THE HEART OF THE MATTER
a special program of the National Emergency Medicine Association (NEMA) 

Week: 608.7

Guest: Dr. Susan Goldstein, Hepatitis branch, Centers for Disease Control

Topic: Adolescent immunization against hepatitis B

Host/Producer: Steve Girard

NEMA: Thanks for joining us. About a million Americans have hepatitis B...200 thousand new cases each year...three quarters between 15 and 39...and 5 thousand deaths are attributed to the disease each year. In kids, it’s very hard to spot...and so, a vaccination program, trying to prevent infection before the child reaches teenage years, is growing around the country. Our guest today is Dr. Susan Goldstein from the Centers for Disease control in Atlanta...

GOLDSTEIN: Hepatitis B is a virus, and it’s a virus that infects the liver. And it can cause two things...it can cause acute infection, which is frequently referred to as yellow jaundice...and people have fever, and yellow looking skin, and yellow eyes, and they can have pain in their stomach...especially in the right upper quadrant, which is where the liver is. But hepatitis B can also cause another syndrome, which is called chronic hepatitis B. That usually presents years, and that can be 10 or 20 or 30 years, after the initial infection....and it presents as chronic liver disease, which includes cirrhosis and something called a patacellular carcinoma, which is actually, really just liver cancer.

Going back to acute infection...when someone gets infected with the virus, it can present in one of two ways: either as symptomatic, acute infection...which is the yellow jaundice that I described, or it can be silent. And a person will not have any symptoms, and they won’t even know that they’re infected with the virus. And the younger somebody is, the more likely they are to have asymptomatic infection. So, most infants and young children don’t have symptomatic infection. We usually see it in older children and in adults. So, it’s very unlikely for a pediatrician to see a child with yellow jaundice. But both the symptomatic, acute infection and the asymptomatic acute infection, can go on and cause chronic infection. Now, you never know what person will develop chronic infection...people who have the acute disease are not more likely to develop chronic disease, compared with people who have asymptomatic acute disease. There’s absolutely no way of telling, no...no. People think that’s it’s more common for someone who has the symptomatic yellow jaundice to go on and develop chronic infection, compared to someone who has no symptoms...but actually, that’s not true. There’s no way of telling.

It’s about 5 to 10 % of people, who have acute infection, both symptomatic and asymptomatic, will go on and develop chronic infection. So, it’s a relatively small proportion...however, the proportion, or the risk of developing chronic infection is related to how old someone is when they become infected. The younger somebody is, and when I say young, I mean infants, early and early childhood...the more likely they are to develop chronic infection.

And we can talk about how hepatitis is transmitted, but, for example, someone who becomes infected at birth from an infected mother, has a 90% chance of developing chronic infection. So it’s very, very high.

NEMA: The vaccine for hepatitis B is a good one, understand...

GOLDSTEIN: It’s a very safe vaccine...and it’s a very effective vaccine. It’s given as a three dose series. The most common side effects are pain at the site of infection and occasionally somebody will develop a mild fever. But there are very, very rarely reports of any kind of severe reaction, and no one has even died from getting the vaccine.

NEMA: Let’s talk about how we can get hepatitis B...

GOLDSTEIN: There are a lot of ways it can be transmitted. What it comes down to is somehow coming in contact with blood that contains the virus. And there are lots of different ways of that happening. And it can be either by direct contact with infected blood...or by indirect contact. Meaning, blood infects some sort of object, and then a person becomes infected by touching that object. So, the most common ways that hepatitis is transmitted in the United States is by sharing needles that injecting drug users use...and the needle becomes contaminated by one person and then another person will use it and become infected. It also can be transmitted by sexual activity. In the olden days, it used to be transmitted by blood transfusion, but now that we screen blood for hepatitis, it’s a very, very, very uncommon occurrence to get hepatitis B that way. It can be transmitted from an infected mother to her child, and that’s usually during birth. And there also can be transmission...although this is very rare in the United States...by such means as folk medicine remedies, such as acupuncture...it can be transmitted by tattooing if the equipment isn’t cleaned or changed between people. And another more common way of transmission is from occupational exposure - a health care worker becoming infected usually from caring for a patient who has the virus.

NEMA: We’ve been immunizing against the disease for only a short while, true?

