Hepatitis: Euler GL

Rangel MC, Coronado VG, Euler GL, Strikas RA. · Adult Vaccine Preventable Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. · Semin Dial. · Pubmed #10795113 No free full text.

Abstract: Pediatric patients on dialysis should receive all the vaccines currently recommended by the ACIP and the AAP for healthy children, except the oral polio vaccine (34, 35). Adult patients should receive the hepatitis B vaccine series, pneumococcal vaccine, yearly influenza vaccinations, tetanus-diphtheria toxoids, and varicella vaccine, if they are susceptible (33, 48, 69). Vaccines are well tolerated by these patients (33), but higher doses and/or additional boosters may be required periodically to adequately protect dialysis patients from vaccine-preventable diseases (33, 36, 37, 82, 83). Following vaccination, antibody concentrations for hepatitis B vaccine should be measured annually and booster doses administered when antibody concentrations fall below protective levels (33, 38). Although both children and adults on dialysis may show an impaired and/or delayed immunologic response to certain antigens, particularly hepatitis B virus and S. pneumoniae, appropriate immunizations can significantly reduce the risk of serious complications from vaccine-preventable diseases (11, 84). Because the protection these vaccines provide may be incomplete or transient, infection control strategies at hospitals and other health care facilities should be implemented simultaneously. Health care providers are encouraged to assess each patients need for vaccinations individually and formulate immunization strategies early in the course of progressive renal disease, ideally before the patient requires dialysis.

McPhee SJ, Nguyen T, Euler GL, Mock J, Wong C, Lam T, Nguyen W, Nguyen S, Huynh Ha MQ, Do ST, Buu C. · Suc Khoe La Vang! (Health is Gold!), the Vietnamese Community Health Promotion Project, Division of General Internal Medicine, Department of Medicine, University of California, San Francisco 94102, USA. · Pediatrics. · Pubmed #12777542 links to  free full text

Abstract: OBJECTIVE: Chronic infection with the hepatitis B virus is endemic in Southeast Asian populations, including Vietnamese. Previous research has documented low rates of hepatitis B vaccine coverage among Vietnamese-American children and adolescents ages 3 to 18. To address this problem, we designed and tested in a controlled trial 2 public health outreach "catch-up" campaigns for this population. DESIGN: In the Houston, Texas metropolitan area, we mounted a media-led information and education campaign, and in the Dallas metropolitan area, we organized a community mobilization strategy. We evaluated the success of these interventions in a controlled trial, using the Washington, DC metropolitan area as a control site. To do so, we conducted computer-assisted telephone interviews with random samples of approximately 500 Vietnamese-American households in each of the 3 study sites both before and after the interventions. We assessed respondents' awareness and knowledge of hepatitis B and asked for hepatitis B vaccination dates for a randomly selected child in each household. When possible, we validated vaccination dates through direct contact with each child's providers. RESULTS: Awareness of hepatitis B increased significantly between the pre- and postintervention surveys in all 3 areas, and the increase in the media education area (+21.5 percentage points) was significantly larger than in the control area (+9.0 percentage points). At postintervention, significantly more parents knew that free vaccines were available for children in the media education (+31.9 percentage points) and community mobilization (+16.7 percentage points) areas than in the control area (+4.7 percentage points). An increase in knowledge of sexual transmission of hepatitis B virus was significant in the media education area (+14.0 percentage points) and community mobilization (+13.6 percentage points) areas compared with the control area (+5.2 percentage points). Parent- or provider-reported data (n = 783 for pre- and n = 784 for postintervention surveys) suggest that receipt of 3 hepatitis B vaccinations increased significantly in the community mobilization area (from 26.6% at pre- to 38.8% at postintervention) and in the media intervention area (28.5% at pre- and 39.4% at postintervention), but declined slightly in the control community (37.8% at pre- and 33.5% at postintervention). Multiple logistic regression analyses estimated that the odds of receiving 3 hepatitis B vaccine doses were significantly greater for both community mobilization (odds ratio 2.15, 95% confidence interval 1.16-3.97) and media campaign (odds ratio 3.02, 95% confidence interval 1.62-5.64) interventions compared with the control area. The odds of being vaccinated were significantly greater for children who had had at least 1 diphtheria-tetanus-pertussis shot, and whose parents were married, knew someone with liver disease, had heard of hepatitis B, and had greater knowledge about hepatitis B. The odds of being vaccinated were significantly lower for older children. CONCLUSIONS: Both community mobilization and media campaigns significantly increased the knowledge of Vietnamese-American parents about hepatitis B vaccination, and the receipt of "catch-up" vaccinations among their children.

