Immunization Action Coalition and the Hepatitis B Coalition

IAC EXPRESS

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Issue Number 434            January 5, 2004

CONTENTS OF THIS ISSUE

  1. CDC reports on U.S. incidence of acute hepatitis B
  2. January 12 is the registration deadline for NIP's Netconference "Current Issues in Immunization"
  3. Paul Offit's vaccine-safety article available on the "Pediatrics" website
  4. CDC issues an update on current U.S. influenza activity
  5. MMWR publishes update on current influenza-related deaths among U.S. children less than 18 years old
  6. Save the date: "Epidemiology and the Prevention of Vaccine Preventable Diseases" to be broadcast in February and March
  7. Updated: IAC makes minor revisions to its VIS professional-education sheet "It's Federal Law!"
  8. Subscribe today: CDC's free electronic news service "Public Health Law News" is looking for readers
  9. January 26 is the deadline for proposals for NACCHO's 2004 annual conference
  10. The Department of Health and Human Services announces rule for Smallpox Vaccine Injury Compensation Program

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ABBREVIATIONS: AAP, American Academy of Pediatrics; ACIP, Advisory Committee on Immunization Practices; CDC, Centers for Disease Control and Prevention; FDA, Food and Drug Administration; IAC, Immunization Action Coalition; MMWR Morbidity and Mortality Weekly Report; NIP, National Immunization Program; VIS, Vaccine Information Statement; WHO, World Health Organization.
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January 5, 2004
CDC REPORTS ON U.S. INCIDENCE OF ACUTE HEPATITIS B

CDC published "Incidence of Acute Hepatitis B--United States, 1990-2002" in the January 2 issue of MMWR. The article is reprinted below in its entirety, excluding references and a figure.

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Hepatitis B virus (HBV) is a bloodborne and sexually transmitted virus that is acquired by percutaneous and mucosal exposure to blood or other body fluids of an infected person. Clinical manifestations of acute hepatitis B can be severe, and serious complications (i.e., cirrhosis and liver cancer) are more likely to develop in chronically infected persons. In the United States, approximately 1.2 million persons have chronic hepatitis B virus (HBV) infection and are sources for HBV transmission to others. However, since the late 1980s, the incidence of acute hepatitis B has declined steadily, especially among vaccinated children. To characterize the epidemiology of acute hepatitis B in the United States, CDC analyzed national notifiable disease surveillance data for 1990-2002. This report summarizes the results of that analysis, which indicated that, during 1990-2002, the incidence of reported acute hepatitis B declined 67%. This decline was greatest among children and adolescents, indicating the effect of routine childhood vaccination. The decline was lowest among adults, who accounted for the majority of cases; incidence increased among adults in some age groups. To reduce HBV transmission further in the United States, hepatitis B vaccination programs are needed that target men who have sex with men (MSM), injection-drug users (IDUs), and other adults at high risk.

CDC analyzed surveillance data for acute hepatitis B cases reported weekly from state health departments and the District of Columbia during 1990-2002. Data included each patient's county of residence, sex, race/ethnicity, and age. Clinical and risk factor data were available for approximately 35% of cases reported since 1990, including death from acute hepatitis B, reported injection-drug use, sex and number of sex partners, and exposure to a household or sex contact during incubation period. Acute hepatitis B incidence was calculated by using population denominators from the U.S. Census Bureau.

Summary of Incidence

During 1990-2002, the incidence of acute hepatitis B declined 67%, from 8.5 per 100,000 population (21,102 total cases reported) to 2.8 per 100,000 population (8,064 total cases reported). By region, in 2002, incidence was highest in the South (3.6), followed by the Northeast (3.5), the West (2.3), and the Midwest (1.6). During 1990-2002, decreases in incidence were greatest in the West (78%), followed by the Midwest (72%), the South (59%), and the Northeast (52%); however, incidence in the Northeast has increased 41% since 1999.

The incidence of acute hepatitis B among men has been consistently higher than among women. In 1990, the incidence among men and women was 9.8 and 6.3, respectively; in 2002, the incidence was 3.7 and 2.2, respectively. Overall, incidence among women has declined more than among men; the male-to-female acute hepatitis B rate ratio was 1.5 in 1990, compared with 1.7 in 2002.

