Hepatitis: Alter MJ

Mast EE, Weinbaum CM, Fiore AE, Alter MJ, Bell BP, Finelli L, Rodewald LE, Douglas JM, Janssen RS, Ward JW, Anonymous00214. · Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), Atlanta, GA 30333, USA. · MMWR Recomm Rep. · Pubmed #17159833 links to  free full text

Abstract: 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.

Mast EE, Margolis HS, Fiore AE, Brink EW, Goldstein ST, Wang SA, Moyer LA, Bell BP, Alter MJ, Anonymous00300. · Division of Viral Hepatitis, National Center for Infectious Diseases, USA. · MMWR Recomm Rep. · Pubmed #16371945 links to  free full text

Abstract: 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.

Alter MJ. · No affiliation provided · J Hepatol. · Pubmed #18023493 No free full text.

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Perz JF, Alter MJ. · No affiliation provided · J Hepatol. · Pubmed #16426700 No free full text.

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Alter MJ. · No affiliation provided · Am Fam Physician. · Pubmed #16127948 links to  free full text

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Alter MJ. · University of Texas Medical Branch, Galveston, Texas 77555, USA. · World J Gastroenterol. · Pubmed #17552026 links to  free full text

Abstract: Globally, hepatitis C virus (HCV) has infected an estimated 130 million people, most of whom are chronically infected. HCV-infected people serve as a reservoir for transmission to others and are at risk for developing chronic liver disease, cirrhosis, and primary hepatocellular carcinoma (HCC). It has been estimated that HCV accounts for 27% of cirrhosis and 25% of HCC worldwide. HCV infection has likely been endemic in many populations for centuries. However, the wave of increased HCV-related morbidity and mortality that we are now facing is the result of an unprecedented increase in the spread of HCV during the 20th century. Two 20th century events appear to be responsible for this increase; the widespread availability of injectable therapies and the illicit use of injectable drugs.

Alter MJ. · Division of Viral Hepatitis, Centers for Disease Control and Prevention, Mailstop D-66, Atlanta, GA 30333, USA. · J Hepatol. · Pubmed #16352363 No free full text.

Abstract: Worldwide, hepatitis B virus (HBV) accounts for an estimated 370 million chronic infections, hepatitis C virus (HCV) for an estimated 130 million, and HIV for an estimated 40 million. In HIV-infected persons, an estimated 2-4 million have chronic HBV co-infection and 4-5 million have HCV co-infection. HBV, HCV and HIV share common routes of transmission, but they differ in their prevalence by geographic region and the efficiency by which certain types of exposures transmit them. Among HIV-positive persons studied from Western Europe and the USA, chronic HBV infection has been found in 6-14% overall, including 4-6% of heterosexuals, 9-17% of men who have sex with men (MSM), and 7-10% of injection drug users. HCV infection has been found in 25-30% of HIV-positive persons overall; 72-95% of injection drug users, 1-12% of MSM and 9-27% of heterosexuals. The characteristics of HIV infected persons differ according to the co-infecting hepatitis virus, their epidemiologic patterns may change over time, and surveillance systems are needed to monitor their infection patterns in order to ensure that prevention measures are targeted appropriately.

Shepard CW, Finelli L, Alter MJ. · Epidemiology Branch, Division of Viral Hepatitis, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30333, USA. · Lancet Infect Dis. · Pubmed #16122679 No free full text.

Abstract: Hepatitis C virus (HCV) is a major cause of liver disease worldwide and a potential cause of substantial morbidity and mortality in the future. The complexity and uncertainty related to the geographic distribution of HCV infection and chronic hepatitis C, determination of its associated risk factors, and evaluation of cofactors that accelerate its progression, underscore the difficulties in global prevention and control of HCV. Because there is no vaccine and no post-exposure prophylaxis for HCV, the focus of primary prevention efforts should be safer blood supply in the developing world, safe injection practices in health care and other settings, and decreasing the number of people who initiate injection drug use.