Lu PJ, Euler GL, Hennessey KA, Weinbaum CM. · Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, NE, Mail Stop E-62, Atlanta, GA 30333, United States. · Vaccine. · Pubmed #19162116 No free full text.

Abstract: BACKGROUND: Hepatitis A is the most common type of hepatitis reported in the United States. Prior to hepatitis A vaccine introduction in 1996, hepatitis A incidence followed a cyclic pattern with peak incidence occurring every 10-15 years. During 1980-1995, between 22,000 and 36,000 hepatitis A cases were reported annually. Since 1996, hepatitis A vaccination recommendations have included adults at risk for infection and children living in communities with the highest disease rates. This study provides the first national estimates of self-reported hepatitis A vaccination coverage among persons aged 18-49 years in the United States. METHODS: We analyzed the 2007 National Immunization Survey-Adult (NIS-Adult) data with restrictions to individuals aged 18-49 years. National estimates of hepatitis A vaccination coverage were calculated based on self-report and multivariable logistic regression analysis was used to identify factors independently associated with hepatitis A vaccination status. RESULTS: Among adults aged 18-49 years, 12.1% (95% confidence interval, CI=9.9-14.8%) had received two or more doses of hepatitis A vaccine in 2007. Hepatitis A vaccination coverage was significantly higher among adults aged 18-29 years (15.6%) and adults aged 30-39 years (12.9%) compared with adults aged 40-49 years (8.3%). Coverage was significantly lower for Hispanics (7.1%) compared with non-Hispanic whites (12.5%). Characteristics independently associated with a higher likelihood of hepatitis A vaccination among persons aged 18-49 years included younger age groups, persons at or above poverty level, persons with public medical insurance, and persons who received influenza vaccination in the past season. CONCLUSIONS: In 2007, self-reported hepatitis A vaccination coverage among adults aged 18-49 years was 12.1%. These data provide the first national hepatitis A vaccination coverage estimates among adults and are very important in planning and implementing strategies for increasing hepatitis A vaccination coverage among adults at risk for hepatitis A.

Jain N, Euler GL, Shefer A, Lu P, Yankey D, Markowitz L. · National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA. · Prev Med. · Pubmed #19100762 No free full text.

Abstract: OBJECTIVES: To report awareness of human papillomavirus (HPV) and HPV vaccine among women aged 18-49 years and, for recommended women aged 18-26 years, estimate initiation of HPV vaccination and describe factors associated with vaccination initiation among a national sample. METHODS: Data were analyzed from the National Immunization Survey-Adult, a nationally representative telephone survey conducted May-August 2007. Questions were asked about awareness of HPV and HPV vaccine and vaccine receipt. RESULTS: A total of 1102 women aged 18-49 years were interviewed, 168 were aged 18-26 years. Overall, awareness of HPV (84.3%) and of HPV vaccine (78.9%) were high. Among women 18-26 years of age, vaccination initiation (> or =1 dose) was 10%. Factors associated with vaccination included not being married, living > or =200% of the federal poverty index, having health insurance, and vaccination with hepatitis B vaccine. HPV vaccination initiation among women aged 27-49 years was 1%. CONCLUSIONS: Awareness of HPV and HPV vaccine were high. Two to 5 months after national HPV vaccination recommendations were published, one in ten women 18-26 years old had initiated the HPV vaccine series. Women at a higher socio-economic level were more likely to receive the vaccination. Vaccination initiation and completion will likely increase over the next years. Monitoring uptake is important to identify sub-groups that may not be receiving the vaccination.

