88%, 81%, and 87%, respectively. Although a disparity in the vaccinations rates persisted, the gap was narrowed (Szilagyi et al., 2002).

Other studies also have found that school-entry mandates are effective in increasing hepatitis B vaccination rates (CDC, 2001b; Koff, 2000; Olshen et al., 2007; Zimet et al., 2008) although such mandates may not be as effective in children in daycare (Stanwyck et al., 2004). CDC (2007) found that about 75% of states reported at least 95% hepatitis B vaccination coverage of children in kindergarten in 2006–2007. Another study reported that hepatitis B vaccine series coverage for children 19–35 months old in 2000–2002 ranged from 49% to 82%, depending on the state (Luman et al., 2005).

Special attention needs to be given to vaccination coverage of foreign-born children from countries that have a high prevalence of hepatitis B; because of their high risk of prior infection, laboratory testing is indicated to determine HBV-infection status.

Recommendation 4-2. All states should mandate that the hepatitis B vaccine series be completed or in progress as a requirement for school attendance.

Parents of foreign-born children from HBV-endemic countries should be given information about testing for HBV and should have their children tested before vaccination.

Adult Vaccination

Hepatitis B vaccination for adults is recommended to high-risk populations—people at risk for HBV infection from infected household contacts and sex partners, from occupational exposure to infected blood or body fluids, and from travel to regions with high or intermediate levels of endemic HBV infection (Mast et al., 2006). The estimated chance that an acute HBV infection will become chronic decreases with increasing age (see Table 4-3). The probability that an acute HBV infection in a 1-year-old will become chronic is 88.5%, but only 9.0% in a 19-year-old (Edmunds et al., 1993). Universal hepatitis B vaccination for adults is not recommended (that is, people born before 1991 do not need to receive the hepatitis B vaccine unless they are at risk for HBV infection). It is not cost-effective; that is, the health benefits achieved do not justify the cost compared with other potential health-care interventions (Gold et al., 1996). Interventions in the United States that cost less than $100,000 per quality adjusted life year (QALY) gained are generally considered to be cost-effective (Owens, 1998; WHO, 2009). Universal hepatitis B vaccination is not cost-effective even in adult Asians and Pacific Islanders, who have a higher prevalence of HBV



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