Alter MJ, Seeff LB, Bacon BR, Thomas DL, Rigsby MO, Di Bisceglie AM. · Division of Viral Hepatitis, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. · Ann Intern Med. · Pubmed #15520428 links to  free full text

Abstract: In the United States, chronic hepatitis C virus (HCV) infection affects an estimated 3 million persons, most younger than 50 years of age. It is one of the leading causes of chronic liver disease morbidity and mortality and the most common indication for liver transplantation. Effective treatment can eradicate the virus and eliminate or reduce liver inflammation and fibrosis, and counseling and immunization can modify or prevent the adverse effect of cofactors (for example, alcohol consumption or co-infections) on disease progression. However, controversy surrounds the need to routinely identify asymptomatic HCV-infected persons. Because no data currently demonstrate that treatment or other interventions will reduce future cases of HCV-related chronic disease and deaths, the U.S. Preventive Services Task Force found insufficient evidence to recommend for or against routine screening for HCV infection in adults at high risk. Chronic hepatitis C would require many years of follow-up to determine the incidence of complication after treatment of or other interventions in asymptomatic persons. It seems inappropriate to wait several decades to measure the impact of early identification of this viral infection when current data support a positive therapeutic effect that points to long-term benefits. In addition, treatment and other interventions must be provided before cirrhosis or liver failure occurs. Therefore, medical and public health professionals should continue the practice of screening persons for risk factors; offering testing to those at increased risk for HCV infection; and providing infected persons with appropriate counseling, medical evaluation, and treatment.

Alter MJ. · Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, USA. · J Hepatol. · Pubmed #14708680 No free full text.

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Alter MJ. · Epidemiologic and Public Health Science, Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. · Semin Liver Dis. · Pubmed #12616449 No free full text.

Abstract: The primary goal of hepatitis B prevention programs is reduction of chronic hepatitis B virus (HBV) infection and HBV-related chronic liver disease. Although donor screening, risk-reduction counseling and services, and effective infection control practices can reduce or eliminate the potential risk for HBV transmission, immunization is by far the single most effective prevention measure. Worldwide, the integration of hepatitis B vaccine into existing childhood vaccination schedules has the greatest likelihood of long-term success. However, by 2000, only 116 of 215 countries had such a policy, representing 31% of the global birth cohort. In addition, efforts must be strengthened to vaccinate older adolescents and adults with high-risk behaviors or occupations in countries where most HBV transmission and the morbidity associated with acute hepatitis B occur among persons in these age groups. Although continued immunization of successive birth cohorts should achieve the eventual elimination of HBV transmission, this will not occur for decades without successful vaccination of adults at increased risk for infection.

Alter MJ. · Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA. · Hepatology. · Pubmed #12407581 No free full text.

Abstract: Hepatitis C virus (HCV) is transmitted by percutaneous or permucosal exposure to infectious blood or blood-derived body fluids. Based on the results of cohort and acute case control studies, risk factors associated with acquiring HCV infection in the United States have included transfusion of blood and blood products and transplantation of solid organs from infected donors, injecting drug use, occupational exposure to blood (primarily contaminated needle sticks), birth to an infected mother, sex with an infected partner, and multiple heterosexual partners. Nosocomial and iatrogenic transmission of HCV primarily are recognized in the context of outbreaks, and primarily have resulted from unsafe injection practices. Transmission from HCV-infected health care workers to patients is rare. Transfusions and transplants have been virtually eliminated as sources for transmission, and most (68%) newly acquired cases of hepatitis C are related to injecting drug use. The primary prevention of illegal drug injecting will eliminate the greatest risk factor for HCV infection in the United States. Other prevention strategies that need to be widely implemented include risk reduction counseling and services and review and improvement of infection control practices in all types of health care settings. Testing for HCV infection should be routinely performed for persons at high risk for infection or who require postexposure management. There are no recommendations for routine restriction of professional activities for HCV-infected health care workers, and persons should not be excluded from work, school, play, and child care or other settings on the basis of their HCV infection status.

