Hepatitis B vaccination is the most effective measure to prevent hepatitis B virus (HBV) infection and its consequences, including cirrhosis of the liver, liver cancer, liver failure, and death. In adults, ongoing HBV transmission occurs primarily among unvaccinated persons with behavioral risks for HBV transmission (e.g., heterosexuals with multiple sex partners, injection-drug users [IDUs], and men who have sex with men [MSM]) and among household contacts and sex partners of persons with chronic HBV infection. This report, the second of a two-part statement from the Advisory Committee on Immunization Practices (ACIP), provides updated recommendations to increase hepatitis B vaccination of adults at risk for HBV infection. The first part of the ACIP statement, which provided recommendations for immunization of infants, children, and adolescents, was published previously (CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices [ACIP]. Part 1: immunization of infants, children, and adolescents. MMWR 2005;54[No. RR-16]:1-33). In settings in which a high proportion of adults have risks for HBV infection (e.g., sexually transmitted disease/human immunodeficiency virus testing and treatment facilities, drug-abuse treatment and prevention settings, health-care settings targeting services to IDUs, health-care settings targeting services to MSM, and correctional facilities), ACIP recommends universal hepatitis B vaccination for all unvaccinated adults. In other primary care and specialty medical settings in which adults at risk for HBV infection receive care, health-care providers should inform all patients about the health benefits of vaccination, including risks for HBV infection and persons for whom vaccination is recommended, and vaccinate adults who report risks for HBV infection and any adults requesting protection from HBV infection. To promote vaccination in all settings, health-care providers should implement standing orders to identify adults recommended for hepatitis B vaccination and administer vaccination as part of routine clinical services, not require acknowledgment of an HBV infection risk factor for adults to receive vaccine, and use available reimbursement mechanisms to remove financial barriers to hepatitis B vaccination.

A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults.

Routine vaccination of children is an effective way to reduce hepatitis A incidence in the United States. Since licensure of hepatitis A vaccine during 1995-1996, the hepatitis A childhood immunization strategy has been implemented incrementally, starting with the recommendation of the Advisory Committee on Immunization Practices (ACIP) in 1996 to vaccinate children living in communities with the highest disease rates and continuing in 1999 with ACIP's recommendations for vaccination of children living in states, counties, and communities with consistently elevated hepatitis A rates. These updated recommendations represent the final step in the childhood hepatitis A immunization strategy, routine hepatitis A vaccination of children nationwide. Implementation of these recommendations will reinforce existing vaccination programs, extend the benefits associated with hepatitis A vaccination to the rest of the country, and create the foundation for eventual consideration of elimination of indigenous hepatitis A virus transmission. This report updates ACIP's 1999 recommendations concerning the prevention of hepatitis A through immunization (CDC. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 1999:48[No. RR-12]:1-37) and includes 1) new data on the epidemiology of hepatitis A in the era of hepatitis A vaccination of children in selected U.S. areas, 2) results of analyses of the economics of nationwide routine vaccination of children, and 3) recommendations for the routine vaccination of children in the United States. Previous recommendations for vaccination of persons in groups at increased risk for hepatitis A or its adverse consequences and recommendations regarding the use of immune globulin for protection against hepatitis A are unchanged from the 1999 recommendations.

https://stacks.cdc.gov/view/cdc/6720/cdc_6720_DS1.pdf

Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP).

These revised recommendations by the Advisory Committee on Immunization Practices concerning prevention of plague update previous recommendations (MMWR 1982;31:301-4). This report includes information and recommendations on vaccination, public health practices, and medical treatment to prevent plague among humans.

