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A “Infectious” “Serum” Viral hepatitis Enterically transmitted Parenterally transmitted other E “NANB” B D C VIRAL HEPATITIS HISTORICAL PERSPECTIVE

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REPORTED CASES OF SELECTED NOTIFIABLE DISEASES PREVENTABLE BY VACCINATION, UNITED STATES, 2001 Hepatitis A Hepatitis B Pertussis Meningococcal disease H. influenzae, invasive Mumps Measles Source: NNDSS, CDC 10,609 7,843 7,580 2,333 1,597 266 116

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HEPATITIS A VIRUS

HEPATITIS A VIRUS:

HEPATITIS A VIRUS RNA Picornavirus Single serotype worldwide Acute disease and asymptomatic infection No chronic infection Protective antibodies develop in response to infection - confers lifelong immunity

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HEPATITIS A - CLINICAL FEATURES Jaundice by <6 yrs <10% age group: 6-14 yrs 40%-50% >14 yrs 70%-80% Rare complications: Fulminant hepatitis Cholestatic hepatitis Relapsing hepatitis Incubation period: Average 30 days Range 15-50 days Chronic sequelae: None

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0 1 2 3 4 5 6 7 8 9 10 11 12 13 Week Response Clinical illness ALT IgM IgG HAV in stool Infection Viremia EVENTS IN HEPATITIS A VIRUS INFECTION

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CONCENTRATION OF HEPATITIS A VIRUS IN VARIOUS BODY FLUIDS Source: Viral Hepatitis and Liver Disease 1984;9-22 J Infect Dis 1989;160:887-890 Feces Serum Saliva Urine 10 0 10 2 10 4 10 6 10 8 10 10 Body Fluids Infectious Doses per mL

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Endemicity Disease Rate Peak Age of Infection Transmission Patterns Early childhood Late childhood/ young adults Young adults High Moderate Low Very low Low to high High Low Very low Adults Person to person; outbreaks uncommon Person to person; food and waterborne outbreaks Person to person; food and waterborne outbreaks Travelers; outbreaks uncommon GLOBAL PATTERNS OF HEPATITIS A VIRUS TRANSMISSION

GEOGRAPHIC DISTRIBUTION OF HEPATITIS A VIRUS INFECTION:

GEOGRAPHIC DISTRIBUTION OF HEPATITIS A VIRUS INFECTION

HEPATITIS A, UNITED STATES:

Most disease occurs in the context of community-wide outbreaks Infection transmitted from person to person in households and extended family settings - facilitated by asymptomatic infection among children Some groups at increased risk specific factor varies do not account for majority of cases No risk factor identified for 40%-50% of cases HEPATITIS A, UNITED STATES

ACUTE HEPATITIS A CASE DEFINITION FOR SURVEILLANCE:

ACUTE HEPATITIS A CASE DEFINITION FOR SURVEILLANCE Clinical criteria An acute illness with: discrete onset of symptoms (e.g. fatigue, abdominal pain, loss of appetite, intermittent nausea, vomiting), and jaundice or elevated serum aminotransferase levels Laboratory criteria IgM antibody to hepatitis A virus (anti-HAV) positive Case Classification Confirmed. A case that meets the clinical case definition and is laboratory confirmed or a case that meets the clinical case definition and occurs in a person who has an epidemiologic link with a person who has laboratory-confirmed hepatitis A (i.e., household or sexual contact with an infected person during the 15-50 days before the onset of symptoms).

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Source: NNDSS, CDC REPORTED CASES OF HEPATITIS A, UNITED STATES, 1952-2002

DISEASE BURDEN FROM HEPATITIS A UNITED STATES, 2001:

DISEASE BURDEN FROM HEPATITIS A UNITED STATES, 2001 Number of acute clinical cases reported 10,609 Estimated number of acute clinical cases 45,000 Estimated number of new infections 93,000 Percent ever infected 31.3%

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INCIDENCE OF HEPATITIS A BY AGE GROUP IN STATES WHERE VACCINATION IS RECOMMENDED & CONSIDERED, 1990-2001

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Race/Ethnicity non-Hispanic Black non-Hispanic White Total Rate (per 100,000) Native American/ Alaska Native Asian Hispanic 10 20 30 110 120 130 10.3 4.6 5.5 6.4 20.7 121.2 0 HEPATITIS A RATES, BY RACE/ETHNICITY; 1994

