Hepatitis B vaccination in childhood
Board of science and education
May 2005
BMA policy is that universal immunisation in childhood for hepatitis B should be introduced.
- What is hepatitis B?
- How is hepatitis B infection spread?
- Why is hepatitis B infection serious for babies?
- How can hepatitis B be prevented?
- What is the hepatitis B vaccination status for children in the UK?
- When should babies have hepatitis B vaccine?
- Is hepatitis B vaccine safe?
- Introduction of hepatitis B vaccine
- Epidemiological data: Worldwide
- Epidemiological data: UK
- Hepatitis B and travel
- In summary - why universal vaccination?
- Further information
- Editorial board
- Acknowledgements
- References
What is hepatitis B?
Hepatitis B (HBV) is a virus that infects the liver. Many people with HBV infection have no symptoms at all and do not know that they are infected. Others have 'flu-like’ symptoms and develop yellowing of the skin and eyes (jaundice). In most cases HBV infection can only be identified by a blood test. Most adults infected with HBV recover fully from the infection, but about 1 in 10 become carriers of the virus and may continue to infect others. About 1 in 5 of these carriers develop serious liver disease later in life [go to reference 1]. 2 billion people worldwide have serological evidence of past or current infection [go to reference 2].
How is hepatitis B infection spread?
‘Hepatitis B virus is transmitted by contact with blood or body fluids of an infected person in the same way as human immunodeficiency virus (HIV), the virus that causes AIDS. However, HBV is 50 to 100 times more infectious than HIV’ [go to reference 3].
Why is hepatitis B infection serious for babies?
Without vaccination, many babies born to mothers who are HBV carriers will become infected. As many as 9 out of 10 babies infected at birth develop long lasting infection and these babies are at risk of developing serious liver disease in adult life. Once infected, they can pass on infection to their close family and other contacts [go to reference 4].
How can hepatitis B be prevented?
Vaccines to prevent HBV are highly immunogenic [go to reference 5], conferring more than 90 percent protection in individuals receiving the complete course of three doses of vaccine, with only minor side effects.
By May 2003, 151 countries had followed the World Health Organisation (WHO) recommendation that they should implement universal infant and/or adolescent HBV vaccination [go to reference 6]. This is an important part of the global effort to eradicate an infection that causes liver failure and cancer.
Low prevalence countries that have already implemented the HBV vaccine include:
Andorra, Italy, Austria, Latvia, Belgium, Luxembourg, Czech Republic, Estonia, Malta, France, Monaco, Germany, Poland, Greece, Portugal, Israel, San Marino, Slovakia, Spain, Switzerland and Turkey [go to reference 7].
What is the hepatitis B vaccination status for children in the UK?
The UK is one of the few developed countries that have not implemented universal neonatal HBV immunisation. Because the burden of HBV in the UK is relatively low, a policy of immunisation of new-borns of carrier mothers and those in high-risk groups has been followed. This approach has limited impact as it fails to identify a large proportion of those at risk and it also ignores the increase in international travel, the rise of HBV and the high rates in some areas of this country. It is time that the policy is reviewed in the light of experience with this selective immunisation policy, the data on efficacy of universal immunisation from other countries, and the proven safety of recombinant vaccines [go to reference 8].
Currently, the Joint Committee on Vaccination and Immunisation (JCVI) is reviewing the UK’s existing policy of offering vaccine only to those belonging to high risk categories. Both the rise in the incidence of HBV infection in high risk groups, particularly evident in recent outbreaks among injecting drug users [go to reference 9], and the increase in prevalence of HBV attributable to immigrants and asylum seekers, suggest that greater attention to prevention of infection is required [go to reference 10].
Parents who want their child vaccinated (if he / she does not fit into one of the priority groups) should speak to their GP or healthcare practitioner. More information on the childhood vaccination schedule in the UK may be accessed at this website: http://www.immunisation.org.uk/article.php?id=97 .
When should babies have hepatitis B vaccine?
Babies born to mothers who are known carriers should have the first dose of vaccine immediately after they are born. The doctor or midwife will arrange this. They will need further doses of vaccine for full protection against infection.