/pdf/recommendations-of-the-advisory-committee-on-immunization-3guz7xi9ha.pdf

Recommendations of the Advisory Committee on Immunization Practices (ACIP)

In low-income countries, infectious diseases still account for a large proportion of deaths, highlighting health inequities largely caused by economic differences. Vaccination can cut health-care costs and reduce these inequities. Disease control, elimination or eradication can save billions of US dollars for communities and countries. Vaccines have lowered the incidence of hepatocellular carcinoma and will control cervical cancer. Travellers can be protected against "exotic" diseases by appropriate vaccination. Vaccines are considered indispensable against bioterrorism. They can combat resistance to antibiotics in some pathogens. Noncommunicable diseases, such as ischaemic heart disease, could also be reduced by influenza vaccination. Immunization programmes have improved the primary care infrastructure in developing countries, lowered mortality in childhood and empowered women to better plan their families, with consequent health, social and economic benefits. Vaccination helps economic growth everywhere, because of lower morbidity and mortality. The annual return on investment in vaccination has been calculated to be between 12% and 18%. Vaccination leads to increased life expectancy. Long healthy lives are now recognized as a prerequisite for wealth, and wealth promotes health. Vaccines are thus efficient tools to reduce disparities in wealth and inequities in health.

https://www.who.int/bulletin/volumes/86/2/07-040089.pdf

Vaccination greatly reduces disease, disability, death and inequity worldwide.

This report is the first of a two-part statement from the Advisory Committee on Immunization Practices (ACIP) that updates the strategy to eliminate hepatitis B virus (HBV) transmission in the United States. The report provides updated recommendations to improve prevention of perinatal and early childhood HBV transmission, including implementation of universal infant vaccination beginning at birth, and to increase vaccine coverage among previously unvaccinated children and adolescents. Strategies to enhance implementation of the recommendations include 1) establishing standing orders for administration of hepatitis B vaccination beginning at birth; 2) instituting delivery hospital policies and procedures and case management programs to improve identification of and administration of immunoprophylaxis to infants born to mothers who are hepatitis B surface antigen (HBsAg) positive and to mothers with unknown HBsAg status at the time of delivery; and 3) implementing vaccination record reviews for all children aged 11-12 years and children and adolescents aged <19 years who were born in countries with intermediate and high levels of HBV endemicity, adopting hepatitis B vaccine requirements for school entry, and integrating hepatitis B vaccination services into settings that serve adolescents. The second part of the ACIP statement, which will include updated recommendations and strategies to increase hepatitis B vaccination of adults, will be published separately.

A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part 1: immunization of infants, children, and adolescents

Objective. —To evaluate the safety and efficacy of a new inactivated hepatitis A vaccine. Design. —Double-blind randomized controlled trial stratified by community. Setting. —Community-based in Thailand. Study Participants. —A total of 40119 children, aged 1 to 16 years, attending 148 primary schools: 38 157 (95%) entered surveillance a mean of 138 days after receiving vaccine dose 1; 33 586 (84%) completed the controlled trial of 532 days; and 31 075 (81%) received crossover vaccine and remained under surveillance until day 844. Intervention. —Participants received hepatitis A vaccine or control hepatitis B vaccine starting January 7,1991 (doses in months 0,1, and 12), and crossed over to the alternate vaccine 18 months later. Main Outcome Measure. —Cases of hepatitis A (symptoms, alanine aminotransferase levels of 45 U/L or higher, and IgM to hepatitis A virus) were identified by evaluating school absences of 2 or more days. Results. —There were no serious adverse reactions despite administration of more than 109000 doses of hepatitis A vaccine. Among initially seronegative recipients of two doses of hepatitis A vaccine, the proportion with 20 mlU/mL or more of antibody to hepatitis A virus before and 5 months after a 1-year booster was 94% and 99%, respectively. Of 6976 episodes of illness during the controlled trial, there were 40 cases of hepatitis A; 38 were in the control group. Of the 40 cases, six, all in controls, occurred after the 1-year booster dose. Following two doses of hepatitis A vaccine (days 138 through 386), protective efficacy was 94% (95% confidence interval, 79% to 99%); cumulative efficacy including the postbooster period (days 138 to 532) was 95% (95% confidence interval, 82% to 99%). The two hepatitis A vaccine recipients who had symptomatic infections (257 and 267 days after dose 1) appeared to have been partially protected since their illnesses were brief and associated with only slight increases in alanine aminotransferase. Conclusions. —Inactivated hepatitis A vaccine is safe; when administered in two doses, it protects against hepatitis A for at least 1 year. ( JAMA . 1994;271:1328-1334)

Protection against hepatitis A by an inactivated vaccine.

