Moving Towards a Universal Hepatitis B Vaccine Program for Canadian Children

B Y THE EARLY 1990s, EVI DENCE HAD AC CU MU LATED THAT THE se lec tive hepa ti tis B vac cine strat egy aimed at high risk in di vidu als was fail ing to stem the tide of hepa ti tis B in fec tion in Can ada. The re ported rates of acute hepa ti tis B and deaths due to hepa ti tis B in fec tion had in creased, not de creased, over the dec ade (1). Both the Na tional Ad vi sory Com mit tee on Im mu ni za tion and the Ca na dian Pae di at ric So ci ety, on re view of the data and ex ami na tion of pos si ble fac tors be hind the fail ure of the se lec tive vac cine pro gram (2), en dorsed the prin ci ple of uni ver sal child hood im mu ni za tion (3,4). The Ca na dian Hepa ti tis B Work ing Group, on re view ing the op tions (the status quo; uni ver sal in fant pro gram; uni ver sal pre ado les cent pro gram; uni ver sal ado les cent pro gram), rec om mended that a pre ado les cent pro gram be added to the cur rent se lec tive strat egy to de crease the rate of new hepa ti tis B in fec tion in Can ada (5). Us ing Ameri can data, Bloom and col leagues (6) showed that the pre ado les cent schoolbased op tion is likely to be the most cost ef fec tive. This as sess ment is thought also to be valid in Can ada since fewer than 3% of re ported acute hepa ti tis B cases oc cur in early child hood, with the dra matic in crease in in ci dence oc cur ring in later ado les cence and young adult hood. Given these demo graph ics, sex ual ac tiv ity and pos si bly also in jec tion drug use ap pear to be im por tant fac tors for hepa ti tis B trans mis sion in Can ada (1,5). Thus, to maxi mize the im pact on the in ci dence of hepa ti tis B in fec tion, a uni ver sal im mu ni za tion pro gram needs to be gin be fore the on set of sex ual ac tiv ity. An ado les cent pro gram may be too late and a pre ado les cent pro gram would have a shorter lag phase be fore ac cru ing bene fits than would an in fant pro gram. A pre ado les cent pro gram has the added ad van tage of need ing smaller doses of vac cine than an adult pro gram while still of fer ing pro tec tion be fore sex ual ac tiv ity be comes com mon. Brit ish Co lum bia, the first prov ince to in tro duce a uni ver sal pre ado les cent hepa ti tis B pro gram, ini ti ated a schoolbased pro gram in 1992, which im mu nized over 90% of eli gi ble 11yearolds (7). Que bec, Yukon and On tario fol lowed suit with uni ver sal pre ado les cent schoolbased pro grams in 1994 aimed at grade 4 (Que bec and Yukon) and grade 7 (On tario) stu dents. Nova Sco tia, New Bruns wick, New found land, Prince Ed ward Is land, Al berta and the North west Ter ri to ries are expected to have pre ado les cent schoolbased pro grams in place by the fall of 1995. New Bruns wick, Prince Ed ward Is land and the North west Ter ri to ries have also started uni ver sal in fant hepa ti tis B im mu ni za tion pro grams in ad di tion to the pre ado les cent pro grams. While all of the prov inces and ter ri to ries that have started the uni ver sal schoolbased pro grams must be ap plauded, this sin gle grade/age strat egy has cre ated some con fu sion for the gen eral pub lic. Why are older chil dren and ado les cents not be ing cov ered since they will be mov ing into the sexu ally ac tive risk group sooner than the eli gi ble pre ado les cents? Cost ap pears to have pre cluded catchup pro grams for ado les cents at the mo ment. To fa cili tate im mu ni za tion for ado les cents and young adults who missed out on the school pro gram, phy si cians in prac tice are en cour aged to of fer hepa ti tis B im mu ni za tion at cost through their of fices. Both of the manu fac tur ers of the cur rently li censed hepa ti tis B vac cines have bulk pur chase pro grams avail able to phy si cians, which can lower the cost for fami lies by ne gat ing the ad di tional dis pens ing fee charges of re tail phar ma cies. Some par ents may be able to have the cost cov ered though pri vate in sur ance if the vac cine is pur chased by pre scrip tion. The di rect line for Merck Frosst Can ada Inc for Re com bi vax is 18002684827, and the di rect line to Smith Kline Beecham Pharma Inc for En gerix B is 18005655468. In some prov inces par ents are also able to pur chase vac cine at cost through their health de part ment. Rou tine pre vac ci na tion screen ing for an ti body is not rec om mended in this popu la tion be cause of the low preva lence of anti-HBS (hepa ti tis B sur face an ti gen) (8). Post vac ci na tion test ing for anti-HBS in healthy per sons is also not PE DI AT RIC IN FEC TIOUS DIS EASE NOTES