol Dependency Scale, was administered to all participants. Participants were examined for liver diseases; blood was drawn for liver function tests and prevaccination pneumococcal antibody levels. Charts of all Native participants were reviewed for alcohol-related diseases. Participants received one dose of the 23-valent pneumococcal vaccine at the time of the initial visit and returned 20 to 55 days after immunization for liver function tests and pneumococcal antibody level measurement. Serotype-specific pneumococcal antibody levels were measured by radioimmunoassay. Logistic regression analysis was used to examine the proportion of persons whose serotype-specific antibody level doubled following vaccination. A model including adjustments for age, sex, and initial antibody level was used to examine the effect of alcohol status and ethnicity on response to the vaccine. Eighty-five persons completed the study. Of these, 41 were chronic alcoholics and 44 were nonalcoholic. Of these, 21 were Alaska Natives and 23 were non-Natives.

RESULTS

Before vaccination, the geometric mean titers (GMTs) were similar in all 3 groups but were slightly higher in Native alcoholic participants for 11 of 12 serotypes tested. For 11 or more serotypes tested, 46% of alcoholics and 27% of nonalcoholics had total antibody levels at or above 500 nanograms of antibody nitrogen per milliliter (p = 0.11). After vaccination, the GMTs were higher in nonalcoholic than in alcoholic participants for serotypes 3, 7F, and 19F (p < 0.05). When Natives and non-Natives were compared, non-Natives had higher antibody levels than Native participants for 10 of 12 serotypes. After vaccination, 83% of alcoholics and 91% of nonalcoholics had pneumococcal antibody levels of more than 500 nanograms of antibody nitrogen per milliliter for at least 11 serotypes. When responses consisting of a twofold or greater increase in antibody level were compared, a greater proportion of nonalcoholics than alcoholics responded to serotypes 3, 4, 7F, 8, and 19F. This difference was significant for types 3 and 19F only (p < 0.05). In alcoholics there was a direct correlation between pneumococcal antibody level and age both before and after vaccination. This was significant before vaccination for serotypes 4, 6B, 18C, and 23F, and after vaccination for these types and for types 1 and 19F. In nonalcoholics there was a correlation between age and antibody response, following vaccination, for serotype 9N and 18C. Alcoholic males had antibody levels higher than that in females for most serotypes, but significantly so only for serotype 12F before vaccination, and for type 14 after vaccination. There were no sex differences seen among nonalcoholics, and no differences in response to vaccine could be detected in patients with or without liver dysfunction.

CONCLUSION

In this study of Alaska Natives with chronic alcoholism, Native and non-Native participants responded adequately to immunization with the 23-valent pneumococcal vaccine, although significant differences in some serotypes were evident.

Seroprevalence of hepatitis B viral markers in 52,000 Alaska Natives

As a part of a program to screen and immunize as many Alaska Natives as possible against hepatitis B infection, hepatitis B virus seromarkers were measured in 52,022 Alaska Natives between 1983 and 1987. Hepatitis B surface antigen (HBsAg) was found in 1,603 persons (3.1%), and 7,155 persons (13.8%) exhibited hepatitis B virus seropositivity. While the prevalence of total seropositivity increased with increasing age (p < 0.001), the proportion of seropositive persons who were also positive for HBsAg was significantly higher in children under age 5 years than in persons over age 60 (p < 0.001). The total hepatitis B virus seropositivity was significantly higher in males than in females (p < 0.001), and a greater proportion of seropositive males than seropositive females had HBsAg (p < 0.001). The prevalence of HBsAg and total seropositivity differed significantly by geographic region (p < 0.001), ranging from 0.5% to 8.2% for presence of HBsAg and from 5.4% to 29% for total seropositivity. Of persons who were HBsAg positive, hepatitis B e antigen was found in 35.4%, and antibody to hepatitis e antigen was found in 49.6%. The prevalence of hepatitis B e antigen significantly decreased with age, while that of antibody to hepatitis e antigen significantly increased. The prevalence of hepatitis B virus seropositivity is high in Alaska Natives, and there are significant differences in both the prevalence of HBsAg and total hepatitis B virus seromarkers by age, sex, and geographic region.