Tokars JI, Arduino MJ, Alter MJ. · Healthcare Outcomes Branch, Hospital Environment Laboratory Branch, Division of Healthcare Quality Fromotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. · Infect Dis Clin North Am. · Pubmed #11570142 No free full text.

Abstract: Infectious complications of hemodialysis include bacterial infections caused by contaminated water or equipment, other bacterial infections (including vascular access infections), and bloodborne viruses (primarily the hepatitis B and C viruses). Infections caused by contaminated water and equipment can be prevented by a well-designed water-treatment system, routine cleaning and disinfection of system components, and routine bacteriologic monitoring of dialysis water and dialysis fluid. Standard precautions with additional measures recommended specifically for dialysis centers will prevent transmission of bacteria and viruses from patient to patient. These precautions include routine use of gloves, handwashing, and cleaning and disinfection of the external surface of the dialysis machine and other environmental surfaces. In addition, preventing transmission of hepatitis B virus infection requires vaccination of susceptible patients and staff, avoiding dialyzer reuse, and use of a dedicated room, dialysis machine, and staff members when treating patients chronically infected with this virus.

Wasley A, Alter MJ. · Hepatitis Branch, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. · Semin Liver Dis. · Pubmed #10895428 No free full text.

Abstract: Hepatitis C Virus (HCV) infection appears to be endemic in most parts of the world, with an estimated overall prevalence of 3%. However, there is considerable geographic and temporal variation in the incidence and prevalence of HCV infection. Using age-specific prevalence data, at least three distinct transmission patterns can be identified. In countries with the first pattern (e.g., United States, Australia), most infections are found among persons 30-49 years old, indicating that the risk for HCV infection was greatest in the relatively recent past (10-30 years ago) and primarily affected young adults. In countries with the second pattern (e.g., Japan, Italy), most infections are found among older persons, consistent with the risk for HCV infection having been greatest in the distant past. In countries with the third pattern (e.g., Egypt), high rates of infection are observed in all age groups, indicating an ongoing high risk for acquiring HCV infection. In countries with the first pattern, injection drug use has been the predominant risk factor for HCV infection, whereas in those with the second or third patterns, unsafe injections and contaminated equipment used in healthcare-related procedures appear to have played a predominant role in transmission. Much of the variability between regions can be explained by the frequency and extent to which different risk factors have contributed to the transmission of HCV. Because different strategies are required to interrupt different patterns of HCV transmission, determining the epidemiology of HCV infection in areas where that information has not yet been assessed is critical for developing appropriate prevention programs.

Alter MJ. · Hepatitis Branch, Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. · J Hepatol. · Pubmed #10622567 No free full text.

Abstract: Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States, and most infected persons are younger than 50 years old. The relative importance of the two most common exposures associated with transmission of HCV, blood transfusion and intravenous drug use (IVDU), has changed over time. Blood transfusion, which accounted for a substantial proportion of HCV infections acquired >10 years ago, rarely accounts for recently acquired infections. In contrast, IVDU has consistently accounted for a substantial proportion of HCV infections and currently accounts for 60% of HCV transmission while sexual exposures account for up to 20%. Other known exposures (occupational, hemodialysis, household, perinatal) together account for about 10% of infections. In the remaining 10%, no recognized source of infection can be identified, although most persons in this category are associated with low socioeconomic level. Case-control studies have found no association with military service or exposures resulting from medical, surgical or dental procedures, tattooing, acupuncture, ear piercing or foreign travel. Reducing the burden of HCV infection and disease in the United States requires implementation of primary prevention activities that reduce or eliminate HCV transmission and secondary prevention activities that reduce liver and other chronic diseases in HCV-infected persons by identifying them and providing appropriate medical management and antiviral therapy. Surveillance and evaluation activities also are important to determine the effectiveness of these programs in reducing the incidence of disease, identifying persons infected with HCV, and promoting healthy lifestyles and behaviors.

