Hepatitis B Immunization Catch-up for Asian & Pacific Islander Children: Programs of the National Task Force on Hepatitis B Immunization, Focus on Asians & Pacific Islanders Gary L. Euler, DrPH, MPH, RRT Adult Vaccine-Preventable Diseases Branch Epidemiology and Surveillance Division National Immunization Program Centers for Disease Control and Prevention Department of Health and Human Services One World Global Health 129 th APHA annual meeting Atlanta, GA October 21-25, 2001
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Hepatitis B Immunization Catch-up for Asian & Pacific Islander Children: Programs of the National Task Force on Hepatitis B Immunization, Focus on Asians.
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Hepatitis B Immunization Catch-up for
Asian & Pacific Islander Children: Programs of the National Task Force on Hepatitis B Immunization, Focus on Asians & Pacific Islanders
Hepatitis B Immunization Catch-up for
Asian & Pacific Islander Children: Programs of the National Task Force on Hepatitis B Immunization, Focus on Asians & Pacific Islanders
Gary L. Euler, DrPH, MPH, RRT
Adult Vaccine-Preventable Diseases Branch
Epidemiology and Surveillance Division
National Immunization Program
Centers for Disease Control and Prevention
Department of Health and Human Services
One World Global Health
129th APHA annual meeting
Atlanta, GA
October 21-25, 2001
ACIP regarding hepatitis B vaccination of AAPI children, 1982-1999
ACIP regarding hepatitis B vaccination of AAPI children, 1982-1999
1985 - More extensive AAPI programs should be considered
1990 - Vaccinate AAPI infants born to first generation immigrants; should consider AAPI children under 7
1991 - Vaccinate AAPI & non-AAPI infants
1995 - Vaccinate AAPI children under 11, born to first generation immigrants; vaccinate all children 11-12 years of age
1998 - Vaccine included in VFC for all children 18 and under
1999 - All children through 18 may begin series, special efforts should be made for those, or whose parents were, born countries with HBV infection rates of 2% or higher
1982 - More extensive AAPI programs may be warranted
MDMAVAFL
WA
IL
NJ
HI
NY
CA
PA
TX
Distribution of AAPI in Top 12 States, 2000(20,000 - 400,000 high risk youth aged 9-18 yrs per state)
Distribution of AAPI in Top 12 States, 2000(20,000 - 400,000 high risk youth aged 9-18 yrs per state)
*Pre K in IL
Implementation
NV
NM
MT
KS
SD
AL
WV
MEVT
'96 or '97
WI
WA
CA
ID
AZ
COMO
OK
IL
GA
PA
NH
CTMA
DC
'00 or '01
AR
ND MN
MI
AK
MD
NJ
'98 or '99FL
VA
NC
SCHAWAII
OR
UT
WY
TX LA
IANE
MS
KY
INOH
TN
NYRI
DE
States Requiring HepB for K/1st* Grade School Entry, 2001
States Requiring HepB for K/1st* Grade School Entry, 2001
Implementation
NH
WA
NVUT
MT
KS
LA
ND
SD
IANE
MI
NC
GAALMS
INOH
PA
TN
WV
ME
MD
'97 or '98
WY
CO
FL
OK
WI
IL
SC
DC
HAWAII
2001
CTNJ
ID
MN
VAKY
AK
MA
RI
'99 or 00
OR
CA
AZ NM
TX
AR
MO
NY
VT
DE
States Requiring HepB for Middle School Entry, 2001States Requiring HepB for Middle School Entry, 2001
*The sampling methods differed between cities: a systematic random sample from the telephone directory list of Vietnamese surnames in Dallas, Houston and Washington D .C.; a systematic random sample from the school district enrollment list of Lao/Hmong surnames in Milwaukee, and a cluster sample of households within geographic areas in St. Paul and Seattle.
†Sampling fractions and response rates differed significantly between cities as shown in these four columns starting with the total number of households contacted, the percentage which participated in the interview, the number found to be eligible, and percentage of eligible who completed the interview.