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NUMBER OF YEARS REPORTED INCIDENCE OF HEPATITIS A EXCEEDED 10 CASES PER 100,000, BY COUNTY, 1987-1997

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Close personal contact ( e.g., household contact, sex contact, child day-care centers) Contaminated food, water (e.g., infected food handlers) Blood exposure (rare) (e.g., injection drug use, rarely by transfusion) HEPATITIS A VIRUS TRANSMISSION

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RISK FACTORS ASSOCIATED WITH REPORTED HEPATITIS A, 1990-2000, UNITED STATES Source: NNDSS/VHSP

PREVENTING HEPATITIS A:

PREVENTING HEPATITIS A Hygiene (e.g., hand washing) Sanitation (e.g., clean water sources) Hepatitis A vaccine (pre-exposure) Immune globulin (pre- and post-exposure )

PREPARATION OF INACTIVATED HEPATITIS A VACCINES:

PREPARATION OF INACTIVATED HEPATITIS A VACCINES Cell culture adapted virus grown in human fibroblasts Purified product inactivated with formalin Adsorbed to aluminum hydroxide adjuvant

HEPATITIS A VACCINES:

Highly immunogenic 97%-100% of children, adolescents, and adults have protective levels of antibody within 1 month of receiving first dose; essentially 100% have protective levels after second dose Highly efficacious In published studies, 94%-100% of children protected against clinical hepatitis A after equivalent of one dose HEPATITIS A VACCINES

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JAMA 1994;271:1363-4; N Engl J Med 1992;327:453-7 Vaccine Site/ Age Group N Vaccine Efficacy (95 % Cl) HAVRIX (GSK) 2 doses 360 EL.U. Thailand 1-16 yrs 38,157 94% (79%-99%) VAQTA Ò   (Merck) 1 dose 25 units New York 2-16 yrs 1,037 100% (85%-100%) Ò  HEPATITIS A VACCINE EFFICACY STUDIES

HEPATITIS A VACCINES :

HEPATITIS A VACCINES Age Volume 2-Dose Schedule Vaccine (yrs) Dose (mL) ( mos) HAVRIX ® # 2-18 720 (EL.U.*) 0.5 0, 6-12 >18 1,440 1.0 0, 6-12 VAQTA ® ## 2-18 25 (U**) 0.5 0, 6-18 >18 50 1.0 0, 6-18 * EL.U. – Enzyme-linked immunosorbent assay (ELISA) units ** Units # has 2-phenoxyethanol as a preservative ## has no preservative Recommended Dosages of Hepatitis A Vaccines

SAFETY OF HEPATITIS A VACCINE:

Most common side effects Soreness/tenderness at injection site - 50% Headache - 15% Malaise - 7% No severe adverse reactions attributed to vaccine Safety in pregnancy not determined – risk likely low Contraindications - severe adverse reaction to previous dose or allergy to a vaccine component No special precautions for immunocompromised persons SAFETY OF HEPATITIS A VACCINE

DURATION OF PROTECTION AFTER HEPATITIS A VACCINATION:

DURATION OF PROTECTION AFTER HEPATITIS A VACCINATION Persistence of antibody At least 5-8 years among adults and children Efficacy No cases in vaccinated children at 5-6 years of follow-up Mathematical models of antibody decline suggest protective antibody levels persist for at least 20 years Other mechanisms, such as cellular memory, may contribute

FACTORS ASSOCIATED WITH DECREASED IMMUNOGENICITY TO HEPATITIS A VACCINE:

Decreased antibody concentration: Concurrent administration of IG Presence of passively-transferred maternal antibody Age Chronic liver disease Decreased seroconversion rate: HIV infection May be related to degree of immunosuppression Liver transplantation FACTORS ASSOCIATED WITH DECREASED IMMUNOGENICITY TO HEPATITIS A VACCINE

USE OF HEPATITIS A VACCINE FOR INFANTS:

USE OF HEPATITIS A VACCINE FOR INFANTS Safe and immunogenic for infants without maternal antibody Presence of passively-acquired maternal antibody blunts immune response all respond, but with lower final antibody concentrations Age by which maternal antibody disappears is unclear still present in some infants at one year probably gone in vast majority by 15 months

COMBINED HEPATITIS A HEPATITIS B VACCINE:

Approved by the FDA in United States for persons > 18 years old Contains 720 EL.U. hepatitis A antigen and 20 μ g. HBsAg Vaccination schedule: 0,1,6 months Immunogenicity similar to single-antigen vaccines given separately Can be used in persons > 18 years old who need vaccination against both hepatitis A and B Formulation for children available in many other countries COMBINED HEPATITIS A HEPATITIS B VACCINE

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Considerations: cost of vaccine cost of serologic testing (including visit) prevalence of infection impact on compliance with vaccination Likely to be cost-effective for: persons born in high endemic areas Older U.S. born adults Older adolescents and young adults in certain groups (e.g., Native Americans, Alaska Natives, Hispanics, IDUs) PRE-VACCINATION TESTING

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High response rate among vaccinees Commercially available assay not sensitive enough to detect lower (protective) levels of vaccine-induced antibody POST-VACCINATION TESTING Not recommended :

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Pre-exposure travelers to intermediate and high HAV-endemic regions Post-exposure (within 14 days) Routine household and other intimate contacts Selected situations institutions (e.g., day-care centers) common source exposure (e.g., food prepared by infected food handler) HEPATITIS A PREVENTION IMMUNE GLOBULIN

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ACIP RECOMMENDATIONS FOR PREVENTION OF HEPATITIS A USING HEPATITIS A VACCINE

HEPATITIS A VACCINATION RECOMMENDATIONS: GUIDING PRINCIPLES:

HEPATITIS A VACCINATION RECOMMENDATIONS: GUIDING PRINCIPLES Need comprehensive strategy to reduce overall rates Routine vaccination of children likely to be most effective Need creative approaches Formulation not available that would allow integration into infant schedule

INCREMENTAL IMPLEMENTATION OF ROUTINE HEPATITIS A VACCINATION OF CHILDREN:

INCREMENTAL IMPLEMENTATION OF ROUTINE HEPATITIS A VACCINATION OF CHILDREN 1996 - Children living in communities with the highest rates 1999- Children living in states/communities with consistently elevated rates during “baseline period” All children nationwide

Reported Hepatitis A Cases, By Year Northern Plains Indian Reservation† South Dakota, 1968-2002:

Reported Hepatitis A Cases, By Year Northern Plains Indian Reservation † South Dakota, 1968-2002 * Estimated first dose coverage (children 2-12 years) = 71% ** 2002 Preliminary data † Counties: Bennett, Corson, Dewey, Jackson, Roberts, Shannon, Todd, Ziebach * † Source: South Dakota Department of Health Vaccination program * **

HEPATITIS A INCIDENCE UNITED STATES AND NATIVE AMERICANS 1990-2001:

HEPATITIS A INCIDENCE UNITED STATES AND NATIVE AMERICANS 1990-2001 Source: NNDSS, CDC Vaccine Licensed ACIP Recommendation Native American United States

1999 RECOMMENDATIONS FOR HEPATITIS A VACCINATION OF CHILDREN STRATEGY:

1999 RECOMMENDATIONS FOR HEPATITIS A VACCINATION OF CHILDREN STRATEGY Further incremental step Not the same everywhere in the country Regional recommendations using rate-based criteria during a “baseline period” Flexible implementation strategies Children or adolescents One or more single age cohorts Selected settings, e.g., day-care

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INCIDENCE OF HEPATITIS A BY REGION, UNITED STATES, 1966-1997 Baseline 1987-97

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1999 ACIP RECOMMENDATIONS FOR ROUTINE HEPATITIS A VACCINATION OF CHILDREN Children Who Should be Routinely Vaccinated - living in states, counties, and communities where the average hepatitis A rate was  20 cases/100,000 during baseline period. Children Who Should be Considered for Routine Vaccination - living in states, counties, and communities where the average hepatitis A rate was <20 but  10 cases/100,000 during the baseline period.

