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• W2092507265 abstract "In 1991, the Global Advisory Group of the Expanded Program of Immunization (EPI) advised that all countries with high or intermediate endemicity of hepatitis B should introduce hepatitis B vaccination into their national immunization programs by 1997, a recommendation endorsed by the World Health Assembly in 1992 (1.Van Damme P Kane M Meheus A Integration of hepattitis B vaccination into national immunization programms.BMJ. 1997; 314: 1033-1036Crossref PubMed Scopus (138) Google Scholar, 2.Kane MA Status of hepatitis B immunization programs in 1998.Vaccine. 1998; 16: S104-S108Crossref PubMed Scopus (81) Google Scholar). Italy did not wait long and in 1991 was the first European country to introduce universal vaccination against hepatitis B virus (HBV) infection in 3-month-old babies and in 12-year-old children, as well as in several defined risk groups (3.Bonanni P Crovari P Success stories in the implementation of universal hepatitis B vaccination: an update on Italy.Vaccine. 1998; 16: S38-S42Crossref PubMed Scopus (18) Google Scholar). Compliance has recently been nearly 95% for newborns and 80% for adolescents, although geographic variations in implementation do exist. Indeed, in Italy, HBV was and in some areas still is rather prevalent. In a population of 57 million, the overall prevalence of HBsAg carriers was estimated at almost 3%, with 1.5 million HBsAg carriers in the early 1980s. This reservoir of HBV poses a significant risk for acquiring HBV infection. Among 530 000 live births annually, the estimated number of babies at risk, born to HBsAg carrier mothers, was around 15 000 in the 1980s (3.Bonanni P Crovari P Success stories in the implementation of universal hepatitis B vaccination: an update on Italy.Vaccine. 1998; 16: S38-S42Crossref PubMed Scopus (18) Google Scholar), and the reported annual incidence of HBV varied between 10–19/100 000. Not surprisingly, Italian physicians, epidemiologists and other healthcare professionals have developed an interest and an expertise in controlling HBV infection and its complications. A Medline search revealed 243 reports from Italy alone on HBV epidemiology and prevention, in the past two decades. The Italian Ministry of Health has introduced an integrated epidemiological surveillance system for acute HBV, called SEIEVA, which covers almost half of the population in Italy. This system has generated a wealth of information, which is of significant value not only for prevention of HBV in Italy, but also for other European and non-European countries. Similar programs are now in place in other European countries, which continuously record the epidemiology of HBV in Europe through collaboration with the Viral Hepatitis Prevention Board (VHPB) located in Belgium (1.Van Damme P Kane M Meheus A Integration of hepattitis B vaccination into national immunization programms.BMJ. 1997; 314: 1033-1036Crossref PubMed Scopus (138) Google Scholar).In this issue of the Journal, Dr Stroffolini and coworkers report a 3.6-fold decline in incidence of acute HBV infection in Italy, from 10.4/100 000 to 2.9/100 000 between 1987 and 1997, respectively, following the introduction of prevention measures against transmission of HBV (4.Stroffolini T Mele A Tosti ME Gallo G Balocchini E Ragni P et al.The impact of hepatitis B mass immunization campaign on the incidence and risk factors of acute hepatitis B in Italy.J Hepatol. 2000; 33: 980-985Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar). In analyzing the data collected through SEIEVA, some important and surprising observations were made: First, the major fall in incidence of new HBV infections (from 10.4/100 000 to 5.1/100 000) occurred between 1987 and 1991, before the introduction of universal immunization against HBV. Second, the highest attack rates for new HBV infections occur in the 15–24-year-old age group. Although both these observations have been known for some time (3.Bonanni P Crovari P Success stories in the implementation of universal hepatitis B vaccination: an update on Italy.Vaccine. 1998; 16: S38-S42Crossref PubMed Scopus (18) Google Scholar), confirmation of this information has important implications for the implementation of prevention measures against acute HBV infection and its complications. The crucial role of universal vaccination against HBV in controlling morbidity and mortality has been repeatedly acknowledged (1.Van Damme P Kane M Meheus A Integration of hepattitis B vaccination into national immunization programms.BMJ. 1997; 314: 1033-1036Crossref PubMed Scopus (138) Google Scholar). By now, over 100 countries provide or are in the process of introducing universal vaccination against HBV to neonates. In some countries in East Asia and Africa, it has been shown that use of HBV vaccines in infants has reduced the prevalence of HBsAg carriers from > 8% to 2% in immunized cohorts (2.Kane MA Status of hepatitis B immunization programs in 1998.Vaccine. 