In the JournalsPerspective

Foreign-born women in US less likely to be vaccinated against HBV

Foreign-born women of reproductive age living in the United States reported significantly lower rates of hepatitis B virus screening and vaccination compared with women of the same age born in the U.S., according to recently published research.

“In the United States, women of reproductive age who seek medical care are not universally offered hepatitis B vaccine,” Greta A. Kilmer, MS, epidemiologist in the CDC’s Division of Viral Hepatitis, and colleagues wrote in Clinical Infectious Diseases.

“Ideally, all women of reproductive age who reside in the United States would have been previously vaccinated for hepatitis B, nearly eliminating the risk of” mother-to-child transmission (MTCT), they wrote. “Although the Advisory Committee for Immunization Practices (ACIP) recognizes that persons born in or emigrating from HBV-endemic countries are at higher risk of having chronic HBV infection than the general U.S. population, U.S. hepatitis B vaccination recommendations do not specifically address vaccination of this population, and screening is not required for immigrants or refugees at the time of entry. Hence, vaccination and screening for HBV among women of reproductive age are crucial to eventually eliminate MTCT.”

Kilmer and colleagues compiled data from the 2013-2015 National Health Interview Survey to include selected adults’ responses to questions about HBV vaccination, screening history and individual and family characteristics. They estimated the prevalence of HBV vaccination and screening self-reported by U.S.- or foreign-born women aged 18 to 44.

Among 24,216 women included in the analysis, 18,897 were born the in the U.S. and 5,319 were not. A lower percentage of foreign-born women reported receiving at least three doses of HBV vaccine compared with U.S.-born women (27.3% vs. 40.9%; t test P < .05). Low rates of vaccination were reported for women born in Mexico and other part of Central America, including the Caribbean islands (18.4%); South America (25.3%); and the Indian subcontinent (31.7%).

There was a smaller percentage difference in screening prevalence between the cohorts, with 31.9% of U.S.-born women reported screening vs. 28.5% of foreign-born women (t test P < .05). Foreign-born Hispanic or Latina Mexican (21%) and Puerto Rican (21.9%) women reported the lowest screening prevalence.

Higher education in both U.S.-born and foreign-born women was associated with higher screening prevalence.

Regarding income, screening was most prevalent among U.S.-born women living below 100% federal poverty level (FPL) and among foreign-born women living at 400% FPL or above.

There was an association between screening prevalence and time living in the U.S., ability to speak English and U.S. citizenship among the foreign-born women.

“Women of reproductive age who migrated to the United States could benefit from targeted vaccination programs,” Kilmer and colleagues concluded. “Public health screening efforts for hepatitis B in the United States may require further assessment, especially for women born in world regions with moderate or high hepatitis B endemicity. Until HBV screening and vaccination among women of childbearing ages are addressed, MTCT of hepatitis B will likely continue to occur in the United States.” – by Bruce Thiel

Disclosures: The authors report no relevant financial disclosures.

Foreign-born women of reproductive age living in the United States reported significantly lower rates of hepatitis B virus screening and vaccination compared with women of the same age born in the U.S., according to recently published research.

“In the United States, women of reproductive age who seek medical care are not universally offered hepatitis B vaccine,” Greta A. Kilmer, MS, epidemiologist in the CDC’s Division of Viral Hepatitis, and colleagues wrote in Clinical Infectious Diseases.

“Ideally, all women of reproductive age who reside in the United States would have been previously vaccinated for hepatitis B, nearly eliminating the risk of” mother-to-child transmission (MTCT), they wrote. “Although the Advisory Committee for Immunization Practices (ACIP) recognizes that persons born in or emigrating from HBV-endemic countries are at higher risk of having chronic HBV infection than the general U.S. population, U.S. hepatitis B vaccination recommendations do not specifically address vaccination of this population, and screening is not required for immigrants or refugees at the time of entry. Hence, vaccination and screening for HBV among women of reproductive age are crucial to eventually eliminate MTCT.”

Kilmer and colleagues compiled data from the 2013-2015 National Health Interview Survey to include selected adults’ responses to questions about HBV vaccination, screening history and individual and family characteristics. They estimated the prevalence of HBV vaccination and screening self-reported by U.S.- or foreign-born women aged 18 to 44.

Among 24,216 women included in the analysis, 18,897 were born the in the U.S. and 5,319 were not. A lower percentage of foreign-born women reported receiving at least three doses of HBV vaccine compared with U.S.-born women (27.3% vs. 40.9%; t test P < .05). Low rates of vaccination were reported for women born in Mexico and other part of Central America, including the Caribbean islands (18.4%); South America (25.3%); and the Indian subcontinent (31.7%).

There was a smaller percentage difference in screening prevalence between the cohorts, with 31.9% of U.S.-born women reported screening vs. 28.5% of foreign-born women (t test P < .05). Foreign-born Hispanic or Latina Mexican (21%) and Puerto Rican (21.9%) women reported the lowest screening prevalence.

Higher education in both U.S.-born and foreign-born women was associated with higher screening prevalence.

Regarding income, screening was most prevalent among U.S.-born women living below 100% federal poverty level (FPL) and among foreign-born women living at 400% FPL or above.

There was an association between screening prevalence and time living in the U.S., ability to speak English and U.S. citizenship among the foreign-born women.

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“Women of reproductive age who migrated to the United States could benefit from targeted vaccination programs,” Kilmer and colleagues concluded. “Public health screening efforts for hepatitis B in the United States may require further assessment, especially for women born in world regions with moderate or high hepatitis B endemicity. Until HBV screening and vaccination among women of childbearing ages are addressed, MTCT of hepatitis B will likely continue to occur in the United States.” – by Bruce Thiel

Disclosures: The authors report no relevant financial disclosures.

    Perspective

    Image of William Schaffner

    The authors of this paper are intent on reducing mother-to-child transmission of HBV. Their particular concern is that foreign-born women of reproductive age often are not serologically screened for prior hepatitis B infection nor sufficiently often offered HBV vaccine. They cite a telling statistic: “An estimated one in five (20.1%) U.S. women who were of reproductive age from 2013-2015 were born outside the United States.” I should not have been surprised, because had the survey been done some decades earlier, my own mother would have been counted among the one in five.

    Using data from the National Health Interview Survey, the authors demonstrate that foreign-born women of reproductive age are notably less likely to be serologically screened or be vaccinated against HBV than their U.S.-born counterparts. I could quibble because these are specifics of clinical care that may not be imprinted in memories and could be challenging for many for whom English is not their first language. Nonetheless, the authors have a point in wondering whether screening/vaccination ought to be more routinely offered to this population.

    The critical issue is the prevention of perinatal transmission. Per the recently updated ACIP recommendations: All pregnant women should be tested for HBsAg during early pregnancy, all HBsAg-positive women should be tested for HBV DNA to guide maternal therapy (a new emphasis) and all infants born to HBsAg-positive mothers should receive hepatitis B vaccine and HBIG within 12 hours of birth. And, of course, every infant should receive the HBV vaccine series beginning at birth.

    Reference:

    Schillie S, et al. MMWR. 2018:doi:10.15585/mmwr.rr6701a1.

    William Schaffner, MD

    Infectious Disease News Editorial Board member
    Professor of preventive medicine, Vanderbilt University

    Disclosure: Schaffner reports being a consultant for Dynavax and a member of a data safety monitoring committee for Merck.