Edward S. Hume, M.D., J.D.: Chinadopt
Hepatitis and Hepatitis Vaccinations
updated 11/1/97
The basic question:
Do you get hepatitis A and hepatitis B vaccinations before you go to China?
Main answer: It depends
Perhaps the only bright side to the increase in time it now takes to adopt from China is that you now have plenty of time to complete a series of vaccinations against hepatitis A and B.
Did I get vaccinated against hepatitis as a child? Many people have received shots of pooled gamma globulin as a temporary passive immunization against hepatitis (usually A). If you're old enough to have kids, I believe you are too old to have had a hepatitis vaccine as a child. The old gamma globulin shots are only good for about two weeks. If you got one, you are not protected now.
You might get exposed to hepatitis in China. You can get vaccinated so that you won't pick it up yourself.
The child you adopt may have active hepatitis. Everyone in the family can get vaccinated --- even those who stay home --- before you go, so that the risk of contracting the disease from interacting with your new child is minimized. Imagine having to handle your child with gloves while you are waiting for your vaccination!
We have had so many hepatitis A outbreaks around here that our county passed an ordnance which requires anyone who handles food (including waitrons) to wear plastic gloves. It is NOT a harmless disease.
Why gamble with your life? Although hepatitis B is normally picked up from contact with blood or other body fluids, a friend of mine picked up by drinking contaminated water in Uruguay. Please consider: if a virus or organism can be picked up by sexual contact (and hepatitis B can be), then warm water or other friendly media could harbor the germ long enough to infect you. Certainly hepatitis B transmission within families is well known. Certainly changing a diaper will put you in contact with "bodily fluids".
Hepatitis B is getting to be enough of a risk in the US that infants now get immunized against it. Routine vaccination implies safety. However, there may be a risk of an autoimmune reaction to the vaccination. This has recently come to my attention and I will post statistics if and when they become available.
You may wish to get both vaccinations (hepatitis A and hepatitis B) as soon as you begin thinking about possibly adopting. If you never adopt, you're still immunized. BOTTOM LINE --- consult with your internist on the risks of exposure versus the risks of vaccination.
Hurry-Up Vaccination Schedules for those traveling soon
More about the ease of getting hepatitis A
How hepatitis B causes disease
Affordability and getting your insurance plan to pay for the vaccinations
Dr. Hendrie's take on these vaccinations
A Letter from a-parents-list on reasons for getting vaccinated.
Dr. Luce on hepatitis A and hepatitis B
A comprehensive Statement on Hepatitis B by pediatricians from adoption-involved institutions.
The Hepatitis B Foundation. Lots of information about hep B.
Hurry-Up Vaccination Schedules
I got on Physicians On-Line and did a MEDLINE search on 2/17/96. I came up with the following abstracts:
If you are looking at going very soon, have your doctor look up the first two papers. The point is this: modifying the vaccination schedule will give you an immunity quickly. You can take boosters later to make it permanent. If you are going to get vaccinated, do it now.
1. Marchou B, Excler JL, Bourderioux C, Salaun J, Picot N, Yvonnet B, Cerisier JE, Salomon H, Auvergnat JC
A 3-week hepatitis B vaccination schedule provides rapid and persistent protective immunity: a multicenter, randomized trial comparing accelerated and classic vaccination schedules.
Service des Maladies Infectieuses et Tropicales, Hopital Purpan, Toulouse, France.
J Infect Dis. 1995 Jul;172(1):258-60
Article Number: UI95318538
ABSTRACT:
Hepatitis B (HB) vaccinations given once weekly for 3 weeks can provide early seroprotection. This study compared immune responses induced by the accelerated (A; days 0, 10, 21) and classic (C; days 0, 28, 56) HB vaccination schedules. Two hundred seventy healthy subjects (95 men, 175 women) with a mean age of 23.8 years received 3 doses of GenHevac B, a recombinant vaccine produced in mammalian cells. The subjects were randomly assigned to schedules A or C. A booster dose was given 1 year later. One month after the third dose, 70% (schedule A) and 92% (schedule C) of the subjects were seroprotected and 100% (A) and 99% (C) had developed anti-pre-S2 antibodies. Before booster injections, 93% (A) and 95% (C) of the subjects were seroprotected, and 1 month after the booster, almost all subjects were seroprotected. A 3-week HB vaccination schedule with GenHevac B can confer early protective immunity lasting up to 1 year.