Response to hepatitis B vaccine of persons positive for antibody to hepatitis B core antigen

The significance of antibody to hepatitis B core antigen (anti-HBc) present in a person's serum without hepatitis B surface antigen (HBsAg) or its antibody (anti-HBs) is unknown. Serum specimens from 281 persons initially positive only for anti-HBc by enzyme immunoassay (EIA) were retested by radioimmunoassay (RIA), and of these, 177 (63%) remained positive for anti-HBc by both assays. Of these 177 persons, 3 were positive for HBsAg, and 72 possessed low levels of anti-HBs [less than 10 sample ratio units; (SRU's)]. When persons positive for anti-HBc by EIA and RIA were given one 20-micrograms dose of plasma-derived hepatitis B vaccine and tested for anti-HBs 1 month later, a booster response was observed in 14 of 41 (34%) persons with low level anti-HBs and 3 of 50 (6%) persons negative for anti-HBs. Of those positive only for anti-HBc by EIA but negative by RIA, only 3 of 37 (8.1%) showed a booster response. Of those who completed the three-dose immunization series and did not show a booster response, 63 of 80 (78.8%) developed anti-HBs levels greater than 10 standard ratio unit. The majority of persons with isolated anti-HBc will have a primary rather than a booster response to hepatitis B vaccine.

Frequency of adverse reactions to hepatitis B vaccine in 43,618 persons

PURPOSE

To determine the incidence of adverse reactions to hepatitis B plasma-derived vaccine.

PATIENTS

Alaska natives (43,618) who received 101,360 doses of hepatitis B vaccine.

METHODS

All adverse reactions, excluding transient fever, myalgia, or soreness lasting less than 3 days, were reported. An intradermal skin test was developed to test purported adverse reactions. Records of the entire population were reviewed for Guillain-Barré syndrome (GBS).

SETTING

A statewide hepatitis B control program for Alaska natives.

RESULTS

Possible adverse reactions occurred in 39 persons. The most frequent adverse reactions were myalgia/arthralgia lasting longer than 3 days (14), followed by skin rashes (eight) and dizziness (seven). Skin tests were performed on 13 persons and were positive in five. Six of the persons with negative skin tests and eight persons who did not undergo skin testing received additional doses of vaccine without any adverse reactions. No increased incidence of GBS was found in the vaccinees.

CONCLUSION

Hepatitis B vaccine is safe and most adverse reactions are coincidental.

DTP immunization and susceptibility to infectious diseases. Is there a relationship?

A two-part study was carried out in Alaskan Native children to evaluate the potential risk of invasive bacterial disease and the occurrence of minor illnesses after immunization with diphtheria and tetanus toxoids and whole-cell pertussis vaccine (DTP). First, a case-control comparison was performed with 186 children who had invasive Haemophilus influenzae type b or Streptococcus pneumoniae disease (cases) and 186 healthy controls matched for sex, region of residence, birth date, and number of DTP immunizations. The proportion of cases and controls immunized in the 30-day period before onset of disease for cases or reference date for controls was identical, suggesting no association with DTP immunization. In a second analysis, the occurrence of any illness, particularly infectious diseases, in 104 study subjects was compared for the period 30 days before and after 377 DTP immunizations. The rate of illness before immunization was 53%, and after immunization, 43%, again suggesting no causative effects from DTP immunization. Despite the high rates of invasive bacterial disease and nearly compete DTP immunization status in this population, no consistent relationship could be demonstrated between DTP immunization and susceptibility to infectious diseases.

Hepatitis B-related sequelae. Prospective study in 1400 hepatitis B surface antigen-positive Alaska native carriers

A total 1400 hepatitis B surface antigen-positive Alaska natives, 824 men and 576 women of all ages, were followed up prospectively over a period of 7815 carrier years for the development of sequelae related to chronic hepatitis B virus infection. During the observation period, 20 cases of hepatocellular carcinoma, 14 cases of chronic active hepatitis, 8 cases of cirrhosis, and 1 case of glomerulonephritis developed in this cohort. The annual incidence of hepatocellular carcinoma was 387 per 100,000 for men and 63 per 100,000 for women. The incidence of chronic active hepatitis and cirrhosis was 193 and 107 per 100,000 in men and 158 and 95 per 100,000 in women, respectively. No cases of either essential mixed cryoglobulinemia or necrotizing vasculitis were seen. Sixty of the hepatitis B surface antigen-positive carriers died, with 13 (21.7%) of the deaths due to hepatocellular carcinoma. The leading cause of death in this group was malignant neoplasms compared with accidents in the general Alaska native population.

Response to hepatitis B vaccine in Alaska natives with chronic alcoholism compared with non-alcoholic control subjects

PURPOSE

This study was designed to determine if (1) alcoholics have a higher prevalence of hepatitis B virus (HBV) serologic markers than do non-alcoholic controls and (2) if they respond to hepatitis B vaccination in a manner similar to that of non-alcoholic controls.