Mast EE, Alter MJ, Margolis HS. · Hepatitis Branch, Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30306, USA. · Vaccine. · Pubmed #10194830 No free full text.

Abstract: Hepatitis B virus (HBV) and hepatitis C virus (HCV) are major causes of acute and chronic liver disease worldwide. Chronic infection with these viruses often leads to chronic liver disease, including cirrhosis or primary hepatocellular carcinoma. Both HBV and HCV are bloodborne viruses; however, HBV is transmitted efficiently by both percutaneous and mucosal exposures, and HCV is transmitted predominantly by percutaneous exposures. Because the relative importance of various modes of transmission of these viruses differs by country, the choice of specific prevention and control strategies depends primarily on the epidemiology of infection in a particular country. Comprehensive hepatitis B prevention strategies should include (1) prevention of perinatal HBV transmission, (2) hepatitis B vaccination at critical ages to interrupt transmission and (3) prevention of nosocomial HBV transmission. The prevention of hepatitis C is problematic because a vaccine to prevent HCV infection is not expected to be developed in the foreseeable future. From a global perspective, the greatest impact on the disease burden associated with HCV infection will most likely be achieved by focusing efforts on primary prevention strategies to reduce or eliminate the risk for transmission from nosocomial exposures (e.g. blood transfusion, unsafe injection practices) and high-risk practices (e.g. injecting drug use).

Moyer LA, Mast EE, Alter MJ. · Centers for Disease Control and Prevention, Atlanta, Georgia, USA. · Am Fam Physician. · Pubmed #9930128 links to  free full text

Abstract: An estimated 3.9 million Americans are infected with hepatitis C virus (HCV), and most do not know that they are infected. This group includes persons who are at risk for HCV-associated chronic liver disease and who also serve as reservoirs for transmission of HCV to others. Because there is no vaccine to prevent HCV infection and immune globulin is not effective for postexposure prophylaxis, prevention of HCV infection is paramount. Patients who are at risk of exposure to HCV should be advised on steps they might take to minimize their risk of infection. Patients who are infected with HCV should be counseled on ways to prevent transmission of HCV to others and to avoid hepatotoxins. They should also be examined for liver disease and referred for treatment, if indicated.

Moyer LA, Mast EE, Alter MJ. · Centers for Disease Control and Prevention, Atlanta, Georgia, USA. · Am Fam Physician. · Pubmed #9917576 links to  free full text

Abstract: Hepatitis C, which is caused by the hepatitis C virus (HCV), is a major public health problem in the United States. HCV is most efficiently transmitted through large or repeated percutaneous exposures to blood. Most patients with acute HCV infection develop persistent infection, and 70 percent of patients develop chronic hepatitis. HCV-associated chronic liver disease results in 8,000 to 10,000 deaths per year, and the annual costs of acute and chronic hepatitis C exceed $600 million. An estimated 3.9 million Americans are currently infected with HCV, but most of these persons are asymptomatic and do not know they are infected. To identify them, primary health care professionals should obtain a history of high-risk practices associated with the transmission of HCV and other bloodborne pathogens from all patients. Routine testing is currently recommended only in patients who are most likely to be infected with HCV.

Alter MJ, Kuhnert WL, Finelli L, Anonymous00051. · Division of Viral Hepatitis, National Center for Infectious Diseases, USA. · MMWR Recomm Rep. · Pubmed #12585742 links to  free full text

