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CHILD SURVIVAL UPDATE 36/2008: THE CASE FOR UNIVERSAL HEP B VACCINATION
Since the 1991 WHA resolution in favor of universal childhood hep B
vaccination, most developing countries have embraced the WHO
recommendation.
Great Britain continues to use the high risk approach, despite the contrary
views of the British Medical Association, outlined below in an editorial
from the British Medical Journal. Since publication of the editorial,
Kamal-Uddin and D'Costa have looked at whether the targeted approach
currently in use in the UK is a successful one. Their work, published
recently in the Archives of Disease of Children (see last reference),
concludes that the British policy does not catch all who should be vaccinated.
With decades of experience to show the safety and efficicay of this
inexpensive vaccine, the switchover from selective to universal hep B
vaccination should be a no-brainer, both in UK and in other countries which continue to
use the selective approach.
Good reading.
BD
Editorials, British Medical Journal
Hepatitis B vaccination
The BMA adds its voice to the call for universal childhood immunisation in
the UK
Hepatitis B virus is a substantial threat to global health, with 360
million people chronically infected and more than 500 000 deaths each year
from fulminant hepatitis, cirrhosis, and liver cancer.1 2 After a call by
the World Health Organization for the global introduction of vaccine
prevention programmes by 1997,3 82% of countries in the world had
introduced universal hepatitis B immunisation by 2005, and at least 55% of
the world's children are now receiving three doses of the vaccine.4
To date, the United Kingdom has not offered universal immunisation, so most
of its citizens are susceptible to infection. At the June 2007 annual
representatives meeting, the BMA voted in favour of adding its voice to
those of other expert groups in the UK calling upon the Department of
Health "to introduce the hepatitis B vaccine into the childhood schedule
without further delay."
The main argument against introducing universal immunisation is the
relatively low incidence of disease in the UK compared with other
countries.5 However, 180 000 people in the UK are chronically infected with
hepatitis B virus and can transmit infection to the unvaccinated
population. Furthermore, the huge global burden of infection means that
growing travel and migration in the 21st century put the UK population at
risk of exposure to hepatitis B from abroad. Indeed, 3.3% of legal migrants
to the UK are thought to be chronically infected, further adding
to the pool of transmitters.6 7
Almost 1300 new cases of acute hepatitis B infection occur each year in the
UK.7 Moreover, 7700 new cases of chronic hepatitis B infection are
detected each year, with huge cost to the National Health Service. Only 300
of these infections are acquired in the UK, however, and the remainder
of cases are identified in people who entered the UK from countries with a
high prevalence of the disease.8
Up to one third of people at risk of infection are difficult to identify.7
9 As many as 40% of infections are acquired perinatally or in childhood,
and infection at this age is far more likely to result in chronic carriage
of the virus than infection in adulthood.7 10 This makes early childhood
an important target for prevention programmes. Fortunately, the hepatitis B
virus can be controlled and, possibly, eventually eliminated by
immunisation with highly effective vaccines.11 Indeed, countries that have
introduced universal childhood immunisation in the past 15 years now have
a new generation of adolescents and young adults among whom transmission is
being interrupted.
A key component of the UK targeted immunisation strategy is preventing
perinatal transmission of hepatitis B virus to infants of mothers who are
found to be infected during antenatal screening. Some studies have shown
high uptake of screening, and one found that 92% of babies exposed
perinatally receive their vaccination within 48 hours of birth and 86%
complete a three dose course.12 To improve coverage of children at risk,
the favoured approach by the UK Joint Committee on Vaccination and
Immunisation5 is to extend the current targeted programme to families with
at least one parent from a country with high prevalence. However, the
committee rightly noted that "selective programmes can be difficult to
implement." Furthermore, such an approach stigmatises people from
particular groups and wrongly suggests that hepatitis B is not a concern
for the rest of the population.
So, unfortunately, targeted strategies alone do not protect the population
against hepatitis B, as it is impossible to reach all those who will be
exposed. The easiest and cheapest way to implement universal immunisation
is to add hepatitis B vaccine to the current UK primary immunisation
schedule in early infancy using a hexavalent vaccine (against diphtheria,
tetanus, pertussis, Haemophilus influenza type b, polio, and hepatitis B).
This would avoid both extra visits to the doctor and more injections for
the infant.
