1. March 8, 2006 New ACIP Hepatitis B Recommendations
and Their Impact on Vaccination of Adults at Risk
March 8, 2006

2. Background Hepatitis B vaccine Hepatitis B infection and disease
Licensed in 1982
Standard three dose regimen
>90% recipients have protective antibody response
Hepatitis B infection and disease
Transmission- perinatal, sexual, parenteral
Risk of chronic disease is age dependent
90% of infants
5% of persons >5 yrs
15-25% die from cirrhosis or cancer

3. Advisory Committee on Immunization Practices
Strategy to Eliminate HBV Transmission
Adults at high risk (1982)
Prevent perinatal HBV transmission ( )
Maternal screening
Newborn vaccination
Universal infant vaccination (1991)
Catch –up vaccination
adolescents years (1995)
all persons <19 years (1999)
Universal birth dose (2005)

4. Hepatitis B Vaccine Coverage, Children Aged 19-35 Months, by Race/Ethnicity, U.S.
Asian-Pacific Islander
HP 2010 target
Black
Hispanic
White
Immunization of infants of all racial groups has increased over the last 10 years, and in 2000 reached the HP2010 target of 90% coverage with 3 doses of hepatitis B vaccine by age 35 months. Coverage levels vary somewhat by race/ethnicity, with Asian children having the highest coverage and black children having the lowest, but all races now have rates right around 90%.
Source: National Immunization Survey

5. Acute Hepatitis B by Age, Unites States, 1990-2004

6. Adult Hepatitis B Vaccine Coverage, 2002
Vaccination of 0-18 yrs recommended 60 50 40
Vaccine coverage, % 30 20 10
19-20
21-25
26-30
31-40
41-50
51-65
65+
Age group, yrs
National Health Interview Survey

7. Hepatitis B Vaccine Coverage Among High Risk Adults
Risk Group
Coverage
Estimate (year, site)
Occupationally-exposed workers
75% ( , national)
Dialysis patients
56% (2002, national)
Men who have sex
with men (MSM)
HIV+ persons in care
9% ( , multi-city)
14% ( , multi-city)
Injection drug users
STD clinic clients
4%-29% ( , multi-city)
10% ( , San Diego)

8. Rate per 100,000 persons (n=60,000 cases)
Reported Acute Hepatitis B Incidence, By Age and Sex, United States, 2004
<5
0.1
0.1
Female
Male
5-9
0.0
0.0
10-14
0.1
0.1
15-19
1.1
0.7
20-24
3.1
3.9
25-29
4.2
6.2
30-34
4.0
6.3
Age group
35-39
4.4
6.0
40-44
3.6
6.2
45-49
2.7
5.1
50-54
2.0
3.8
55-59
1.3
2.6
60+
0.8
1.7
Rate per 100,000 persons (n=60,000 cases)

9. Revision of ACIP Adult Hepatitis B Recommendations
Goals
Assure coverage of those at highest risk
Recommend strategies to increase coverage
Process
Oct 2004: Convene ACIP working group
Jan-Mar, 2005: Invite public comment
Feb 2005: ACIP review
May 2005: Consultation with external partners
June 2005: ACIP review
Summer 2005: CDC convened work groups
October 2005: ACIP approved recommendations

10. Barriers to Hepatitis B Vaccination in Adults
Financial
Cost of vaccine
Reimbursement for supply and delivery
Provider practices
Awareness/priority
Time constraints
Patient acceptance
Preventive service
Acknowledgement of risk
Three dose schedule

11. Hepatitis B Vaccination In High-Prevalence Settings
Demonstration projects in STD and other high prevalence settings established:
High patient acceptance of first dose ( 75-85%)
Feasibility of vaccinating as part of routine services
Funding is a major barrier
Local champions are key

12. Hepatitis B Vaccination In Primary Care Settings
Settings care for many high risk adults
Report 40% of STDs
Risk-targeted vaccination is most efficient
~15-20% of all adults report risk factors for infection
Risk identification is recommended (e.g. USPSTF)
Many patients are reluctant to report risks
Few evaluations conducted
Models of successful implementation in this setting

13. Revised ACIP Recommendations for Adult Hepatitis B Vaccination

14. Revised ACIP Recommendations for Adult Hepatitis B Vaccination
Adults recommended to receive vaccine
Sexual
Parenteral
Other (travelers)
All persons seeking protection from HBV
Recommended implementation strategies by setting

15. HIV/STD treatment centers Drug abuse treatment facilities
2005 ACIP Recommendations Care Settings Where All Adults Should Receive Hepatitis B Vaccine
HIV/STD treatment centers
Drug abuse treatment facilities
HIV/AIDS testing facilities
Facilities serving MSM
Correctional facilities
When feasible, administer vaccine in outreach settings

16. Risk based (opt-in strategy) Most efficient
2005 ACIP Recommendations Primary Care Settings: Tailor Strategy to Fit Practice Setting
Risk based (opt-in strategy)
Most efficient
Basis to provide other prevention services
Age-based (opt-out)
Vaccinate low risk persons
Less stigmatizing
Routinely inform patients of the value of HBV vaccination
Vaccinate all persons seeking protection from HBV

17. Barriers and Strategies: Fiscal
Recommendations
Cost of vaccine supply and delivery
Use of multiple resources (state, federal)
Implement cost recovery mechanisms (i.e., billing)
Facilitate bulk purchase

18. Barriers and Strategies: Providers
Recommendation
Risk ascertainment intrusive and time-consuming
Simplify risk assessment
Adopt alternative strategies
Vaccination not a priority/Lack of time
Inform and remind providers about hepatitis B and vaccination
Implement standing orders

19. Barriers and Strategies: Patients
Recommendation
Lack of awareness
Create demand through outreach to risk populations
Perceived stigma of risk behaviors
Risk factor acknowledgement not required for vaccination
Don’t return to complete vaccine series
Tracking and reminder systems needed
Concerns about series completion should not preclude series initiation

20. Impact of ACIP Recommendations on Hepatitis B Vaccination Coverage
Impact is dependent on implementation of the recommendations.
ACIP statement provides a framework for action
Follow through by CDC and partner organizations will determine success

21. Key Factors for Success
Commitment of CDC and immunization partners
Establish as priority for new CDC organization
Craft guidance for STD/ HIV/VH programs
Develop marketing, training, and education
Support state/local coordinators for adult Hep B program
Resources for adult Hep B vaccination purchase/delivery
Monitoring of progress by ACIP