PATIENTS AND METHODS

The study was designed as a case-control study, and 129 Alaska Natives were recruited. Alcoholics were recruited from inpatient wards, outpatient clinics, a soup kitchen serving the homeless, and several alcohol rehabilitation centers; control subjects were recruited primarily from among Alaska Native Hospital employees. A standardized questionnaire, the Alcohol Dependency Scale (ADS), was administered to all participants. Each participant was screened for hepatitis B serologic markers, had liver function studies performed, and was examined for evidence of liver disease. Participants seronegative for HBV markers received three doses of hepatitis B vaccine. Linear regression analysis was performed to compare the amount of alcohol intake and variables associated with liver disease with the response to hepatitis B vaccination and antibody levels achieved. Using an ADS score of greater than 13, 64 participants were classified as chronic alcoholics, and 60 were classified as controls.

RESULTS

HBV seropositivity was found in 22 alcoholics (34.4%) and seven controls (11.7%). After adjusting for age and sex, this difference was significant (chi 2 MH = 6.57, df = 1; p = 0.012). Abnormal levels of liver transaminase occurred significantly more often in alcoholic participants than in control subjects (chi 2 MH = 4.91, df = 1; p = 0.026). Of 95 seronegative persons, 72 received three doses of hepatitis B plasma-derived vaccine. Alcoholic subjects and control subjects did not differ significantly in their response to vaccination. Only four alcoholics and two controls did not develop antibody to hepatitis B surface antigen (anti-HBs) after hepatitis B vaccination, and two alcoholics and three controls had anti-HBs levels less than 10 SRU by radioimmunoassay. Mean anti-HBs levels measured in milli-international units (mIU) for the 62 responders showed a decrease in the anti-HBs level with increasing age (p less than 0.001). There was no difference in the mean anti-HBs log10 mIU between alcoholics and controls younger than 45 years of age, but in persons greater than 45 years of age, alcoholics had a lower mean anti-HBs log10 mIU level than did controls; this difference, however, was not significant (p greater than 0.10).

CONCLUSION

Chronic alcoholics have a higher prevalence of HBV seromarkers than do age-matched controls. Seronegative alcoholics, especially those under age 45, respond well to hepatitis B vaccination, and such vaccination should be considered in all chronic alcoholic persons.

Hepatitis B-related sequelae. Prospective study in 1400 hepatitis B surface antigen-positive Alaska native carriers

A total 1400 hepatitis B surface antigen-positive Alaska natives, 824 men and 576 women of all ages, were followed up prospectively over a period of 7815 carrier years for the development of sequelae related to chronic hepatitis B virus infection. During the observation period, 20 cases of hepatocellular carcinoma, 14 cases of chronic active hepatitis, 8 cases of cirrhosis, and 1 case of glomerulonephritis developed in this cohort. The annual incidence of hepatocellular carcinoma was 387 per 100,000 for men and 63 per 100,000 for women. The incidence of chronic active hepatitis and cirrhosis was 193 and 107 per 100,000 in men and 158 and 95 per 100,000 in women, respectively. No cases of either essential mixed cryoglobulinemia or necrotizing vasculitis were seen. Sixty of the hepatitis B surface antigen-positive carriers died, with 13 (21.7%) of the deaths due to hepatocellular carcinoma. The leading cause of death in this group was malignant neoplasms compared with accidents in the general Alaska native population.

Spondyloarthropathy and rheumatoid arthritis in Alaskan Yupik Eskimos

In a Yupik Eskimo population, the prevalence, incidence and clinical features of rheumatoid arthritis (RA) were similar to those described for the United States population in general. More frequent than RA were seronegative spondyloarthropathic disorders, many of which could not be classified by existing disease criteria. Of the adult patients with spondyloarthropathy only half could be classified as having Reiter's syndrome (RS), ankylosing spondylitis (AS) or psoriatic spondylitis. The remaining patients had many signs and symptoms consistent with spondyloarthropathy, but they either did not meet the diagnostic criteria for any specific disease or had features pathognomonic of more than one. The clinical manifestations of the patients who did not meet standard disease definitions are summarized and compared to those of the patients with RS, AS and psoriatic spondylitis. Because of the many shared features, we believe that these as yet unclassified disease states belong with AS and RS in a single spondyloarthropathic disease spectrum and should be defined and recognized as such.