Pediatricians Take the Lead in Fight to Halt Hepatitis B : Health: The U.S. government and a doctors' group call for vaccination of children--who generally are not at high risk--as well as adolescents, in attempt to head off disease's spread.

By SHARI ROAN

June 2, 1992 12 AM PT

TIMES HEALTH WRITER

Like many parents around the nation, Cathi Thomas of Arcadia was perplexed this spring when a pediatrician recommended a new immunization--against the hepatitis B virus--for her children.

“I was totally surprised,” says Thomas, whose children are 5 and 2. She didn’t know the disease had become so widespread, she says, and was “confused about what hepatitis B is.”

Thomas is hardly alone. Physicians, health clinic operators and many parents are taking a crash course on the hepatitis B virus (HBV), after the release of new guidelines from the federal government and the American Academy of Pediatrics that call for vaccination for all infants, children and adolescents.

The new strategy is unusual in that most childhood vaccines target diseases that threaten children, like measles, mumps and pertussis.

Children under age 12 are generally not considered to be at high risk for HBV. But by immunizing infants now, health officials hope to eradicate the disease in the next three decades. “The thinking is if we can immunize newborns at this time, perhaps we will have a completely immunized population in 15 years or so,” says Dr. Richard J. Duma, director of the National Foundation for Infectious Diseases.

A scarcity of funds to purchase vaccine will mean the recommendations will not go into effect for several months in many public health departments.

Hepatitis B is a highly contagious virus that can produce flu-like symptoms, jaundice and, eventually, cirrhosis or liver cancer. It has no cure, although treatment can reduce the symptoms. The consequences for infected youngsters are particularly grave: An estimated 25% of all carrier infants will die from liver cancer or cirrhosis during their adult lives.

Although the disease is spread primarily through sexual contact or from infected mothers to their infants at birth, it also can be transmitted through blood products, contact with open skin lesions and saliva.

Infection rates in the United States increased dramatically in the 1970s and early ‘80s before a vaccine became available. Although the vaccine has been available for the last decade, federal health officials say the national strategy on who should get the vaccine has failed. In recent years, the vaccine was recommended for anyone at high risk: primarily pregnant women with HBV, heterosexuals and homosexuals with multiple sex partners and intravenous drug users.

But hepatitis B rates have not dropped significantly. An estimated 300,000 Americans are still infected yearly, making the virus second only to gonorrhea as the most common reportable sexually transmitted disease. One in 20 Americans is estimated to be infected with HBV. The virus is 100 times more contagious than the virus that causes AIDS, says Duma.

“We’ve tried just to target high-risk groups,” Duma says. “That strategy has failed. It has not cornered the disease at all.”

High-risk adults still should be immunized and widespread immunization of adolescents should have a more immediate effect, curbing HBV rates during the next few years.

“The incidence of hepatitis B really takes off between the ages of 12 and 18,” says Dr. Wilbert Mason, director of the division of infectious diseases at Childrens Hospital in Los Angeles. “That’s when adolescents start acquiring it because of (sexual) activity.”

Two major problems remain in the effort to eradicate hepatitis B:

* The federal government has not allocated sufficient funds to make the vaccine available to all children and adolescents.

* Many people know little about HBV. Because the virus can be spread from mother to child or through casual contact, public health officials say even many pediatricians fail to recognize it as a common sexually transmitted disease. Parents rarely view it as a threat to their children and teen-agers.

For reasons that are poorly understood, some people become permanent carriers (at least one million Americans) and can infect others.

Among those carriers, about half suffer from active, chronic infections and become very ill. The rest, who experience no infection or symptoms, can infect others unknowingly and are called silent carriers.

“Of the large percentage of people who become infected, there is a significant number who will go on to experience chronic relapsing hepatitis, or cancer of the liver or cirrhosis,” Duma says.

The younger a person is when infected, the more likely that person will become a carrier and become severely ill later in life. Between 25% and 50% of children infected before age 5 become carriers; 6% to 10% of all infected adults do.

Because sexually active people ages 18 to 39 are most likely to contract the disease, they are a priority for immediate immunization. Among children, the dearth of public funds for immunization will mean that only newborns and adolescents will be targeted for vaccination now.

