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Broadeining Hepatitis B Vaccination considered for all adults  
  Viral hepatitis remains a health risk, although vaccines are available and effective. How best to use these vaccines remains under discussion.
By Susan J. Landers, AMNews staff. Sept. 26, 2005.
Washington -- Many in the health community believe the time is right to broaden the assault against hepatitis B, and they hope to persuade the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices to recommend its vaccine for all adults.
The committee is scheduled to discuss the vaccine during its Oct. 26-27 meeting, but a draft revision of its HBV recommendations, the first revision in 14 years, continues to endorse a risk-based vaccination strategy that targets people in prison, men who have sex with men and people with multiple sex partners.
The committee may also consider lowering the age for administering the hepatitis A vaccine to reflect the arrival on the market of a new vaccine approved for children as young as 1 year old. The vaccine had previously been used only for children age 2 and older.
The prevention of viral hepatitis is still a major public health challenge. Despite effective vaccines for hepatitis A and B, both continue to be among the most commonly reported vaccine-preventable diseases in the nation, according to the CDC.
There have been major gains made in the fight against hepatitis A, thanks to its routine inclusion in the childhood vaccination schedule. Still, hepatitis B cases have not registered as sharp a decline, despite the fact that its vaccination is also recommended for all children.
For example, the number of cases of hepatitis A in the nation dropped from 31,000 in 1996, or nearly 12 cases for every 100,000 people, to 7,650 cases in 2003, or 2.6 cases for every 100,000 people. During the same period, the number of hepatitis B cases dropped from 10,637, or 4 cases per 100,000, to 7,526, or 2.6 cases per 100,000.
Urging expansion
While the ACIP's draft recommendations are generally considered to be strong, they stop short of supporting an age-based, universal hepatitis B vaccine for adults, a step many in the public health arena would like to see taken.
The change is needed for a number of reasons, said several health groups and physicians who wrote to ACIP in anticipation of next month's meeting. For one thing, the additional time it takes to screen patients for risk factors for hepatitis B is an obstacle in primary care settings, according to a letter to ACIP from the Immunization Action Coalition, an advocacy group based in St. Paul, Minn.
"Discussing sensitive lifestyle issues (e.g., sexual preferences and practices, needle use and other drug use) and reviewing 10 screening questions with one's patients are not possible within the time allotted for a visit to the physician's office," the coalition wrote in a June letter.
"The questions have such baggage attached to them," said Deborah Wexler, MD, executive director of the coalition.
"Patients may not want to admit that they had more than one sex partner in the last six months or that they are gay or they are using illegal drugs or have a sexually transmitted disease," she said.
"It's really time we start offering this vaccine to everyone. We must explain to people how the disease spreads. All it takes is an exposure to blood."
In addition, taking a sex history can open a Pandora's box of sensitive personal issues that may require special training to help patients sort through, wrote the group. Plus, patients often do not want their risk behaviors recorded in medical records that could be used by insurers.
The extra funding for such an endeavor would be needed only for the duration of a catch-up program for those who missed being vaccinated as children and teens, the group added.
The Migrant Clinicians Network, which is comprised of physicians who treat workers in community and migrant health centers and local health departments, also urged ACIP to broaden its recommendation. "Basing the need for hepatitis B vaccination on sexual risk also perpetuates the stigma around hepatitis, rather than promoting the necessity of current vaccinations as routine preventive health care," noted its letter.
Some groups said they would like people up to age 40 or 50 to receive the vaccine while others suggest up to age 25. Recent increases in the incidence of hepatitis B among people ages 20 to 39 and even among those older than 40 would suggest that people up to age 50 should be vaccinated, wrote Jeffrey Davis, MD, Wisconsin's state epidemiologist for communicable diseases.
When the hepatitis B vaccine was introduced, it didn't have the positive impact that was expected, said Jules Dienstag, MD, professor of medicine at Harvard Medical School. One of the reasons was that about a third of people who got hepatitis B were not in any high-risk group, he said.
"It became apparent that if we were to prevent every case of hepatitis B we would have to find a way to vaccinate most all the population," said Dr. Dienstag. "In our society, we have the infrastructure to vaccinate children before they go to school. We don't have the infrastructure to vaccinate adults."
Adult shots make up for those missed in children

If an adult vaccination track should be developed, as many physicians suggest, the hepatitis B and hepatitis A vaccines could be highlighted, at least until the cohort of adults who missed these as children and teens are immunized.
A move is on to urge the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices to recommend that all adults receive the hepatitis B vaccine.
Increasing the number of adults receiving this shot could be a positive step toward stopping the spread of viral hepatitis, several physicians said.
Although there has been a dramatic reduction in hepatitis A cases, which can be spread through contaminated food, there remains a susceptible adult population, noted Jules Dienstag, MD, professor of medicine at Harvard Medical School in a Sept 1 editorial in the New England Journal of Medicine. The increase in imported food means that more outbreaks are possible, he added.
"Paradoxically," he wrote, "as hepatitis A becomes less common, the burden of new infection shifts from children to adults, and the frequency of clinically severe acute hepatitis A increases -- an unintended consequence of progress."
Several recent outbreaks, including one last year involving a Pennsylvania restaurant in which three people died and hundreds were sickened, point up the severity of the situation.
"Some would argue that you can't vaccinate everyone; it's too expensive," Dr. Dienstag said. "I would argue that if we are still having adults in the prime of life going to restaurants and getting hepatitis, is that the appropriate response? I don't know."
Deborah Wexler, MD, executive director of the Immunization Action Coalition in St. Paul, Minn., believes that the hepatitis A vaccine is underutilized. The ACIP recommends it for anyone who wants it, she noted.
"It's an excellent vaccine. It's efficacious. And I think we should embrace the opportunity to be protected against this disease which continues to kill people."
National AIDS Treatment Advocacy Project (NATAP)

Centers for Disease Control and Prevention on hepatitis vaccines (
Immunization Action Coalition on hepatitis
National Viral Hepatitis Roundtable on the CDC Advisory Committee on Immunization Practices' adult hepatitis B vaccination and screening recommendations (
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