[Note that their standard schedule is at 0, 4 and 8 weeks, as opposed to the U.S. standard of 0, 1 and 6 months. The French schedule would leave most of us vaccinated with plenty of time to travel.]
2. Sandman L, Davidson M, Krugman S
Inactivated hepatitis A vaccine: a safety and immunogenicity study in health professionals.
Department of Pediatrics, New York University School of Medicine, New York 10016.
J Infect Dis. 1995 Mar;171 Suppl 1():S50-2
Article Number: UI95181911
ABSTRACT:
The safety and immunogenicity of an inactivated hepatitis A vaccine (HM175) were evaluated in 151 seronegative health professionals (age range, 21-65 years; mean, 30). A 720-ELISA unit dose was administered to 78 vaccinees at 0, 1, and 6 months and to 73 vaccinees at 0, 1, and 12 months. Seroconversion rates were 90% in both groups 1 month after the first inoculation and 99% and 100%, respectively, 1 month after the second inoculation. Geometric mean antibody titers (GMTs) 1 month after the third inoculation were highest in the group vaccinated at 0, 1, and 12 months. GMTs were higher in women than in men. The vaccine was well tolerated; the most frequent side effect was transient soreness at the site of inoculation. No serious adverse reactions were observed. Thus, HM175 inactivated hepatitis A vaccine is safe and highly immunogenic.
[Note the high success rate one month after a single shot, and the virtually complete success two months after starting (i.e.-one month after the second shot).]
The CDC has this to say: "For adults [the vaccine] is given in a two dose schedule with the second dose administered 6-12 months after the first. For children and adolescents [the vaccine] is given in a 3 dose series; the second dose 1 month after the first dose and the third dose 6-12 months after the first dose. Travelers can be considered to be protected four weeks after receiving the initial vaccine dose. Individuals who will travel to intermediate or high risk areas less than 4 weeks after the initial dose of vaccine should also be given IG (0.02 ml/kg of body weight), but at a different injection site."
Again, unless you're leaving next week, it's probably a good idea to get the vaccine. If you're leaving next week, get a gamma globulin shot (your doctor will explain it to you).
VHPB: summary of strategies and recommendations. Viral Hepatitis Prevention
Board.
WHO Regional Office for Europe, Copenhagen, Denmark.
Vaccine 1995;13 Suppl 1():S61-3
Article Number: UI96047684
ABSTRACT:
The Viral Hepatitis Prevention Board (VHPB) believes that stronger action is needed to control hepatitis B. Vaccinating those identified as at 'high risk' has failed to make a significant impact on the epidemiology of the disease. Many people with hepatitis B do not fall into any of the 'classic' high-risk groups and efforts to reach these groups have been unsuccessful. The VHPB supports the recommendation of the World Health Organization (WHO) that hepatitis B vaccine should be incorporated into national universal vaccination programmes by 1997. The recommendation came initially from the Global Advisory Group of the Expanded Programme on Immunization and was endorsed in 1992 by the World Health Assembly, the governing body of WHO which consists of representatives of all WHO member states. The WHO Working Group on the control of viral hepatitis in Europe, which met in Munich in 1991, concluded that the routine immunization of infants and adolescents should receive the highest priority. Universal infant and adolescent strategies have their own benefits and drawbacks; the VHPB has looked carefully into the rationale for and against these strategies. The prerequisites for implementing these strategies are discussed. A combined infant and adolescent strategy emerges as having many of the advantages of the individual approach and fewer disadvantages. Universal vaccination is clearly the most effective strategy for preventing hepatitis B. Its timely and successful implementation, even in countries with medium and low prevalence, is a priority. There is no reason why hepatitis B should not follow the success of smallpox, polio, diphtheria and measles vaccination.
["Universal vaccination" means we all get shots, which is what I'm urging.]
From: Bryan Green
Sent: Monday, March 04, 1996 7:58 PM
Subject: vaccinations
One major reason to get the Hepatitis B vaccinations before
travel is purely emotional. If your child should test positive,
you won't have to worry about risk of transmission, and you can
treat your child as lovingly as possible without worry of
exposure. . You may find, if your child tests positive, that you
become caught up in a roller coaster ride of getting information
- and you may also find that health care workers are not as well
informed on transmission within families as you might like. They
have been known to give information that frightens families
unnecessarily. If you and the rest of your family are already
immunized, you don't have to worry about rushing around to get
shots and worrying about what if you were exposed before you knew
your child would test positive. Don't make the mistake of
assuming your child will not test positive - it can happen and it
has happened. Some families opt to read the limited info agencies
give on Hep. B, and disregard this, assuming it could happen to
someone else. If you go on the assumption that you just might be
the family that gets to bring home a wonderful little child who
just happens to test positive, then getting the shots is the
obvious route to go.