This approach is already widely used in Europe to prevent childhood
hepatitis B infection, and a cohort of immune individuals will eventually
reach adulthood. The addition of one more antigen to the current
pentavalent combination vaccine should have little, if any, effect on the
cost of the primary immunisation schedule. However, although universal
immunisation of infants could eventually prevent new cases beyond the
neonatal period, the high rate of chronic carriers in migrants to the UK
means that a targeted neonatal screening programme is still needed to
prevent perinatal transmission for the foreseeable future.
At this time, infant immunisation alone is insufficient to limit the
transmission of hepatitis B virus, because of ongoing transmission among
the non-immune adult population and the difficulty in identifying and
reaching people at risk. For this reason, the current targeted programme
aimed at high risk groups (injecting drug users, prisoners, etc) needs
strengthening to reduce the burden of new infections until those in a
universal immunisation programme reach adulthood.
The recent proposal to introduce vaccination for human papillomavirus
vaccine in pre-adolescents next year (to prevent cervical cancer) could
provide a vehicle for implementing a concomitant adolescent hepatitis B
programme (to prevent liver cancer). This would generate a cohort of
immune individuals more quickly than universal infant immunisation alone
and hasten the control of the hepatitis B virus in the UK.
Andrew J Pollard, reader in paediatric infection and immunity
Oxford Vaccine Group, Department of Paediatrics, University of Oxford,
Children's Hospital, Oxford OX3 9DU
andrew.pollard@paediatrics.ox.ac.uk.
--------------------------------------------------------------------------------
Competing interests: AJP conducts clinical trials on behalf of Oxford
University, sponsored by GlaxoSmithKline Vaccines, Novartis Vaccines,
Sanofi Pasteur, Sanofi Pasteur MSD, and Wyeth Vaccines and has received
funds from vaccine manufacturers to attend scientific meetings. The
University of Oxford has received unrestricted grants for educational
meetings organised by AJP. Industry sourced honorariums for lecturing or
writing are paid directly to an independent charity or an
educational/administrative fund held by the department of paediatrics,
University of Oxford.
Provenance and peer review: Commissioned; not externally peer reviewed.
References
Hepatitis B vaccines. Wkly Epidemiol Rec 2004;79:255-63.[Medline]
Lavanchy D. Hepatitis B virus epidemiology, disease burden, treatment, and
current and emerging prevention and control measures. J Viral Hepat
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Van Damme P, Vorsters A. Hepatitis B control in Europe by universal
vaccination programmes: the situation in 2001. J Med Virol
2002;67:433-9.[CrossRef][ISI][Medline]
WHO. Hepatitis B. Geneva: WHO, 2005.
Joint Committee on Vaccination and Immunisation. Minutes of the meeting
held on Wednesday 18 October 2006. London: Department of Health, 2006.
www.advisorybodies.doh.gov.uk/jcvi/mins181006draft.htm
Hahne S, Ramsay M, Soldan K, Balogun K, Mortimer P. Hepatitis B incidence
among South Asian children in England and Wales: implications for
immunisation policy. Arch Dis Child 2003;88:1082-3.[Abstract/Free Full
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Hahne S, Ramsay M, Balogun K, Edmunds WJ, Mortimer P. Incidence and routes
of transmission of hepatitis B virus in England and Wales, 1995-2000:
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Foundation for Liver Research. Hepatitis B: out of the shadows. London,
2004. www.ucl.ac.uk/liver-research/hepatitis-report.pdf
Mangtani P, Heptonstall J, Hall AJ. Enhanced surveillance of acute
symptomatic hepatitis B in England and Wales. Commun Dis Public Health
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Edmunds WJ, Medley GF, Nokes DJ, Hall AJ, Whittle HC. The influence of age
on the development of the hepatitis B carrier state. Proc Biol Sci
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Center for Disease Control and Prevention. Global progress toward universal
childhood hepatitis B vaccination, 2003. MMWR Morb Mortal Wkly
Rep 2003;52:868-70.[Medline]
Sloan D, Ramsay M, Prasad L, Gelb D, Teo CG. Prevention of perinatal
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This article has been cited by other articles:
Kamal-Uddin, S, D'Costa, S (2008). Is targeted hepatitis B vaccination
working?. Arch. Dis. Child. 93: 811-812 [Full text]