1998; 16: S104-S108Crossref PubMed Scopus (81) Google Scholar). In Taiwan, the first country to introduce massive immunization, a reduction in the incidence of HBV-associated hepatocellular carcinoma among children can already be confirmed (5.Chang MH Chen CJ Lai MS Hsu HM Wu TC Kong MS et al.Universal hepatitis B vaccination in Taiwan and the incidence of hepatocellular carcinoma in children.N Engl J Med. 1997; 336: 1855-1859Crossref PubMed Scopus (1572) Google Scholar). Prevention of new HBV infections through universal infant vaccination is cost effective (6.Holliday SM Faulds D Hepatitis B vaccine. A pharmacoeconomic evaluation of its use in the prevention of hepatitis B virus infection.Pharmacoeconomics. 1994; 5: 141-147Crossref PubMed Scopus (23) Google Scholar). The introduction of such a program in Italy has already led to an estimated cost saving of about US $ 244 million in direct and indirect health costs in the first 6 years of the universal vaccination program (3.Bonanni P Crovari P Success stories in the implementation of universal hepatitis B vaccination: an update on Italy.Vaccine. 1998; 16: S38-S42Crossref PubMed Scopus (18) Google Scholar).Yet the old and new HBV vaccines, either plasma or yeast derived, can fail (7.Zannolli R Morgese G Hepatitis B vaccine: current status.Ann Pharmacother. 1997; 31: 1059-1066PubMed Google Scholar). Non-responsiveness may be attributed to genetically determined factors, old age, to disease or drug-induced immune suppression as well as inadequate storage or injecting techniques. Therefore, immunization against HBV, although important and usually highly successful, may induce a false sense of safety. Thus additional measures for prevention of HBV should not be ignored. The massive campaign against HIV and the global access to the Internet have no doubt contributed to an increased awareness of the need to take precautions against a number of viral and bacterial infections including HBV. This awareness has been and is being translated into improved compliance with immunization. However, this may not be enough. The present study provides some disturbing data on the frequency of non-mutually exclusive risk factors among Italian patients with acute HBV infection. These risk factors continue to pose a threat for HBV transmission, despite the success of the Italian immunization program. While the risk of acquiring HBV infection through blood transfusion remained low and steady from 1987 to 1997, the risk seems to have increased for sexual partners of HBsAg carriers, for dental therapy and for intravenous drug addicts. Furthermore, there is a certain risk of contracting HBV during surgical intervention, although this risk has not increased during the 12 years of the surveillance period. However, other parenteral exposures such as ear piercing, tattooing and acupuncture are responsible for an increasing number of new infections. The report by Stroffolini et al. in this issue of the Journal supports the argument that other measures, in addition to universal immunization against HBV, should complement efforts to eradicate HBV infection. These include improvement in the safety of invasive surgical, medical and dental interventions; increasing the safety of blood products; screening of pregnant women for HBsAg; providing disposable needles to intravenous drug addicts and most importantly increasing awareness of adolescents and young adults of the need to take precautions during sexual intercourse. These are important lessons that apply to all European and many non-European countries worldwide. A similar observation to the Italian experience was made in the United States where the majority of new HBV cases among 65 000 acute HBV infections occurred in young adults (8.Mast EM Williams IT Alter M Margolis HS Hepatitis B vaccination of adolescent and adult high-risk groups in the United States.Vaccine. 1998; 16: S27-S29Crossref PubMed Scopus (50) Google Scholar). Thus, healthcare authorities should give the highest priority to prevention programs in adolescents. Some countries, such as Italy, Canada, France, Portugal, Spain and the Unites States, have already recognized this risk group by providing catch-up immunization against HBV (9.Tepper ML Universal hepatitis B immunization: young adolescent immunization.Vaccine. 