Back to list of papers
The ease of picking up hepatitis A
first, a posting by Nancy Hendrie, M.D.
(as of early 1996, this pediatrician had made 17 trips to China with groups of adopting parents. Dr. Hendrie posted this on the A-Parents China list 3/4/96)
I would not DREAM of traveling to any third world country without Hep A protection --- either the Hep A vaccine (2 shots if 6 months lead time) or at least one of them at least two weeks before travel; if inadequate time for the vaccine, get gamma globulin (which gives three months protection) as you are ready to leave. Hep A is NOT a trivial disease in many adults, as it may be in many youngsters. It is common in orphanage populations (as it is in some day care populations in this country). It is passed in contaminated food or water, or e.g., by handling gastrointestinal waste of an infected person.
Water sources are not always dependable --- and handwashing among food handlers is often just not even a thought. (Ask to see the latrine facilities for the kitchen help when you get out in the provinces --- can be really educational --- often not any hand washing facility at all, in pretty primitive toilet facility) In addition, commonest fertilizer in China is "night soil" --- It is easy to get Hep A protection- DON'T leave home without it!
Hep B protection is a great idea too, and highly recommended, but IT IS NOT spread in food and water; you can get it after you get home if your child is positive. (Spreads by blood contact, venereal, needles}
NW Hendrie M.D.
and a 3/5/96 posting in response to a question on gamma globulin:
If you note my suggestion carefully --- gamma globulin is suggested for those people who do NOTHING until less than two weeks prior to leaving- then gamma globulin is better than nothing for protection against Hep A, a very real problem in China. (there is no antibody response from the new Hep A vaccine adequate to protect you if you have less than 2 weeks to trip time, in fact the CDC says you need 3 weeks to build antibody.) Gamma globulin is heat treated and fully screened; I think it is irresponsible to infer scary things --- I agree, it is ONLY designed to protect against Hep A in this case , but that is really the most likely thing you need to be protected from while ON THE TRIP. (My advice comes from Massachusetts General Hospital and the CDC --- that's good enough for me!)
NW Hendrie MD
Dr. Hendrie's views on health issues of Chinese adoptees (on the FCC website)
And a posting from an e-mail list:
From:
PATGORM@oitvms.oit.umass.edu
Sent: Friday, March 29, 1996 11:29 AM
Subject: Re: Hepatitis shots
I really recommend those shots. During my first trip I picked up some kind of hepatitis something. It remains only vaguely diagnosed, but when I returned from China and had blood work done for life insurance, I was turned down due to soaring liver function numbers! I didn't feel ill, so this took me by great surprise. As I said, the doctor couldn't definitely diagnose it, but he was sure it was not the result of the shots themselves. The liver function numbers lowered slowly over about 6 months, and after a while returned to normal. I was quite careful in China in terms of what I ate, drank and other health habits, so I was impressed by how easy it was to pick up "something".
During my second trip I managed to stay well.
Patricia
PATGORM@oitvms.oit.umass.edu
How hepatitis B causes disease
All things "-itis" are inflammations. Hepatitis B is an autoimmune response to hepatocytes infected with HBV.
Translation: Hepatitis B is a body's attack on its own liver cells with germ-killer cells and antibodies. The body's immune system attacks the liver cells because they are infected with the hepatitis B virus.
Active Hepatitis B is where there is virus loose in the blood stream and the body's immune system is attacking liver cells.
One can have a chronic (long-lasting) active (ongoing) hepatitis (inflammation of the liver cells) without having viruses in the blood stream. One can also have an on-again, off-again Hepatitis.
On the other hand, being a hepatitis B carrier means that one has hepatitis B virus particles in the blood stream without an autoimmune response --- that is, no hepatitis.
Although some carriers and some people with other forms of persistent hepatitis B can develop serious health problems, many also can lead relatively active lives. In other words, it is not a physical or psychological death sentence: if your kid has Hepatitis B, in other words, don't despair. Just get competent medical help. See also Is There Life after Hepatitis B on the FCC website.
If your kid has Hepatitis B virus in her blood, and if you and all who will hold her have been successfully vaccinated, your risks of contracting Hepatitis B are very much lower. You will not have to gown and glove to give her the physical attention she needs (and you want to give her).
