Universal Hepatitis B Immunization

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764 PEDIATRICS Vol. 95 No. 5 May 1995

EXPERIENCE

AND

REASON--Briefly

Recorded

“In Medicine one must pay attention not to plausible theorizing but to experience and reason together. .. .I agree that theorizing is to be approved, provided that it is based on facts, and systematically makes its deductions from what is observed. .. .But conclusions drawn from unaided reason can hardly be serviceable; only those drawn from observed fact.” Hippocrates: Precepts. (Short communications of factual material are published here. Comments and criticisms appear as letters to the Editor.)

Universal

Hepatitis

B

Immunization

ABSTRACT. Objective. To determine the practices of

US nurseries, neonatal intensive care units (NICUs), and

pediatricians regarding universal hepatitis B vaccination.

Design. Descriptive cross-sectional survey.

Participants. One hundred forty term nurseries, 152

NICUs, and 157 pediatricians.

Selection procedure. Nurseries and NICUs were

system-atically sampled from the 1992 American Hospital

Asso-ciation Guide to provide equal sampling from each re

gion of the country. Pediatricians were systematically

sampled from a national list of practicing pediatricians

supplied by Ross Laboratories to provide equal sampling

from each state.

Results. The response rates were 95% (n 133) for term

nurseries, 95% (n 144) for NICUs, and 83% (n 131) for

pediatricians. Sixty-two nurseries (47%) provide routine

hepatitis B vaccine (HBV) to their infants. Eighty-five

NICUs (59%) routinely vaccinate their preterm infants; 62

(73%) initiate the series just before discharge; and 11

(13%) do so at birth. Principal reasons for not vaccinating

include cost and a preference to allow the primary-care

physician to initiate the series. One hundred ten (85%)

pediatricians provide universal hepatitis B vaccination.

Principal reasons for not vaccinating include cost and

parents opting against vaccination.

Conclusions. More than half of NICUs provide HBV

routinely to their preterm infants, predominantly just

before hospital discharge. A minority of NICUs are

ini-tiating vaccination at birth, which may provide

subopti-mal seroconversion. Although less than half of

partici-pating term nurseries are routinely vaccinating before

discharge, 85% of pediatricians do initiate HBV by two

months of age. The principal reasons for not providing

vaccine are financial.

ABBREVIATIONS. HBV, hepatitis B vaccine; CDC, Centers for Disease Control; AAP, American Academy of Pediatrics; NICU,

neonatal intensive care unit.

Hepatitis B infection is a significant cause of

morbidity and mortality in the United States. The

first hepatitis B vaccine (HBV) was licensed in 1982.

In November 1991, the Immunization Practices

Advisory Committee of the Centers for Disease

Con-trol (CDC) announced their recommendation for

universal immunization of infants against hepatitis

Received for publication Jun 20, 1994; accepted Aug 26, 1994.

Reprint requests to (S.C.K.) The Pediatric and Adolescent Center, 1070 North Curtis, Suite 150, Boise, ID 83706.

B.’ In February 1992, the American Academy of

Pe-diatrics (AAP) issued their own recommendations

for universal vaccination, with administration of the

first dose of vaccine to newborns before hospital

discharge.2

The purposes of this study were: (1) to assess the

current practices of nurseries, neonatal intensive care

units (NICUs), and pediatricians regarding routine

hepatitis B vaccination; and (2) to assess reasons for

not adopting universal vaccination.

METhODS

One hundred forty term nurseries and 152 NICUs were sys-tematically sampled from the 1992 American Hospital Association

Guide to provide equal sampling from each region of the country. Between October and November 1993, telephone surveys were conducted with physicians or nurses staffing the nurseries and

NICUs.

One hundred fifty-seven pediatricians were systematically sampled from a national list of pediatricians supplied by Ross Laboratories to provide equal sampling from each state. Initial

survey attempts were by telephone between October and

Novem-ber 1993. Because of difficulty contacting pediatricians by phone, the survey was mailed in November 1993 to pediatricians we were unable to reach by telephone. Two follow-up notices were sent to nonresponders.

