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

n=2197

0

10

20

30

40

50

60

70

80

90

100

1984 1985 1986 1987 1988 1989 1990 1991 1992 1993Year of Birth

Per

cen

tag

e V

acci

nat

ed

HebB-3 >18 mo in cities with no intervention*

HepB-3 <=18 mo in cities with no intervention*

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.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998

YEAR

PE

RC

EN

T V

AC

CIN

AT

ED

2/90: ACIP recommends API infant vaccination

11/91: ACIP recommends universal infant vaccination

8/95: ACIP recommends catch-up vaccination of all first-generation API children aged < 11 yrs.

Infant rate§, cities without targeted programs

Infant rate§, cities with targeted programs

Catch-up rate¶, cities with targeted programs

Catch-up rate¶, cities without targeted programs

School AAPI HepB-3 coverage assessments, 1999-2000

School AAPI HepB-3 coverage assessments, 1999-2000

School Age/Grade n HepB-3%

9 in Los Angeles 2nd 517 72%

4th 520 52%

Chicago Public K-2,5-7th 5953 75%

3rd,4th,8th 6771 23%

Alachua, Co. FL Public 7th-9th 104 95%

10th-12th 76 16%

Seattle, Mandarin 6-18 171/348 72% (36%)*

Houston, Vietnamese 6-18 179/300 55% (33%)*

Sacramento, Cantonese 6-16 110 95%

Atlanta, Mandarin 6-18 242 21%-58%†

* Known vaccinees/total population† 45 students completed the HepB series through on-site clinics raising overall coverage to 86%.

Estimates* of number (%) of AAPI children born 1984-1993 who received

HepB-3 by October 2000

Estimates* of number (%) of AAPI children born 1984-1993 who received

HepB-3 by October 2000

California 168,000 (42%) New York City 48,000 (56%)Hawaii 43,000 (62%)Florida 10,500 (44%)

*Based on data from coverage surveys, school assessments, school entry laws, and reported doses administered.

Year 2004 GoalYear 2004 GoalAt the close of year 2004, 90% or more

of AAPI children* will have received the hepatitis B vaccination series.

* Under the age of 19 years

*National Immunization Survey data available for 19-35 months of age, 1994-99

Overall coverage among AAPI children 2-18 years is 69%

90% Goal by Close of 2004

Cohorts of focusnow these ages .

Birth cohorts of NIS* as of 2001

36 mo

nth

s prio

r

0

10

20

30

40

50

60

70

80

90

100

AGE

Per

cen

t w

ith

3 d

ose

s

of

Hep

BCoverage estimates* for third hepatitis B vaccine

dose among API children by age, October 2001Coverage estimates* for third hepatitis B vaccine

dose among API children by age, October 2001

9 10 11 12 13 14 15 16 17 182 3 4 5 6 7 8

Knowledge About Hepatitis B Among Parents of AAPI Adolescents, Alachua County, Florida, 2000

(n = 116/247)

Knowledge About Hepatitis B Among Parents of AAPI Adolescents, Alachua County, Florida, 2000

(n = 116/247)

• Response rate = 47%

• Mostly Asian Indian (37%), Chinese (25%), Korean (10%), and Filipino (8%)

• College (80%); Foreign born (90%); Non English spokenin the home (85%)

• Knew that three HepB shots were needed (69%)

• Knew HBV attacked the liver (79%)

• Knew that children playing transmit HBV (32%)

• Knew HBV is not transmitted in food and water (42%)

Chart Review Results of Vietnamese-American Children Aged 7-17 Years, Boston, 2001

Chart Review Results of Vietnamese-American Children Aged 7-17 Years, Boston, 2001

M oved or sought care elsew here n=13

Im m une due to prior exposure n=42 (31%)

Chronic infection n=3 (2%)

Vaccinated n=76 (82% of eligibles)

All 3 dosesn=4

2 dosesn=6

1 dosen=7

Needing vaccine n=17* (19% of eligibles)

Total patients n=151

* 9 were vaccinated during the intervention = 91% coverage* 9 were vaccinated during the intervention = 91% coverage

Survey of Vietnamese-American Parents of Children aged 7-17 Years,

Boston, 2001 (n=55/88)

Survey of Vietnamese-American Parents of Children aged 7-17 Years,

Boston, 2001 (n=55/88)

• 63% response rate

• 71% heard of hepatitis B virus

• 60% heard of hepatitis B vaccine

• 75% of parent-reported vaccination confirmed by chart review

Summary of WA State ActivitiesSummary of WA State Activities

• Formed Advisory Group and WA State Task Force on Hepatitis B Immunization.

• Developed and distributed educational materials, including translated posters and brochures(7 languages).