Abstract: Testing for the presence of antibody to hepatitis C virus (anti-HCV) is recommended for initially identifying persons with hepatitis C virus (HCV) infection (CDC. Recommendations for prevention and control of hepatitis C virus [HCV] infection and HCV-related chronic disease. MMWR 1998;47[No. RR-19] :1-33). Testing for anti-HCV should include use of an antibody screening assay, and for screening test-positive results, a more specific supplemental assay. Verifying the presence of anti-HCV minimizes unnecessary medical visits and psychological harm for persons who test falsely positive by screening assays and ensures that counseling, medical referral, and evaluation are targeted for patients serologically confirmed as having been infected with HCV. However, substantial variation in reflex supplemental testing practices exists among laboratories, and an anti-HCV-positive laboratory report does not uniformly represent a confirmed positive result. These guidelines expand recommendations for anti-HCV testing to include an option for reflex supplemental testing based on screening-test-positive signal-to-cut-off (s/co) ratios. Use of s/co ratios minimizes the amount of supplemental testing that needs to be performed while improving the reliability of reported test results. These guidelines were developed on the basis of available knowledge of CDC staff in consultation with representatives from the Food and Drug Administration and public health, hospital, and independent laboratories. Adoption of these guidelines by all public and private laboratories that perform in vitro diagnostic anti-HCV testing will improve the accuracy and utility of reported anti-HCV test results for counseling and medical evaluation of patients by health-care professionals and for surveillance by public health departments.

Chung YH, Di Bisceglie AM, McMahon BJ, Lanier AP, Harpster A, Alter MJ, Parkinson AJ, Zanis C. · Liver Disease Section, National Institutes of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA. · Int J Circumpolar Health. · Pubmed #10528471 No free full text.

Abstract: Chronic infection with hepatitis B or C viruses is a common underlying condition in patients with hepatocellular carcinoma worldwide. We studied serum and liver tissue from a cohort of Alaska natives with hepatocellular carcinoma (HCC) for evidence of hepatitis B, C and G viral infection using conventional serological tests as well as the sensitive polymerase chain reaction. Evidence of HBV infection was found in 25 and possible HCV infection in two cases. Among the remaining 11 patients, four had a history of recent or remote alcoholism while seven had no recognizable risk factors for HCC. Only one was seropositive for HGV RNA and that was an individual with a history of alcoholism. Non-tumorous liver tissue was available for study in six of these seven cases. Histological features of chronic hepatitis were present in five. Thus, at least five of 38 (13%) Alaska natives with HCC appeared to have chronic hepatitis not related to HBV or HCV infection, suggesting the possibility of some form of previously unrecognized chronic liver disease predisposing to HCC.

Schwarz KB, Garrett B, Alter MJ, Thompson D, Strathdee SA. · Department of Pediatrics, Johns Hopkins Medical Institutions, Johns Hopkins Children's Center, Baltimore, MD 21287, USA. · J Health Care Poor Underserved. · Pubmed #18469428 No free full text.

Abstract: Our objective was to investigate hepatitis C virus (HCV) seroprevalence in homeless caregivers and their children 2-18 years of age living in a family. During a 30-month period from October 2001 through April 2004 in Baltimore, 170 caregivers enrolled and 168 of these accepted testing for antibody to HCV (anti-HCV), as did all 336 children and adolescents enrolled. Main results. None of the children younger than 18 years old were HCV seropositive; in striking contrast, however, 32 (19%) caregivers were seropositive. Most (59%) were previously unaware of their HCV serostatus. History of ever injecting drugs was the strongest predictor of HCV seropositive status in the caregivers, reported by 14% overall, and by 71% of HCV positives. Conclusion. The homeless families were very receptive to our HCV seroprevalence study and are likely also to be receptive to shelter-based HCV prevention programs for young children and adolescents as well as for adults.