Participants were asked if they routinely vaccinated newborns

of hepatitis B surface antigen-negative mothers. In addition, an

open-ended question addressed reasons for not adopting univer-sal vaccination. NICU participants were also asked the timing of initiation of vaccination in preterm infants.

RESULTS

One hundred thirty-three term nurseries

partici-pated, for a response rate of 95%. Respondents were

approximately equally distributed among regions of

the country. Sixty-two (47%) respondents routinely

provide HBV to all their term infants. Fifty-five (41%)

vaccinate only a subset of their infants. This subset

included predominantly mothers who are high risk

or unregistered (n = 24) and pediatrician’s choice

(n = 22). There was a nearly statistically significant

difference between universal immunization rates in

nurseries not associated with NICUs versus those

associated with NICUs. Nine of the 29 (31%) term

nurseries located in hospitals without NICUs

pro-vide HBV routinely versus 53 of the 102 (52%)

nurs-eries with an affiliated NICU (P = .075 by ). There

was no significant difference in routine vaccination

rate by region of the country (Table).

One hundred forty-four NICUs participated, for a

response rate of 95%. Respondents were

approxi-mately equally distributed among regions of the

country. Eighty-five (59%) routinely provide HBV to

their preterm infants. Sixty-two (73%) begin the

vaccine series

just

before discharge, whereas 11

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EXPERIENCE AND REASON 765

TABLE. Percent Providing Routine HB V by Region

Region No. Respondents! Region

% (n) Routinely Vaccinating

Term nurseries*

Northeast 32 47% (15)

South 34 53% (18)

Midwest 31 58% (18)

West 36 31% (11)

NICUst

South 40 52% (21)

Midwest 33 76% (25)

West 37 43% (16)

Pediatricians*

South 46 85% (39)

Midwest 33 88% (29)

West 33 85% (28)

* P = NS by . t P < .05 by x’.

(13%) do so at birth. Thirty-one (22%) vaccinate only

a subset of their infants, predominantly those with

high risk or unregistered mothers (n = 17) and those

who remain hospitalized for more than 1 to 2 months

(n = 9). Twenty-eight (19%) NICUs do not vaccinate

any of their preterm infants, citing high cost and lack

of reimbursement (n = 9) and a preference to allow

the primary pediatrician to initiate the series (n = 9).

Routine vaccination rates did not differ by NICU

level. Twenty-eight of the 49 (57%) level 2 NICUs

provide routine vaccination for their infants versus

53 of the 87 (61%) level 3 NICUs (P = NS). Routine

vaccination rates did differ by region; the

midwest-em region had the highest rate of universal

vaccina-tion (Table).

One hundred thirty-one pediatricians participated,

for a response rate of 83%. Seventy-five were

sur-veyed by mail, 56 by telephone. A median of 80% of

all newborns seen by participants had received their

first dose of HBV before nursery discharge. One

hundred ten (85%) respondents routinely begin the

HBV series before the age of 2 months. Principal

reasons for not providing vaccine induded high cost

and alternate less-expensive means of vaccination

via the health department (n = 7) and parents opting

against the HBV (n = 4). Routine vaccination rates

did not differ by region (Table).

DISCUSSION

There are approximately 300 000 new cases of

hep-atitis B infection each year in the United States, and

it is estimated that more than I million Americans

have chronic infection.’ After the

first

HBV was

licensed, the CDC recommended vaccination of

in-dividuals at high risk and universal screening of

pregnant women.3 Despite these strategies, the

inci-dence of hepatitis B infection continued to rise,”