By age, the most significant decline (89%) in acute hepatitis B incidence during 1990-2002 occurred among persons aged 0-19 years, from 3.0 in 1990 to 0.3 in 2002. Among persons aged 20-39 and 40 years and older, acute hepatitis B incidence declined 67% and 39%, respectively; however, the majority of this decline occurred during 1990-1998. Since 1999, the incidence of acute hepatitis B has increased 5% among males aged 20-39 years and 20% and 31%, respectively, among males and females aged 40 years and older. Among 6,790 (32%) of the 21,102 cases reported in 1990 and 3,079 (38%) of the 8,064 cases reported in 2002 for which risk factor data were available, the proportion of persons who reported injection-drug use was similar (17% and 15%). However, the proportion of heterosexuals reporting multiple sex partners increased from 14% to 29%, as did the proportion of self-identified MSM, from 7% to 18%. During 1990-2002, the proportion of MSM reporting multiple sex partners was approximately 50%.

Examples of Local Trends

Data from two counties illustrate the changing epidemiology of acute hepatitis B in the United States. In both counties, overall incidence and incidence among children have declined. In Baltimore County (Baltimore, Maryland), acute hepatitis B incidence has been consistently higher than the national average. Since 1990, incidence has declined 26% overall; however, during 2000-2002, incidence increased 15%. In 2002, Baltimore County reported 50 acute hepatitis B cases (29 among men and 21 among women) for an overall incidence of 6.6; incidence for men and women was 8.1 and 5.3, respectively, with a male-to-female rate ratio of 1.5. Of the 38 persons with available risk factor data, 15 (40%) reported injection-drug use, eight (21%) reported having multiple heterosexual sex partners, and three (8%) reported both risk factors; six (16%) persons reported exposure to an HBV-infected household or sex contact, and three (8%) reported being an MSM.

Since 1990 in Mecklenburg County (Charlotte, North Carolina), reported acute hepatitis B incidence has been above the national average; however, during the same period, incidence has declined 82%. In 2002, Mecklenburg County reported 39 acute hepatitis B cases (28 among men and 11 among women) for an overall incidence of 5.6; incidence for men and women was 8.2 and 3.1, respectively, with a male-to-female rate ratio of 2.6. Risk factor data were available for all 39 cases; eight (21%) persons reported having multiple heterosexual sex partners, eight (21%) reported being MSM, and three (8%) reported both risk factors. Five (13%) persons reported exposure to an HBV-infected household or sex contact; no persons reported injection-drug use.

Editorial Note:

In 1991, a comprehensive strategy to eliminate HBV transmission was implemented in the United States and has reduced the incidence of acute hepatitis B among children. The strategy included universal infant vaccination, universal screening of pregnant women, and postexposure prophylaxis of infants born to infected mothers to prevent perinatal HBV infection; since 1982, adolescents and adults at high risk have been recommended to receive HBV vaccine. In 1995, the strategy was expanded to include routine vaccination of all adolescents aged 11-12 years and, in 1999, to include all persons aged 0-18 years who had not been vaccinated previously. The incidence of acute hepatitis B has declined steadily during the preceding decade, in part because of successful vaccination and other prevention programs. The observed decline in the incidence of acute hepatitis B among children occurred coincident with an increase in hepatitis B vaccination coverage among children aged 19-35 months, from 16% in 1992 to 90% in 2000.

Since 1999, after more than a decade of decline, hepatitis B incidence among men aged older than 19 years and women aged 40 years and older has increased. The most common risk factors reported among adults with acute hepatitis B continue to be multiple sex partners, MSM, and injection-drug use. Different high-risk behaviors accounted for the majority of transmissions in different locales.

Increases in sexually transmitted diseases (STD), including syphilis and human immunodeficiency virus (HIV) infection among MSM have been attributed to increases in high-risk sexual behavior (e.g., unprotected anal intercourse with more than one partner and unsafe sex while under the influence of alcohol or recreational drugs). Changes in patterns of sexual behavior also could be responsible for the increasing transmission of HBV among MSM.

In 1982, the Advisory Committee on Immunization Practices recommended hepatitis B vaccination for sexually active homosexual and bisexual men and IDUs and, in 1985, for heterosexuals with multiple sex partners or a recent STD. Trends in acute hepatitis B infection also reflect poor vaccination coverage among persons who engage in these behaviors. Of 3,432 young MSM in seven U.S. metropolitan areas, only 9% had received HBV vaccine. In a San Diego County, California, survey, only 6% of IDUs had completed the 3-dose HBV vaccine series.