The ability of human semen and saliva to transmit hepatitis B virus (HBV) by parenteral and nonparenteral routes was studied. Semen, donated by a hepatitis B surface antigen (HBsAg)- and hepatitis B e antigen (HBeAg)-positive carrier, was administered to one gibbon by subcutaneous inoculation and to another by intravaginal instillation. Both developed HBsAg, followed by the development of antibody to HBsAg (anti-HBs) and antibody to hepatitis B core antigen (anti-HBc). Saliva from two donors who were HBsAg- and HBeAg-positive was pooled and administered subcutaneously to two gibbons and orally to five others. The animals inoculated subcutaneously developed HBsAg followed by anti-HBs, but none of the gibbons exposed orally developed evidence of HBV infection. Thus, semen and saliva of HBsAg carriers can be infectious, and venereal transmission of HBV by semen can occur. Transmission of HBV in saliva can also occur through breaks in the skin, but experimental transmission of HBV by saliva administered orally has not been accomplished.

Experimental transmission of hepatitis B virus by semen and saliva

Viremia, fecal shedding and antibody responses to hepatitis E virus (HEV) infections are poorly understood. To better characterize HEV infections, these responses were examined in 67 patients with acute markers for hepatitis E who were admitted to the Infectious Disease Hospital in Kathmandu, Nepal in 1993. A single stool and multiple sera from each patient were examined using polymerase chain reaction to detect HEV RNA. Sera were also examined for antibodies to HEV. Viremia, fecal shedding, and IgM and IgG to HEV were detected in 93%, 70%, 79%, and 87% of 67 patients, respectively. Viremia or fecal shedding (or both) were detected in 14 patients from whom IgM and IgG to HEV were not detected. Viremia lasted at least 2 weeks in nearly all subjects and at least 39 days in 1 subject. Our results suggest that viremia is a common occurrence in patients infected with HEV.

Viremia, Fecal Shedding, and IgM and IgG Responses in Patients with Hepatitis E

A pool of whole-mouth saliva collected from five human carriers of hepatitis B surface antigen, subtype adr, was found to contain antigen particles with mean diameters of 23.3 and 41.8 nm as seen by immune electron microscopy. Two gibbons received subcutaneous injections of the pooled saliva and developed serological and, in at least one animal, biochemical evidence of hepatitis B virus infection at 12 and 22 weeks, respectively. Although none of eight other gibbons that were exposed by the nasal or oral routes were infected, the experiment demonstrated that human saliva can serve as a vehicle for the transmission of hepatitis B virus.

Transmission of Hepatitis B Virus to Gibbons by Exposure to Human Saliva Containing Hepatitis B Surface Antigen

To determine hepatitis E virus (HEV) infection and disease rates in the Kathmandu Valley of Nepal, serum was collected from 757 healthy Nepalese (ages 12-48 years) during March and September 1992 and September 1993. At each visit, reports of interval illness were obtained. Sera were examined for IgG to HEV, using a commercially available kit. Seroconversion was used as a marker for HEV infection, and an episode of hepatitis E was defined as a history of jaundice with seroconversion. Seroprevalence ranged from 16% to 31% and increased with age, whereas both infection and disease rates decreased with age. Infection and disease rates were as high as 99/1000 and 45/1000 person-years, respectively. These results highlight the importance of sporadic hepatitis E as a public health problem among adolescents and young adults in this region.

Rapin Snitbhan

Papers

Protection against hepatitis A by an inactivated vaccine.

Experimental transmission of hepatitis B virus by semen and saliva

Viremia, Fecal Shedding, and IgM and IgG Responses in Patients with Hepatitis E

Transmission of Hepatitis B Virus to Gibbons by Exposure to Human Saliva Containing Hepatitis B Surface Antigen

Rates of Hepatitis E Virus Infection and Disease among Adolescents and Adults in Kathmandu, Nepal