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Taking a Shot at Protection

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Taking a Shot at Protection OUTLOOK LIVER CANCER HEMIS/ALAMY A mother and baby at a hospital in Baganuur, Mongolia. Infant vaccination against hepatitis B could reduce the country’s cripplingly high rate of liver cancer. VACCINES by vaccinating as many children as possible; they have made considerable progress, but the virus is proving to be a tricky target. Not all chil- dren are getting vaccinated, and those who are Taking a shot at still sometimes get infected. Until those gaps can be closed, and until decades have passed and immunized children grow into adulthood, HBV will remain a major threat to public health. protection Early vaccination is crucial in the fight against HBV, which is generally transmitted during childbirth or through dirty needles or sex. More A vaccine to prevent hepatitis B, the most common cause of than 90% of adults exposed to the virus clear the liver cancer, has promise — and limitations. infection within six months, most with few or no symptoms. But the younger that someone is exposed, the greater the odds of a chronic BY KAREN WEINTRAUB sees hope for the future. Four years earlier, he infection. Younger immune systems seem to helped that same woman to deliver a healthy be less able to fight the infection without help, he worldwide hepatitis B virus (HBV) baby boy. The infant immediately received the says Vinh Pham, an infectious-disease specialist epidemic frequently feels personal for HBV vaccine, greatly increasing the odds that at the New York University Langone Medical Indermohan Narula, a physician in he would not develop the same disease as his Center. If infants are exposed to HBV during TUlaanbaatar, Mongolia. Earlier this year, he saw mother. Stories such as this portend a healthier birth, immediate vaccination can erase the virus a young woman whose liver was so scarred by future for Mongolia, which currently has the from their systems. But an unvaccinated child HBV infection that, were she to continue her world’s highest rate of liver-cancer mortality who picks up the virus during the first year of pregnancy, she would have put her life at risk. — here and elsewhere, the main cause of this life will almost certainly develop a chronic infec- Her liver disease was untreatable, so he did what disease can be eliminated by the HBV vaccine. tion, and 15–25% of these children will eventu- he could: he encouraged her to protect herself by More than 240 million people worldwide are ally die from related liver cancer or cirrhosis. ending the pregnancy and avoiding fatty foods chronically infected with HBV, according to The World Health Organization has recom- and alcohol. “The question now is what she can the World Health Organization, and the virus mended universal infant vaccinations against do for herself and her family,” he says. is responsible for just over half of the world’s HBV since 1992. As of 2012, 183 nations rou- Despite such sad encounters, Narula, who cases of liver cancer and about 30% of all cases tinely vaccinate infants, and 79% of children is team leader of the Global Fund to Fight of cirrhosis (scarring of the liver)1. Public-health worldwide are protected. “That was really AIDS, Tuberculosis and Malaria in Mongolia, officials are trying to protect future generations the first vaccine that got [widespread] uptake S12 | NATURE | VOL 516 | 4 DECEMBER 2014 © 2014 Macmillan Publishers Limited. All rights reserved LIVER CANCER OUTLOOK in the developing world,” says Paul Offit, an holding. The data suggest that booster shots infectious-disease specialist at the Children’s IMMUNITY BOOST are not generally needed — at least so far, says Hospital of Philadelphia in Pennsylvania. Taiwan launched a programme of universal Chien-Jen Chen, a liver-cancer researcher and As with most vaccines, however, implemen- infant vaccination against hepatitis B virus vice president at the Genomics Research Center 1348–1355 (2009) (HBV) in 1986. Since then, rates of HBV tation rates are still below where they should infection in the country have tumbled, along at Academia Sinica in Taipei. “It seems to be 101, be, says Neal Halsey, director of the Insti- with rates of childhood liver cancer. that the hepatitis B vaccine has very long-term tute for Vaccine Safety at the Johns Hopkins 30 protection,” he says. Bloomberg School of Public Health in Balti- But vaccinations do not always guarantee more, Maryland. The problem is particularly 22.5 complete immunity. A study first published in acute, Halsey says, in central African countries, 2012 found low rates of infection — around which have some of the highest rates of HBV in Taiwan 15 2% — in nearly 9,000 Taiwanese high-school 3 ET AL. J. NATL CANCER INST. CANCER INST. AL. J. NATL ET infection. More vaccinations in these countries students who had been vaccinated as children . 