Schwarz K, Garrett B, Lee J, Thompson D, Thiel T, Alter MJ, Strathdee S. · Johns Hopkins University School of Medicine, 600 N. Wolfe Street-Brady 320, Baltimore, MD 21287, USA. · J Urban Health. · Pubmed #18274908 links to  free full text

Abstract: Homeless youth are at increased risk for hepatitis B virus (HBV) infection and HBV vaccine coverage is poor in this group. The purpose of our study was to determine if a shelter-based HBV vaccine program in children and adolescents 2-18 years of age with a randomized controlled trial using a culturally appropriate HBV video could increase HBV vaccine coverage rates. Subjects were randomized to an 8 min HBV video or a control, smoking prevention video. Before exposure to the videos, HBV knowledge, and demographics were assessed in caregivers and adolescents. HBV vaccine no. 1 was offered to all subjects who did not produce a vaccine record; subsequently, an accurate HBV vaccine history was obtained from medical providers. Subjects were asked to return 1 and 3 months after visit 1, HBV vaccine was offered to all with incomplete coverage, and HBV knowledge was reassessed. There were 328 children and adolescents cared for by 170 caregivers enrolled in the study. One hundred and four had incomplete HBV vaccine coverage. Data are reported for all family units with at least one subject needing vaccine. There were 53 children and adolescents randomized to the HBV video vs. 51 to the smoking video. HBV knowledge scores of caregivers improved at Visit no. 2 vs. no. 1 in the HBV video group (p = 0.01) but not in the smoking group (p = 0.82). Similar results were observed for adolescents in the HBV video group (p = 0.05) but not in the smoking group (p = 0.40). Exposure to the HBV video vs the smoking video had a significant effect on return rates for vaccine at Visit no. 2 (59 vs. 31%; p = 0.05) but not at Visit no. 3 (47 vs. 18%, p = 0.06). The shelter-based vaccine program was very effective in increasing HBV coverage rates in the entire group of 328 children and adolescents enrolled in the study, from 68% coverage at baseline to 85% at the conclusion of the study. We conclude that shelter-based HBV vaccine programs can be highly effective in increasing vaccine coverage rates in older children and adolescents. A brief exposure to a culturally appropriate HBV video improves HBV knowledge and may improve return rates for vaccine.

Simard EP, Miller JT, George PA, Wasley A, Alter MJ, Bell BP, Finelli L. · Division of Viral Hepatitis, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA. · Infect Control Hosp Epidemiol. · Pubmed #17564979 No free full text.

Abstract: BACKGROUND: Hepatitis B virus (HBV) infection is a well recognized risk for healthcare workers (HCWs), and routine vaccination of HCWs has been recommended since 1982. By 1995, the level of vaccination coverage among HCWs was only 67%. OBJECTIVE: To obtain an accurate estimate of hepatitis B vaccination coverage levels among HCWs and to describe the hospital characteristics and hepatitis B vaccination policies associated with various coverage levels. DESIGN: Cross-sectional survey. METHODS: A representative sample of 425 of 6,116 American Hospital Association member hospitals was selected to participate, using probability-proportional-to-size methods during 2002-2003. The data collected included information regarding each hospital's hepatitis B vaccination policies. Vaccination coverage levels were estimated from a systematic sample of 25 HCWs from each hospital whose medical records were reviewed for demographic and vaccination data. The main outcome measure was hepatitis B vaccination coverage levels. RESULTS: Among at-risk HCWs, 75% had received 3 or more doses of the hepatitis B vaccine, corresponding to an estimated 2.5 million vaccinated hospital-based HCWs. The coverage level was 81% among staff physicians and nurses. Compared with nurses, coverage was significantly lower among phlebotomists (71.1%) and nurses' aides and/or other patient care staff (70.9%; P<.05). Hepatitis B vaccination coverage was highest among white HCWs (79.5%) and lowest among black HCWs (67.6%; P<.05). Compared with HCWs who worked in hospitals that required vaccination only of HCWs with identified risk for exposure to blood or other potentially infectious material, hepatitis B vaccination coverage was significantly lower among HCWs who worked in hospitals that required vaccination of HCWs without identified risk for exposure to blood or other potentially infectious material (76.6% vs 62.4%; P<.05). CONCLUSIONS: In the United States, an estimated 75% of HCWs have been vaccinated against hepatitis B. Important differences in coverage levels exist among various demographic groups. Hospitals need to identify methods to improve hepatitis B vaccination coverage levels and should consider developing targeted vaccination programs directed at unvaccinated, at-risk HCWs who have frequent or potential exposure to blood or other potentially infectious material.