• Supported household cluster survey to assess hepatitis B immunization coverage rates

• Conducted hepatitis B testing and immunization clinics in Chinese Language Schools

• Conducted media outreach

Media Outreach – WA StateMedia Outreach – WA State

• Conducted between 1/1/01 and 3/31/01

• Media training for task force members prior to outreach

• Attended Lunar New Year Events

• Press release statewide

• Ads placed in Asian newspapers

• Media packets to Asian newspapers

– Brochures, fact sheet, translated personal stories, list of spokespersons

Hepatitis B Vaccination Coverage among Immigrants and Refugees in the 1984-1993 Birth Cohorts,

San Diego County, 2000-2001

Hepatitis B Vaccination Coverage among Immigrants and Refugees in the 1984-1993 Birth Cohorts,

San Diego County, 2000-2001

3543

86

100 100

85

73

020406080

100

Per

cen

t V

acci

nat

ed

Cambodian

LaoHm

ongVietnam

ese

ChineseKurdishSom

aliEthnicity

n = 20 7 14 7 8 26 26 n = 20 7 14 7 8 26 26

HepB-3 Rates in Vietnamese children in Dallas, Houston, & Washington DC, 2000

(n=1539)

HepB-3 Rates in Vietnamese children in Dallas, Houston, & Washington DC, 2000

(n=1539)

0

50

100

150

200

3 4 5 6 7 8 9 101112131415161718

Age

Sam

ple

Size

00.10.20.30.40.50.6

Rate

McPhee S, et al. UCSF unpublished, 2001.McPhee S, et al. UCSF unpublished, 2001.

Change in HepB-3 Rates Among Vietnamese Children in Dallas, Houston, and Washington DC, 1998-2000

(Provider Verified, n=720)

Change in HepB-3 Rates Among Vietnamese Children in Dallas, Houston, and Washington DC, 1998-2000

(Provider Verified, n=720)

-60%

-40%

-20%

0%

20%

40%

60%

80%

Age cohorts in 2000

Cha

nge

in v

acci

natio

n ra

te

Dallas Houston DC

5 6 7 8 9 10 11 12 13 14 15 16 17 185 6 7 8 9 10 11 12 13 14 15 16 17 18

McPhee S, et al. UCSF unpublished, 2001.McPhee S, et al. UCSF unpublished, 2001.

Knowledge of Vietnamese Adult Survey Respondents by Site, Pre and Post Intervention, 1998-2001

(n = 500-523 per site)

Knowledge of Vietnamese Adult Survey Respondents by Site, Pre and Post Intervention, 1998-2001

(n = 500-523 per site)

0 10 20 30 40 50 60 70 80 90 100

D.C.Dallas

HoustonD.C.

DallasHouston

D.C.Dallas

HoustonD.C.

DallasHouston

Ever heard of liver disease*Ever heard of liver disease*

Knew of free HepB shots* Knew of free HepB shots*

Agreed can get HBV from smoking

Agreed can get HBV from smoking

Ever heard of HBV infection*Ever heard of HBV infection*

Pre followed by post percent of respondentsPre followed by post percent of respondents

Continued--Continued--McPhee S, et al. UCSF unpublished, 2001. McPhee S, et al. UCSF unpublished, 2001.

QuestionsQuestions SitesSites

*Post by site, p<0.01*Post by site, p<0.01

Knowledge of Vietnamese Adult Survey Respondents by Site, Pre and Post Intervention, 1998-2001 (Cont.) (n = 500-

523 per site)

Knowledge of Vietnamese Adult Survey Respondents by Site, Pre and Post Intervention, 1998-2001 (Cont.) (n = 500-

523 per site)

0 10 20 30 40 50 60 70 80 90 100

D.C.Dallas

HoustonD.C.

DallasHouston

D.C.Dallas

HoustonD.C.

DallasHouston

Agreed HBV causes liver cancer*

Agreed HBV causes liver cancer*

Agreed can get HBV from sex*Agreed can get HBV from sex*

Agreed HBV causes lung cancer

Agreed HBV causes lung cancer

Agreed can get HBV from toothbrush*

Agreed can get HBV from toothbrush*

Pre followed by post percent of respondentsPre followed by post percent of respondents

McPhee S, et al. UCSF unpublished, 2001. McPhee S, et al. UCSF unpublished, 2001.

QuestionsQuestions SitesSites

*Pre to Post each site, p<0.01*Pre to Post each site, p<0.01

APIA Hepatitis B Interventions, Chicago, 2001APIA Hepatitis B Interventions, Chicago, 2001

• HepB-3 rates among 8,980 APIA K-12 students in public schools—70%; 9-12 rates—52% n=2013

• Free HepB to APIA adults—580 series complete in 5 Asian communities since Nov. 2000

• Adult screening for Ch, Viet, Cam, Ind, Kor, Lao—800 clients

• 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

hours, 59 (12%) HBsAg+

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

CDC Screening Steps

Jade Ribbon Screening Steps -- 1Jade Ribbon Screening Steps -- 1

• To determine if currently infected– Test all for HBsAg (save blood for more tests)

• Up to 15% of AAPI adults will be positive

• To determine if susceptible• Test all, who are HBsAg-negative, for anti-HBc

• If anti-HBc negative and in a risk group offer hepatitis B vaccine

– Risk groups include having a sexual partner or

household member who is infected, having more than

one sexual partner in 6 months, having sex with men,

injecting illegal drugs, being a health care worker,

working in another job where exposure to blood is likely.

Jade Ribbon Screening Steps -- 2Jade Ribbon Screening Steps -- 2

• If HBsAg-positive:– Test for ALT, if 2x normal test for HBeAg

• HBeAg indicates active HBV replication

• If positive is candidate for anti-HBV treatment– Epivir-HBV (lamivudine, an antiviral drug that

inhibits hepatitis B viral replication)

– Intron A (interferon alpha-2b, an immuno-modulator which stimulates the immune system to kill hepatocytes infected with the virus)

Jade Ribbon Screening Steps -- 3Jade Ribbon Screening Steps -- 3

• 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