Kottiri BJ, Friedman SR, Euler GL, Flom PL, Sandoval M, Neaigus A, Des Jarlais DC, Zenilman JM. · Office of HIV AIDS, US Agency for International Development, 1300 Pennsylvania Avenue, NW, Washington, DC 20523, USA. · J Urban Health. · Pubmed #16033931 No free full text.

Abstract: We conducted a community-based study of the prevalence and correlates of hepatitis B virus (HBV) infection and immunization among young adults in a "drug supermarket" neighborhood in New York City. Four hundred eighty-nine young adults ages 18-24 years were recruited from Bushwick, Brooklyn through multistage household probability sampling (n = 332) and targeted sampling (n = 157), interviewed, and tested for three hepatitis B markers (HBsAg, anti-HBc, and anti-HBs). Serological evidence of HBV infection was found in 8.0% (6.0% in the household sample and 12.1% in the targeted sample) and of hepatitis B immunization in 19.6% (22.6% in the household sample and 13.4% in the targeted sample). HBV infection was higher among young adults who either used crack or injected drugs and among those who traded sex for money or drugs. Having Medicaid was significantly associated with lower odds of infection in the household sample and higher odds of immunization in the targeted sample. Although adolescent hepatitis B immunization has been a public health priority in the United States since 1995, nearly three-quarters of young adults in this community did not have serological evidence of being either exposed or immunized. Whereas subsequent younger generations benefited from universal childhood hepatitis B immunization, this particular cohort of young adults who live in communities like Bushwick presents a unique group for prevention intervention.

Jain N, Yusuf H, Wortley PM, Euler GL, Walton S, Stokley S. · Health Services and Research Branch, National Immunization Program, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA. · Fam Med. · Pubmed #15243828 links to  free full text

Abstract: BACKGROUND AND OBJECTIVES: Although an effective vaccine against hepatitis B has been licensed in the United States since 1981, and successful childhood vaccination programs have been implemented, hepatitis B virus transmission continues to occur among high-risk adults. In this study, we identified factors associated with receipt of one or more doses of hepatitis B vaccine among adults at high risk for hepatitis B infection. METHODS: We analyzed data from the 2000 National Health Interview Survey of selected adults ages 18-49 years who were at high risk for hepatitis B infection (n=1,036). Multivariable regression analysis was conducted to determine factors independently associated with vaccination. RESULTS: Although more than 80% (n=841) of high-risk adults reported previous visits to a clinician during the past year, only 30% (n=498) of men and 31% (n=538) of women reported having received a single dose of hepatitis B vaccine. Young age (18-29 years), never being married, past blood donation, and past human immunodeficiency virus (HIV) testing were independently associated with receiving vaccination for men. For women, young age (18-29 years) and previous vaccinations were significant factors associated with vaccination receipt. Additionally, having a primary care source (men) and seeing an obstetrician-gynecologist provider in the past year (women) were significantly associated with vaccination. CONCLUSIONS: Hepatitis B vaccination rates for high-risk adults are low, and missed opportunities are frequent. Additional strategies are needed to increase immunization rates of adults at high risk for hepatitis B.

Zhou F, Euler GL, McPhee SJ, Nguyen T, Lam T, Wong C, Mock J. · National Immunization Program, CDC, Public Health Service, US Department of Health and Human Services, Atlanta, Georgia 30333, USA. · Pediatrics. · Pubmed #12777543 links to  free full text