Persons at high risk for HBV infection often seek health care in settings in which vaccination services could be provided. During 1996-1998, approximately half of persons reported with acute hepatitis B had been treated for an STD or incarcerated: 89% of IDUs, 35% of MSM, and 70% of persons with multiple sex partners. Both STD clinics and correctional facilities are settings in which hepatitis B vaccination services are recommended.

The findings in this report are subject to at least two limitations. First, the quality of surveillance data varies at local and state levels. Second, national viral hepatitis case-reporting is incomplete; only approximately 35% of all reported cases contain risk factor data.

The decline in acute hepatitis B among children indicates that successful hepatitis B vaccination programs are possible. These programs must consider the local epidemiology of hepatitis B and identify ways to reach populations at high risk. Integration of hepatitis B vaccination into health-care programs that target persons at high risk is feasible and cost effective. Hepatitis B vaccination programs have been implemented in STD clinics, juvenile and adult detention facilities, HIV-counseling and -testing centers, and other sites.

No national adult hepatitis B program exists that is similar to those that have proven successful for children and adolescents. Components of a national adult vaccination program must include policies for vaccination, including methods for achieving higher vaccination rates among adults at greatest risk and appropriate resources to support implementation.

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To access a web-text (HTML) version of the complete article, go to: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5251a3.htm

To access a ready-to-copy (PDF) version of this issue of MMWR, go to: http://www.cdc.gov/mmwr/PDF/wk/mm5251.pdf

Receive a FREE electronic subscription to MMWR (which includes new ACIP statements) by going to
http://www.cdc.gov/mmwr/mmwrsubscribe.html
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January 5, 2004
JANUARY 12 IS THE REGISTRATION DEADLINE FOR NIP'S NETCONFERENCE "CURRENT ISSUES IN IMMUNIZATION"

Scheduled for January 15, from noon to 1 pm ET, the Netconference "Current Issues in Immunization" is designed to provide clinicians with up-to-date information on immunization. It will focus on two topics: influenza and vaccine storage and handling.

The conference requires pre-registration. Registration will close when the course is full or on January 12 (midnight eastern time).

To register for the conference, go to:
http://www2a.cdc.gov/nip/isd/ciinc/default.asp

For additional information, go to: http://www.cdc.gov/nip/ed/ciinc/default.htm or call (404) 639-8225.
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January 5, 2004
PAUL OFFIT'S VACCINE-SAFETY ARTICLE AVAILABLE ON THE "PEDIATRICS" WEBSITE

On December 6, 2003, AAP's journal "Pediatrics" published "Addressing Parents' Concerns: Do Vaccines Contain Harmful Preservatives, Adjuvants, Additives, or Residuals?" Written by Paul A. Offit, MD, and Rita K. Jew, PharmD, the article summarizes the authors' review of the data. The abstract is reprinted below.

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Vaccines often contain preservatives, adjuvants, additives, or manufacturing residuals in addition to pathogen-specific immunogens. Some parents, alerted by stories in the news media or information contained on the World Wide Web, are concerned that some of the substances contained in vaccines might harm their children. We reviewed data on thimerosal, aluminum, gelatin, human serum albumin, formaldehyde, antibiotics, egg proteins, and yeast proteins. Both gelatin and egg proteins are contained in vaccines in quantities sufficient to induce rare instances of severe, immediate-type hypersensitivity reactions. However, quantities of mercury, aluminum, formaldehyde, human serum albumin, antibiotics, and yeast proteins in vaccines have not been found to be harmful in humans or experimental animals.

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To access a web-text (HTML) version of the abstract, go to:
http://pediatrics.aappublications.org/cgi/content/abstract/112/6/1394

To access a web-text (HTML) version of the complete article, go to:
http://pediatrics.aappublications.org/cgi/content/full/112/6/1394

To access a ready-to-copy (PDF) version, go to:
http://pediatrics.aappublications.org/cgi/reprint/112/6/1394.pdf
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January 5, 2004
CDC ISSUES AN UPDATE ON CURRENT U.S. INFLUENZA ACTIVITY

CDC published "Update: Influenza Activity--United States, December 14-20, 2003" in the January 2 issue of MMWR. Portions of the article are reprinted below.