GOLDSTEIN: Beginning in 1992, the ACIP, which is the American Committee on Immunization Practices....which is made up of people from various government and non-government organizations...such as the CDC and the National Institutes of Health and the American Medical Association and the various pediatric and family practice societies...recommended that all children be vaccinated with the three dose hepatitis B series beginning at birth. And it’s actually been a very effective program, and now...five years after the beginning of the program...about 70% of children who have reached the age of two have received three doses of the hepatitis B vaccine. Now, obviously we still have a ways to go, in that we’d like 100% of two year olds to have received the three doses, but I think we’ve made great progress in the last 5 years. Recently, the ACIP has recommended that not only

NEMA: But now, the ACIP is recommending 11 to 12 year olds get immunized...right?

GOLDSTEIN: And the reason they made this recommendation is there are a lot of children born before 1992 that didn’t have the benefit of the 1992 recommendation to by vaccinated at birth, and so they never received the hepatitis B vaccine. And what we’re doing with the adolescent recommendation is what we call ‘catch-up’ vaccination. Vaccinating anyone who was born before the recommendation for infant immunization came into being...but also anybody who was born after the recommendation, but for some reason didn’t get vaccinated. Can get vaccinated now. Now they chose 11 to 12 years of age for a few reasons. First of all, it’s important that we vaccinate kids as early as possible before they put themselves into any situations where they might be at risk for acquiring hepatitis. Now, most hepatitis in the United States is actually acquired after age 15, so we need to make sure kids are vaccinated when they’re adolescents...before they reach the mid teen years, when they begin to engage in high risk behaviors. And we thought that 11 to 12 years of age was young enough that we would be able to vaccinate them before they engage in high risk behaviors, but also they...it was an age at which were still able to access them. That they hadn’t yet dropped out of school, and especially in large, urban populations, kids tend to drop out of school at early ages. It was an age where they were still willing to listen to parents and physicians when they recommended the vaccine, and they were willing to accept taking the vaccine. And it’s also an age when people are still going to the doctors...as kids get older, they tend to go to the doctor less and less. And so, if there’s no infrastructure to vaccinate them...if there’s no reason to go to the doctor, they’re not going to be vaccinated.

NEMA: But many parents are confused about why their kids need the protection...after all, they’re kids are not going to have unprotected sex or use intravenous drugs...how can they be at risk?

GOLDSTEIN: There are a lot of ways that the virus can be transmitted that a lot of parents feel their children are not at risk of engaging in. And that’s probably true...however, there are a couple of caveats. First of all, you don’t always know what situations a child will face when they’re in their 20’s, 30’s, 40’s...that you don’t think they’re going to face when they’re 11 and 12 years old. But also, there are times when hepatitis is transmitted by some of these less risky modes of transmission. And it is possible that they’ll play sports in school and come in contact with somebody who has chronic hepatitis, and can transmit the virus...and they can get some of that person’s...if it’s some sort of contact sports...can be exposed to that person’s virus. It’s also possible that that child is going to grow up and go to medical school, or nursing school...or becomes some other sort of health care professional, and that will put them at risk to the virus. So, it’s better that they get vaccinated early on. Now there are also times that people get infected and we just don’t know how they got infected...and you don’t know that your child won’t necessarily be one of those young adults or adults. And so it’s much, much better to be safe...and go ahead and vaccinate...then to end up in a situation where they actually got infected...even though they didn’t engage in anything that’s considered a high risk behavior.

NEMA: Individual states have the power to institute a vaccination program for hepatitis B...and some require shots before kindergarten, some before 5th grade....and many colleges are now requiring students be immunized before their freshman year. Our thanks to Dr. Susan Goldstein of the Centers for Disease Control.

SPOT: Small pages....big advice on parenting...from infants to teens. What to expect, emotionally and physically, as your child grows. How to develop positive discipline,how to deal with kids and TV, adolescent issues, drug education, fighting, single and step parenting...it’s all in the ‘Little Book of Parenting, available through the National Emergency Medicine Association. Call 1-800-332-6362 for more information.

NEMA: Thanks for joining us for today’s program. If you have any comments or suggestions, contact this station. Or visit our home page at:

www.nemahealth.org/

...for a look at transcripts of this or past programs, or to find out more

about the National Emergency Medicine Association. I’m Steve Girard at The Heart of the Matter.