Under a universal immunisation policy all other babies should complete a course of vaccine during the first year of life. It is essential that babies receive the full course of vaccine at the right times for it to work. Furthermore, when universal HBV vaccination is introduced in childhood, there will also need to be a ‘catch-up’ initiative among older children.
Is hepatitis B vaccine safe?
The vaccine is safe and millions of doses have been given to babies worldwide without serious side effects. In some babies the site of the injection may become red and swollen, but this does not last for long.
In the last decade concerns have been raised that HBV vaccine may be associated with development of the neurological disorder multiple sclerosis (MS). However, numerous scientific studies and expert panel reviews have failed to find a link between the HBV vaccine and MS.
The studies on HBV vaccine and MS have been reviewed by the World Health Organisation Global Advisory Committee on Vaccine Safety. It states that ‘multiple studies and review panels have concluded that there is no link between MS and HBV vaccination’. The WHO also affirms that the recent study by Hernán and colleagues does not provide sufficient evidence to link HBV vaccination to MS, and does not justify discontinuation or modification of HBV vaccination programmes.
In addition, a review by the Institute of Medicine Immunisation Safety Review Committee in 2003 found that there was no link found between HBV vaccine and certain neurological disorders such as MS. A systematic review from the Cochrane Vaccines Field in 2003, also found no evidence of an association between HBV vaccine and MS. Recent statements by the US Centres for Disease Control, and the National Network for Immunisation Information support this position.
For further detail on this and other references relating to HBV vaccine safety please refer to the briefing from the National Centre for Immunisation Research and Surveillance (NCIRS)[go to reference 11].
Introduction of hepatitis B vaccine
Italy was the first industrialised country to introduce mass vaccination against HBV. Following the collection of epidemiological data on age-specific incidence rates of infection, a law was passed in 1991, which established mandatory immunisation of neonates and 12-year-old adolescents. The first data on compliance with vaccination, both in infants and in adolescents, indicated the success of the programme, which was helped by good vaccination delivery services and awareness of the risks of HBV both in physicians and the public [go to reference 12].
Ten years on from routine HBV vaccine introduction in Italy, evidence has accumulated on the epidemiological impact of universal immunisation. Coverage is on average >90% and is >or=95% in many areas of Italy. Incidence of acute HBV, already declining before 1991, was further decreased by the routine vaccination programme. Furthermore, passive surveillance of adverse events following HBV vaccination supported the excellent safety record of HBV vaccines [go to reference 13].
There are also positive reasons for low-incidence countries such as the UK to implement a programme of universal vaccination, based on the ethical presumption that where a potentially devastating disease is easily preventable, those at potential risk should be protected, particularly where the infection is on the increase and will carry on in that direction unless a universal immunisation programme is introduced [go to reference 32].
Epidemiological data: Worldwide
An estimated 350 million people worldwide (5% of the world’s population) are chronic carriers. About a quarter of these carriers will develop serious liver disease, including chronic hepatitis, cirrhosis, and primary hepatocellular carcinoma [go to reference 14] which results in more than one million deaths each year [go to reference 15] and [go to reference 16]. HBV also causes 16 million healthcare related infections in the tropics every year [go to reference 17] and [go to reference 18].
HBV is prevalent in Africa and South East Asia, with rates of current or past infection as high as 50-80%. Death from cirrhosis or hepatoma occurs in up to one third of carriers who acquired HBV perinatally [go to reference 19].
‘High rates of chronic HBV infection are also found in the Amazon and the southern parts of Eastern and Central Europe. In the Middle East and Indian sub-continent, about 5% are chronically infected. Infection is less common in Western Europe and North America, where less than 1% are chronically infected. Young children who become infected with HBV are the most likely to develop chronic infection. About 90% of infants infected during the first year of life and 30% to 50% of children infected between 1 to 4 years of age develop chronic infection. The risk of death from HBV-related liver cancer or cirrhosis is approximately 25% for persons who become chronically infected during childhood’ [go to reference 20].
Epidemiological data: UK
The Department of Health estimates that there are around 180,000 people chronically infected with HBV in the UK [go to reference 21]. ‘In addition, there are at least 1,300 cases of symptomatic acute hepatitis B each year and 7,700 new cases of chronic hepatitis B. Of these new chronic cases, around 300 people were infected within this country, while the remainder, some 96%, have entered this country, generally from areas of high prevalence where HBV is frequently transmitted from mother to child. Many people with asymptomatic infections are also infectious, and quite often remain undiagnosed until they present with overt disease’ [go to reference 22]. Rates of infection are likely to rise with increases in foreign travel and the impact of migration [go to reference 23].