Abstract: OBJECTIVE: To ascertain the cost-effectiveness and benefit-cost ratios of 2 public health campaigns conducted in Dallas and Houston in 1998-2000 for "catch-up" hepatitis B vaccination of Vietnamese-Americans born 1984-1993. DESIGN: Program evaluation. SETTING: Houston and Dallas, Texas. PARTICIPANTS: A total of 14,349 Vietnamese-American children and adolescents. INTERVENTIONS: Media-led information and education campaign in Houston, and community mobilization strategy in Dallas. Outcomes were compared with a control site: Washington, DC. MAIN OUTCOME MEASURES: Receipt of 1, 2, or 3 doses of hepatitis B vaccine before and after the interventions, costs of interventions, cost-effectiveness ratios for intermediate outcomes, intervention cost per discounted year of life saved, and benefit-cost ratio of the interventions. RESULTS: The number of children who completed the series of 3 hepatitis B vaccine doses increased by 1176 at a total cost of 313,904 dollars for media intervention, and by 390 and at 169,561 dollars for community mobilization. Costs per child receiving any dose, per dose, and per completed series were 363 dollars, 101 dollars, and 267 dollars for media intervention and 387 dollars, 136 dollars, and 434 dollars for community mobilization, respectively. For media intervention, the intervention cost per discounted year of life saved was 9954 dollars and 131 years of life were saved; for community mobilization, estimates were 11,759 dollars and 60 years of life. The benefit-cost ratio was 5.26:1 for media intervention and 4.47:1 for community mobilization. CONCLUSION: Although the increases in the number of children who completed series of 3 doses were modest for both the Houston and Dallas areas, both media education and, to a lesser degree, community mobilization interventions proved cost-effective and cost-beneficial.

Euler GL, Wooten KG, Baughman AL, Williams WW. · Epidemiology and Surveillance Division, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. · Pediatrics. · Pubmed #12728137 links to  free full text

Abstract: OBJECTIVES: To estimate race/ethnicity-specific prevalence of hepatitis B surface antigen (HBsAg) in pregnant urban women and to evaluate factors associated with maternal HBsAg testing. METHODS: A multicenter, retrospective chart review was conducted of a racially/ethnically stratified random sample of maternal/infant charts of 10 523 women who gave birth to live infants during 1990-1993 in 4 urban areas in the United States. Data were collected on multiple variables, including demographic variables, HBsAg test dates and results, prenatal care type, and amount and source of payment. RESULTS: HBsAg prevalence among white non-Hispanics was 0.60% (95% confidence interval [CI]: 0.22-0.98), black non-Hispanics 0.97% (95% CI: 0.48-1.47), Hispanics 0.14% (95% CI: 0.01-0.26), and Asians 5.79% (95% CI: 4.42-7.16). HBsAg testing rates increased from 56.6% in 1990 to 78.2% in 1993. Factors associated with not being tested varied by urban area, but in the combined area model, they were having no or private prenatal care (odds ratios: 18.75 and 5.07, respectively) and being black (odds ratios: 2.08). Only 20.9% (95% CI: 19.1%-22.8%) of those not tested prenatally were tested at delivery. The expected number of infants born to HBsAg-positive study-area women was 3327 using study prevalence rates, compared with 1761 using national rates. CONCLUSIONS: To help ensure that all urban infants who are born to HBsAg-positive women receive appropriate prophylaxis, health officials in urban areas should use urban-area prevalence rates to ascertain completeness of reporting maternal HBsAg positivity. Needed steps to increase maternal HBsAg testing rates include ensuring that more pregnant women receive prenatal care, promoting testing by private providers, educating providers about testing in all racial and ethnic groups, and reminding providers to test at delivery those women not tested prenatally.

Euler GL, Copeland J, Williams WW. · Epidemiology and Surveillance Division, National Immunization Program, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA. · Am J Epidemiol. · Pubmed #12697579 links to  free full text

Abstract: During 1992-2000, the authors studied compliance with perinatal hepatitis B prevention recommendations, including vaccination of household contacts, at four metropolitan sites in Connecticut, Georgia, Texas, and Michigan. Demographic and hepatitis B-related knowledge, attitudes, practices, and barrier data were collected on pregnant women testing positive for hepatitis B surface antigen and on their infants, children, and household and sexual contacts. Generalized estimating equations with repeated measures in a multivariable model were used to obtain adjusted relative risks of household noncompliance. In 1,458 households studied, 1,490 infants and 3,502 other contacts were identified. Among infants, vaccination start/finish rates were 92%/72%, and 73% were serotested postvaccination. Prevaccination serotesting rates among contacts were 22% preenrollment and 47% postenrollment. Among 2,519 contacts whose immunity status was susceptible or unknown, the vaccination start/finish rate was 45%/41%. Site-specific adjusted relative risks of household noncompliance compared with Texas were 2.14 (Michigan), 1.96 (Georgia), and 1.30 (Connecticut). Mother's birth in the United States increased the relative risk of household noncompliance (1.32). Home visits, implemented only in Texas, most likely account for higher compliance rates in that state. Findings may indicate that many perinatal programs could achieve higher overall rates of infant and contact identification; pre- and postvaccination serologic testing in contacts and infants, respectively; and contact hepatitis B vaccination.