likely because individuals in high-risk groups are

difficult to identify and often underuse preventive

health measures.5 In addition, 30% to 40% of acute

hepatitis B infections in the United States occur in

individuals without identifiable risk factors.2

Universal hepatitis B vaccination has been

recom-mended for the past 2.5 years. Previous authors have

attempted to assess pediatricians’ reactions to these

recommendations. Freed, et al4 surveyed all licensed

pediatricians in North Carolina in January 1992 (after

the CDC recommendation, but before the AAP

rec-ommendation). Although 82% of respondents were

aware of the CDC’s recommendations, only 32%

thought universal vaccination was necessary for

their practice. The authors identified one possible

barrier to vaccination: pediatricians’ perceptions that

parents would refuse three vaccinations at one visit.4

A subsequent survey was performed by the AAP

and the CDC in October 1992. They found that

ap-proximately 50% of pediatricians agreed with

uni-versa! infant vaccination against hepatitis B. The

rea-sons cited for not adopting this strategy included

concern about waning immunity and the possible

need for booster doses of vaccine, cost effectiveness,

safety

of the vaccine, and the addition of another

immunization to the schedule for infants.6

Eight months after their initial survey, Freed et a!7

sent follow-up questionnaires to their original

sam-ple of pediatricians. Although 66% of respondents

thought universal vaccination was warranted, only

53% practiced universal vaccination for their

pa-tients. Barriers to universal vaccination identified

in-cluded cost to parents or practice, parental

percep-tion that the vaccine is unnecessary, and physician or

nurse perception that three injections at one visit is excessive.7

The present study was an attempt to assess the

acceptance of universal hepatitis B immunization

among NICUs, nurseries, and pediatricians across

the United States. More than half of NICUs are

pro-viding HBV to their preterm infants. The majority do

so at discharge, but a minority initiate vaccination at

birth. Although the optimal time to initiate HBV in

preterm infants born to hepatitis B surface

antigen-negative mothers has not been established,8 the

liter-attire suggests that early initiation of vaccination

may lead to suboptimal seroconversion rates.9

Per-haps this information needs to be better

communi-cated to physicians caring for preterm infants to

op-timize the strategy of universal vaccination.

Although less than half of the participating term

nurseries are routinely vaccinating before discharge,

85% of pediatricians do initiate HBV by 2 months of

age. This high level of acceptance (higher than in any

previous study) may be related to the amount of time

that has elapsed since the recommendations were

promulgated. The principal reasons for not

provid-ing vaccination are financial. We did not find

prac-titioners to be overly concerned with adding a third

shot to well-child visits, or with the possible need for

booster doses.

Sus C. KIM, MD

LAURA N. Snsi, MD

ROSEMARY CASEY, MD

JENNIFER A. PiNTo-MTiN, PiiD

Division of General Pediatrics

The Children’s Hospital of Philadelphia Philadelphia, PA 19104

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766 EXPERIENCE AND REASON REFERENCES

I. Centers for Disease Control. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices

Advisory Committee. MMWR. 1991;40:1-25

2. Committee on Infectious Diseases, American Academy of Pediatrics. Universal hepatitis B immunization. AAP News. 1992;8:13-22

3. Centers for Disease Control. Protection against viral hepatitis: recom-mendations of the Immunization Practices Advisory Committee.

MMWR. 199039:1-26

4. Freed GL, Bordley WC, Clark SJ, Konrad TR. Reactions of pediatricians to a new Centers for Disease Control recommendation for universal immunization of infants with hepatitis B vaccine. Pediatrics. 199391: 699-702

5. Committee on Infectious Diseases. Universal hepatitis B immunization.

Pediatrics. 1992;89:795-800

6. Controversy surrounds policy of universal infant immunization against hepatitis B. Vaccine Bull. 1993$eptember:4-5

7. Freed GL, Bordley WC, Clark SJ, Konrad TR. Universal hepatitis B immunization of infants: reactions of pediatricians and family physi-clans over time. Pediatrics. 199493:747-751

8. American Academy of Pediatrics. Hepatitis B. In Peter G, ed. Red Book.

Report of the Committee on Infectious Diseases. 23rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 1994:231

9. Lau Y, Tam AYC, Ng KW, et a!. Response of preterm infants to hepatitis B vaccine. I Pediatr. 1992;121:962-965

Does

Hunger

Cause

Obesity?

Both hunger and obesity occur with an increased

frequency among poorer populations in the United

States.’6 Because obesity connotes excessive energy

intake, and hunger reflects an inadequate food

sup-ply, the increased prevalence of obesity and hunger

in the same population seems paradoxical. Although

a variety of environmental, social, behavioral, or

physiologic mechanisms could cause both problems

independently, an alternative possibility is that

hun-ger and obesity are causally related. The following

case report supports this hypothesis.

