Strategies to control Hepatitis B infection in theState of Amazonas, Brazil.
Based on this inormation, we devel-oped a project to control HBV inectionin the State o Amazonas in September1987. This project was supported by the Brazilian Ministry o Health and Amazonas Government. The authorso this Project were: José Carlos Fer-raz da Fonseca, Leila Melo Brasil and Wornei Miranda Braga (researchers o the Fundação de Medicina Tropical do Amazonas). Strategies were based onrecommendations made by the ViralHepatitis Consultative Commission o the Ministry o Health, Brazil. In 1988,our rst task was to develop a program which educated local populations livingin 11 hyperendemic areas about thebenets o immunization. The program was implemented in two phases. Phase I In hyper-endemic areas o HBV and HDV inection, including the ruraland urban populations o 11 counties,all children 0 to 9 years old were vac-cinated (without previous screening).The target group included 27,893 inurban areas and 56,127 in rural areas.In Phase II, vaccination was gradually extended to the remaining counties o the western Amazon region, vaccinatingchildren 0-4 years o age.Following these campaigns, vaccination was targeted toward: a) all newborns(integration o the vaccine into theNational Programme o Immunization);b) immigrants to the north Amazonarea; c) all health care providers;d) multi transused patients; e) chronicrenal disease patients undergoing dialy-sis; ) Hansen’s disease patients;g) institutionalized (high risk patients);i) those o Asian origin; j) military personnel; k) indigenous populations;l) householders o HBsAg positivepeople; m) high risk groups (malehomosexuals, sex workers, intravenousdrug abusers). In October, 1989 (urban area), the vac-cination program against HBV inec-tion was initiated, using three doses,10 mcg recombinant DNA hepatitis B vaccine, on a 0, 1, 6 month vaccinationschedule. In January, 1990 the program was extended to the rural areas. Parallelto this special program, we conducteda pilot study to evaluate the immuno-genicity o two dierent doses (10 mcgand 20 mcg) o this vaccine in the vil-lage o Codajás (Solimões River, State o Amazonas), an HBV and HDV hyperen-demic area. Ater one year this special program was extended to 14 municipalities inthe State o Amazonas, along with theinitiation o the vaccination programamong health workers. During 1991, the vaccination program covered all chil-dren rom 0 to 4 years old living in the60 municipalities in our area. In 1992the vaccine against HBV inection wasintegrated into the Regional Program o Immunization o the State o Amazonas,Brazil. HBV vaccination was incorpo-rated into the National Program o Immunization in 1995, including PublicHealth workers and high risk groups o patients.
Results of hepatitis B vaccination programin the State of Amazonas, Brazil
In the rst year, coverage o HB vac-cine (special program) was extremely high with an estimated 82,020 children vaccinated. 97.5% o the target popula-tion received the rst dose, 89.6% thesecond dose and 78.1% the third dose.Four years ater the start o vaccination,the percentageo seroconver-sion (anti-HBs> 10 IU/l) was79% (10mcg)and 95,2% (20mcg), p<0.05.High geomet-ric mean titerso antibody were observedat 237.0 IU/Iand 610.0 IU/l with 10 mcgand 20 mcg,respectively. The high anti-HBs titersobserved in some children are probably the result o a natural booster responseater contact with HBV.By October 2006, the number o chil-dren < 1 year old ully vaccinated inthe State o Amazonas was 658,920. Inour region, rom 1994 to 2004 a total o 973,704 individuals rom 1 to 20 yearsold received three doses o vaccine. It is estimated that 45.2% o the generalpopulation living in the State o Amazo-nas have now been vaccinated.Changes in the prevalence o HBsAgcarriers and the incidence o HBV acute viral hepatitis in hyperendemic areas 10 years ater starting the immunizationprogramme (1989-1999) were dramatic.HB immunization reduced the preva-lence o carriers o HBsAg rom 15.3%to 3.7% in the village o Lábrea (Purusriver) and rom 16.7% to 5.8% in the o State o Amazonas (gure 2).Beore the mass vaccination in hyperen-demic areas, the etiology o acute hepa-titis was HBV in 51.4% and the HAV in42.1% o the cases. Ten years ater themass vaccination 94.6% o acute hepati-tis was due to HAV and only 3, 8% HBV.These results indicate that universal vac-cination o inants less than nine yearsold and the integration o HB vaccineinto the National Program o Immuniza-tion was eective in dramatically reduc-ing the endemic status o HB inectionin the general population, even in thehighly remote rural villages.
Eradication of Hepatitis B virus infection in the State of Amazonas
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2 • WORLD DIGESTIVE HEALTH DAY: VIRAL HEPATITIS
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