1998; 16: S23-S26Crossref PubMed Scopus (13) Google Scholar). Others have concentrated on newborns and young babies. Surprisingly until recently, countries such as the United Kingdom including Ireland, the Netherlands the Scandinavian countries and Japan chose to provide vaccines only to defined risk groups. The migration of workers and populations across Europe and the world has led to a profound change in the epidemiology of HBV infection where residents from countries with high and intermediate endemicity for HBV mix with inhabitants of countries with low endemicity. As a result, prevention policies including vaccination which are targeted at distinct populations at risk are doomed to fail, as has been previously recognized in the United States (10.US Department of Health and Human Services. Centers for Disease Control: hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination.MMWR. 1991; 40: 1-25PubMed Google Scholar). The Italian experience suggests that a concerted European action requires the combination of universal immunization against HBV with improvement in education and awareness among sexually active teenagers and young adults. Special attention should be given to improving the safety of surgical and dental procedures. The rate of HBV carriers among physicians and dentists in Central and East European countries is not well recorded, and even in Western European countries nosocomial HBV infection still requires much better control.Finally, we should keep in mind that hepatitis B is widespread and about half of the world population has already been infected (of whom ∼90% have recovered). Therefore, although the introduction of universal vaccination programs worldwide has indeed made a tremendous impact on the epidemiology of this serious infection, the global results of immunization will only be evaluable in one or more decades. Meanwhile, in addition to conventional vaccination, new and innovative preventive and educational measures must be introduced, especially for defined risk groups such as adolescents and young adults, as justified by the present report. Third-generation HBV vaccines which provide fast seroprotection after the priming dose may also be of value (11.Shapira MY Zeira E Adler R Shouval D Rapid seroprotection against hepatitis B following the first dose of Pre-S1/Pre-S2/S vaccine.J Hepatol. 2000; 33 (in press)Google Scholar). Such PreS/S hepatitis B vaccines may provide cover in situations where rapid protection is required, for example, pending elective surgery in areas at risk or in sexually transmitted disease (STD) clinics where compliance of patients is sometimes limited. In 1991, the Global Advisory Group of the Expanded Program of Immunization (EPI) advised that all countries with high or intermediate endemicity of hepatitis B should introduce hepatitis B vaccination into their national immunization programs by 1997, a recommendation endorsed by the World Health Assembly in 1992 (1.Van Damme P Kane M Meheus A Integration of hepattitis B vaccination into national immunization programms.BMJ. 1997; 314: 1033-1036Crossref PubMed Scopus (138) Google Scholar, 2.Kane MA Status of hepatitis B immunization programs in 1998.Vaccine. 1998; 16: S104-S108Crossref PubMed Scopus (81) Google Scholar). Italy did not wait long and in 1991 was the first European country to introduce universal vaccination against hepatitis B virus (HBV) infection in 3-month-old babies and in 12-year-old children, as well as in several defined risk groups (3.Bonanni P Crovari P Success stories in the implementation of universal hepatitis B vaccination: an update on Italy.Vaccine. 1998; 16: S38-S42Crossref PubMed Scopus (18) Google Scholar). Compliance has recently been nearly 95% for newborns and 80% for adolescents, although geographic variations in implementation do exist. Indeed, in Italy, HBV was and in some areas still is rather prevalent. In a population of 57 million, the overall prevalence of HBsAg carriers was estimated at almost 3%, with 1.5 million HBsAg carriers in the early 1980s. This reservoir of HBV poses a significant risk for acquiring HBV infection. Among 530 000 live births annually, the estimated number of babies at risk, born to HBsAg carrier mothers, was around 15 000 in the 1980s (3.Bonanni P Crovari P Success stories in the implementation of universal hepatitis B vaccination: an update on Italy.Vaccine. 1998; 16: S38-S42Crossref PubMed Scopus (18) Google Scholar), and the reported annual incidence of HBV varied between 10–19/100 000. Not surprisingly, Italian physicians, epidemiologists and other healthcare professionals have developed an interest and an expertise in controlling HBV infection and its complications. A Medline search revealed 243 reports from Italy alone on HBV epidemiology and prevention, in the past two decades. The Italian Ministry of Health has introduced an integrated epidemiological surveillance system for acute HBV, called SEIEVA, which covers almost half of the population in Italy. This system has generated a wealth of information, which is of significant value not only for prevention of HBV in Italy, but also for other European and non-European