Dr. Luce on Hepatitis A and Hepatitis B
From: LuceMV@aol.com
Sent: Thursday, March 28, 1996 11:53 PM
Subject: A Pediatrician's Two Cents
[Dr. Luce is a pediatrician in a large children's hospital in
Philadelphia]
(I'm trying to simplify this somewhat for clarity. For those with more questions, I suggest the CDC's WWW page and/or a book that any university medical library or pediatrician/GP/family doc should have called "1994 Red Book." The "red book" is our bible when it comes to the most current US recommendations for infectious disease issues in children).
Hep A is generally a mild "GI" bug in most little tikes causing fever, loss of appetite, nausea, and actually, most common of all, *no* symptoms at all in infants and preschoolers in daycare centers. Adults, on the other hand, usually get pretty hammered by Hep A. (Incidentally, the same thing happens with chicken pox-- as a kid, *usually* just a nuisance -- but as an adult, *usually* much more severe) Adults more commonly get yellow or jaundiced from Hep A and are more likely to progress to fulminant hepatic failure. There is no carrier state, and it is possible to become immune once you've had the infection. Note that I said "possible." The only way to make sure you're immune is to have an obscure blood test or simply to get the vaccine "Havrix." Why bother?
*Because,* it is VERY easy to get in close, one on one child care situations; it is VERY hard to tell if a certain child has Hep A because most little kids have no symptoms, and because China is one of many countries where Hep A is endemic. The vaccine also happens to be cheap, when compared to a liver transplant. Ask your doctor to help you work with your insurance co. to get them to pay for the vaccine, if possible.
Every kid in the US is now being vaccinated with Hep B vaccine in infancy. You get Hep B largely through the same routes as HIV (i.e. unprotected sex, needle sharing/IV drug abuse, body fluid exchange, hetero- & homosexual sex...) but it's MUCH easier to get (i.e., by being a close household contact). We're vaccinating infants for risks they only might experience later on in life, for one very good reason. Infants have mom's and dad's who take them to the doctor. We think the vaccine's protection is lifelong, so it makes sense to give it when we're seeing kids regularly. The other reason is that Hep B is a lousy disease to get. Once you get it, it is possible to become "chronically infected" or a "carrier." They are both the same thing; essentially the virus is hanging out in your system waiting to either 1) infect someone else 2) give you liver cancer or 3) give you liver cirrhosis. Hep B is endemic in China, it's hard to tell who has it (again fancy blood tests are needed), it is easily transmitted by close contact, eventually the entire US population will be immunized, and YOU SHOULD BE TOO! Again Hep B vaccine also happens to be cheap, when compared to a liver transplant. Ask your doctor to help you work with your insurance co. to get them to pay for the vaccine, if possible.
Please confirm what I've said above with what your own doctor advises if you have questions. My babble above is intended merely as info, not as formal medical advice. ( my lawyer will be so proud of me, for that little disclaimer! :-) )
I can be reached at <rescuebird@aol.com>
-Geoff
LuceMV@aol.com
From: LuceMV@aol.com
Sent: Monday, April 01, 1996 9:47 AM
Subject: Re: A Pediatrician's Two Cents
Thank you for your note. I am now realizing how much my note proved that "the best laid plans oft go awry."
Discouraging people from adopting in China was the last thing I had intended, but after reading your note, I can see how one might read that into my note. You are clearly well read on the subject, and I wouldn't discount yourself as a "layperson." My goal in simplifying the matter was purely to demonstrate the benefit of vaccination not the seriousness or prevalence of hepatitis in China. You're absolutely right, the risks are small and are *not* a reason not to adopt in China. Rather than launch into a technical and detailed discussion of hepatitis' risks, prevalence, etc. (which your resources, the CDC, and infectious disease experts have already done nicely), I merely chose to say to people; "Hey, why not make all that discussion a moot point and simply get the vaccines?"
