Mark A. Kane

Immunization Policies and Vaccine Coverage Among Adults The Risk for Missed Opportunities

A substantial proportion of vaccine-preventable diseases occur among adults. Each year, there are more than 20,000 influenza-associated deaths during epidemics, approximately 40,000 deaths related to pneumococcal disease, and one to five cases of diphtheria. More than 300,000 hepatitis B infections occur annually, mostly in patients 15 to 29 years old. From 1982 to 1986, 96% of patients with tetanus were age 20 and older. Among young adults, 5% to 20% are susceptible to rubella and measles, and outbreaks occur where these persons congregate. Most adults are not immunized, despite recommendations for vaccines against these diseases. Vigorous efforts are needed to implement strategies to reduce disease incidence, morbidity, and death among adults.

Aetiological Agent of Enterically Transmitted Non-A, Non-B Hepatitis

Virus-like particles (VLPs) with a mean diameter of 32 nm were recovered from the stools of three acute phase cases of enterically transmitted non-A, non-B hepatitis (ET-NANBH) occurring in the Soviet Union, North Africa and North America. VLPs from two of these cases were studied in detail and were shown to react specifically with antibody in acute phase sera obtained from other cases of ET-NANBH in Asia, the Soviet Union, North Africa and North America. Partially purified VLPs were found to sediment at 183S in sucrose gradients and to cross-react with antibody in acute phase sera from geographically isolated cases of ET-NANBH. The latter virus preparations were also used to document the seroconversion of experimentally ET-NANBH-infected cynomolgus macaques to 32 nm VLPs. Our findings indicate that one virus or class of viruses is responsible for the majority of ET-NANBH.

Hepatitis B infection in the United States: Recent trends and future strategies for control

Viral hepatitis is the second most common reportable infectious disease in the United States, with hepatitis B accounting for about 45 percent of cases. Although approximately 25,000 cases of hepatitis B are reported to the Centers for Disease Control each year, it is estimated that there are actually about 300,000 annual infections (up from 200,000 in the early 1980s). This increase has occurred despite the availability of a safe and effective hepatitis B vaccine since 1982. Hepatitis B occurs primarily in young adults because of lifestyle or occupationally related exposure. Reported cases in homosexual men have decreased, probably because of changes in behavior related to the acquired immunodeficiency syndrome epidemic. Cases due to heterosexual transmission and intravenous drug use are increasing. The proportion of cases in health care workers has decreased, possibly because 30 to 40 percent of high-risk health care workers have been vaccinated. Because of the increase in hepatitis B infection, the strategy of controlling this disease by vaccinating high-risk groups must be reconsidered. Alternative strategies include selective or universal immunization of infants or adolescents. Although integrating hepatitis B vaccine into infant immunization programs takes advantage of the existing system, it would not lead to measurable disease reduction for two decades. Immunizing adolescents would more rapidly reduce the incidence of hepatitis B, but currently no structured health care setting reaches them.

Hepatitis B virus transmission between children in day care.

We investigated two situations involving hepatitis B virus exposure among children in day care. In the first a 4-year-old boy who attended a day care center developed acute hepatitis B; another child at the center, who had a history of aggressive behavior (biting/scratching), was subsequently found to be a hepatitis B carrier. No other source of infection among family and other contacts was identified and no other persons at the center became infected. In the second situation a 4-year-old boy with frequently bleeding eczematous lesions was discovered to be a hepatitis B carrier after having attended a day care center for 17 months. Testing of contacts at the center revealed no transmission to other children or staff (representing 887 person months of exposure). Nationwide surveillance data showed that for the period 1983 to 1987, 161 children 1 to 4 years of age were reported with acute hepatitis B. After children with known hepatitis B risk factors were excluded, 25% (7 of 28) of children with known day care status were reported as day care attendees, a percentage comparable to national estimates of day care attendance by this age group. This is the first reported case of hepatitis B virus transmission between children in day care in the United States. Although it appears that day care transmission of hepatitis B is infrequent, further studies are needed to define the risk more accurately.

Antibody to Hepatitis B Surface Antigen and Screening Before Hepatitis B Vaccination

Excerpt The availability of a safe and effective hepatitis B vaccine has stimulated debate about the most effective ways to use this product. Because the vaccine is costly and because tests for hep...

Cost-effectiveness of hepatitis-B vaccine in Greece : a country of intermediate HBV endemicity

We evaluated the cost-effectiveness of (a) a vaccination program for the prevention of hepatitis B; and (b) the two commercially available vaccines (Merck Sharp and Dohme; Pasteur Institute) in Greece, a country of intermediate endemicity. We examined cases of hepatitis-B infection prevented and the expected medical costs among the high-risk groups of medical and nursing students, hospital personnel, and the general population. Employing a vaccination program reduces considerably the risk of infection, especially in the high-risk groups, while it increases the total cost. The vaccines are very comparable in terms of both health and economic outcomes. Sensitivity analysis indicated that vaccine cost, incidence of hepatitis B, and compliance were the key factors for the choice of (a) whether to undertake an extensive program to prevent hepatitis-B infection and its chronic sequelae; and (b) which vaccine to administer.