§This column shows the number of children in each city in birth cohorts 1984-1993 for which vaccination histories were collected—the denominators for the coverage percentages in the Hep B-1 and HepB-3 columns to the far right. In Dallas, Houston, and Washington D.C., a high and low rate was calculated using all children in the sample for the low rate and for the high rate (in parentheses) using only those children reported on follow-up by a provider as one of their patients.¶ First or third dose in the hepatitis B vaccination series verified using official written records from parents, schools and/or providers. In Dallas, Houston, and Washington D.C., only provider records were used because the parent interviews were conducted by telephone.**Primarily Vietnamese (32%), Chinese (19%), Filipino (19%), and Cambodian (12%).
†Households
Cities*Total
n
TotalResponse
Rate %EligiblesIdentified
Eligible Response
Rate %
Childrenin
Sample§ Ethnicity HepB-1¶
%HepB-3
%
Dallas 3801 72 549 91 332 (177)
Vietnamese 28 (52)
18 (36)
Houston 4743 65 539 94 314 (132)
Vietnamese 25 (61)
14 (36)
Milwaukee 275 99 271 76 207 Lao/Hmong 82 51
St. Paul 1391 56 209 96 586 Hmong 80 67
Seattle 4200 95 272 100 412 Pan Asian** 79 65
Washington, D.C.
3550 79 503 93 346 (127)
Vietnamese 25(56)
15(43)
¶
Hepatitis B vaccination coverage rates among Asian American and Pacific Islander children born
1984-1993 – six city surveys, 1998
Hepatitis B vaccination coverage rates among Asian American and Pacific Islander children born
1984-1993 – six city surveys, 1998
*Dallas, Houston, and Washington, D.C.
1CDC. Hepatitis B vaccination coverage among Asian and Pacific Islander children—United States, 1998. MMWR 2000;49:616-9.
**Milwaukee, St. Paul, and Seattle
HepB-3 >18 mo in cities with ongoing programs**
HepB-3 <=18 mo in cities with ongoing programs**
Cumulative HepB-3 coverage among AAPI children in six cities by year of birth, 19981
n=2197
Cumulative HepB-3 coverage among AAPI children in six cities by year of birth, 19981
Yearly hepatitis B dose-1 vaccination rates among Asian American and Pacific Islander (AAPI) infants and children in cities* with AAPI hepatitis B vaccination programs and cities† without AAPI targeted programs, six city surveys, 1998
Yearly hepatitis B dose-1 vaccination rates among Asian American and Pacific Islander (AAPI) infants and children in cities* with AAPI hepatitis B vaccination programs and cities† without AAPI targeted programs, six city surveys, 1998
*Milwaukee, St. Paul, and Seattle. In 1998 the overall coverage rates of the first dose (HepB-1) in surveyed populations were 79%.†Dallas, Houston, and Washington, D.C. In 1998 the overall HepB-1 rates in surveyed populations were 28%.§Percent vaccinated during the year of those born during the year; average n’s:120.5 (range = 69-152) in group with programs; 99.2 (range = 83-118) in group for intervention study.¶Percent vaccinated during the year of all previously unvaccinated with first birthday in some prior year; aged 1 - 14 years; average n’s: 404.7(182-660, except for 8 in 1984 and 77 in 1985 ) in group of cities with ongoing programs; 920.7 (range 363-1245) in group of cities chosen for the catch-up intervention study.
• Provider training on HBV diagnostics and treatments—6 provider sessions in 4+ hospitals
• High School Peer Education—with University of Illinois• VFC provider survey—post intervention levels collected,
analysis and comparison to pre intervention pending
APIA HepB Interventions, Los Angeles 2001APIA HepB Interventions, Los Angeles 2001• Medical Provider
– CME seminar 11/00, San Gabriel Valley—100 providers– AFIX in 3 offices of 111 ages 15-18 y—60% HepB-3 rate.
• Community – Focus group selection of messages and venues– Posters, brochures (4200), radio (200x), newspapers, – Educational presentations to community groups in Mandarin,
Cantonese and Vietnamese—300 adults
• High school – Class room education and mobile clinic
• 620 (40%) of 1550 students are API• 83 (13%) API students participated• 18 (22%) had one or more HepB at start of intervention• 62 (72%) completed the series during the intervention• Incentive of $5 movie coupon for each HepB shot
Expenditures$268,660
• $51/child:education database training
• $41/dose :
outreach vaccinesupplies
Hepatitis B vaccination
• 1470 doses to 1113 children
• HepB-1 rates 8% to 34%
• HepB-3 rates 4% to 16%
Cost ratios:(1-3)
• $348/protected child
• $11,500/year of life saved (106 years)*
• $4.44 benefits/$1.00 invested** Assuming a 30% life-time rate of HBV infection is prevented in this populationby vaccination. Costs discounted at 3%.