England and Wales – HBV notifications [go to reference 24]
1992: 489
2003: 1151
Northern Ireland (laboratory reports of Hepatitis B) [go to reference 25]
1992: 34
2003: 76
Scotland
In 2002, 354 cases of HBV infection were reported by laboratories to the Scottish Centre for Infection and Environmental Health (SCIEH); in 2000 and 2001, 360 and 357 cases were reported respectively. Of the 354 reports in 2002, 37 mentioned injecting drug use as the patient’s principal risk factor. It is likely that the majority of cases acquired infection through injecting practices.
There are no robust estimates of how much treatment of chronic hepatitis B (CHB) costs the NHS. Of countries for which burden of disease estimates are available, the country with prevalence and population closely matching that of the UK is Germany. Harbarth et al (2000) estimated the total cost of HBV in Germany to be £589 million. However, the burden of CHB to any country depends crucially on its population and the prevalence of hepatitis B [go to reference 26].
For a more detail discussion of the economic burden of HBV please refer to - Hepatitis B: Out of the shadows: A report into the impact of hepatitis B on the nations health (October 2004). Foundation for Liver Research.
Hepatitis B and travel
As destinations become more diverse, with people increasingly travelling outside Europe the opportunity for HBV transmission is much greater. As such, HBV vaccine should also be considered for a wider range of travellers, including those who may travel to areas endemic for HBV, may be exposed by virtue of their sexual practices, or may be exposed to unscreened or inadequately screened blood or blood products or inadequately sterilised medical and surgical equipment [go to reference 27].
In summary - why universal vaccination?
- 350 million people are chronic carriers worldwide
- They have 15 – 40% risk of death from HBV - related liver disease [go to reference 28].
- HBV is highly infectious and transmissible (HBV is 50-100 times more infectious than the AIDS virus [go to reference 29])
- 2 billion people (1 out of 3 people) have serological evidence of past of current infection [go to reference 30].
- 10-30 million will become infected each year
- HBV causes chronic hepatitis, cirrhosis, and primary hepatocellular carcinoma
- Each year acute and chronic HBV infection causes 1 million deaths worldwide
- Treatment options for patients who are already infected are limited. The currently available drugs are effective only in selected subsets of patients and have low efficacy rates, and their long term impact on occurrence of complications remains unknown [go to reference 31].
- Strategies to immunise those at high risk have failed to control the disease
- Vaccination is the most effective method of preventing HBV infection
You can get more information about HBV from:
Children's Liver Disease Foundation
(Specialises in children with liver disease)
36 Great Charles Street
Birmingham B3 3JY
Tel: 0121-212-3839
Fax: 0121-212-4300
E-mail: info@childliverdisease.org
Website: www.childliverdisease.org
The British Liver Trust
(Specialises in adults with liver disease)
The British Liver Trust
2 Southampton Road
Ringwood
Hampshire
BH24 IHY
Tel: 0870 770 8028
E-mail: info@britishlivertrust.org.uk
Website: www.britishlivertrust.org.uk
Editorial board
A briefing from the BMA Board of Science
Chairman, Board of Science - Professor Sir David Carter
Director of professional activities - Professor Vivienne Nathanson
Head of science and education - Dr Caroline Seddon
Research and writing - Nicky Jayesinghe
Contributor - Dr Sam Everington
Acknowledgements
The Board is very grateful for the help provided by Professor Christopher A Ludlam (Professor of Haematology & Coagulation Medicine, Royal Infirmary, Edinburgh) and Dr Philip P Mortimer (Virologist, Health Protection Agency).
References
[1] Department of Health: Hepatitis B: How to protect your baby (2002) www.dh.gov.uk/assetRoot/04/10/16/64/04101664.pdf (accessed 2 March 2005)
[2] World Health Organisation: www.who.int/mediacentre/factsheets/fs204/en/
[3] World Health Organisation: www.who.int/mediacentre/factsheets/fs204/en/
[4] Department of Health: Hepatitis B: How to protect your baby (2002) www.dh.gov.uk/assetRoot/04/10/16/64/04101664.pdf (accessed 2 March 2005)
[5] Sexually Transmitted Infections: British Medical Association - 2002
[6] Centre for Disease Control and Prevention. Global progress toward universal childhood hepatitis B vaccination, 2003. MMWR 2003;52:868–70.