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Rate > 20/100,000* Recommended Rate 10-20/100,000* Considered Rate < 10/100,000* Not statewide 1999 ACIP RECOMMENDATIONS FOR STATEWIDE ROUTINE HEPATITIS A VACCINATION OF CHILDREN * Based on average incidence rate during baseline period (1987- 97)

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Hepatitis A Incidence, United States, 1980-2002* 1999 ACIP recommendations 2002 rate* = 2.9 1996 ACIP recommendations 1995 vaccine licensure *2002 rate provisional

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Incidence of Hepatitis A by U.S. Region, 1990-2002* 86 % 89 %  50% *2002 rate provisional

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DOSES OF PEDIATRIC HEPATITIS A VACCINE PURCHASED BY PUBLIC SECTOR BY U.S. REGION, 1995-2002

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Summary of Hepatitis A Incidence by Region: Baseline, 2001, and 2002 % Baseline Cases % Cases 2001 Rate/100,000 Recommended 25.9 4.5 3.6 Considered 16.1 3.8 1.8 No statewide 5.6 3.4 2.8 Baseline 2001 2002* *2002 rate provisional

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1987-97 average incidence 2002 incidence > = 20 10 - 19 5 - 9 0 - 4 Rate per 100,000 Hepatitis A Incidence

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TOP 10 STATES WITH THE HIGHEST HEPATITIS A RATES 7 Connecticut 33 Utah 7 Kansas 30 Washington 6 Maryland 24 Oklahoma 6 Massachusetts 24 South Dakota 6 Texas 21 Idaho 5 Florida 21 Nevada 5 California 20 California 7 Rhode Island 40 New Mexico 8 Arizona 40 Oregon 12 Georgia 45 Alaska 14 D.C. 48 Arizona Rate Avg. rate NOW 2001 THEN 1987 - 1997

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HEPATITIS A RATE, BY AGE AND GENDER UNITED STATES, 1990 Age 60+ 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 <5 Female Male 11.9 10.1 26.7 26.7 17.2 17.7 14.1 12.8 20.4 16.1 22.2 15.8 17.7 11.4 13.5 7.9 10.3 6.4 7.7 5.6 5.9 4.4 5.9 3.8 3.4 2.8 Rate

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Female Male Age 60+ 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 <5 2.5 2.2 4.7 4.7 3.6 3.5 3.4 2.8 6.3 3.8 7.5 3.6 9.3 2.8 8.7 2.3 6.1 2.1 5.6 2.2 5.2 2.6 3.6 2.4 2.8 2.4 HEPATITIS A RATE, BY AGE AND GENDER UNITED STATES, 2001 Rate

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HEPATITIS A INCIDENCE BY GENDER, UNITED STATES, 1990-2001 0 2 4 6 8 10 12 14 16 18 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 Male Female Ratio \ Cases per 100,000 Year Male : Female Rate Ratio

ACIP RECOMMENDATIONS PERSONS AT INCREASED RISK OF INFECTION, 1996:

ACIP RECOMMENDATIONS PERSONS AT INCREASED RISK OF INFECTION, 1996 Men who have sex with men Illegal drug users International travelers Persons who have clotting factor disorders Persons with chronic liver disease

STD Treatment Guidelines MMWR May 10, 2002 51(RR06):

STD Treatment Guidelines MMWR May 10, 2002 51(RR06) “ Vaccination against hepatitis is the most effective means of preventing sexual transmission of hepatitis A and B.”

Integration of services for high-risk adults:

Integration of services for high-risk adults Reports of converging epidemics (STD, HIV, hepatitis) impacting MSM, IDU, and others at risk Integration of services that target MSM, IDU, and others at risk saves $$$ and improves services

Lack of integrated prevention activities leads to…:

Lack of integrated prevention activities leads to… Individuals infected with HIV, hepatitis and other STDs remain undiagnosed, untreated and uninformed Infected and uninformed have higher levels of risky behavior and continue to transmit Counseling is mistakenly based on limited diagnosis and individuals at risk for HAV and HBV don’t get immunized

HEPATITIS A IN THE UNITED STATES -2002:

HEPATITIS A IN THE UNITED STATES -2002 National rate lowest yet recorded Continued monitoring needed to determine if low rates sustained and due to vaccination Evaluation of age-specific rates to assess impact of vaccination strategy Rates increasing in some states Occurring among adults in high risk groups (e.g. MSM, drug users)

HEPATITIS A VACCINATION IN THE UNITED STATES CHALLENGES FOR THE FUTURE:

HEPATITIS A VACCINATION IN THE UNITED STATES CHALLENGES FOR THE FUTURE Continue implementation of the current recommendations for vaccination of children Sustain vaccination in face of falling rates Further reduce incidence Vaccination of high-risk adults Vaccination of children nationwide

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