Hepatitis D virus infection in Illinois state facilities for the developmentally disabled. Epidemiology and clinical manifestations

OBJECTIVE To define the epidemiology and clinical manifestations of hepatitis D virus infection in an institutionalized population. DESIGN A case-control study of hepatitis B carriers with and without serologic evidence of hepatitis D virus infection. Demographic, institutional, and medical data were obtained through questionnaires and chart review. Clinical status was assessed by liver function assays. SETTING Thirteen Illinois state facilities for the developmentally disabled. PARTICIPANTS Clients (238) who were hepatitis B carriers. RESULTS Antibody to hepatitis D virus (anti-HDV) was detected in 71 of 238 (30%) hepatitis B carriers. Nine of thirteen facilities housed positive clients. Previous residence at one facility, designated B, was the strongest correlate of anti-HDV positivity; 85% of positive persons had lived there compared with 16% of negative controls (odds ratio 28.3 [95% CI, 13.2 to 60.7], P less than 0.001). Past hepatitis episodes were more common among anti-HDV-positive clients (37% compared with 7%) (odds ratio, 7.5 [95% CI, 3.0 to 19.1], P less than 0.001) and occurred mainly at facility B from 1950 to 1975. Liver function tests were infrequently abnormal among anti-HDV-positive clients. CONCLUSIONS Results show widespread hepatitis D virus infection in our institutionalized population and suggest that transmission occurred mainly in the past at the overcrowded facility B. The low prevalence of laboratory evidence of chronic liver disease in the anti-HDV-positive clients may be explained by increased mortality among those originally infected from 1950 to 1975.Abstract Objective:To define the epidemiology and clinical manifestations of hepatitis D virus infection in an institutionalized population. Design:A case-control study of hepatitis B carriers with...

Hepatitis B transmission in school contacts of retarded HBsAg carrier students

A prospective study was performed to assess the rate of transmission of hepatitis B from mentally retarded carrier students to susceptible mentally retarded peer students or school staff. Eighteen hepatitis B carriers were integrated into a public school program for the developmentally disabled, and serum hepatitis B markers were monitored in staff and students over 14 months. During this time no susceptible staff acquired hepatitis B serologic markers. Of susceptible students, 1.8% demonstrated seroconversion, but the route of infection is likely to have been outside the classroom environment. The results indicate that the risk of hepatitis B transmission is low in this particular school program.

Epidemiology and Prevention of Hepatitis A in Travelers

OBJECTIVE To assess the risk of hepatitis A in international travelers and to recommend preventive measures. DATA SOURCES Index Medicus, 1974 through 1983; MEDLINE, 1984 through 1993; and unpublished data of the Centers for Disease Control and Prevention. STUDY SELECTION Review of all retrospective and cohort studies on hepatitis A and other vaccine-preventable diseases in travelers, of seroepidemiologic surveys of hepatitis A virus (HAV) antibodies in travelers, of data on the various hepatitis A vaccines, of economic analyses, and of recommendations of recognized organizations. DATA EXTRACTION Independent analysis by multiple observers. DATA SYNTHESIS The incidence rate for unprotected travelers, including those staying in luxury hotels, is estimated to be three per 1000 travelers per month of stay in a developing country. Persons eating and drinking under poor hygienic conditions have a rate of 20/1000 per month. This makes hepatitis A the most frequent infection in travelers that may be prevented by immunization. In many industrialized countries persons born after 1945 have an HAV antibody seroprevalence (immunity) of less than 20%. New inactivated HAV vaccines induce protective antibodies in more than 95% of recipients and offer protection estimated to last for 10 years or more, whereas protection by immune globulin lasts only 3 to 5 months. CONCLUSIONS Hepatitis A vaccine, or immune globulin where HAV vaccine is not available, is recommended for all nonimmune travelers visiting developing countries. Prescreening for antibodies to HAV in travelers living in countries with low prevalence is usually not necessary in persons born after 1945.

Hepatitis B infection in ophthalmologists.

A seroepidemiologic survey of ophthalmologists in Western Pennsylvania was performed to define the hepatitis B virus (HBV) exposure risk for this subspecialty population. Of 70 participating ophthalmologists, only 5 (7.1%) had serologic evidence of prior hepatitis (positive hepatitis B surface antibody and antibody to the core antigen of hepatitis B). No participants were found to be HBsAg (hepatitis B surface antigen) positive. The infection rate for ophthalmologists appears lower than that previously described for physicians involved in surgical and nonsurgical medical specialties. However, caution is still recommended since hands and surgical instruments may become contaminated with HBV from the blood and secretions of hepatitis B patients or carriers.