[7] World Health Organisation Office for Europe: www.vhpb.org/files/html/Meetings_and_publications/VHPB_Meetings/Kyiv2004/pdf/S31enEmiroglu.pdf (accessed 12 April 2005)
[8] Preventing and treating hepatitis B infection: Rakesh Aggarwal and Piyush Ranjan: BMJ 2004;329:1080-1086 (6 November), doi:10.1136/bmj.329.7474.1080
[9] Stevenson J , Tannahill M, Biggs V. An outbreak of acute hepatitis B infection among injecting drug users in Inverclyde, Scotland. Commun Dis Public Health 2001;4:60–3.
[10] Determinants of universal adolescent hepatitis B vaccine uptake L A Wallace and J C Bramley et al: Archives of Disease in Childhood 2004;89:1041-1042
[11] www.ncirs.usyd.edu.au/index.html
[12] Bonanni P Implementation in Italy of a universal vaccination programme against hepatitis B: Vaccine. 1995;13 Suppl 1:S68-71.
[13] Bonanni P, Pesavento G and Bechini A et al, Impact of universal vaccination programmes on the epidemiology of hepatitis B: 10 years of experience in Italy: Vaccine. 2003 Jan 30;21(7-8):685-91.
[14] Van Damme P, Kane M & Meheus A (1997): Integration of hepatitis B vaccination into national immunisation programmes BMJ ;314:1033
[15] WHO. Hepatitis B fact sheet WHO/24. Geneva: WHO, 2000. www.who.int/inf-fs/en/fact204.html
[16] WHO. Hepatitis B. Geneva: WHO, 2002 www.who.int/emc-documents/hepatitis/docs/whocdscsrlyo20022.pdf
[17] Lavanchy D. Hepatitis B epidemiology, disease burden, treatment, and current and emerging prevention and control measures. J Viral Hepat 2004;11: 97-107.
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[19] Adams KM, Gardiner LD & Assefi N: Healthcare challenges from the developing world: post-immigration refugee medicine BMJ 2004;328:1548-1552
[20] World Health Organisation: www.who.int/mediacentre/factsheets/fs204/en/
[21] Department of Health. Getting ahead of the curve. A strategy for combating infectious diseases. London DH, 2002.
[22] Foundation for Liver Research. Hepatitis B: out of the shadows. London, Foundation for Liver Research, 2004. www.ucl.ac.uk/liver-research/hepatitis-report.pdf
[23] Department of Health. Getting ahead of the curve. A strategy for combating infectious diseases. London DH, 2002.
[24] Health Protection Agency
[25] Communicable Disease Surveillance Centre, Northern Ireland
[26] Hepatitis B: Out of the shadows: A report into the impact of hepatitis B on the nations health. Foundation for Liver Research: October 2004. www.ucl.ac_.uk/liver-research/hepatitis-report.pdf (accessed 12 April 2005)
[27] Zuckerman JN, Steffen R. Risks of hepatitis B in travellers as compared to immunisation status. J Travel Med 2000; 7: 170-174
[28] Tassopoulos NC, Papaevangelou GJ, Sjogren MH, Roumeliotou-Karayannis A, Gerin JL, Purcell RH. Natural history of acute hepatitis B surface antigen-positive hepatitis in Greek adults. Gastroenterology 1987;92: 1844-50.
[29] World Health Organisation: www.who.int/mediacentre/factsheets/fs204/en/ (accessed 12 April 2005)
[30] World Health Organisation: www.who.int/mediacentre/factsheets/fs204/en/ (accessed 12 April 2005)
[31] Aggarwal A & Ranjan P: Preventing and treating hepatitis B infection BMJ 2004;329:1080-1086 (6 November).
[32] Dawson, A J (2005) An ethical argument in favour of routine Hepatitis B vaccination in very low incidents countries such as the UK. The Lancet: Infectious Diseases. 5 (2): pp120-125