Kamili S, Krawczynski K, McCaustland K, Li X, Alter MJ. · Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA, 30333, USA. · Infect Control Hosp Epidemiol. · Pubmed #17464909 No free full text.

Abstract: OBJECTIVE: To determine effect of environmental exposure on the survival and infectivity of hepatitis C virus (HCV). METHODS: Three aliquots of chimpanzee plasma containing HCV and proven infectious HCV inoculum were dried and stored at room temperature, 1 aliquot for 16 hours, 1 for 4 days, and 1 for 7 days. A chimpanzee (CH247) was sequentially inoculated intravenously with each of these experimental inocula, beginning with the material stored for 7 days. Each inoculation was separated by at least 18 weeks of follow-up to monitor for infection. The concentration of HCV RNA was measured and quasi species were sequenced for each experimental inoculum and in serum samples from CH247. RESULTS: Evidence of HCV infection developed in CH247 only after inoculation with the material stored for 16 hours. No infection occurred after inoculation with the material stored for 7 days or 4 days. Compared with the original infectious chimpanzee plasma, the concentration of HCV RNA was 1 log lower in all 3 experimental inocula. The same predominant sequences were found in similar proportions in the original chimpanzee plasma and in the experimental inocula, as well as in serum samples from CH247. CONCLUSION: HCV in plasma can survive drying and environmental exposure to room temperature for at least 16 hours, which supports the results of recent epidemiologic investigations that implicated blood-contaminated inanimate surfaces, objects, and/or devices as reservoirs for patient-to-patient transmission of HCV. Healthcare professionals in all settings should review their aseptic techniques and infection control practices to ensure that they are being performed in a manner that prevents cross-contamination from such reservoirs.

Gershon RR, Sherman M, Mitchell C, Vlahov D, Erwin MJ, Lears MK, Felknor S, Lubelczyk RA, Alter MJ. · Mailman School of Public Health, Columbia University, New York, NY 10032, USA. · Infect Control Hosp Epidemiol. · Pubmed #17230384 No free full text.

Abstract: OBJECTIVE: To determine the prevalence and risk factors for bloodborne exposure and infection in correctional healthcare workers (CHCWs).Design. Cross-sectional risk assessment study with a confidential questionnaire and serological testing performed during 1999-2000. SETTING: Correctional systems in 3 states. RESULTS: Among 310 participating CHCWs, the rate of percutaneous injury (PI) was 32 PIs per 100 person-years overall and 42 PIs per 100 person-years for CHCWs with clinical job duties. Underreporting was common, with only 25 (49%) of 51 PIs formally reported to the administration. Independent risk factors for experiencing PI included being age 45 or older (adjusted odds ratio [aOR], 2.41 [95% confidence interval (CI), 1.31-4.46]) and having job duties that involved needle contact (aOR, 3.70 [95% CI, 1.28-10.63]) or blood contact (aOR, 5.05 [95% CI, 1.45-17.54]). Overall, 222 CHCWs (72%) reported having received a primary hepatitis B vaccination series; of these, 150 (68%) tested positive for anti-hepatitis B surface antigen, with negative results significantly associated with receipt of last dose more than 5 years previously. Serologic markers of hepatitis B virus infection were identified in 31 individuals (10%), and the prevalence of hepatitis C virus infection was 2% (n=7). The high hepatitis B vaccination rate limited the ability to identify risk factors for infection, but hepatitis C virus infection correlated with community risk factors only. CONCLUSION: Although the wide coverage with hepatitis B vaccination and the decreasing rate of hepatitis C virus infection in the general population are encouraging, the high rate of exposure in CHCWs and the lack of exposure documentation are concerns. Continued efforts to develop interventions to reduce exposures and encourage reporting should be implemented and evaluated in correctional healthcare settings. These interventions should address infection control barriers unique to the correctional setting.