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Influenza activity in the United States continued to increase during December 14-20, 2003. The proportion of patient visits to sentinel providers for influenza-like illness (ILI) overall was 7.7%, which is above the national baseline of 2.5%. Influenza activity was reported as widespread by health departments in 45 states, New York City, and the District of Columbia; four states reported regional influenza activity; and one state reported local influenza activity. . . .

Antigenic Characterization

Of the 330 influenza viruses collected by U.S. laboratories since October 1 and characterized antigenically by CDC, 326 were influenza A (H3N2) viruses, two were influenza A (H1) viruses, and two were influenza B viruses. The hemagglutinin proteins of the influenza A (H1) viruses were similar antigenically to the hemagglutinin of the vaccine strain A/New Caledonia/20/99. Of the 326 influenza A (H3N2) isolates that have been characterized, 80 (25.0%) were similar antigenically to the vaccine strain A/Panama/2007/99 (H3N2), and 246 (75.0%) were similar to a drift variant, A/Fujian/411/2002 (H3N2). Both influenza B viruses characterized were similar antigenically to B/Sichuan/379/99.

Pneumonia and Influenza (P&I) Mortality Surveillance

As of the week ending December 20, P&I accounted for 7.8% of all deaths reported through the 122 Cities Mortality Reporting System. The epidemic threshold for that week was 7.8%. . . .

Weekly updates on influenza activity will be published in MMWR during the influenza season. Additional information about influenza activity is available from CDC at http://www.cdc.gov/flu

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To access a web-text (HTML) version of the complete article, go to: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5251a5.htm

To access a ready-to-copy (PDF) version of this issue of MMWR, go to: http://www.cdc.gov/mmwr/PDF/wk/mm5251.pdf
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January 5, 2004
MMWR PUBLISHES UPDATE ON CURRENT INFLUENZA-RELATED DEATHS AMONG U.S. CHILDREN LESS THAN 18 YEARS OLD

CDC published "Update: Influenza-Associated Deaths Reported Among Children Aged Less Than 18 Years--United States, 2003-04 Influenza Season" in the January 2 issue of MMWR. Originally published in the web-based "MMWR Dispatch," the update has not been available in hard-copy format until now.

To access a web-text (HTML) version of the update online, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5251a4.htm

To access a ready-to-copy (PDF) version of this issue of MMWR, go to: http://www.cdc.gov/mmwr/PDF/wk/mm5251.pdf
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January 5, 2004
SAVE THE DATE: "EPIDEMIOLOGY AND THE PREVENTION OF VACCINE PREVENTABLE DISEASES" TO BE BROADCAST IN FEBRUARY AND MARCH

A live, four-part satellite broadcast by CDC, "Epidemiology and the Prevention of Vaccine Preventable Diseases," is scheduled from noon to 3:30 pm ET on four consecutive Thursdays: February 19 and 26, and March 4 and 11. Individual registration begins January 22. Watch future issues of "IAC EXPRESS" for details.

To access a course overview from the website of the Public Health Training Network, go to:
http://www.phppo.cdc.gov/PHTN//epv04/default.asp
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January 5, 2004
UPDATED: IAC MAKES MINOR REVISIONS TO ITS VIS PROFESSIONAL-EDUCATION SHEET "IT'S FEDERAL LAW!"

In December 2003, IAC revised one of its VIS professional-education sheets, "It's Federal Law! You Must Give Your Patients Current Vaccine Information Statements (VISs)." IAC added information on the rabies VIS, which the Centers for Disease Control and Prevention updated on 11/4/03.

To access a web-text (HTML) version of the updated sheet, go to:
http://www.immunize.org/catg.d/2027law.htm

To access a ready-to-copy (PDF) version, go to:
http://www.immunize.org/catg.d/2027law.pdf
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January 5, 2004
SUBSCRIBE TODAY: CDC'S FREE ELECTRONIC NEWS SERVICE "PUBLIC HEALTH LAW NEWS" IS LOOKING FOR READERS

CDC published "Notice to Readers: Subscriptions to the CDC Public Health Law News" in the January 2 issue of MMWR. The notice is reprinted below in its entirety.