Economic analysis of AAPI HepB catch-up project, Philadelphia, 1995
n = 4,384 children born 1983-1993
Economic analysis of AAPI HepB catch-up project, Philadelphia, 1995
n = 4,384 children born 1983-1993
1. Deuson R, et al. Ped Acad Soc mtg APS & SPR 1998. New Orleans, LA.2. Deuson R, et al. Arch Pediatr Adolesc Med 2001;155:909-14.3. Margolis HS, et al. JAMA 1995;274:1201-8.
The Asian Liver Centerat Stanford University
The Asian Liver Centerat Stanford University
• Only non-profit organization in the United States founded to address the high incidence of hepatitis B and liver cancer in Asians and Asian Americans
• Launched the Jade Ribbon Campaign on May 21, 2001 to coincide with Asian Heritage Month
The Jade Ribbon CampaignThe Jade Ribbon Campaign• Jade Ribbon symbol & health brochures/posters in 4
languages (Chi, Vie, Eng & Kor)
• Distribution nationwide & worldwide as far as Norway & Indonesia
• Network: 130+ local & national Community Partner Organizations—student groups, to professional organizations, o restaurants, to health clinics
• Filming of patient interviews and stories
• Production of 30 s PSA aired several times/week over 2 months on local Asian networks
– Featured actress May Chin from Oscar-nominated film Wedding Banquet
– Currently in production: PSA featuring actor Chow Yun Fat from Crouching Tiger, Hidden Dragon
The Jade Ribbon CampaignThe Jade Ribbon Campaign
• Bus Ads: 1,200 Interior Cards, 260 Tail Light Posters, 25 strategically placed Bus Shelters
• Media Coverage since 5/21/01 Press Conference
– Over 10 television or radio interviews/broadcasts B, including Asian and non-Asian networks
– Over 20 articles in Asian and non-Asian publications, including featured articles in the San Francisco Chronicle and San Jose Mercury News
• Comprehensive website : http://liver.stanford.edu• Phone line : 650-72-LIVER • Free Screening Event 7/28/01: 486 people in 5
AAPI Hepatitis B Vaccination Catch-up can now prevent
AAPI Hepatitis B Vaccination Catch-up can now prevent
• In target group of 500,000 9-19 year olds
• 10% would be infected with hepatitis B virus (HBV) in next 20 years– 50,000 acute infections
• 5% of 50,000 go on to chronic HBV – 2500 chronic infections
• 10% of 2500 die early of cirrhosis or liver cancer– 250 deaths unless treated effectively
Remove all barriers to hepatitis B vaccination:
If can’t pay don’t charge Walk-in vaccination Evenings and weekend hours No PE prior to vaccination
Reminder, track and recall Standing orders Interpreters
Recommendations (cont.)
High school interventions make sense in urban schools with high proportions of African-American and AAPI students.
One-on-one provider in-office training is essential to ensure reduction of barriers.
Sero-screening can be helpful.
Recommendations (cont.)
Reasons for sero-screening Older teenagers and adults request it 5-15% if immigrants will be chronically infected Knowing status can help improve outcomes and prevent transmission
Requirements if sero-screening Funding for sero-testing Referral physicians for follow-up Funding for adult HepB Counseling services Place first priority on HepB for aged <19 years
Give HepB-1 at blood draw
Further Discussion
To determine who is susceptible Test all for anti-HBc (Ab to HBV core Ag)
Negative indicates susceptibility Positive indicates past or current infection
To determine who is infectedTest those who have anti-HBc for HBsAg
The surface protein of the HBV Positive indicates current infection
• ALT 2x normal and HBeAg-negative– Mutant HBV– Chronic hepatitis C – Steatohepatitis (fatty liver)
• ALT elevation less than 2x normal– ALT measurements every 6 months
• After age 30-40– Alpha-fetoprotein level every 6 months – Ultrasound of the liver once a year – With cirrhosis -- every 3-4 m & every 6 m, respectively