7.5 would greatly reduce rates of cirrhosis and liver Infection rates were highest in teenagers whose 6-year-olds cancer decades into the future. among infection rate HBV 0 mothers were also infected, suggesting that the Universal infant vaccination against HBV 1989 1991 1993 viral load received during birth might have has proven to be hugely successful in many Before vaccinations After vaccinations overwhelmed the vaccine. countries. The United States instituted such a 0.60 Across the Formosa Strait, in China, a uni- programme in 1991; before then, about 18,000 versal infant immunization programme that children under the age of 10 were infected 0.45 started in 1992 is credited with protecting 367–370 (1999)/M.-H. CHANG there every year. About half caught the virus 80 million children from HBV infection. When 179, . 0.30 from their mothers during childbirth, Offit vaccinations began, nearly 10% of children says, and the rest were infections passed on 0.15 under the age of five had the virus. By 2006, the through unprotected sex (including rape), infection rate had dropped below 1%. But this 100,000 people in Taiwan Liver-cancer incidence per Liver-cancer 0 sharing dirty needles, or casual interactions 6–9 10–14 15–19 resounding success has a potentially troubling ET AL. J. INFECT. DIS AL. J. INFECT. ET such as sharing a toothbrush or washcloth. Age at liver-cancer diagnosis footnote. According to a 2013 study, many of Vaccination has now almost eliminated the the viruses that remain in the younger popula- infection among this age group. tion have accrued mutations — a sign that the in infectious-disease modelling at the London pathogen might be evolving under the selec- INOCULATION DEFERRED School of Hygiene and Tropical Medicine. tive pressure of vaccines4. Doctors are watch- SOURCES: H.-M. HSU SOURCES: Preventive strategies are not limited to universal “It’s not necessarily the highest priority when ing carefully for any sign of a new strain that is infant vaccination programmes — Canada and compared with other changes to the vaccine broadly resistant to vaccination. some countries in Europe vaccinate children at programme that we could and should intro- For now, researchers see no reason why even school, between the ages of 10 and 12. Such an duce,” he says. more babies around the world cannot be vac- approach works well in nations without a lot of In many countries, however, screening cinated. A three-dose vaccine regimen can mother-to-child transmission and where there programmes trying to identify those at high- cost US$30 or less and rarely triggers an aller- is infrastructure to provide the multi-shot vac- est risk are simply ineffective. In the 1980s and gic response or any serious complication. “It’s cination in adolescence. It would not, Halsey early 1990s, the United States targeted vacci- really a very safe vaccine,” says Halsey. Despite argues, be as effective in the United States, nation to adults at highest risk — including this, some parents remain uncomfortable with where vaccinations are not given in schools sex workers, intravenous drug users and men vaccines, not trusting them to do more good and where healthy who had sex with men — and recommended than harm. “We begged for cancer vaccines for teenagers typically universal screening of pregnant women. But several decades,” Halsey says. “Parents should see a doctor just once “In the long run, that policy failed because “people didn’t iden- not be hesitant to protect their child against a a year. In addition, the hepatitis B tify as being at high risk”, Halsey says, and relatively common cause of cancer.” parents in the United vaccine will be vulnerable mothers, including sex workers, Liver cancer is an expensive disease in terms States have been slow one of the most slipped through the cracks. The rates of new of both human lives and treatment cost (see to accept the idea of cost-effective HBV infections in adults barely budged. It was page S4). According to Edmunds, “in the long giving vaccines asso- vaccines.” another reminder that human behaviour can run, the hepatitis B vaccine will be one of the ciated with sexually undermine even the best vaccines, and even most cost-effective vaccines. But it takes a very transmitted diseases more reason why nationwide infant immuni- long time to achieve those gains.” Public-health to their children. The backlash against another zation programmes might — at least for some systems focus their resources where they are cancer vaccine, one typically given to young countries — be the most effective option. most acutely needed. Does it make more sense adolescents to protect against cervical cancer to spend public money addressing a virus that caused by the human papilloma virus (HPV), THE WAY FORWARD will not cause liver cancer for decades or a virus has led researchers to speculate that attempts to Taiwan, which has had universal vaccination such as HIV that is causing pain and suffering move HBV vaccination from infancy to adoles- since 1986, provides perhaps the best example today? At this point, says Edmunds, that is a cence would elicit a similar parental reaction .
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