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Public Health Law News is a free electronic newsletter published every weekday except holidays by CDC's Public Health Law Program. The newsletter contains summaries of news reports on public health law and related subjects; announcements of public health law--related publications, conferences, congressional hearings, and other events; a news quotation of the day; and other timely material. The newsletter is available at http://www.phppo.cdc.gov/od/phlp Information about subscribing via e-mail is available at http://www.cdc.gov/subscribe.html

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To access a web-text (HTML) version of the notice, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5251a6.htm

To access a ready-to-copy (PDF) version of this issue of MMWR, go to: http://www.cdc.gov/mmwr/PDF/wk/mm5251.pdf
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January 5, 2004
JANUARY 26 IS THE DEADLINE FOR PROPOSALS FOR NACCHO'S 2004 ANNUAL CONFERENCE

January 26 is the deadline for session and speaker proposals for the 2004 annual conference of the National Association of County and City Health Officials (NACCHO). The conference will be held on July 14-17 in St. Paul, MN. Its theme is "Shaping Our Potential: Competencies, Capacities, and Core Functions in Local Public Health."

For information on submitting a proposal, go to:
http://www.naccho.org/general915.cfm

For information on the conference, go to:
http://www.naccho.org/files/documents/2004_naccho_annual.html

For additional information, contact Caryn Ayers by email at carynayers@conferencemanagers.com or by phone at (301) 984-9450, ext. 17.
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January 5, 2004
THE DEPARTMENT OF HEALTH AND HUMAN SERVICES ANNOUNCES RULE FOR SMALLPOX VACCINE INJURY COMPENSATION PROGRAM

On December 19, 2003, CDC published an official Health Alert Network Info Service Message about the interim final rule for the Smallpox Vaccine Injury Compensation Program. The message is reprinted below in its entirety.

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This is an official CDC HAN Info Service Message

Distributed via the HAN Info Service
December 19, 2003, 14:15 EST (2:15 PM EST)

HHS ISSUES RULES FOR SMALLPOX VACCINE INJURY COMPENSATION PROGRAM

HHS [Department of Health and Human Services] Secretary Tommy G. Thompson today announced an interim final rule that implements a law Congress passed earlier this year to identify and compensate people injured as a result of receiving a smallpox vaccine. The interim rule for the new Smallpox Vaccine Injury Compensation Program describes eligibility criteria, the process for requesting benefits and receiving payments, and other necessary policies and procedures. Funded at $42 million, the program provides financial and medical benefits to eligible members of an HHS-approved smallpox emergency response plan who sustain certain medical injuries caused by a smallpox vaccine.

In addition, unvaccinated individuals injured after coming into contact with vaccinated members of an emergency response plan--or with a person with whom the vaccinated person had contact--may be eligible for program benefits. The program also provides benefits to survivors of eligible individuals whose death resulted from a covered injury.

Those who wish to file a claim will find forms and information at www.hrsa.gov/smallpoxinjury HHS is also making special efforts to ensure that all those involved in the smallpox vaccination effort, and especially anyone who may have been injured, will receive notification quickly that the claims system is now operational.

The interim rule was scheduled to be published in the Dec. 16, 2003, Federal Register and will be effective immediately. The public may comment on its contents, and HHS may amend it later based on those comments.

HHS began implementation of the compensation program by publishing a Smallpox Vaccine Injury Compensation Table in the Aug. 27, 2003, edition of the Federal Register. The table became effective upon publication. The table identifies medical injuries and adverse effects presumed to have been caused by a smallpox vaccine or contact. It also lists time intervals in which the first symptom or manifestation must appear in order for the presumption of a vaccine-caused injury to apply. The benefit of such a table is that a causal relationship need not be demonstrated between a smallpox vaccine and an injury listed in it. Because it is possible to incur a medical injury not listed on the table that may have been caused by a smallpox vaccination or contact, a person who can present sufficient evidence to prove likely causation may still be eligible for program benefits.

In order to be eligible to receive benefits, requesters must satisfy the filing deadlines described in the interim final rule. Because these deadlines may fall as early as Jan. 24, 2004, individuals interested in applying for benefits with the program are encouraged to file a Request Form as soon as possible. Anyone interested in eligibility or application information can contact the Smallpox Vaccine Injury Compensation Program, located in HHS' Health Resources and Services Administration, at (888) 496-0338, or by sending an email to smallpox@hrsa.gov

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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 January 6, 2004