Issue Number
277 October
16, 2001
CONTENTS OF THIS ISSUE
- Letter from the Executive Director: Give the birth dose
of hepatitis B vaccine to all infants prior to hospital discharge
- CDC publishes notice to readers on anthrax
investigation
- CDC issues public health dispatch on polio in the
Philippines
- New translations! Spanish versions of "Are You at Risk
for Hepatitis A" and "B" and "C" now available
- 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.
*****************************
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
*****************************
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:
*****************************
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
*****************************
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:
*****************************
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.
*****************************
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
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