Immunization Action Coalition and the Hepatitis B Coalition

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Issue Number 277            October 16, 2001

CONTENTS OF THIS ISSUE

  1. Letter from the Executive Director: Give the birth dose of hepatitis B vaccine to all infants prior to hospital discharge
  2. CDC publishes notice to readers on anthrax investigation
  3. CDC issues public health dispatch on polio in the Philippines
  4. New translations! Spanish versions of "Are You at Risk for Hepatitis A" and "B" and "C" now available
  5. Revised! English version of "Are You at Risk for Hepatitis B?"

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October 16, 2001
LETTER FROM THE EXECUTIVE DIRECTOR: GIVE THE BIRTH DOSE OF HEPATITIS B VACCINE TO ALL INFANTS PRIOR TO HOSPITAL DISCHARGE

The following letter is an adaptation of an open letter from the Immunization Action Coalition (IAC) to the Advisory Committee on Immunization Practices, American Academy of Pediatrics, American Academy of Family Physicians, American College of Obstetrics and Gynecology, National Medical Association, National Asian Pacific Islander Task Force on Hepatitis B Prevention, and the American Hospital Association. 

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The Immunization Action Coalition urges all health professionals and hospitals to protect all infants from hepatitis B virus (HBV) infection by administering the first dose of hepatitis B vaccine to every infant at birth and no later than hospital discharge.

Approximately 19,000 women with chronic hepatitis B infection give birth in the United States each year. Ninety percent of perinatal infections can be prevented by postexposure prophylaxis given within 12 hours of birth. Tragically, many babies are exposed to HBV at birth but do not receive appropriate postexposure prophylaxis. 

Because thimerosal has been removed from all pediatric hepatitis B vaccines in the United States, concerns about thimerosal should no longer be an obstacle for practitioners in enacting a universal birth dose policy.

Why is such a policy necessary? Following are some of the ways infants who are not vaccinated at birth become infected:

  • The pregnant woman is tested and found to be hepatitis B surface antigen (HBsAg) positive but her status is not communicated to the newborn nursery. The infant receives neither hepatitis B vaccine nor HBIG protection at birth.
       
  • A chronically infected pregnant woman is tested but with the wrong test, HBsAb (antibody to hepatitis B surface antigen), instead of HBsAg. This is a common mistake since these two test abbreviations differ by only one letter. Her incorrectly ordered test result is "negative," so her doctor believes her infant does not need postexposure prophylaxis.
      
  • The pregnant woman is HBsAg positive but her test results are misinterpreted or mistranscribed into her prenatal record or her infant's chart. Her infant does not receive HBIG or hepatitis B vaccine.
       
  • The pregnant woman is not tested for HBsAg either prenatally or in the hospital at the time of delivery. Her infant does not receive hepatitis B vaccine in the hospital even though the vaccine is recommended within 12 hours of birth for infants whose mothers' test results are unknown.
       
  • The woman is tested in early pregnancy for HBsAg and is found to be negative. She develops HBV infection later in pregnancy but it is not detected, even though it is recommended by CDC that high-risk women be retested later in pregnancy. The infection is not clinically detected by her health care provider so her infant does not receive hepatitis B vaccine or HBIG at birth.
       
  • The mother is HBsAg negative but the infant is exposed to HBV infection postnatally from another family member or caregiver. This occurs in 2/3 of the cases of childhood transmission.

While there are advantages to giving the first dose at a later well-baby visit, these are advantages of administrative convenience. The primary advantage of giving the first dose at birth is that IT SAVES LIVES.

IAC recently asked hepatitis coordinators at every state health department as well as at many city/county CDC projects to express their views about providing hepatitis B vaccine in the hospital. Their responses contained many examples of children who were unprotected or inadequately protected due to health professionals not ordering, misordering, misinterpreting, mistranscribing, and miscommunicating the hepatitis B test results of their mothers. In order to overcome these failures, all 50 states overwhelmingly endorse providing a birth dose.

These state coordinators' reports tell us that no matter how well health care providers think they are doing with HBsAg screening of all pregnant women, serious mistakes continue to occur; children are unnecessarily being exposed without the benefit of postexposure prophylaxis, and at least one baby has died.

What is the answer? Vaccinate every baby in the hospital prior to discharge regardless of the HBsAg status of the mother. For those providers who choose  to use hepatitis B-containing combination vaccine, i.e., Comvax, they may do so. However, since this vaccine cannot be given at birth, monovalent hepatitis B vaccine must be given at birth and then the hepatitis B vaccine series can be completed with three doses of the combination vaccine. Giving four doses of hepatitis B vaccine has been shown to be safe in several clinical studies.

Hepatitis B vaccine is one of the most effective vaccines available. Studies have shown that infants of the most highly infectious mothers (HBsAg+ and HBeAg+) who receive postexposure prophylaxis with hepatitis B vaccine alone (without HBIG) at birth are protected in 90-95% of cases, essentially the same level of protection afforded by administering hepatitis B vaccine in addition to HBIG. Even higher rates of protection with postexposure prophylaxis have been demonstrated in infants born to less infectious mothers (HBsAg+ and HBeAg-).

Please read the survey [see link below] and examples from statements we have received from hepatitis coordinators describing their experiences with  failures of the current system, failures that can be largely prevented by administering hepatitis B vaccine to infants before they go home from the hospital.

Your support for providing a birth dose of hepatitis B vaccine to infants while still in the hospital will protect and save lives that are now being put at risk.