To answer other questions in your letter-- The earlier one gets Hep B, the more likely one is to have problems. (i.e. evidence of liver irritation and a higher future risk of cirrhosis or cancer). But, the vast majority of people who get Hep B merely become carriers. Other than the risk of transmitting hepatitis to someone else, the vast majority of carriers do not experience any other problems, nor do they go on to cirrhosis or cancer. They might be more likely, though, to have their disease reawaken and transition to cirrhosis, cancer, or other problems, if they had something else throw their immune system off-track (i.e., if they were immune-suppressed with chemotherapy, AIDS, etc.). So, everyone who gets Hep B experiences life altering symptoms in the *short term* acute phase of the disease (nausea, jaundice, and the unlikely possibility of fulminant hepatic failure). After the initial illness, a few become naturally immune and, therefore, are not carriers. Most become carriers and live normal lives (except they can give Hep B to someone else, and they can get into trouble if they had their immune systems thrown off track), a few of these carriers develop laboratory evidence or even clinically visible evidence of liver irritation and therefore have chronic hepatitis. Even speaking of these folks in particular,( those with chronic hepatitis,) only a small percentage will go on to cirrhosis or cancer.
So what's the bottom line? For what it's worth, I (and my wife) are absolutely going to adopt from China, and we are both going to get the available hepatitis vaccines (Havrix and Hep B). When we get back, I think it would make sense to find out what our daughter's hepatitis status is. Has she had the disease and become immune? is she a carrier? or does she have lab evidence of liver inflammation and therefore is she one of the small percentage of carriers who also have chronic hepatitis?
I hope my rambling-on above helps! And I apologize for the over-dramatization in my initial note.( I had hoped the response to my note would be "Yecch, hepatitis sounds lousy, lets just get the vaccines" rather than "Yecch, hepatitis sounds lousy, lets forget adopting from China."
Cheers! --Geoff<<
[I, for one, do not believe Geoff over-dramatized the issue at all. When you think how much we are spending to adopt and raise children, the cost of the vaccinations takes on a certain perspective. Our biological children could develop hepatitis here in the U.S. without our ever leaving the country. --- Ed]
Affordability
and getting your insurance plan to pay for the vaccinations
From: Judy Stevens
Sent: Tuesday, April 09, 1996 9:55 PM
Subject: Re: Will HMO Pay for Hep Shots?
Initially our HMO told us they wouldn't cover the cost of Hepatitis A and B vaccines since they were considered to be 'travel vaccines'. We had also explained to them that we were going to China to adopt our daughter and would be living with her for several weeks before we would be able to have her tested for Hepatitis B.
We then wrote a strong letter to both our primary physicians and the HMO citing
- the high incidence (60%)of Hepatitis B within the Chinese
population
- the easy transmission through close family contact (diapering,
etc.) and
- that by not paying for our vaccines they were unnecessarily
putting us (her
parents) at risk of acquiring the disease as well since we would
not be able to
have our daughter tested for Hepatitis B until after we had
possibly been
exposed by our daughter.
We also demanded to have a letter signed by the director of the HMO indicating the reasons for their refusal.
They paid for the shots.
Judy Stevens <blvd27@capital.net>
From: alliance
Sent: Wednesday, May 01, 1996 12:46 AM
Subject: RE: Hepatitis vaccinations and insurance
We recently went through the struggle of getting Hepatitis
A & B vaccinations approved through our HMO. They would not
cover ANY travel-related vaccinations (considered a luxury item).
But, once I cited the CDC recommendations from the CDC website
and stressed that we wanted the vaccines because we would have a
dependent child at potential risk of Hepatitis, they willingly
provided the vaccinations. Once I'd gotten that far, they went
ahead with Hep A as well.
Hepatitis A is usually transferred via the oral-fecal route and would most likely be contracted by ingesting contaminated food or water. However, I believe a case can be made that your child could be infected with Hep A when you get her. Then, if you were to change her diaper and forget to wash your hands before dinner...voila! Having a family member with the disease (or at risk of) was definitely the deciding factor on whether or not our HMO would cover the expense (even though the doctor ordered the vaccinations). In fact my HMO's plan office was directly referred to the CDC recommendations.
I suggest you do not even mention the fact you are traveling to get her, because they will TUNE OUT the minute they hear the word travel! Just stay with the justification that you are adopting a child who could be at risk. It may just work for you!
alliance <alliance@e-z.net>
BOTTOM LINE #1-Get both hepatitis A and B vaccination series as soon as you begin thinking about possibly adopting. If you never adopt, you're still immunized.
BOTTOM LINE #2-It's probably not too late to get your vaccinations until you have less than one month before you leave. At that point, it's probably best to get a gamma globulin shot within a week of travel (on the other hand, when I had one in college, it HURT!).
BOTTOM LINE #3-Since your child may come home with hepatitis, everyone in the family should get vaccinated --- including those staying home.