FEATURE
(continued from page 11)
one of the 28 risk indications listed in Table 4. The risks listed
will include every pregnant patient since all pregnant women are
screened for six sexually transmitted diseases and should be on
the universal list and the MIP.
HBV is transmitted by percutaneous or mucosal exposure to
infectious blood or bodily fluids containing blood and has been
detected in serum, semen and saliva as being infectious. HBV is
stable in the environment, resists both drying and heat and re-
mains viable for more than seven days in environmental surfaces
at room temperature.
ACIP does not have pregnancy as a universal recommendation
but it should be when reviewing the risk indications. It belongs on
the MIP platform.
TABLE 4: ACIP RISK INDICATIONS FOR HEPATITIS B VIRUS
VACCINE (2)
TYPE OF RISK
EXAMPLE
Occupational
Risks -Healthcare workers
-Public Service workers: Police, EMS, Firefighters
-Laboratory workers in contact with human
secretions
Lifestyle Risks -Bisexual persons or men who have sex with men
-Heterosexual persons with multiple partners
-Persons who have been diagnosed with a
sexually transmitted disease
-Persons who have been screened for a S.T.D.
-Intravenous drug abusers
Special patient -Persons with hemophilia
groups
-Patients undergoing renal dialysis
-Patients with chronic liver disease
-Patients who are HIV or HCV positive
Environmental -Household and sexual contacts of person with
Risks
HBV
_Patients and staff of correctional facilities
-Prison Inmates
-Immigrants and refugees
-International Travelers to endemic areas
Immuno
compromise
-Congenital acquired immune compromising
illness
-Chronic renal disease
-Nephrotic syndrome
-Leukemias
-Hodgkin’s disease
-Diseases requiring immune suppressive drugs
-Solid organ transplants
Multiple myeloma
HEPATITIS A
The current ACIP recommendations for the hepatitis A vaccine
is that all persons between ages one and 19 years receive the vac-
cine as well as others with any of 15 risk indications listed in Table
5. During the years 1980-1999, an estimated 271,000 symptomatic
and asymptomatic infections occurred in the United States annu-
12
LOUISVILLE MEDICINE
TABLE 5: RECOMMENDATIONS FOR RECEIPT OF HEPATITIS A
VIRUS VACCINE (15)
TYPE OF RISK
EXAMPLE
Occupational Risk -Employees of food service businesses
-Food handlers
-Child care workers
-Workers exposed to sewage
-Persons working with non-human primates
Lifestyle Risk -Homosexual or bisexual persons
-Use of injection and non injection illegal
drugs
Special Patient
Groups -Persons with blood clotting disorders
-Persons with chronic liver disease
-Person who desire not to contract HAV
Environmental Risk -International travelers
-Children attending daycare centers
-Institutionalized persons or staff
-HAV epidemic
ally with an estimated 100 persons dying from acute liver failure.
Since the introduction of HAV vaccine the number of cases has
dropped to as low as 24,000 cases in 2004. Currently, there is an
ongoing HAV epidemic in Jefferson County, Ky., with greater than
800 cases and 70 deaths in the last year. No primary source has
been identified but the homeless population, and those who abuse
drugs plus their household contacts, have suffered many cases.
A large outbreak occurred in 2003 at a restaurant in Pennsyl-
vania with 601 cases, 124 hospitalizations and three deaths. The
source was traced to imported green onions from Mexico that
were used to make salsa.
HAV vaccine is highly immunogenic with protective antibod-
ies formed in 90 percent of adults and 96 percent of children one
month after the first dose. After the second dose all persons had
protective antibodies with high geometric mean antibody titers.
Pregnancy is not a contradiction to HAV vaccine and data in-
dicates no apparent risk for adverse events in the fetus. The vac-
cine paradigm shift from a list of recommended and risk-based
vaccines to the Maternal Immunization Platform (MIP) should
make remembering which vaccines are needed easier.
ACIP has deemed Influenza and Tdap to be universal and HBV,
HAV and PPSV23 vaccines as subject to risk indications which are
not easily remembered and consequently not done. ACOG refuses
to take the lead and ACIP has failed to recommend converting
risk-based recommendations into an actionable, universal plat-
form. Clinicians will follow universal recommendations but fail to
remember risk-based recommendations. Universal recommenda-
tions work better and are easier to remember, to protect the moth-
ers of our children and grandchildren.
Dr. Gall practices obstetrics, gynecology and women’s health as part
of the University of Louisville Physicians Group.