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Friday, 5th of September 2008 Print

 Since the 1991 WHA resolution in favor of universal childhood hep B
 vaccination, most developing countries have embraced the WHO
 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.
 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
 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.
 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
 Van Damme P, Vorsters A. Hepatitis B control in Europe by universal
 vaccination programmes: the situation in 2001. J Med Virol
 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.
  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
  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:
 implications for immunisation policy. J Clin Virol
  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
  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
  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
 transmission of hepatitis B to babies at high risk: an evaluation. Vaccine
 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]


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