countries. Similar programs are now in place in other European countries, which continuously record the epidemiology of HBV in Europe through collaboration with the Viral Hepatitis Prevention Board (VHPB) located in Belgium (1.Van Damme P Kane M Meheus A Integration of hepattitis B vaccination into national immunization programms.BMJ. 1997; 314: 1033-1036Crossref PubMed Scopus (138) Google Scholar). In this issue of the Journal, Dr Stroffolini and coworkers report a 3.6-fold decline in incidence of acute HBV infection in Italy, from 10.4/100 000 to 2.9/100 000 between 1987 and 1997, respectively, following the introduction of prevention measures against transmission of HBV (4.Stroffolini T Mele A Tosti ME Gallo G Balocchini E Ragni P et al.The impact of hepatitis B mass immunization campaign on the incidence and risk factors of acute hepatitis B in Italy.J Hepatol. 2000; 33: 980-985Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar). In analyzing the data collected through SEIEVA, some important and surprising observations were made: First, the major fall in incidence of new HBV infections (from 10.4/100 000 to 5.1/100 000) occurred between 1987 and 1991, before the introduction of universal immunization against HBV. Second, the highest attack rates for new HBV infections occur in the 15–24-year-old age group. Although both these observations have been known for some time (3.Bonanni P Crovari P Success stories in the implementation of universal hepatitis B vaccination: an update on Italy.Vaccine. 1998; 16: S38-S42Crossref PubMed Scopus (18) Google Scholar), confirmation of this information has important implications for the implementation of prevention measures against acute HBV infection and its complications. The crucial role of universal vaccination against HBV in controlling morbidity and mortality has been repeatedly acknowledged (1.Van Damme P Kane M Meheus A Integration of hepattitis B vaccination into national immunization programms.BMJ. 1997; 314: 1033-1036Crossref PubMed Scopus (138) Google Scholar). By now, over 100 countries provide or are in the process of introducing universal vaccination against HBV to neonates. In some countries in East Asia and Africa, it has been shown that use of HBV vaccines in infants has reduced the prevalence of HBsAg carriers from > 8% to 2% in immunized cohorts (2.Kane MA Status of hepatitis B immunization programs in 1998.Vaccine. 1998; 16: S104-S108Crossref PubMed Scopus (81) Google Scholar). In Taiwan, the first country to introduce massive immunization, a reduction in the incidence of HBV-associated hepatocellular carcinoma among children can already be confirmed (5.Chang MH Chen CJ Lai MS Hsu HM Wu TC Kong MS et al.Universal hepatitis B vaccination in Taiwan and the incidence of hepatocellular carcinoma in children.N Engl J Med. 1997; 336: 1855-1859Crossref PubMed Scopus (1572) Google Scholar). Prevention of new HBV infections through universal infant vaccination is cost effective (6.Holliday SM Faulds D Hepatitis B vaccine. A pharmacoeconomic evaluation of its use in the prevention of hepatitis B virus infection.Pharmacoeconomics. 1994; 5: 141-147Crossref PubMed Scopus (23) Google Scholar). The introduction of such a program in Italy has already led to an estimated cost saving of about US $ 244 million in direct and indirect health costs in the first 6 years of the universal vaccination program (3.Bonanni P Crovari P Success stories in the implementation of universal hepatitis B vaccination: an update on Italy.Vaccine. 1998; 16: S38-S42Crossref PubMed Scopus (18) Google Scholar). Yet the old and new HBV vaccines, either plasma or yeast derived, can fail (7.Zannolli R Morgese G Hepatitis B vaccine: current status.Ann Pharmacother. 1997; 31: 1059-1066PubMed Google Scholar). Non-responsiveness may be attributed to genetically determined factors, old age, to disease or drug-induced immune suppression as well as inadequate storage or injecting techniques. Therefore, immunization against HBV, although important and usually highly successful, may induce a false sense of safety. Thus additional measures for prevention of HBV should not be ignored. The massive campaign against HIV and the global access to the Internet have no doubt contributed to an increased awareness of the need to take precautions against a number of viral and bacterial infections including HBV. This awareness has been and is being translated into improved compliance with immunization. However, this may not be enough. The present study provides some disturbing data on the frequency of non-mutually exclusive risk factors among Italian patients with acute HBV infection. These risk factors continue to pose a threat for HBV transmission, despite the success of the Italian immunization program. While the risk of acquiring HBV infection through