Euler GL, Copeland JR, Rangel MC, Williams WW. · National Immunization Program, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA. · Pediatr Infect Dis J. · Pubmed #12586975 No free full text.

Abstract: BACKGROUND: Annually 20,000 infants are born to hepatitis B surface antigen (HBsAg)-positive US women. Without prophylaxis 30% risk chronic hepatitis B virus infection, and 25% of those risk dying from resulting liver cirrhosis or liver cancer as adults. METHODS: We attempted to interview each HBsAg-positive pregnant woman reported to the health department between 1992 and 1997, to provide their infants with immunoprophylaxis at birth and in the clinic or home and to serotest at 9 to 15 months of age. RESULTS: Of 879 women reported, 92% enrolled; 787 delivered 796 live infants; 91% of infants received hepatitis B immunoglobulin; 98, 95 and 89% received hepatitis B vaccine (HepB) Doses 1, 2 and 3, respectively; and 80% were serotested. Of these 2.2% were HBsAg-positive and 97% had antibody to HBsAg (anti-HBs) of > or =10 mIU/ml. Anti-HBs concentrations measured in 504 infants were 10 to 99 mIU/ml (25%), 100 to 999 mIU/ml (43%) and > or =1000 mIU/ml (29%). Serotesting was less likely among infants of mothers <20 years of age [odds ratio (OR) 2.5]; white, non-Hispanic (OR 2.8); or with a household income of <$15,000/year (OR 2.0). Lower antibody titers were found when serotesting at 4 to 12 months than at <4 months after HepB-3 (OR 1.8 to 4.4), with HepB-3 receipt <6 months after HepB-2 (OR 2.5) and when household income was <$15,000/year (OR 2.1). CONCLUSIONS: Centralized case management with home visits resulted in high rates of complete immunoprophylaxis and postvaccination testing among infants born to HBsAg-positive women. Perinatal immunoprophylaxis was immunogenic under routine public health use, with higher anti-HBs titers occurring in infants tested <4 months postvaccination. Because infants in households with low income had higher rates of nonprotective antibody responses, they may benefit from extra efforts to ensure that serotesting is conducted postvaccination.

Euler GL. · Hepatitis Activity, National Immunization Program, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, MS E-61, Atlanta, GA 30333, USA. · Asian Am Pac Isl J Health. · Pubmed #11846361 No free full text.

Abstract: PURPOSE: The purpose of this paper is to report on progress in addressing a major health disparity. During the 1970s hepatitis B virus (HBV) infection rates in U.S. Asian American and Pacific Islander (AAPI) children were 20-30 times higher than among white children. These rates remained 17 times greater among AAPI children into the 1990s. Now, although almost 90% of AAPI children born after 1993 receive hepatitis B vaccine (HepB) in time to prevent HBV infection, many born before 1993 do not. Among this group, household HBV transmission remains relatively high--0.5%-1% annually. METHODS: In the mid-1980s household HBV transmission was studied among AAPI communities and by 1999 HepB coverage surveys, demonstration projects, and interventions in schools, communities, and provider offices were conducted followed by ethnic-specific controlled trials and cost-benefit research. The goal was established to reach 90% coverage by 2004. PRINCIPAL FINDINGS: Since 1995, catch-up efforts raised HepB coverage among AAPI children born 1983-1993 from 10% to 60%. Now, AAPI children targeted for catch-up are 9-19 years of age. Currently, most students entering middle school have not received their HepB series, but recently enacted middle school entry requirements in 26 states and Washington D.C. ensure at least 60% of AAPI students receive HepB by 12 years of age. High school students are less likely to have received HepB--no high school entry regulations are present to ensure vaccination. CONCLUSIONS: Much progress has been made toward eliminating this health disparity. More progress can be made if more health departments in the largest cities conduct high school HepB interventions, starting in schools with the highest numbers of AAPI. In addition, physicians and nurses can remove existing barriers to vaccination services and implement effective tracking/reminder/recall procedures to ensure the AAPI teenagers in their practice receive HepB.