At the Los Angeles County Health Department, officials say that HBV vaccine is still available only to high-risk adults, infants of women who are carriers, their family members and those exposed to them on a regular or intimate basis. (Immunizing a newborn infected by his or her mother can help prevent the development of infection.)

But health officials say they expect the federal government to make vaccine available this summer to begin immunizing all infants in the public health-care system.

Meanwhile, several large health maintenance organizations, including Kaiser Permanente, have begun immunizing all infants. Kaiser officials say they also offer vaccination to older children and adolescents who are at high risk of infection.

Private health insurance usually does not cover immunizations of any kind. So parents of children ages 1 through 12 should discuss the costs and benefits of hepatitis B vaccination with their pediatricians, says Dr. Caroline Hall, chairwoman of the American Academy of Pediatrics’ Committee on Infectious Diseases. The vaccine costs the private physician almost $11 a dose. With costs for administering the shot, parents can probably expect to pay double that--about the same as they pay for other childhood immunizations.

Because pediatricians don’t usually worry about or see hepatitis B in their patients, Hall fears they will decide the vaccine is not important enough to recommend to parents.

“We’re asking pediatricians to bear the burden of immunizing children for a disease that will occur as adults,” Hall says.

Newborns should receive three inoculations of HBV vaccine: While still in the hospital, again at 1 to 2 months and then between six and 18 months. This schedule can be altered for infants who do not receive their first dose until after leaving the hospital.

The doses can be given safely, doctors say, at the same time as other childhood vaccinations. Officials predict that HBV vaccine will soon be combined with another common vaccine, possibly DTP (diphtheria-tetanus-pertussis).

For older children and adolescents, the first two doses of the vaccine should be given one month apart. The third dose is recommended six months after the first inoculation but can be given later.

Health officials don’t expect a debate over the vaccine’s safety, says Dr. Nick Roulakis, an Arcadia pediatrician who recommends the vaccine:

“We know parents have concerns about the safety of the vaccine. But there are no serious side effects reported in children. The vaccine is very safe. This is probably the most technologically advanced vaccine that we have.”

That safety stands in stark contrast to the potential repercussions of contracting hepatitis B, health officials say. But convincing sexually active teen-agers of such risks is not easy. Moreover, providing the entire three-shot HBV regimen will be difficult during the teen-age years when visits to doctors become less common.

“One of the missions we’re undertaking is to educate the adolescent and young adult population that (hepatitis B) is out there,” says Duma, of the infectious diseases foundation. “It’s very common. You don’t know when you’re going to encounter it.”

Studies estimate that HBV is sexually transmitted in about half of all cases. And yet, Duma points out, a recent survey showed that only 12% of the adults questioned knew that the disease could be sexually transmitted.

Wendy Marx doesn’t recall hearing any warnings about hepatitis B while a student at Duke University during the 1980s. Marx fell ill with HBV in 1989, five months after graduating and moving to San Francisco to begin her marketing career.

“I was like a lot of people my age; everyone told me about AIDS, but no one told me about hepatitis B,” says Marx, 24.

Marx developed flu-like symptoms and eventually became jaundiced--a telltale sign of HBV infection. Three weeks later she lapsed into a coma, the infection raging in her liver. Marx required two liver transplants (the virus attacked her liver after the first) to survive. She still carries the hepatitis B virus, but it is now inactive and she has no symptoms.

“It’s a tragedy that anyone should get this,” Marx says. “The vaccine has been around for 10 years. I think young people would get the vaccine if they knew the facts about how serious hepatitis B is and that it’s completely preventable. But people don’t know about hepatitis B--even though it’s 100 times more infectious than AIDS.”

Candidates for Immunization

Who should be immunized with Hepatitis B vaccine?

* Newborns and infants under one year old.

* Hemophiliacs and other recipients of some blood products.

* Intravenous drug users.

* Heterosexuals, especially adolescents and young adults, who have had more than one sex partner in the previous six months.

* Heterosexuals who have recently had a sexually transmitted disease.

* Sexually active homosexual and bisexual males.

* Those who have had household or sexual contacts with HBV carriers.

* Those who have had household or other contacts with people from countries with high HBV infection rates.

* Staff and residents of institutions for the developmentally disabled, especially if attended by known HBV carrier.

* Hemodialysis patients.