blood transfusion remained low and steady from 1987 to 1997, the risk seems to have increased for sexual partners of HBsAg carriers, for dental therapy and for intravenous drug addicts. Furthermore, there is a certain risk of contracting HBV during surgical intervention, although this risk has not increased during the 12 years of the surveillance period. However, other parenteral exposures such as ear piercing, tattooing and acupuncture are responsible for an increasing number of new infections. The report by Stroffolini et al. in this issue of the Journal supports the argument that other measures, in addition to universal immunization against HBV, should complement efforts to eradicate HBV infection. These include improvement in the safety of invasive surgical, medical and dental interventions; increasing the safety of blood products; screening of pregnant women for HBsAg; providing disposable needles to intravenous drug addicts and most importantly increasing awareness of adolescents and young adults of the need to take precautions during sexual intercourse. These are important lessons that apply to all European and many non-European countries worldwide. A similar observation to the Italian experience was made in the United States where the majority of new HBV cases among 65 000 acute HBV infections occurred in young adults (8.Mast EM Williams IT Alter M Margolis HS Hepatitis B vaccination of adolescent and adult high-risk groups in the United States.Vaccine. 1998; 16: S27-S29Crossref PubMed Scopus (50) Google Scholar). Thus, healthcare authorities should give the highest priority to prevention programs in adolescents. Some countries, such as Italy, Canada, France, Portugal, Spain and the Unites States, have already recognized this risk group by providing catch-up immunization against HBV (9.Tepper ML Universal hepatitis B immunization: young adolescent immunization.Vaccine. 1998; 16: S23-S26Crossref PubMed Scopus (13) Google Scholar). Others have concentrated on newborns and young babies. Surprisingly until recently, countries such as the United Kingdom including Ireland, the Netherlands the Scandinavian countries and Japan chose to provide vaccines only to defined risk groups. The migration of workers and populations across Europe and the world has led to a profound change in the epidemiology of HBV infection where residents from countries with high and intermediate endemicity for HBV mix with inhabitants of countries with low endemicity. As a result, prevention policies including vaccination which are targeted at distinct populations at risk are doomed to fail, as has been previously recognized in the United States (10.US Department of Health and Human Services. Centers for Disease Control: hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination.MMWR. 1991; 40: 1-25PubMed Google Scholar). The Italian experience suggests that a concerted European action requires the combination of universal immunization against HBV with improvement in education and awareness among sexually active teenagers and young adults. Special attention should be given to improving the safety of surgical and dental procedures. The rate of HBV carriers among physicians and dentists in Central and East European countries is not well recorded, and even in Western European countries nosocomial HBV infection still requires much better control. Finally, we should keep in mind that hepatitis B is widespread and about half of the world population has already been infected (of whom ∼90% have recovered). Therefore, although the introduction of universal vaccination programs worldwide has indeed made a tremendous impact on the epidemiology of this serious infection, the global results of immunization will only be evaluable in one or more decades. Meanwhile, in addition to conventional vaccination, new and innovative preventive and educational measures must be introduced, especially for defined risk groups such as adolescents and young adults, as justified by the present report. Third-generation HBV vaccines which provide fast seroprotection after the priming dose may also be of value (11.Shapira MY Zeira E Adler R Shouval D Rapid seroprotection against hepatitis B following the first dose of Pre-S1/Pre-S2/S vaccine.J Hepatol. 2000; 33 (in press)Google Scholar). Such PreS/S hepatitis B vaccines may provide cover in situations where rapid protection is required, for example, pending elective surgery in areas at risk or in sexually transmitted disease (STD) clinics where compliance of patients is sometimes limited." @default.
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• W2092507265 title "Is universal vaccination against hepatitis B sufficient for control of HBV infection? Lessons from the immunization campaign in Italy" @default.
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