Deuson RR, Brodovicz KG, Barker L, Zhou F, Euler GL. · National Immunization Program, Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services, Atlanta, GA, USA. · Arch Pediatr Adolesc Med. · Pubmed #11483118 links to  free full text

Abstract: OBJECTIVE: To ascertain the cost-effectiveness and the benefit-cost ratios of a community-based hepatitis B vaccination catch-up project for Asian American children conducted in Philadelphia, Pa, from October 1, 1994, to February 11, 1996. DESIGN: Program evaluation. SETTING: South and southwest districts of Philadelphia. PARTICIPANTS: A total of 4384 Asian American children. INTERVENTIONS: Staff in the community-based organizations (1) educated parents about the hepatitis B vaccination, (2) enrolled physicians in the Vaccines for Children program, and (3) visited homes of children due for a vaccine dose. Staff in the Philadelphia Department of Public Health developed a computerized database; sent reminder letters for children due for a vaccine dose; and offered vaccinations in public clinics, health fairs, and homes. MAIN OUTCOME MEASURES: The numbers of children having received 1, 2, or 3 doses of vaccine before and after the interventions; costs incurred by the Philadelphia Department of Public Health and the community-based organizations for design, education, and outreach activities; the cost of the vaccination; cost-effectiveness ratios for intermediate outcomes (ie, per child, per dose, per immunoequivalent patient, and per completed series); discounted cost per discounted year of life saved; and the benefit-cost ratio of the project. RESULTS: For the completed series of 3 doses, coverage increased by 12 percentage points at a total cost of $268 660 for design, education, outreach, and vaccination. Costs per child, per dose, and per completed series were $64, $119, and $537, respectively. The discounted cost per discounted year of life saved was $11 525, and 106 years of life were saved through this intervention. The benefit-cost ratio was 4.44:1. CONCLUSION: Although the increase in coverage was modest, the intervention proved cost-effective and cost-beneficial.

Jenkins CN, McPhee SJ, Wong C, Nguyen T, Euler GL. · Vietnamese Community Health Promotion Project, Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, · Pediatrics. · Pubmed #11099621 links to  free full text

Abstract: OBJECTIVE: Persons with chronic hepatitis B virus (HBV) infection are at increased risk of chronic hepatitis, cirrhosis, and liver cancer. Although HBV infection is relatively uncommon in the United States, the disease is endemic in persons born in Southeast Asia, including Vietnamese-Americans. Current US infant immunization recommendations and state-mandated school-entry programs have left many nontargeted age-cohorts unvaccinated and at risk of infection. To assess the need for catch-up hepatitis B immunizations, this study reports the hepatitis B immunization rates of Vietnamese-American children 3 to 18 years old living in the metropolitan areas of Houston and Dallas, Texas, and the Washington, DC, area. DESIGN: We conducted 1508 telephone interviews with random samples of Vietnamese households in each of the 3 study sites. We asked for hepatitis B immunization dates for a randomly selected child in each household. Attempts were made to verify immunization dates through direct contact with each child's providers. Low and high estimates of coverage were calculated using reports from providers when reached (n = 720) and for the entire sample (n = 1508). RESULTS: Rates of having 3 hepatitis B vaccinations ranged from 13.6% (entire sample) to 24.1% (provider reports, Dallas), 10. 3% to 26.4% (Houston), and 18.1% to 37.8% (Washington, DC). Children living in the Texas sites, older children, children whose families had lived in the United States for a longer time, and children whose provider was Vietnamese or who had an institutional provider were less likely to have been immunized. The odds of being immunized were greater, however, for children who had had at least 1 diphtheria, tetanus toxoid, and pertussis shot, and whose parents had heard about HBV infection, and were married. CONCLUSIONS: The low rates of hepatitis B vaccine coverage among children and adolescents portend a generation which, too old to benefit from infant programs and school entry laws, will grow into adulthood without the protection of immunization. Increased efforts are needed to design successful catch-up campaigns for this population.