CASE REPORT

A.B. (not her real initials) was a 7-year-old African American girl first brought to the Weight Control Program of the Boston Floating Hospital in December 1992. At the time of her initial examination, A.B. weighed 80 kg and was 144 cm tall. According

to National Center for Health Statistics growth charts, she was 220% of her ideal body weight. Her triceps skin fold was greater than 40 mm, indicating that a substantial portion of her excess

weight was fat. Her blood pressure was normal. Acanthosis nig-ricans was present. Aside from her obesity, the remainder of A.B.’s physical examination was unremarkable. A urinalysis showed no glucosuria.

A.B. lived with her mother, a single parent, who was dependent

on Aid for Dependent Children and food stamps for the family’s support. Both parents had ahistory of obesity. Her father’s obesity improved after gastric bypass surgery. Her mother’s obesity improved after she developed hyperthyroidism. A.B.’s mother, maternal aunt, and maternal grandparents all had non-insulin-dependent diabetes mellitus.

As the clinic’s involvement with the family progressed, the mother indicated that household food shortages significantly

ian-Received for publication Mar 28, 1994; accepted Aug 16, 1994. Reprint requests to (W.H.D.) Tufts University School of Medicine/New England Medical Center, Box 213, 750 Washington St. Boston, MA 02111. PEDIATRICS (ISSN 0031 4005). Copyright © 1995 by the American Acad-emy of Pediatrics.

paired her abifity to provide her daughter with the low-caloric-density foods that we recommended for weight reduction. This was a particular problem before the time that the mother received her second welfare check each month. The first check of the month was spent on her rent payments, so that before the second check arrived, the family frequently lacked money to buy food. At these times, the family would rely on high-fat foods, such as pasta seasoned with extra oil, chicken wings, or beans and hot dogs, to prevent hunger. When we identified these times as potential pe-nods that contributed to her daughter’s obesity, the mother re-duced the fat she was serving but maintained the volume of food. Her daughter independently reduced her consumption of sugared fruit drinks and began to lose weight. At the time of her last visit, A.B. had lost 2.3 kg.

DISCUSSION

At least two possibilities could explain the

asso-ciation of hunger and obesity in the same patient.

In this family, the increased fat content of food

eaten to prevent hunger at times when the family

lacked the money to buy food represents the most

likely reason for the association of obesity and

hunger. An alternative possibility is that obesity

may represent an adaptive response to episodic

food insufficiency.

The most analogous animal and human models

to examine the latter possibility emerge from

re-cent studies of weight cycling. These studies arose

from the suggestion that weight cycling in humans

was associated with an increased morbidity and

mortality in humans.7 Likewise, studies of cyclical

food restriction in animals suggested that

subse-quent weight losses would occur more slowly and

weight regain more quickly as cycles of food

re-striction and refeeding progressed.8 Although only

limited support for each of these hypotheses has

been published,9”0 the effect of weight cycling on

body fatness has rarely been examined. Rats do not

seem to overshoot the weight of control animals

when food intake is restored after one or more

periods of food restflchofl9”2 In humans, studies

of women of normal weight13 and those who were

obese’4 suggested that cyclic dieters had

signifi-cantly more body fat and less fat-free mass than

women in their respective control groups who did

not diet cyclically. The small sample sizes and the

possibility that women who are obese or perceive

themselves as obese are more likely to diet

empha-size the caution with which these observations

should be interpreted.

The association of binge eating with dietary

re-straint among subgroups of adults who are obese15”6

may represent another example of a physiologic

ad-aptation to periods of food surfeit and insufficiency.

The suggestion that body weights of restrained

diet-ers who binge are greater than those of binge eaters

who are not restrained eaters supports this

hypoth-esis,’6 but no studies have linked self-reports of

re-strained eating directly with actual reductions in

food intake. Furthermore, the physiologic response

to cyclic dieting or binge eating among restricted

eaters may differ from the response to involuntary

food restriction.

Despite the limited resources available to the

mother and child described here, dietary

modifica-tions achieved weight reduction. Our observations

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1995;95;764

Pediatrics

Susan C. Kim, Laura N. Sinai, Rosemary Casey and Jennifer A. Pinto-Martin