Deborah L. Wexler, M.D.
Executive Director
Immunization Action Coalition

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To read the results of IAC's survey of state health department hepatitis coordinators, go to: http://www.immunize.org/birthdose/survey.htm

To view the entire open letter with accompanying table, journal articles and background information, and cases of harm resulting from missed birth doses,  go to IAC's Birth Dose page at: http://www.immunize.org/birthdose
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October 16, 2001
CDC PUBLISHES NOTICE TO READERS ON ANTHRAX INVESTIGATION

"Ongoing Investigation of Anthrax--Florida, October 2001" was published by CDC in the October 12, 2001, issue of Morbidity and Mortality Weekly Report (MMWR). The synopsis reads as follows:

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On October 4, 2001, the Palm Beach County Health Department, Florida State Department of Health, and CDC reported a case of anthrax in a 63-year-old resident in Florida. An environmental investigation identified one sample taken from the individual's workplace as positive for anthrax. Testing of additional samples is in progress. Bacillus anthracis was identified in one nasal sample from another worker in the building, which suggests exposure. The county health department is notifying persons who might have been in the building for at least 1 hour since August 1, to offer prophylactic antibiotic treatment. Additional information about anthrax is available from local and state health departments and from CDC at: http://www.bt.cdc.gov 

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To obtain the complete text of this article online, go to: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5040a5.htm

To obtain a camera-ready (PDF format) copy of this issue of MMWR, go to: http://www.cdc.gov/mmwr/PDF/wk/mm5040.pdf

HOW TO OBTAIN A FREE ELECTRONIC SUBSCRIPTION TO THE MMWR:
To obtain a free electronic subscription to the "Morbidity and Mortality Weekly Report" (MMWR), visit CDC's MMWR website at: http://www.cdc.gov/mmwr Select "Free MMWR Subscription" from the menu at the left of the screen.  Once you have submitted the required information, weekly issues of the MMWR and all new ACIP statements (published as MMWR's "Recommendations and Reports") will arrive automatically by e-mail.
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October 16, 2001
CDC ISSUES PUBLIC HEALTH DISPATCH ON POLIO IN THE PHILIPPINES

CDC issued a public health dispatch, "Acute Flaccid Paralysis Associated with Circulating Vaccine-Derived Poliovirus--Philippines, 2001," in the October 12, 2001, issue of Morbidity and Mortality Weekly Report (MMWR). The synopsis reads as follows:

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Since March 2001, three cases of acute flaccid paralysis (AFP) associated with a type-1 vaccine-derived poliovirus (VDPV) have been confirmed in the  Philippines: an eight-year-old boy from Northern Mindanao, a three-year-old boy in Laguna province, and the most recent case (with July onset), a 14-month-old boy from Cavite province. These viruses were detected through  the enhanced global surveillance for VDPV established following a VDPV polio outbreak in Haiti and the Dominican Republic (Hispaniola) in late 2000. The World Health Organization is working with the Department of Health, Philippines, to coordinate a detailed field investigation into this polio outbreak, including enhanced case finding, expanded specimen collection, and rapid laboratory analyses. The results of the investigation will determine the scope of immunization response activities. Circulating VDPV are rare and likely caused by low immunization coverage.

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CDC notes that travelers to the Philippines should be sure that they are vaccinated appropriately against polio according to national recommendations.

To obtain the complete text of this article online, go to: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5040a3.htm

To obtain a camera-ready (PDF format) copy of this issue of MMWR, go to: http://www.cdc.gov/mmwr/PDF/wk/mm5040.pdf

HOW TO OBTAIN A FREE ELECTRONIC SUBSCRIPTION TO THE MMWR: see story #2.
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October 16, 2001
NEW TRANSLATIONS! SPANISH VERSIONS OF "ARE YOU AT RISK FOR HEPATITIS A" AND "B" AND "C" NOW AVAILABLE

IAC now offers these helpful patient screening questionnaires in Spanish as well as in English and Turkish. Many thanks to the State of California Immunization Program for providing translation services. All three questionnaires are available in Spanish on our website in both HTML and PDF formats.

To obtain "Are You at Risk for Hepatitis A?", go to:
HTML: http://www.immunize.org/catg.d/2190a-01.htm
PDF: http://www.immunize.org/catg.d/2190a-01.pdf

To obtain "Are You at Risk for Hepatitis B?", go to:
HTML: http://www.immunize.org/catg.d/2191b-01.htm
PDF: http://www.immunize.org/catg.d/2191b-01.pdf

To obtain "Are You at Risk for Hepatitis C?", go to:
HTML: http://www.immunize.org/catg.d/2192c-01.htm
PDF: http://www.immunize.org/catg.d/2192c-01.pdf
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October 16, 2001
REVISED! ENGLISH VERSION OF "ARE YOU AT RISK FOR HEPATITIS B?"

Please reorder or redownload the English version of the patient screening questionnaire "Are You at Risk for Hepatitis B?" We have fixed a mistake in question #2 pertaining to travel duration.

The question previously read: "Have you traveled or do you plan to travel for 3 months or more to a place where hepatitis B is common (Asia, Africa, Middle East, Eastern Europe, Amazon Basin of South America, Pacific Islands)?"

The phrase "3 months" was incorrect and has been changed to "6 months." The version with "3 months" errs on the side of being too conservative and identifies more people as "at risk" than is warranted. IAC apologizes for any inconvenience this may have caused.

To obtain the revised "Are You at Risk for Hepatitis B?" in English, go to:
HTML: http://www.immunize.org/catg.d/2191hepb.htm
PDF: http://www.immunize.org/catg.d/2191hepb.pdf

 

Immunization Action Coalition1573 Selby AvenueSt. Paul MN 55104
E-mail: admin@immunize.org Web: http://www.immunize.org/
Tel: (651) 647-9009Fax: (651) 647-9131

This page was updated on October 16, 2001